MC0611 - Medical Chronicle

MEDICAL
CHRONICLE
Est 1965 | Circ 15 000
The Doctor’s Newspaper
June 2011
Telephonic Consultation Initiatives the
‘Wrong Medicine’ for Patient Care?
The legality of several private health care initiatives
using modern technology to consult and advise patients has come under severe fire from the Health
Professions Council of SA (HPCSA) and the South
African Medical Association (Sama). However, providers of these services argue that legislation and
regulations governing telemedicine in SA haven’t yet
caught up with the times and that barring providers
from using it prevents patients from quick access to
medical services which they will otherwise not have
access to.
The HPCSA has urged the public not to use the
services of Hello Doctor, a company that uses telephone consultations to diagnose patients, prescribe
medicine and even supply sick notes, or that of MTN/
Sanlam’s Care Connect telephonic health information offering, until its Committee for Undesirable
Business Practices has had time to review their business models.
The body has also warned doctors to not use
the Hello Doctor platform to offer their services because it will constitute a breach of the ethical rules
that govern­ its members. The committee will make
a ruling once the two services have submitted their
business models for review.
Sama too has slammed the launch of Hello Doctor
describing it as a breach of patients’ rights such as
practitioner-patient relationship, patient confiden­
tiality and informed consent, as well as being ‘disastrous and unethical’.
Hello Doctor CEO,
Andy Milné, countered the allegations
saying that the 350
practitioners that form
part of their network
are subject to the regulatory guidelines of the
HPCSA and subscribe
to the Hippocratic
Oath.
Andy Milné,
In terms of in- Hello Doctor CEO
formed consent, he said each doctor is obliged to
ensure that there is informed consent and this has
become even more relevant with the advent of the
Consumer Protection Act (CPA), which requires that
Earlier ARV Treatment Key to
Turning SA’s AIDS Epidemic Around
Initiating HIV-positive patients on antiretroviral
(ARV) therapy at CD4 counts of between 350 and
550 could potentially avert between 300 000 and
400 000 new infections per year in SA and significantly decrease positive patients’ risks of contracting
opportunistic infections, particularly tuberculosis
(TB). If introduced in conjunction with other proven
HIV transmission prevention interventions, it could
put the country firmly on course to reverse the spread
of the epidemic within the next decade.
These are the key
messages from a landmark study conducted
in SA and various
other countries that
showed a 96% reduction of HIV transmission in serodiscordant
couples when the infected partner received
early ARV treatment.
Conducted by the Prof Ian Sanne
HIV Prevention Trials from the Clinical HIV
Network
(HPTN) Research Unit at Wits
and funded by the and MD of Right to Care
US National Institutes of Health AIDS division, the
HPTN 052 trial started in April 2005 and was due to
end in 2015. However, it was halted in May last year
after an interim review by the study’s data and safety
monitoring board concluded that ‘it was clear that the
use of ARVs by HIV-infected individuals with relatively healthier immune systems substantially reduced
transmission to their partners’. The results of the randomised clinical trial involving almost 1800 couples
in Africa (100 in SA), Asia and North and South
America, support the findings of several observational
studies showing the effectiveness of ARVs in reducing
the infectiousness of HIV-infected individuals.
Last year, epidemiologist Dr Brian Williams from
the SA Centre for Epidemiological Modelling and
Analysis told a meeting of the American Association
for the Advancement of Science that earlier ARV
treatment could make HIV-infected people virtually
noninfectious, stopping the spread of HIV within
five years resulting in the elimination of HIV/AIDS
in the next 40 years.
SA guideline review urged
Commenting on the findings of the HPTN 052
trial, one of the principal investigators, Prof Ian
Sanne from the Clinical HIV Research Unit of the
University of the Witwatersrand and managing director of Right to Care, said the results supported
the view that SA should urgently review its ARV
treatment guidelines to allow for therapy initiation
at CD4 <350 for everybody. Serious consideration
should also be given to increase it to 500 in the near
future.
According to Prof Sanne, starting treatment at
CD4 <350 would add an estimated R1bn to the cost
of the current ARV programme in SA, but would significantly reduce the costs associated with new infections and the treatment of patients who now have to
wait until their CD4 counts drop to 200 and who
are already sick when they access treatment. The cost
of increasing it to 500 or less has not been calculated
yet, but the benefits of ‘test and treat immediately’ are
significant, as has been proven by the study.
Of the 28 cases of HIV transmission that occurred
during the trial and linked to the infected partner, 27
infections were among the 877 couples in which the
HIV-infected partner delayed ARV treatment. Only
one case of HIV infection occurred among the 886
couples in which the HIV-infected partner began immediate treatment.
There were 105 morbidity and mortality events 65 events in the delayed treatment arm and 40 in the
immediate treatment arm. Seventeen cases of extra­
pulmonary TB were found among HIV-infected participants in the delayed treatment group compared
with three cases in the immediate treatment arm.
... to page 2
consumers be given the whole story or all the details.
“We do not understand where there is a breach of
patients’ rights and are seeking further information
on the matter. Our confidentiality processes are stringent as only authorised medical personnel have access
to the information, with each access obviously having
a record of entry, each call is recorded and password
protected.”
He added that their process of confidentiality is,
in fact, much better than most face-to-face consultations because the medical information is only available to the medical practitioner concerned.
He acknowledged that this ‘relationship’ is not
the same as a patient-GP relationship, but added
that it is a relationship not dissimilar to a hospital or
... to page 2
// Highlights //
Specialist Managed
Shortage Care
HIV/AIDS
The link
Training alone To the benefit between HIV
of patients or and preterm
won’t fill the
profits?
gaps
births
P6
P41
P69
Psychiatry
Depression
during
pregnancy
undertreated
P77
page 2 | medical chronicle | June 2011
// News
Capsules
Paediatric surgeon
shortage a crisis
The severe shortage of paediatric surgeons in
SA is reaching critical proportions impacting
particularly on the health of children who need
elective surgery in the state sector. According
to the SA Association of Paediatric Surgeons,
there are currently only 27 registered paediatric
surgeons in the country, meaning that there is
only one for every two million people in SA
compared to one for every 300 000 people in
the UK and one for every 400 000 in the US.
The majority of these surgeons (10) work in the
Western Cape, six in Gauteng, five in KwaZuluNatal, three in the Eastern Cape and one in
the Free State, while the other two work in the
private sector only.
MCC pulls Avandia
The Medicines Control Council (MCC) has
withdrawn registration for the former blockbuster diabetes drug rosiglitazone (Avandia). It
follows a decision last year to withdraw the drug
in Europe after research showed it increased the
risk for heart attacks and bone fractures. The
manufacturer of the drug, GlaxoSmithKline
has indicated that it did not intend to appeal
the MCC’s decision.
Adcock acquires Bioswiss
South African pharmaceutical company, Adcock Ingram Healthcare has acquired a controlling stake in Bioswiss, a specialised diabetes
pharmaceutical company that distributes a
range of human biosimilar insulins and a range
of diabetic diagnostic products (Glucometer and
test strips). Commenting on the acquisition,
Adcock Ingram CEO, Dr Jonathan Louw, said
Bioswiss would provide Adcock Ingram immediate entry into the growing diabetes market.
He said the introduction of a biosimilar insulin
range would allow the company to provide a
cost-effective alternative for people living with
diabetes. Currently, there are approximately
six million people in SA living with diabetes.
J&J to retain CT plant
Johnson & Johnson (J&J) has decided to retain
its manufacturing facility in Cape Town. The
company earlier announced that the facility
would be closed at the end of last year, but according to J&J regional vice president: supply
chain, Filip de Keersmaecker, it was recommended that the facility be retained within the
company’s internal manufacturing network.
The facility manufactures a range of over-thecounter products and employs approximately
200 people. J&J has two manufacturing operations in SA - in East London and in Cape Town. UTi to build R530m
warehouse
Pharmaceutical distributor UTi Pharma has
begun with the construction of a R530m warehouse and distribution centre in Meadowview,
Johannesburg that is to be completed in October
2013. UTi’s associate company, Chronic Medicine Dispensary, will also be located in the facility. Company CEO, Holger Eckholt, said the
centre will triple UTi’s distribution capability.
Med-e-Mass boosts
software offering
Med-e-Mass, part of Bytes Healthcare Solutions, recently added HEALTHone, (electronic
patient record software) to their wide range of
practice management solutions. The software
is an interactive clinical record system that improves practice efficiency and profitability and
allows for smooth interoperability and exchange
of information, said Med-e-Mass MD, Gideon
Brits. The product can be customised and refined to meet the needs of GPs and specialists as
well as to comply with a variety of requirements
such as those set for occupational health, ARV
treatment and injuries on duty.
Telephonic Consultation
Initiatives the ‘Wrong
Medicine’ for Patient Care?
... from page 1
clinic environment where patients do not get to see
the same doctor each time.
Sama chairperson, Dr Norman Mabasa, said his
organisation does not support any initiative that discouraged face-to-face consultation between patient
and doctor.
Hello Doctor has since stopped its services, not because it believes it is wrong, said Milné, but out of
respect for their patients, clients, the doctors and the
HPCSA.
“This has had a massive financial impact on
our business, but until we have the support of the
HPCSA, we will not proceed with this area of the
business.”
HPCSA and Hello Doctor was held at the end of last
month to discuss a way forward. It was during this
meeting that the HPCSA requested Hello Doctor to
submit its business model.
In regard to the HPCSA’s call on the public to not
use these services, Milné said they were extremely disappointed that the powers that be have chosen to say
this before understanding what it is that Hello Doctor
does.
“If they had spoken to us first and found out
what we’re about and then still were of the opinion
that our services were as they have portrayed to the
media, then I would have applauded their proactive
approach.”
He added that he was shocked that the HPCSA issued what he described as a ‘precipitous and irresponsible’ press release before knowing the facts.
“It’s like finding a person guilty before even charging him,” he said.
Services not approved by the HPCSA
In response to the question of whether or not
Hello Doctor has been approved or registered by the
HPCSA, Milné said this aspect has been beset with
inaccuracy.
Hello Doctor is not a practice and that means it
does not have to register with the HPCSA. In addition, they don’t employ any doctors nor do they undertake medical services.
The initial doctor group, ER Consulting Inc, however, is a registered medical practice and all the doctors in their network are registered with the HPCSA.
The doctors have developed a set of clinical protocols,
procedures and processes, which forms the basis of
the clinical governance of the Hello Doctor system.
This system has been developed over many years in
clinical practice, is based on international standards
and is refined to cater for the local South African environment, Milné added.
“Doctors using the Hello Doctor platform will not
attend to just anything or any ailment. The clinical
governance rules and triage system means that only
the appropriate group of primary health care problems will be addressed.”
If a patient is not suitable for the system, then he/
she is encouraged to consult with his/her doctor or go
to an emergency department.
“We are not trying to take work away from other
doctors. In fact, we believe that this process, if embraced by doctors, will compliment their practices
and grow the referral base of patients.
Unethical medicine
The HPCSA also accused Hello Doctor of practising unethical medicine and called on health care
practitioners to continue ‘upholding the general ethical rules and regulations and to refrain from offering
services that contravene these rules and regulations,
including offering or participating in unethical telemedicine practises’.
Milné strongly denied that they were practising
unethical medicine and said they hope to dissuade
the HPCSA of this notion. A meeting between the
Earlier ARV Treatment
Key to Turning SA’s AIDS
Epidemic Around
... from page 1
“It is not only easier to bring down patients’ viral
load to undetectable when they are well than when
they are sick, but it will also help to reduce the number of patients that are diagnosed but don’t return for
follow-up and monitoring. Many of them only come
back when they become ill and already have TB,
adding significantly to the cost of treatment,” said
Prof Sanne.
Treatment alone not enough
However, he stressed that earlier treatment is not
enough to turn the tide on the epidemic. It will have
to be implemented in conjunction with other interventions that have been proven in recent years to reduce the risk of transmission, such as male circumcision, the use of tenofovir gel before or after sex and
the impact of ‘knowing your status’ to ensure that
those who are negative remain negative and those
who are positive get treatment.
system aimed at facilitating access to health care for
millions of South Africans,” said Pienaar.
Telemedicine not ‘illegal’
According to Milné, there is currently no legislation that prohibits telemedicine or ehealth in SA.
He acknowledged that the HPCSA did issue
‘some’ draft guidelines, but added that these ‘have
not yet seen the light of day’. The only reference to the
HPCSA’s views on telemedicine is what appears to be
an executive committee comment, which states that
consultations cannot be done by telephone, he added.
“Despite Milné’s contention to the contrary, the
HPCSA does indeed have rules that clearly prohibit
the type of services offered by Hello Doctor. This is
encapsulated in Ethical Rule 23 (5):
“A practitioner may prescribe or supply medicine or a
medical device: Provided that such practitioner has ascertained the diagnosis of the patient concerned through
a personal examination of the patient or the report of a
practitioner who has.”
According to Milné this rule does not specifically
mention telemedicine and, more importantly, the
HPCSA cannot put in place any guideline or rule
which is in conflict with its enabling legislation and
the national health policy - which just happens to
have telemedicine as one of its stated priorities.
He suggested that those who believe that telemedicine was contrary to the guidelines should ask
why the government has set up a special task team to
implement telemedicine.
Telemedicine is the future
Karel Pienaar, managing director of MTN SA,
stressed that their service is a mobile health information and education service and not telemedicine. One
of their first offerings, the Nurses Advisory Helpline,
does not provide telephonic diagnosis, prescriptions
or sick notes, he added.
The purpose of the helpline is to facilitate access to
basic health care information and education. This is
done through utilising the reach of the cell phone to
provide medical education and information to callers, he explained.
“The product offerings focus on health information and education and comply with all relevant legislation governing the provision of health care,” said
Pienaar.
He added that the provision of such educational
and information services is undertaken by professional nurses. The information provided is not to be used
as a substitute for a medical practitioner’s diagnosis or
treatment relative to the specific medical condition
or query.
“Under no circumstances is this helpline a conclusive diagnosis (or treatment) of the alleged ailment and not a substitute for conventional medical
care, but a complementary service to the health care
Milné accused the HPCSA and Sama of procrastination, saying that while the rest of the country has
transformed over the years, it seems as though these
two bodies have stagnated.
He added that the concept of telemedicine has
been embraced by a number of countries including
the US, Canada, India, Mexico and Australia.
“Telemedicine is huge and will continue to develop
as a way to provide health care,” said Milné.
In addition, technology (and times) has changed,
and he believes that the doctors that are utilising the
Hello Doctor platform should be seen as progressive
and hailed as champions of better patient care for all.
When time, technology and needs change, rules
and ethics need to be changed too, to accommodate
the best interest of the patient, he added.
“It must also be remembered that the Health
Professions Act came about in 1974, long before our
Constitution, and the guidelines and various ethical
practice directives are based on the then old order
interpretation of the legislation and do not and have
not taken into account the technological advances
of the past 15 years let alone the Competition Act,
the Consumer Protection Act and the Electronic
Communications Transactions Act.”
Milné said they will continue to engage and consult with the HPCSA with a view to ironing out
whatever misunderstandings were communicated or
inferred to ensure that common ground is reached,
which will be in the best interest of the health care
sector and the public, he concluded.
“All these findings feed together into a body of interventions that we need to consider when we make
decisions on what should be prioritised for funding
at a public health level. The concept is similar to a
jigsaw puzzle that has to be put together for different
populations,” Prof Sanne explained.
“For instance, the use of tenofivir gel may be considered predominantly for prevention of transmission
to young heterosexual women where you have a serodiscordant couple and the partner doesn’t qualify yet
for ARV treatment.”
In addition, the circumcision campaign should
be accelerated. Studies conducted in recent years
have shown that circumcision could reduce the HIV
transmission rate to men by between 50% and 60%,
but to have a major impact in SA, it will have to reach
at least six million men between the ages of 15 and 49,
Prof Sanne noted.
However, the gateway to ensure that these interventions succeed in reducing infections is to continue
government’s HIV Counselling and Testing (HCT)
campaign.
“We are still far away from having identified all
those who are infected in the country and from
developing a treatment plan for all those who are positive. The HTC campaign needs to be sustained with
the same target of testing 15 million per year for at
least another 10 years and a culture needs to develop
where people want to know their status and are willing to test on an ongoing basis,” Prof Sanne added.
Currently, SA only has around 1.2 million people
of the estimated five to six million who are infected
on treatment, with government preparing to increase
its ARV rollout to three million people in 2016.
Based on data from the Wits HIV Research Group
at the Helen Joseph Hospital in Johannesburg, raising the CD-4 count to 500 would translate in an estimated increase of 30% in the number of patients who
would be eligible for treatment.
Although the expected surge in demand for treatment would put increased pressure on government
to obtain more funding, train more health workers,
improve the clinic system and increase the procurement and distribution of ARVs, Prof Sanne said this
is achievable.
“It is not an insurmountable task. We have already
gone a third of the way and we can go the remaining
two-thirds.”
Care Connect
medical chronicle | June 2011 | page 3
News //
Health System Not Fit for NHI
But we’re Getting There: Minister
Health
minister
Dr Aaron Motsoaledi
has urged South
Africans who are
concerned
about
the establishment of
the National Health
Insurance (NHI) to be
patient, as government
is working around the
clock to finalise the Dr Aaron
long-awaited
docu- Motsoaledi,
ment to be released for health minister
public comment.
“The problem is that many believe that NHI is
just the release of a document. For us in health, we
know that it also involves an extensive preparation
of the health care system, while at the same time
preparing a policy document and, in this case, the
re-engineering of the health care system is vital,”
Dr Motsoaledi said in his budget vote speech at the
end of last month.
Announcing an increase in his department’s budget from R21.7bn in the 2010/11 financial year to
R25.7bn in the 2011/12 financial year, he said an
additional R16.1bn has been allocated at provincial
level for preparatory work for the NHI.
Current system not fit for NHI
But the minister stressed that no NHI can
ever survive in the current health system.
“I know that at face value, problems in the health
system are said to be existing only in the public
sector and the private sector must be left alone to
some wayward phenomena called market forces,
even though these market forces dismally failed to
stop or, more appropriately, caused the most recent
global economic collapse,” Dr Motsoaledi said.
He said while it is true that the public health care
system is ‘bedevilled’ by very poor management and
a dire shortage of resources that have resulted in poor
quality of care, the overall health care system, both
public and private, will be completely re-engineered.
“The present health care system is characterised
by four very clearly identified negatives. It is unsustainable, very destructive, extremely costly and very
hospicentric or curative in nature. For any intervention dealing with the cost of health care, such as the
NHI, to make any sense, a complete re-engineering
of the current health system is essential and it is an
obligation placed upon our shoulders.”
Ringing in the changes
Elaborating on the changes envisaged for the
health care system, Dr Motsoaledi said it will involve
three main interventions: the first being the establishment of a district-based model that will start
with the deployment of a team consisting of a principal obstetrician, paediatrician, family physician,
advanced midwife and senior primary care nurse
in each district. The team’s main focus will be on
the reduction of maternal and child mortality in the
country.
Dr Motsoaledi said he had consulted all the deans
of the eight medical schools in the country, the professional associations of paediatricians, obstetricians,
family physicians, the Colleges of Medicines and
the nursing fraternity, and that they have given their
support to the initiative.
The intention is to have the plan in place by the
end of this year, which, he said, will, for the first
time, require the creation of these posts at district
level.
“We are absolutely determined to make sure that
this model is implemented. Once appointed, these
teams will deal with guidelines and protocols at antenatal care clinics, labour wards, postnatal health
care and paediatrics, and child health clinics.”
In addition, the teams will be responsible for the
training of interns, community service doctors and
medical officers.
The second stream will include a school health
programme, which will be instituted with the assistance of the Ministers of Basic Education and Social
Development. The third stream will be a ward-based
primary health care model, which will deploy at least
10 well-trained health workers per ward.
Such a model has already been implemented in
Brazil, where 30 000 community health care workers have been deployed to various communities. It
will also be employed in India soon.
According to Dr Motsoaledi, a total of 251 teams
have been deployed in SA in the past three months
and have reached 41 000 families. At least 18% of
the people that have been tested in the process were
found to have TB. He pointed out that in the past,
most of these cases would not have been picked up
with many of them only presenting at health facilities ‘when it was already too late’.
Kidney Scandal Surgeons Allegedly Paid
to Perform Transplants
The state has proceeded with charges against the
surgeons and transplant unit staffers accused of performing illegal kidney transplants in the Netcare St
Augustine Hospital in Durban between 2001 and
2003. The six face 461 counts of fraud, forgery, uttering, assault and the unlawful acquisition, use or
supply of tissue, blood or gametes. The four surgeons
also face a charge of using or possessing proceeds
gained from unlawful activities, after it has emerged
that they were paid R2m for their role in what has
been dubbed the Israeli transplant scheme.
Four of the six accused appeared in the commercial crime court in Durban at the end of last
month. The other two accused, transplant unit
staffers Lindy Dickson and Melanie Azor were excused by the state. They face additional charges of
fraud and uttering.
Court documents list Drs John Robbs, Ariff
Haffejee, Neil Christopher and Mahadev Naidoo
as having received R371 000, R1m, R225 000
and R310 000, respectively, for performing the
transplants.
The accused face 109 counts of fraud in terms of
section 29 of the Human Tissue Act of 1983, 109 of
assault with the intent to do grievous bodily harm,
109 of unlawful acquisition, use or supply of tissue, blood or gamete and 92 counts of acquisition
and the use or possession of proceeds gained from
unlawful activities.
According to the state prosecutor, Adv Robin
Palmer, “The accused took the opportunity and,
well-knowing that it did not comply with the law
and the policy, put into operation the Israeli transplant scheme.”
The state also contends that the accused were
well aware that the suppliers and recipients were
not related, as required in terms of the policy, and
were aware they had been recruited to be part of
the organ trade. In addition, five of the donors were
younger than 21, which means they were legally incapable of giving consent.
In their court documents, the state briefly highlights the role of Netcare’s national transplant coordinator, Dr Belinda Rossi, who travelled to Israel
to attend meetings to gain information as to the
possibility of performing kidney transplant operations in Netcare hospitals in SA. It is unclear at this
stage what her role in the scheme was. She has since
left Netcare and is now the transplant coordinator at the Wits Donald Gordon Medical Centre
in Johannesburg. She will potentially be called as
a state witness.
The accused still maintain their innocence, saying they were the victims of a ‘scam’. Their attorney,
Drs John Robbs and Ariff Haffejee, two
of the four surgeons who, according to
the latest charge sheet received a total of
R2m to perform the illegal transplants
Altus van Rensburg, said they were considering
bringing an application to have the charges against
them dropped.
One of their other co-accused, Dr Jeff Kallmeyer,
pleaded guilty last year and was fined R150 000.
He has since turned state witness. Charges against
Netcare were dropped last year after the hospital
group pleaded guilty to 102 counts on the three
main charges relating to 109 illegal kidney transplants conducted from 2001 to 2003 at Netcare’s St
Augustine’s Hospital in Durban. The group paid a
R4m fine and a confiscation order of R3.8m.
‘Perverse Incentives’ Radiologist Found Guilty
Well-known Pretoria radiologist, Dr Henry Syming­
ton has been found guilty of paying more than R7m
in ‘perverse incentives’ to colleagues to entice them to
relocate their medical practices to the Netcare Pretoria
East Hospital and to refer patients to the facility.
He appeared before the disciplinary committee of
the Health Professions Council of SA (HPCSA) last
month and was found guilty on all six charges dating
back from 1996 to 1999.
The six counts were combined for the purpose of
sentencing. He was sentenced to a period of five years
suspension from practice, wholly suspended for five
years on condition that he is not found guilty of either giving or receiving any form of perverse incentives or any form of incentives that may compromise
the independence of medical professionals during the
period of suspension.
In sentencing Dr Symington, the HPCSA said that
he has ‘a direct or indirect interest or shareholding in
the Netcare Pretoria East Hospital’ and that he aimed
to increase the income or turnover of the hospital.
In addition, Dr Symington has a ‘financial interest’
in the magnetic resonance imaging scanner used at
the hospital and therefore benefitted from its use.
The HPCSA found him guilty of breaching the
ethical norms, values and principles of his profession as well as undermining or compromising the
independence of the specialists to whom he paid the
incentives. Among the specialists who accepted his
‘incentives’ are four orthopaedic surgeons, Drs Chris
Neser, A de Villiers, HJ van Wyk, and JA Louw,
neurologist, Dr P Kritzinger and neurosurgeon,
Dr PT Slabbert.
Contents
News
Opinion
1
24
Clinical
Cardiac Medicine
25
Managed Care
36
Oncology
43
Surgery 46
Winter Ailments
47
Asthma/Allergy 55
Gastroenterology 65
HIV 69
Pain Management
71
Nutrition
75
Psychiatry 77
ADHD 78
Wound Care
83
Professional Advertising 85
Periscope
87
Bonitas Finally
Placed under
Curatorship
Bonitas Medical Fund and the Council for Medical
Schemes (CMS) have agreed to a settlement which
effectively brings the two-year dispute between the
parties to an end, in the best interests of the scheme’s
members.
In terms of a court order issued by the South
Gauteng Court last month, Joseph Maluleke was appointed curator for a period of 90 days during which
time he will be in control of Bonitas. Acting principal
officer, Gerhard van Emmenis, will revert to his former position of COO.
Maluleke has served as Bonitas’ compliance officer
since his appointment by the court nine months ago.
His appointment as the scheme’s curator, with Van
Emmenis reverting to COO, was approved by the
CMS and will ensure continuity and stability. In granting the curatorship order, Justice Nigel
Willis emphasised that he was not placing the scheme
under curatorship due to financial or other difficulties. A curator was deemed necessary to regularise the
governance of Bonitas, he said.
The scheme’s 2010 audited financial results showed
a sharp increase in year-on-year surpluses and its solvency ratio strengthened to 36.5%, which is significantly higher than the required 25% minimum. The Registrar of Medical Schemes, Dr Monwabisi
Gantsho, who personally attended the court proceedings, reiterated that the CMS would give Bonitas and
the curator all the support necessary to ensure that the
interests of members are protected.
The council has been trying to put the scheme
under curatorship since the beginning of last year after
it was found that its board was not fit to manage or
control the affairs of the scheme.
An earlier independent investigation also found
that the trustees had been negligent and that they had
broken their fiduciary duties towards the scheme and
its beneficiaries. The findings related to eight allegations involving the investment of more than R80m of
members’ money in, among others, the Louis Pasteur
Hospital in Pretoria, Clinix and an incomplete property development in KwaZulu-Natal that allegedly
put members’ money at risk.
A business relationship between the scheme’s
former principal officer, Bafana Nkosi and the courier pharmacy company, Pharmacy Direct was also
probed. Nkosi was suspended in 2009, but resigned
before he could face a disciplinary hearing.
page 4 | medical chronicle | June 2011
// News
Quality of Health Care in SA ‘Appalling’
The quality of health care in SA is ‘appalling’, said
Prof Morgan Chetty, chairman of the Independent
Practitioners Association of SA Foundation and
CEO of the KwaZulu-Natal Managed Care
Coalition, in a speech at the Africa Health: Quality
Assessment and Improvement Conference held in
Johannesburg last month.
He added that hospitals and clinics have always
had to bear the brunt of quality assessments, while
the quality of services rendered by private practitioners are not assessed, due to a lack of legislation.
He said that he has been fiercely criticised by
practitioners because of his efforts to implement the
assessment of private practices. They accuse him
of interfering with their democratic rights. He is,
however, willing to accept the criticism if it means
an improved health care system in SA.
Quality vs costs
One of the big problems in the SA health care environment, he expounded, was the fact that quality
has, to a large extent, taken a backseat to efforts to
manage health care costs.
Another huge problem is the existence of in­
equality in the health care system. It would be
unfair to produce or deliver health care or to get
involved in an intervention if this is not taken into
account, he observed.
Prof Chetty added that there are unfortunately
only a few examples of sustained quality assurance
evaluations in developing countries. The reason
for this is that the majority of evaluations focus
on measuring the mortality and morbidity rates of
a hospital. This is then used to classify a facility.
These ­studies also often only focus on intervention
processes instead of quality.
“It is appalling to know how little emphasis is
placed on quality when doctors practice medicine
in this country. We keep saying we don’t have
­money or people available to measure quality.”
He added that improving quality is not always
expensive. When investigating the possibility of
implementing a quality assessment system, it is
extremely important to not only evaluate the population coverage and the technological merits of
a health intervention, but to also ensure that the
quality of the services provided compares to prescribed standards.
What is quality and why is it important?
Quality must be defined in the light of the provider’s technical standards and the patient’s expectations, explained Prof Chetty.
Another definition is: The proper performance
according to standards of interventions that are
known to be safe, are affordable to the society in
question and have the ability to produce an impact
on mortality, mobility, disability and malnutrition.
The most comprehensive and perhaps the simplest definition of quality is that used by the advocates of total quality: ‘Doing the right thing right,
right away’, he added.
“We must be extremely aware that the big word
for the future is consumerism. We keep forgetting
the fact that the consumer is going to have a right
to question the quality of service that he or she is
given.”
Tenets of quality
According to Prof Chetty, the four tenets of
quality are: Meeting the needs and expectations of
the patients in the community and not necessarily
meeting the needs of the health care system that
is going to pay for the provision of those services;
keeping detailed notes about examinations and
findings; the quality of the intervention as well as
a competitive team approach in solving problems
and quality improvement.
“Don’t be afraid to outsource some of your
services or to ask colleagues for assistance. The
biggest blunders often happen when we are confident about doing things which we should not be
­doing,” he advised.
Implementating quality assurance
The key activities before a quality assurance
SA Gets its First Urology Skills Lab
According to Janine Volschenk from J&J, enThe Pretoria Urology Hospital, Johnson & Johnson
doscopic surgery is the future. Not only does it
(J&J) and Karl Storz Endoskope recently joined forces
limit the time the patient spends in theatre and
to establish the first dedicated urology skills laborain hospital, but it also reduces the patient’s need
tory in the country.
for pain medication and the risk of infection. This
According to Dr Marius Bongers, one of the three
means that the patient’s recovery time is much
surgeons based at the hospital, the skills laborafaster compared to traditional methods.
tory will allow urologists from across the country to
Experts from J&J and Storz will provide trainpractise and fine-tune their skills. Basic, laparoscopic
ing to urologists who wish to sharpen their skills.
procedures are not a problem for most urologists, but
General manager of Karl Storz Endoskope,
reconstructive surgeries often pose a challenge.
Marion Burgess, said it was a priviledge for her
“New laparoscopic techniques are developed regucompany to partner with the Pretoria Urology
larly, which makes it extremely important for uroloHospital. Colin Atkinson from J&J shared her
gists to have access to a dry laboratory where they can
sentiments and together with Dr Bongers and
practise and fine-tune their skills to ensure that they
Dr Izak van Heerden officially opened the skills
stay on top of their game,” said Dr Bongers.
laboratory.
The skills laboratory contains equipment that alAccording to Dr Bongers, urologists from both
lows urologists to practise their skills in a dry labothe public and private sectors are welcome to use
ratory and to teach their brains to work in the third
the skills laboratory.
dimension, he added.
From left to right: Marion Burgess, general manager at Karl Storz, Dr Marius Bongers,
Colin Atkinson from Johnson & Johnson and Dr Izak van Heerden. Drs Bongers and
Van Heerden are both from the Pretoria Urology Hospital
programme is implemented include sharing or
communicating the reasons why you want to implement a programme with your patients as well as
your staff - even the cleaner; managing the changes that the implementation will bring with it; interrogating your own practice regularly to identify
shortcomings and reviewing your supervisory and
related management activities.
Goals of a quality assurance
Each stakeholder in the health care sector has
their own goals. The World Health Organization
defines the goal of a primary care quality assurance programme as follows: To be the delivery of
an effective, preventive and curative health care
service to the full population, equitably and efficiently, while protecting individuals from catastrophic health care costs.
Prof Chetty added that one of the biggest problems in SA is the fact that the health care system
is too focused on curative care, instead of holistic,
preventive and promotive care.
Health care providers are stuck in the domain
of curative care, because that is what they get paid
for. Health systems must be responsive to the
needs and demands of a population.
Elsewhere in Africa, the focus is on essential,
rather than comprehensive care. It is extremely
important that essential care evolves into comprehensive care, he explained.
Why should quality be assessed?
“I think government needs tools to monitor
and evaluate the functioning of the system on
a routine basis, which will allow them to make
sound decisions about the health care system,
funding, organisations and policies. To do that,
we need information and though we have a lot of
data available in SA, we do not collect, collate or
use it correctly. As a result, we cannot ‘create’ information on which to base decisions,” concluded
Prof Chetty.
Tips on How to Achieve
and Sustain Accreditation
Well-known English
critic, essayist and reformer John Ruskin
said quality is never an
accident; it is always
the result of intelligent effort. And hard
work, added accreditation ‘veteran’ Laura
Ziady, nurse educator
at Medi-Clinic SA:
Central Region.
Laura Ziady,
Ziady presented a nurse educator at
paper at the Africa Medi-Clinic SA:
Health: Quality As­ Central Region
sess­ment and Improvement Conference held in
Johannesburg last month entitled Achieve and
Sustain Accreditation. She has been involved in the
accreditation process of two hospitals in the Free
State over the past 20 years.
According to her, the ‘road’ to quality assurance
starts with accreditation. Other elements that are essential to the success of a quality assurance programme
include best care bundles or services packages; assessment tools such as clinical audits, surveys and electronic event logs; retrospective medical record audits;
clinical governance aimed at the systematic raising of
health care standards; and the management of poor
hospital performance and compliance through quality assurance coordinators’ continuous assessments.
In her presentation, she emphasised the importance of accreditation, saying that it not only
creates awareness about quality of care, but it also
clarifies the definitions of quality of care, provides
direction for initiatives such as total quality managements and can be used as a tool for international categorisation and recognition.
This is becoming extremely important as a result of globalisation, she added.
Data collection
For an accreditation process to be successful, all involved parties should be kept informed of the benefits,
process and timeline of the accreditation programme.
A baseline assessment should be done making use of
internal as well as external assessors. Baseline quality
data, for example medication errors, health care associated infection rates, antibiotic use and postsurgical
complications should be collected and analysed.
“Establish an ongoing data collection and monitoring system to identify problems and to track
progress,” advised Ziady.
In addition, detailed project plans should be
developed that include policy and procedure revision management by committed champions and
‘mock surveys’ should be done four to six months
before the accreditation survey target date.
“It is also important to plan final revisions and
corrections, because the better prepared you are, the
better the outcome of the assessment,” she added.
To sustain accreditation, hospitals should never
become complacent, but should ensure that quality
measures that are put in place are sustained.
Ziady said it is also important to create a culture
of self-supporting improvement and self-assessment
which will encourage staff members to address existing problems as well as new concerns. To do that, a
maintenance programme of the implemented improvements must be introduced, she recommended.
She also advised that hospitals do regular minisurveys in key or high-risk areas where problems
have been experienced in the past.
Maintaining accreditation
To maintain accreditation, regular, structured,
critical and comprehensive performance self-assessments need to be undertaken. The objectives
of these self-assessments are to progressively improve operation efficiency, heighten and enhance
staff morale and encourage team work.
“Self-assessments have to be applied consciously
and active efforts should be introduced to maintain high professional care standards,” said Ziady.
Other important issues in maintaining accreditation are the implementation of a system to review
performance, (which is essential, because if staff are
aware of their performance, it can stimulate improvement). To ensure that staff ‘own’ the process, it is
extremely important to continually motivate them;
continuous comparison with performance indicators
can be used to track the initial achievement of goals,
however, it is essential that measures be put in place
to track progress and retrospective reviews of the
appropriateness of hospital care (patient document
audits, appropriateness of intensive care or high care
accommodation) should be conducted regularly.
In addition, said Ziady, audit trails have to be
developed as proof that accreditation is not a onetime effort.
She acknowledged that accreditation is not only
moonlight and roses, but that there is a downside
to it as well.
“Accreditation is extremely resource-intensive
and requires time, finances, human resources and
expertise. It is also often viewed by staff as ‘inspection by government’ or policing. This can lead to
the underreporting of negative events.”
However, if accreditation is phased separately, it
can have a positive impact on the cost of accreditation, she concluded.
page 6 | medical chronicle | June 2011
// News
Training More Specialists Not the Only
Answer to Cure SA’s Ailing Health System
Research undertaken by the Colleges of Medicine
of SA (CMSA) shows that SA is well below the
standards set by the World Health Organization
(WHO) in terms of the number of health care
professionals required per 1000 population to deliver quality health services. This does not bode well
for government’s proposed implementation of its
National Health Insurance (NHI) system, which,
according to health minister, Dr Aaron Motsoaledi,
requires an additional 80 000 health care professionals to succeed.
According to Prof Zephne van der Spuy, of the
department of obstetrics and gynaecology at
the University of Cape
Town (UCT), the
CMSA’s research shows
that there are many
different issues which
need to be considered.
In 2008 the WHO
reported that SA has Prof Zephne van der
0.77 medical profes- Spuy,
sionals per 1000 popu- head: department
lation in contrast to of obstetrics and
1.85 and 1.98 for Brazil gynaecology at UCT
and Mexico. The CMSA research, however, suggests
that SA only has 0.57 medical professionals per 1000
population and that both the public and private sectors are underserved. SA currently has approximately
0.20 medical and dental specialists per 1000 population and for a middle income country, the WHO
estimates there should be at least 0.40 specialists per
1000 population.
To reach WHO standards, we would have to
double the number of specialists and subspecialists
in practice in our country, which is an unattainable
goal in the short term, and we need to develop alternative solutions, added Prof Van der Spuy.
‘Out of the box’ thinking needed
Her suggestion is that innovative and alternative
solutions have to be looked at, including a possible
review of the training programme.
“We need to recognise that in countries such as
the UK, with a population of 60 million, there are
120 000 doctors, while with a population of 50
million, we have 25 000 doctors. A large number
of graduates qualify every year, but they are often
not being fed back into the public sector system
because of a lack of funded training specialist and
subspecialist posts in the country and the fact that
some of them leave the country or go into private
practice after completing their studies,” Prof Van
der Spuy explained.
Although the Health Professions Council of SA
(HPCSA) has recognised that SA has the capacity
to train these specialists and subspecialists and they
can make an enormous difference in some areas of
health care, these posts are not created.
The shortage of skills is not simply among surgeons and anaesthetists; many other disciplines
have been affected and the fact that SA is not
reaching the Millennium Development Goals for
health indicates problems with service provision in
women’s health, paediatrics and public health.
This is a universal problem around the country,
Prof Van der Spuy added, and it has been compounded in some areas by cutbacks in service provision, which include decreases in operating time for
the surgical disciplines, which impacts on training.
Central to this is the availability of re­lated disciplines such as skilled nursing staff, ­theatre sisters
and professions such as physiotherapy.
Shortage of anaesthetists
Prof Gert van Zyl, dean of the faculty of health
sciences
at
the
University of the Free
State (UFS), agreed
and said one of the
major
stumbling
blocks that they face
is the shortage of anaesthetists,
which
impacts on the training of all surgical
disciplines.
Prof Gert van Zyl,
“Without adequate dean: faculty of health
theatre time, you can- sciences at UFS
not train surgeons. This, in turn, leads to longer
waiting lists,” he added.
Although some of the problems that they have
experienced have been addressed by Dr Motsoaledi,
financial restraints, vacant posts, a shortage of registrar posts and bureaucratic red tape are still some
of the challenges that have to be addressed.
Until all these issues have been sorted out, the
UFS will not increase the number of specialists that
can be trained at the institution. Unfortunately the
wheels of government turn slowly, Prof Van Zyl
added.
Improvements
He did however acknowledge that some improvements have been introduced since Dr Motsoaledi
took over the reins in 2009. These include for e.g. increased security at Pelonomi Hospital since the rape
of a doctor last year, an increase in the number of
available beds at the facility, a decrease in the number of vacant posts at the hospital and a promise of
funding for training equipment.
Prof Marietjie de Villiers, deputy dean: education in the faculty of health sciences at Stellenbosch
University (SU), said the training of medical specialists is a complex matter that involves a number of
stakeholders, including universities, provincial health
departments, the Department of Higher Education
and Training (DoHET) and the Department of
Health (DoH).
She agrees that the shortage of training posts
and medical consultants to supervise the training
is definitely contributing to the shortage of trained
specialists.
According to Prof De Villiers, another problem faced by universities is the fact that Master of
Medicine (MMed) programmes are costly. It takes
between four and five years to complete, while
universities only receive a subsidy for one year per
student.
“It is therefore often not cost-effective for universities to run these programmes,” she added.
Prof Van der Spuy pointed out that the HPCSA
recognises that there are some 1400 unfilled training
posts at specialist and many at subspecialist levels,
indicating that the infrastructure is in place for filling these vacancies and embarking on training.
The situation with subspecialist training is more
difficult as the funding is complex and the majority
of the recognised training posts are unfilled and unfunded. The solutions include being sure that the infrastructure requirements approved by the HPCSA
are not undermined by cutbacks in staff, particularly
trainers.
The funding, which the DoHET has provided
for the faculties of health sciences of SA, has made
a major positive impact on both undergraduate and
postgraduate training and hopefully this will continue into the future.
In his budget speech this year, the Minister of
Finance, Pravin Gordhan, indicated that funding
was available for additional registrar posts and it is
hoped that the impact will be seen in the near future,
said Prof Van der Spuy.
Prof De Villiers subscribes to Prof Van der Spuy’s
view that the solution is not only about ­creating
more posts.
She proposed the development of an over­arching
framework that looks at all the constraints and opportunities regarding this matter. In an effort to
find a solution to the problem, SU has implemented
structures of formal and informal communication
with the Western Cape DoH.
Changes in ratios
In order to increase the number of specialists and
subspecialists in the country, the Subcommittee for
Postgraduate Education and Training (Medical) of
the HPCSA conducted a review of the trainer vs
trainee ratio.
The body consulted with all stakeholders including universities, professional associations/societies
and government institutions and developed a trainer/trainee ratio policy in January 2009. The policy
was implemented at a workshop held in August last
year to which all the stakeholders were invited.
“As it is our mission to ensure our country’s citizens have access to quality health care, the implementation of the new ratios for specialists and subspecialists will address the urgent need for specialists
in the country while ensuring a high standard of
training is still adhered to,” said Marella O’Reilly,
acting CEO and registrar of the HPCSA.
The trainer/trainee ratios have been doubled in
most disciplines including for e.g. anaesthesiology,
dermatology, family medicine, medical genetics,
neurology, ophthalmology, paediatrics, pathology
and radiation oncology. Subspecialist training ratios
that have been increased include for e.g. clinical haematology, endocrinology, ­geriatric medicine, medical oncology, maternal and foetal medicine and child
psychiatry.
Although the changes in the trainee ratio have
been welcomed, it does not address the underlying
problem of sufficient operating theatre facilities and
surgical opportunities for trainees in the surgical
disciplines. The new ratios can only be implemented
once the HPCSA approves an increase in the number of students that can be trained at academic institutions, said Prof van der Spuy.
According to Prof De Villiers, the changes in the
ratios have been useful in some instances, while in
others they have been fortunate to maintain the current high-level supervision needed to produce good
quality medical specialists.
New Hope for Patients Waiting for Lung Transplants in SA
There is nothing more inspiring and rewarding than seeing someone who was dying recover
fully and go on to lead a normal, fruitful life, said
pulmonologist and transplant specialist, Dr Paul
Williams.
He was speaking
at a function held
at Netcare Milpark
Hospital last month
to honour transplant
survivors.
However,
having
recently
returned from the
International Society Dr Paul Williams
for Heart and Lung pulmonologist and
Tr a n s p l a n t a t i o n transplant specialist
Conference in the US, Dr Williams is, for the first
time in many years, hopeful that long waiting lists
may soon be a thing of the past due to new scientific advances that may spell a paradigm shift in
the field of transplantation.
“When it comes to organ transplantation, SA
has the capacity to do as well as the rest of the
world,” said Dr Williams.
“Similarly, we also have the potential to fall
terribly behind as there are new developments in
the field every year and it is important to stay up
to speed. The future of organ transplantation depends on the availability of suitable donor organs,
of which there is a growing shortage worldwide.
Our only hope, therefore, is to use and salvage as
many organs as possible in order to make the most
of what we have,” explained Dr Williams.
At present, only 10%-15% of the organs referred for lung transplantation are useable. Hearts
and kidneys, on the other hand, are a great deal
more resilient than lungs and they also do not
have the same high rejection rates.
Because of the very short lifespan of donor
lungs, lung transplant surgeons have, for many decades, followed strict guidelines to get the donor
organ into the recipient as quickly as possible.
Apart from that, very few of the lungs donated are
of the quality required to meet the strict criteria
for transplantation. Now, however, all this may be
changing.
Breakthrough discovery
According to a recently published study in the
New England Journal of Medicine, the number of
donor lungs and successful transplants may be
dramatically increased by treating the organs on
a perfusion machine for several hours prior to
transplantation.
Describing it as the most exciting development
in lung transplantation since its inception some
25 years ago, Dr Williams explained that the development enables the repair and use of 85% of
lungs that could previously not be used because of
tissue damage.
Instead of keeping lungs in the traditional
­bucket of ice to safeguard them, a very clever
method has been devised at the Toronto General
Hospital in Canada whereby the lungs are hooked
up to a type of ‘ventilator’ that resembles an
incubator.
As part of the new technique, liquid comprising oxygen, proteins and nutrients is pumped into
the donor lungs after they have been removed and
transported to the hospital of the recipient.
“In this way, the lungs can be kept and treated
for 12 hours or longer,” Dr Williams said.
“At present, if the lungs are not perfect, we cannot use them. However, just imagine if we had
the potential to harvest and retrieve donor lungs
successfully.
We could even have a team looking at the organs and repairing them. The idea is that one will
take organs that were turned down due to unsuitability and make them ‘better’ through a variety
of techniques.”
There will be no rush to get recipients into
­theatre. Instead, surgeons will be able to observe
the lungs for 12 hours, while flushing them with
anti­biotics and immunosuppressant medication
that could lower the risk of rejection.
He noted that while there are many reasons to
explore the new breakthrough, it will, without
doubt, prove expensive and time consuming to
develop the programme successfully.
“Thinking of the 20-25 patients that we have
on the lung transplant waiting list at Netcare
Milpark Hospital at any given time, there are
ample reasons to get the programme up and running as soon as possible.
“I believe that it is imperative that we make
an effort to change the status quo and help those
patients who we currently have to send away,”
Dr Williams said.
page 8 | medical chronicle | June 2011
// News
SA Human Genome Project Will Benefit Local Society
In an article that appeared in the authoritative scientific journal Nature, entitled ‘What is the human genome
worth’, it is reported that the US Human Genome Project generated almost $800bn (R5513bn) in economic
benefits over a period of 22 years. It is also estimated that the project generated more than 300 000 jobs over that
period. In addition, DNA-based products and technologies exceeded R310bn in 2009.
In a bid to strengthen SA’s capacity in this growing field, government recently threw its weight
behind the establishment of the southern African
Human Genome Programme (SAHGP).
Heading the programme is Prof Michael Pepper
and Prof Michelle Ramsay from the Universities
of Pretoria and the Witwatersrand respectively.
Prof Pepper cautioned that the benefits of the
programme should not merely be measured in
financial terms, but rather in the improvements in
the health care sector. The Department of Science
and Technology (DST) provided seed funding for the
programme, which was launched earlier this year.
Since then the stakeholders have been putting
together a comprehensive report for the DST in
order to secure further funding. The programme
has attracted support from many sectors including
several government departments, said Prof Pepper.
Objectives of the SAHGP
The main objectives of the SAHGP are to develop capacity for genomic research in southern
Africa, to establish resources which include a
database and sample repository and to translate
knowledge and information into improvements in
human health.
In a presentation at the Africa Health: PanAfrican Ethics, Human Rights and Medical Law
Conference hosted
in Johannesburg last
month, Prof Pepper
highlighted the various important applications of genome
sequencing.
These include, for
example, its positive
impact on molecular medicine, DNA
forensics, archaeo­
Michael Pepper,
logy, anthropology, extraordinary professor
evolution and human in the department of
migration,
energy immunology, faculty of
sources as well as ag- health sciences, UP
riculture and livestock breeding.
In terms of molecular medicine, genome sequencing can be used to prevent diseases because
of its predictive value. When combined with
preventative measures or changes in lifestyle prescribed by health care practitioners on the basis
of information obtained as a result of sequencing,
this approach has the potential to prevent diseases
with a definable genetic component.
Personalised medicine
Sequencing allows health care practitioners to
personalise medicine, which may reduce the risk
of adverse drug reactions and increases a patient’s
rate of recovery.
Because sequencing has the potential to play
a huge role in pharmacogenomics, it can have a
huge impact on the treatment of a patient through
rational drug design. Knowing the sequence of
an affected gene can also assist in the design and
implementation of gene therapy.
Social, ethical and legal issues
Prof Pepper cautioned that in order for the
project to succeed, national, local ethnic and
gender-specific differences have to be recognised.
He added that it is also extremely important that
common vs rare diseases are prioritised.
Despite the many benefits that genome sequencing holds, Prof Pepper said that there were
still many groups that question the ethics of the
project. They feel that researchers are interfering
with ‘mother nature’ and thus working against
evolution.
They also fear the potential of genetic accidents
and the dangers associated with designer orga­
nisms and cloning. While reproductive cloning is
universally banned, designer organisms are here to
stay, he said.
People also fear that sequencing can lead to
genetic discrimination against individuals on the
basis of their genetic information or that it can
lead to communities being discriminated against
because of their susceptibility to diseases, their
ancestry or ethnicity as well as their historical
background.
Prof Pepper stressed that all data will be anonymised and will remain confidential. In addition, access to information will be restricted.
He added that a research project such as this
cannot be undertaken without the approval of research ethics committees and the informed consent of individuals and communities.
Traditional and cultural beliefs and norms as
well as the literacy levels of participants in ­studies
are taken into consideration before a study is
initiated.
Prof Pepper concluded by stressing that research in genome sequencing will not only benefit
a country’s scientific community, but will benefit
society as a whole.
medical chronicle | June 2011 | page 11
News //
Lymphoedema: Misunderstood and Misdiagnosed in SA
The lack of understanding of the causes and treatment of lymphoedema leads to needless suffering by countless
people worldwide.
Nana Ntombela, has
suffered from primary
lymphoedema since the
age of 16 and has been
bedridden since 2009.
Called ‘elephant woman’ by people in the community, Ntombela’s left leg weighed approximately
50kg and, at 1.45m in diameter, was almost three
times larger than her right. For years, she has failed
to receive proper treatment by public health facilities
and was advised that amputation would be the only
solution.
Media attention to her plight resulted in a mercy
mission involving Netcare, physiotherapist Allison
Dendy, who specialises in lymphoedema, vascular
surgeon Dr Dirk le Roux and journalist, Megan
Small, from ETV’s 3rd Degree.
After just 20 days of specialised physiotherapy,
Ntombela’s calf reduced down to 64cm. An operation on 25 May removed 7kg of loose skin and two
days later, her leg diameter had reduced to 50cm.
Like many Zulu women, Ntombela was born
without lymph nodes in one of her legs, causing
the onset of lymphoedema at age 16. Other causes
of lymphoedema are accidental injury to the lymph
as well as surgery, and elephantiasis, a condition
caused by mosquito lava in tropical and subtropical
countries.
Dendy is one of a handful of physiotherapists in
SA qualified in Complete Decongestive Therapy
(CDT) for lymphoedema. CDT uses a combination of manual lymph drainage (MLD), compression therapy, decongestive exercises, and skin and
nail care to improve and manage the condition,
thought to be suffered by up to three million people
worldwide.
Neither doctors nor physiotherapists are provided
with adequate training in their undergraduate studies, she believes. Often, interventions by beauty therapists purportedly offering manual lymph drainage
also cause more harm than good.
According to Dendy, common mistakes in the
treatment of an oedematous limb include prescribing a diuretic to reduce the swelling and prescribing
a compression garment.
Even more damaging is to prescribe both together.
Although diuretics initially draw off the water content of the oedema, protein molecules contained in
the lymph are left behind and draw more lymph
into the tissue. Often, the patient is prescribed more
diuretics and the cycle begins again, with the limb
becoming progressively more difficult to treat.
Bandaging without MLD serves merely to hold
the fluid, not move it down to healthy lymph vessels
that will, in turn, drain the lymph into the venous
system. MLD is a gentle, manual treatment technique that requires knowledge of the lymph vascular
system to be effective. Skin is also already compromised by the condition, so it is important to understand how to perform the massage without causing
further damage.
Cellulitis is one of the frequent complications of
lymphoedema and early treatment with anti­biotics
is essential to ensure that infection does not become
systemic.
Ntombela’s case has led to a widespread acknowledgement of the urgent need for funding of a support
organisation to provide treatment education and to
assist the high numbers of indigent lymphoedema
sufferers. Since the screening of the story in March
2011, Dendy is now treating a further 10 pro bono
patients.
An integrated approach to the care of lymphoedema patients involving a general practitioner, physiotherapist, exercise therapist, dietician, counselling
services and, where appropriate, a vascular surgeon,
can result in an excellent prognosis for the majority
of lymphoedema sufferers.
Nana Ntombela’s leg before she received treatment
After 20 days of specialised physiotherapy and an operation
to remove the loose skin the leg’s diameter was reduced from
1.45m to 50cm
medical chronicle | June 2011 | page 13
News //
Law in Practice
Elsabé Klinck
Money, the Root of all Uncertainty for Doctors
With the scrapping of the Reference Price List
(RPL) and in the absence of guidelines as to
what one should charge, and for what one should
charge, many practitioners are looking for guidance as to how they should be billing.
A reference ... is only a reference
The RPL and the Health Professions Council
of SA’s (HPCSA) ethical tariff were merely references and not fixed fees. Each practitioner still
would have to decide what he/she would charge
under which circumstances.
An agreement or acknowledgement that one
should charge at, or at a certain percentage of,
such a reference price would still amount to anticompetitive behaviour.
The rationale behind competition law
The idea behind healthy competition is that
it should benefit consumers by leading to lower
prices­ or better value for the same price. The
part of the competition law that is very relevant
to health care practices is the prohibition on
collusion.
Competitors should not sit around the same
table and agree on what fees they should charge.
Groups should therefore be careful to not nego­
tiate on behalf of all the competitors in a group
and should also refrain from giving advice
that could be construed as, in the words of the
Competition Commission, ‘smoothening the uncomfortable state of competition’.
In competition law, the price for goods or
services must bear a reasonable relation to the
economic value of those goods or services.
A nonexcessive price is one that is determined by
competitive conditions in the relevant market.
But it is often argued that health care is not a
‘voluntary’ market with supply and demand driving prices.
As patients have to go to doctors and often do
not have the information to select a provider on
competitive grounds or the muscle to negotiate
better fees with a provider, the market is not competitive and price sensitive.
The Consumer Protection Act
To complicate matters further, the Consumer
Protection Act (CPA) contains a number of provisions on pricing:
• Prices must be ‘adequately’ displayed, e.g.
consumers should know upfront what they are
in for, or at least receive a sufficiently detailed
quotation to allow them to make an informed
decision.
• Prices must not be unfair, unreasonable or
unjust.
In general terms, a ‘fair price’ would include a
price that treats everyone as they should be treated­.
A ‘reasonable’ price is a price that is backed up by a
good reason or rationale, e.g. changes in underlying cost structures or how complicated the service
is.
A ‘just’ price, would be a price that is also legally justifiable and in line with applicable legal
principles.
Payment in full, unless ...
The interpretation of Regulation 8 by the
Council for Medical Scheme’s Appeals Board
also gives professionals some indication as to
what level of charges would be eligible for such
full payment.
Circular 24 of 2009 clarified that ‘so long as
the service providers’ fees were not un­reasonable
or unprofessional, the medical scheme involved
was obliged to pay those fees in full without any
co-payment or the use of deductibles’.
Section 41 of the Health Professions Act of
1974 gives the Professional Boards of the HPCSA
the power to investigate and rule on unprofessional conduct.
But Section 53 goes even further. It gives the
Professional Board the right ‘to determine the
amount which, in the opinion of the professional
board, should have been charged in respect of
the services to which the account relates, and the
board shall, as soon as possible after receipt of the
application, determine the said amount and notify the practitioner and the patient in writing of
the amount so determined’.
Section 53 also guides practitioners on communicating with patients on fees, stating that
‘unless the circumstances render it impossible for
him/her to do so’, the practitioner should inform
the patient or responsible person of the fee that
he/she intends to charge, but only ‘when so requested by the person’ or ‘when such fee exceeds
that usually charged for such services’.
This communication standard however differs
from that set out by the CPA that requires price
disclosure upfront.
So, what is a practitioner to do?
1. Develop a billing policy for your practice that
covers issues such as how to deal with differences between scheme benefits and your fees,
discounts for cash payments or early settlements of accounts.
2. Let patients know upfront what the most frequently charged fees are, and when they will
receive quotations for services you render.
3. Base fees on sound, rational considerations
such as practice costs, patient profile, accommodating vulnerable patients, experience, etc.
4. Ensure that coding is done correctly in your
practice. Provide ICD10-codes, as this enables schemes and other providers, such as
pharmacists, to ensure that vital patient information is communicated.
5. Resist the temptation to ‘build some fat’ into
fees, where such cannot be justified by rational considerations. Particular care should
be taken where goods and/or services are
bundled, such as in the case of global fees or
so-called ‘package deals’. Similarly, underfunding of professional fees could force practitioners to under-service patients.
6. Keep tabs on developments at the HPCSA,
Council for Medical Schemes, and Consumer
Commission, as new rulings may provide further guidance as to how fees should be set.
page 14 | medical chronicle | June 2011
// News
Shortage of Pharmacists a Global Problem
It seems as though SA is not the only country experiencing a shortage of pharmacists. The World Health Organization
(WHO), the United Nations and the International Pharmaceutical Federation (FIP) joined forces early in 2000 to launch a
Pharmacy Education Taskforce whose aim is to facilitate a ‘concerted and collective global action’ to train more pharmacists.
Pharmacists represent the third largest health care
professional group in the world. According to the
WHO, the shortage of pharmacists is especially worrying in regions such as sub-Saharan Africa, where
in many communities, the pharmacist is the most
accessible or often the sole provider of health care
advice and services.
Developed countries, however, have not been
spared and many have reported huge shortages. For
example, it is estimated that the US has a shortage of
3000 pharmacists.
In a report entitled Global Pharmacy and Migration
Report, the FIP highlighted some of the reasons for
the shortage of pharmacists. Some of these include:
• Increases in the volume of prescriptions.
• Growth in the population over the age of 65.
• Greater administrative requirements for hand­
ling third-party payments.
• The changing role of pharmacists.
• The growing proportion of women in the profession who are less likely to work full time.
Situation in SA
Ivan Kotzé, executive director of the
Pharmaceutical Society of SA (PSSA), recently said
that SA’s critical shortage of trained pharmacists
could have a negative impact on the expansion of the
industry in future.
According to Andy Gray, a senior lecturer in the
department of therapeutics and medicines management at the University of KwaZulu-Natal (UKZN),
SA has fewer pharmacists per 100 000 population
than the median for upper-middle income countries.
In 2010, 12 218 pharmacists were registered at the
South African Pharmacy Council (SAPC), serving
a population of approximately 50 million, meaning
that SA has an average of less than 24 pharmacists
per 100 000 population, more than 50% less than
the required 50 per 100 000.
“However, that also ignores the large number who
is not practising, and the very skewed distribution.
In 2010, only 2966 pharmacists were employed in
the public sector, responsible for meeting the needs
of 85% of the population,” said Gray.
In addition, it is estimated that 40% of the pharmacists working in the private sector, is based in
Gauteng.
of their pharmacies. The retail group currently has
19 stores, but plans to open another four in the
coming weeks. They also have problems filling their
vacancies.
50
Experts agree that the number one reason for the
shortage of pharmacists in the country is as a result
of constraints on the number of students who can be
trained at universities as well as the limited number
of training institutions available in the country.
SA currently only has nine training facilities as opposed to the 13 it had prior to the amalgamation of
many of the country’s universities and technikons in
2004.
Another reason for the shortage is the fact that
huge numbers of trained pharmacists leave the country annually, said, Dr Gill Enslin, head of the department of pharmaceutical sciences at the Tshwane
University of Technology (TUT).
The FIP reported that in 2001, approximately
1000 pharmacy students graduated in SA and in the
same year 600 emigrated. While many leave, only
a handful of international pharmacists applied for
positions in the country. In fact, figures indicate that
since 2003, only 18 international pharmacists have
registered with the SAPC.
The number of pharmacists
required per 100 000
population. SA has 24.
The impact of the shortage on health
care services
Gray added that the total number of new graduates remains static at about 350-400 per year, which
is hampering the development of pharmaceutical
services. KwaZulu-Natal, for example, reported
a vacancy rate of 76% last year, while 66% of the
Department of Health’s posts were vacant.
Things don’t look much better in the private sector. Kotzé cited Clicks and Pick ‘n Pay as examples
of groups whose expansion plans are being severely
hampered by the shortage of pharmacists.
Clicks currently has 382 outlets and 266 in-store
pharmacies. They plan to increase their number of
pharmacies to 500 countrywide. However, they currently have 200 vacancies, despite the fact that they
pay higher salaries than the state.
Pick ‘n Pay too has plans to expand the number
Top Proposals for Cost-efficient Care
Limiting antibiotic prescribing for certain respiratory
infections, avoiding imaging for low back pain and
osteoporosis screening for certain patients and not ordering cardiac screening tests in low-risk patients are
among the suggestions to make primary care more
affordable and efficient, according to a report posted
online in the Archives of Internal Medicine. The article
is part of the journal’s ‘Less Is More’ series.
These recommendations resulted from a project of
the National Physicians Alliance (NPA) in the US
aimed at improving the quality and cost-effectiveness of health care. Doctors were asked to compile
the top five practices in primary care that they think
could be changed to make care more affordable and
high-quality.
“Each activity was to be well supported by evidence, have beneficial effects on patient health by improving treatment and/or reducing risks and, where
possible, reduce costs of care,” the article stated.
The participating doctors represented the three
primary care specialties: family medicine, internal
medicine and paediatrics.
They participated in teleconference calls to suggest
list items, which were then weighed against evidence
in the scientific literature. A mass email to all NPA
members recruited 172 other doctors for a second
round of field testing, which involved completing the
same survey that the initial testers completed. The
two groups of participants agreed with the following
practices:
Family medicine: Limit early imaging for
low back pain, avoid the routine prescription of
anti­biotics for sinus infections, avoid ordering electrocardiograms (ECGs) or other cardiac screening in
low-risk patients with no symptoms, reserve Pap tests
for patients age 21 years or older who have not had
hysterectomies for benign disease, and reserve dualenergy x-ray absorptiometry (DEXA) osteoporosis
scans for women ages 65 years and older and men 70
years and older or who have risk factors.
Internal medicine: Limit early imaging for low
back pain, do not order full blood counts or urinalysis for screening in healthy adults with no symptoms,
avoid ordering ECGs or other cardiac screening in
low-risk patients with no symptoms, limit initial
statin prescriptions to generic medications, and reserve DEXA osteoporosis scans for women ages 65
years and older and men 70 years and older or who
have risk factors.
Paediatrics: Avoid prescribing anti­biotics for
sore throats unless tests for streptococcus are positive, ­limit diagnostic imaging for minor head injuries
without loss of consciousness or other risk factors,
do not refer middle-ear infections (otitis media with
effusion) to specialists too early, tell parents to avoid
giving children over-the-counter cough and cold
medicines, and ensure that inhaled corticosteroids
are used properly by patients with asthma.
The authors pointed out that some of the items
appear on multiple lists. This commonality across
specialties reinforced the importance and relevance
of addressing overuse of these activities, they wrote.
Source
JAMA media release
Reasons for the shortages of
pharmacists
Solutions
The most obvious solution would be to increase
the number of pharmacists in SA, and retaining
them for the country by making the pharmacy profession more desirable for young pharmacists, said
Dr Enslin.
“This can be done in numerous ways including,
e.g. job satisfaction, advertising of the various sectors
and diverse areas in which pharmacists can be employed (not traditionally occupied by pharmacists)
and the utilisation of all the skills that a generalist
pharmacist has.”
Gray agreed and added that the fact that the training facilities are all based in metropolitan areas also
poses a problem.
As a result, some training facilities, such as the
one at the UKZN, are massively over-subscribed.
The UKZN received more than 5000 applications
this year, but could only accommodate 80 students.
His solution is to increase the size of existing
training institutes. The UKZN has received substantial funding to build a new academic health complex
and it is anticipated that this will, once built, allow
for the pharmacy intake to be increased.
“That seems the best way to use the scarce academic resources. Training institutions have also
argued for new graduates to be able to do community service at universities, which will help them to
recruit and retain future academics and researchers.
The solution also partly lies in improving the capa­
city and number of technicians, aiming at a 1:1 technician: professional ratio in time (it’s 1:3 at present),”
said Gray.
The TUT, in partnership with the University of
Limpopo, annually trains 60 students. They too
have decided to increase their capacity and will be
establishing an independent pharmacy department
at the TUT. This will add another 60 to the number
of students that they train annually.
Dr Enslin explained the reason for this is because
they have grown into a research-focused school and
need to be able to accommodate academic interns,
which they can’t do under the current partnership
agreement.
“Due to the wording in the Pharmacy Act, we
need to generate student subsidies for TUT independently, as this would be more efficient. We have the
infrastructure to do so and the country needs more
pharmacists,” she added.
Prof Oppel Greeff, head of the department of
pharmacology at the University of Pretoria (UP),
agreed that the relatively small number of pharmacists that can be trained at the various institutions
poses a problem, but disagreed that the number of
training facilities was inadequate.
He was part of the ministerial task team in the
1980s that investigated the number of institutions
offering pharmacy training in the country and re­
commended that SA reduce the number of training
institutions to nine, which was on par with international standards.
According to him, legislation has had a huge impact on the profession, because small retailers are
largely being replaced by groups such as Clicks,
DisChem and Pick ‘n Pay. This makes it impossible
for the small retailers to survive, which makes pharmacy an ‘unattractive’ career choice for many.
He said a revision of the training programmes
might also be something to consider. Currently,
pharmacists undergo general training with no option for specialisation. This severely hampers pharmacists’ career options. In addition, he added, the
role of pharmacists in the health care sector must be
acknowledged and they must be paid accordingly.
The future
The shortage of pharmacists and strategies to address the situation was discussed at length at the
PSSA, Commonwealth Pharmacists Association and
the South African Pharmacy Council Conference,
which was held in Durban earlier this month.
page 16 | medical chronicle | June 2011
// News
Reference Book to Ease GPs’ Admin Burden
Members of the Alliance of South African
Independent Associations (Asaipa) will soon have
access to a handy ‘one-stop’ reference book that
contains all the information they regularly need in
running their practices.
Aimed at easing GPs’ heavy administrative burden, the book was designed by Dr Mike Nicholas,
chairperson of the Western Cape Independent
Practitioners Association (IPA), with the support of
an editorial board consisting of Dr Wessel Neuhoff
of the East Rand IPA and Dr Shanaze Ghood of
the Pretoria IPA.
Sponsored by Arctic Health, the book covers an
array of information, including ICD-10 codes, continued professional development (CPD), details of
clinical programmes and courses presented at the
different universities’ faculties of health sciences
and contact details of the medical associations and
other bodies that GPs work with on a regular basis.
“Although most of
this information is
available on the internet and computer programmes, it is sometimes difficult to access,
especially for the older
generation of GPs who
are not computer literate. This book compiles
everything in a single The designer of the
user-friendly
source GP reference book,
that doctors can keep Dr Mike Nicholas
on their desks for easy reference,” said Dr Nicholas.
It contains an up-to-date, condensed version of
the ICD-10 codes that was obtained with the cooperation from the SA Medical Association (Sama)
and includes both the clinical diagnosis and its description in layman’s terms.
The section on CPD points includes a comprehensive article compiled with the assistance of the
Health Professions Council of SA (HPCSA) on
how the system works, how many points a doctor
needs in the different categories to comply with the
requirements, how the information should be kept
and for how long. In addition, a separate page is
provided for doctors to write down the details and
dates of the CPD events they have attended.
All the statutory requirements doctors have to
comply with to practise in SA are included in the
book as well as the forms GPs have to fill in for the
annual renewal of their registration at the HPCSA,
their Sama membership and to apply for or renew
dispensing licences.
Information about professional indemnity and
the companies from which it can be obtained is
also provided.
To allow for data to be updated on a regular
basis, the book is published in a file format that
allows for pages to be replaced when information
changes. It will also provide the sponsor the opportunity to market its products directly to GPs and
to change the advertisements when new products
become available.
“It is a working document that will provide doctors with easy access to key information, which will
not only save them time, but will also alleviate their
administrative burden,” Dr Nicholas said.
The book is availably free of charge to Asaipa’s
1300 members and will be delivered directly to
them within the next few weeks.
Research
Offers Simpler
TB Treatment
Results from one of the largest US government
clinical trials on tuberculosis (TB) preventive
therapy­ to date, suggest that treatment for latent
TB infection may soon be easier than ever before.
The trial results showed that a supervised onceweekly regimen of rifapentine and isoniazid taken
for three months was just as effective as the standard
self-administered nine-month daily regimen of isoniazid, and was completed by more participants. Sponsored by the Centres for Disease Control
and Prevention (CDC), the trial tested the effectiveness of this new preventive TB treatment regimen among persons with latent TB infection who
are at high risk for progression to TB disease. The new regimen to treat latent TB reduces the
doses required for treatment from 270 daily doses
to 12 once-weekly doses, making it much easier for
patients to take. The study
The study lasted approximately 10 years and
included 8053 participants over the age of two
who lived in countries with low or medium TB
incidence, including the US, Canada and Brazil.
Because of a known drug interaction between some
anti-HIV drugs and rifapentine, HIV-infected persons taking antiretrovirals were not eligible for enrolment in the study.
Participants were randomised to receive one of
two preventive treatment options - a regimen consisting of three months of once-weekly rifapentine
900mg and isoniazid 900mg given with supervision (that is, directly observed therapy), or the
current standard regimen used to treat latent TB
infection, consisting of nine months of daily isoniazid 300mg, which was not supervised (that is,
self-administered by the participant). The new regimen was found to be safe and as effective as the standard regimen in preventing new
TB cases with very few cases developing in either
study arm. Seven cases occurred among those receiving the new treatment regimen compared to 15
among those receiving the standard treatment.
Additionally, the percentage of participants completing the new, shorter regimen was substantially
higher (82%) than the percentage completing the
standard regimen (69%).
The researchers cautioned that these results are
only directly applicable to countries with low-tomedium incidence of TB. Additional studies will
likely be needed before this new regimen can be
recommended in countries with a high incidence
of TB.
medical chronicle | June 2011 | page 17
News //
Advertorial
Updating Doctors on the Latest Clinical Practice
The academic programme kicked off with
Dr Dominic Giampaolo delivering a presentation at the breakfast symposium on new research
insights into multiple sclerosis. The aim was to assist the GP in optimum management of patients
with this potentially debilitating condition.
This was followed by a cardiometabolic session
consisting of a lecture on the current trends in hypothyroidism, with an emphasis on control, by
Dr Helena Oosthuizen. Diabetes management,
comparing new and older, more established therapies, was discussed by Dr André Pieterse. This theme
was concluded by Prof Neels Potgieter’s presentation
on novel advances in hypertension treatment.
Dr Anthony Rodrigues then enlightened the
dele­gates on infertility and its management. One
of the highlights was undoubtedly the discussion
around the new sexually transmitted infections
guidelines, by Prof David Lewis. The management
of urinary tract infections and resistance issues
was placed in the limelight by Dr Adrian Brink.
A debate between the latter two speakers and a
general Q&A added an interactive element to the
symposium.
Prof Neels Potgieter
Dr Anthony Rodrigues
Doctors were the lucky recipients of a repository of
knowledge in various therapeutic areas, including
the cardiometabolic field, at Merck Serono SA’s first
medical symposium, which took place on 7 May at
the Bytes Conference Centre in Midrand.
The objective of the symposium was not only to
present new and topical clinical information, but
also to create a discussion forum, while assisting GPs
to achieve their CPD requirements. To celebrate
this momentous occasion, the maximum number of
CPD points allowed per day (24 points) was made
available to doctors who attended the eight-hour
meeting and filled in the necessary questionnaires.
Leading experts in their respective clinical areas
were meticulously chosen to ensure the highest
quality of disseminated information.
Academic programme and speakers
Drs André
Pieterse
and Helena
Oosthuizen
The future
The fruitful day culminated in a much-needed
ethical lecture by Prof Charles Feldman.
Overall, delegates were extremely complimentary and the organisers received excellent feedback.
Doctors felt that the presentations were insightful
and definitely achieved the aims that were set.
Klaus Boehm, managing director of Merck SA,
said it perfectly in his opening address: “Merck
Serono as a company strives to become a centre of excellence for sub-Saharan Africa, through
strengthening partnerships, providing education
and by delivering new and better treatments to fulfill the needs of the communities we serve.”
The intention of Merck is that this inaugural
event will set the stage for an annual Merck Serono
medical symposium.
“We hope that everyone enjoyed this year’s meeting and took pleasure in the offering of excellent
speakers, informative presentations and interactive
exhibition stands. Thanks to everyone who sacrificed an entire Saturday to attend this event,” said
Dr Louis van der Hoven, head of medical and regulatory, Merck Serono South East Africa. “We will
take heed of your advice and ensure that our next
event will be grander and even more successful.”
Dr Adrian Brink (left) and Prof David Lewis
Klaus Boehm (left) and Dr Dominic Giampaolo
Never Neglect Ethics
Ethics is a pivotal aspect of every doctor’s life, especially with reference to the manner in which he or
she practices clinical medicine. This seminar awarded five CPD points to emphasise its importance.
Ethics: Lecture overview
Merck Serono representatives engage with delegates
Delegates socialise in the exhibition area
In his presentation, Prof Charles Feldman,
head of pulmonology at the University of the
Witwatersrand, focused on the four basic pillars
of ethics which are autonomy, beneficence, non­
maleficence and justice.
Autonomy is one of the more modern con­
siderations in ethics, and recognises the independent decision-making capacity of the autonomous
person. This primary pillar of ethics encompasses
the procedure of informed consent, which is an
essential requirement prior to many activities in
clinical practice.
The requirements for comprehensive informed
consent are well described and include threshold,
disclosure and consent elements. The recent introduction of the Children’s Act has brought with it
changes to the age at which an individual (in other
words a child) may consent to various medical interventions and procedures.
Maleficence and beneficence include the concept
of ‘do no harm’ and ‘do good’, respectively, and are
the oldest ethical principles. One should always
balance potential harm against doing good when
determining whether any intervention is ethical in
the individual patients.
Justice is also a more modern ethical pillar and
includes the consideration of distributive justice,
which gives guidance as to how to manage and
distribute medical care within the constraints of
limited resources. The rapidly emerging resistance
of micro-organisms to many anti­biotics, predominantly as a consequence of inappropriate anti­biotic
use, has substantial ethical considerations.
One of the leading recommendations to tackle
such resistance issues has been to restrict the right
of doctors to prescribe anti­biotics. Such a restriction
potentially brings ethical conflicts to the fore, firstly
since it challenges the individual doctor’s autonomy.
Additionally, the patients attending a facility
with a restricted antibiotic policy may well not be
aware of such restrictions, expecting their doctor to
act only in their best interest, and therefore they
do not have complete disclosure of their potential
medical treatment.
However, inappropriate antibiotic prescribing
itself has ethical considerations. For example, it is
well described that antibiotic use at the end of life,
often in a futile situation, is an unnecessary wasteful use of anti­biotics that itself contributes substantially to driving antibiotic resistance.
Prof Charles Feldman
medical chronicle | June 2011 | page 19
News //
To Avoid Litigation, Make Sure you Know your Patient
Medical malpractice
suits are extremely
difficult to win and
that is why the majority of cases in SA are
settled out of court,
said Ronald Bobroff,
senior director of
Ronald Bobroff and
Partners Inc, president
of the SA Association Ronald Bobroff,
of Personal Injury president of the SA
Lawyers and a 30-year Association of Personal
veteran in the field of Injury Lawyers
medical negligence and medical law.
Speaking at the Africa Health: Pan-African
Ethics, Human Rights and Medical Law
Conference, Bobroff said South African judges are
often less inclined to find doctors guilty of negligence than, for example, their US counterparts. In
addition, malpractice litigation is a relatively new
field in SA, while it has almost become standard
practise in the US and is fast gaining momentum
in the UK and Australia.
“This type of litigation is extremely important
because it holds the medical fraternity accountable
for the mistakes that they have made. It also offers
patients recourse,” he added.
Another reason why judges hesitate to find physicians guilty of negligence is because of SA’s acknow­
ledged lack of resources. As a result, judges may
adopt a less stringent test. It must also be remembered that judges want to punish callous and negligent practitioners and not caring physicians, he said.
Yet another reason why the chance of winning a
suit against a physician is difficult is because local
experts often do not want to testify against their
colleagues. As a result, international experts have
to be brought in, which increases the costs of litigation ten-fold, and can act as a deterrent to potential
plaintiffs.
In addition, judges also take into consideration
the fact that patients often do not provide all the
relevant information pertaining to their symptoms,
which makes it extremely difficult for the doctor to
prescribe an effective treatment regimen.
In essence, negligence is hard to prove. All a
practitioner has to show is that he/she has the necessary skills to perform his/her task at an appropriate level and that he/she displayed good judgement
in the choices that he/she made, explained Bobroff.
He added that, in his experience, very few doctors are negligent and that a small minority unfortunately often give the profession a bad name.
No substitution for a doctor’s hands
Having said that, he added that there are some
physicians who view their patients as objects rather
than people.
It should be remembered that there is no substitute for the ‘hands’ of a doctor and that the personal touch can go a long way to protect him/her
against litigation by facilitating a proper diagnosis.
“Personal attention is often neglected and the
majority of modern health care professionals have
become over-reliant on objective testing, which
often does not tell the full story.”
His advice to health care practitioners: Get to
know your patient!
The importance of informed consent
Bobroff had his audience in stitches when he explained that Roman Dutch law views surgery as a
form of assault because the patient is ‘poisoned by
anaesthesia, paralysed to avoid movement during
surgery, sliced open with a sharp knife, sometimes
has bones broken, sawed or drilled and after all
this is stitched close’. Fortunately, this ‘assault’ is
decriminalised because the patient volunteers to be
‘assaulted’.
The law therefore views this as a voluntary assumption of risk. However, that does not relieve
the medical professional from his/her burden of
informing the patient of the reasonable risks associated with the procedure.
He cited a recent case where a dentist removed
the wisdom teeth of a patient, but did not warn
him of the 1% chance that he might sustain nerve
NHI to Put Pharma
under Pressure
Although pharmaceutical expenditure has been observed to grow significantly with the implementation of National Health Insurance (NHI) schemes
in several countries, little has been put forward on
what the potential impact of NHI would be to the
pharmaceutical sector in SA.
“It is certain that the implementation of the proposed NHI will increase consumption of prescription medicines in SA, especially considering that the
proposed scheme is envisaged to be comprehensive
and to cover the cost of these. With the implementation of NHI, it is expected that more people will seek
medical care,” said Frost & Sullivan’s health care research analyst, Tinotenda Sachikonye.
At the heart of the proposed scheme is the focus
on primary and ambulatory care, which is cheaper
than hospital care. It has been observed in several
countries that primary and ambulatory care results
in higher prescriptions after doctors’ visits.
“With this in mind, lucrative opportunities
should be expected in the pharmaceutical space with
the implementation of NHI,” noted Sachikonye. But
is this really true?
The reality is, given SA’s current fiscal position,
the sustainability of the NHI scheme will be of key
importance. Demand for prescription medicines
will increase, but so will the stringency of cost-­
containment strategies.
Furthermore, cost containment on the demand
side, particularly in the form of flat co-payments,
would not be in the spirit of NHI in this country as
this would make medicines inaccessible to the poor. Already, some cost-containment measures, such
as price control in the form of the single-exit price
in the private sector, are in place.
“Based on experiences of other countries, we
can certainly expect more cost-containment measures; some that will benefit certain pharmaceutical ­players while threatening the survival of others,”
said Sachikonye.
For example, Frost & Sullivan anticipates a system of mandatory generic prescribing and dispensing under which only generic medicines will be
reimbursed under the NHI scheme.
In addition, limited formularies will likely be
put in place. Only drugs on the formulary will be
paid for by the NHI. It is expected that ‘drug use
reviews’, particularly in terms of prescribing habits
will be used.
Such measures may be employed to deter prescribers from over-prescribing, which would limit
the demand for pharmaceuticals, in order to contain costs.
It is believed that the dynamics in the pharmaceutical space will change under NHI, Sachikonye said.
“Branded firms should be pondering whether
it is worth their stay in SA under NHI, or at least
strategise on how to remain afloat with this change
in regulations. Is it worth staying just for the supply
of niche medicines for which there are no generics?”
Another consideration is whether local generic
firms will meet the anticipated increased demand;
or whether this will increase SA’s reliance on ­generic
medicines imports.
damage as a result of the procedure. After the surgery was done, the patient was left with a drooping
mouth.
He then proceeded to sue the dentist. The court
found in favour of the patient, because the judge
found that the dentist did not inform the patient of
the risk and therefore did not offer him the option
of a referral to a maxillofacial surgeon.
The judge did, however, acknowledge that there
was no evidence of negligence on the part of the
dentist, but that the risk to the patient would probably have been less if the procedure was done by a
surgeon.
The dentist’s insurers funded an appeal and the
appeal court subsequently reversed the decision of
the High Court and found in favour of the dentist.
In their judgement they said there was no causal
link between the lack of informed consent and the
harm which occurred.
The patient testified that even if he had been
warned of the risk of nerve damage, he would still
have consented to the treatment and therefore the
absence of informed consent would have made no
difference.
inform the patient of the reasonable risks associated
with the treatment. For example, it is a well-known
fact that all surgery is risky. The surgeon, however,
is only obliged to warn the patient of reasonable anticipated risks and alternative treatment options,”
explained Bobroff.
He added that misunderstandings will often be
avoided if the surgeon enters into a written contract
with the patient before treatment commences. The
contract should be a standard agreement that sets
out the reasonably anticipated complications and
risks associated with a procedure.
“Courts do not expect you to do the impossible,
but to do the best you can,” said Bobroff.
How to avoid becoming a defendant
• Good communication - if a patient perceives
his/her practitioner as caring, he/she will be less
inclined to sue.
• Examine your patient.
• Be a caring, competent practitioner.
Who determines quantum?
Bobroff explained that the value of a claim is
calculated objectively and is based on quotations
obtained from appropriate experts.
For example, in a recent case where a father sued
a health care facility after his son was diagnosed
with cerebral palsy as a result of negligence, reports
were obtained from paediatricians, who estimated
the medical/care costs for the rest of the victim’s
anticipated life span, the costs associated with accommodating the victim in a care facility, lifetime
loss of income and general damages in respect of
the loss of life quality.
The choice of appropriate experts is determined
by the specialist personal injury attorney. The plaintiff’s attorney is under an ethical duty to obtain
the maximum appropriate damages for the client
whereas the defendant’s attorney would contend for
the lowest possible damages.
The opposing experts will either agree on a probable lifetime scenario failing which the matter proceeds to trail with the judge making the final decisions on the damages to be awarded.
According to Bobroff, nonfinancial damages e.g.
compensation for the loss of amenities of life, pain
and suffering and other intangibles are very modest
in SA. South African law also does not make provision for punitive damages although this is the case
in most other developed countries.
What is informed consent?
Section 6 of the National Health Act stipulates
that health care practitioners must inform ‘users’ of
their health status and the various treatments options available to them.
Medical law, however, makes it clear that a
health care professional is not obliged to warn a patient of every risk, because, in many instances, the
risks associated with the treatment are too remote.
“All that a practitioner is obliged to do is to
Roman Dutch law
views surgery as a form
of assault because the
patient is ‘poisoned,
paralysed, sliced open
with a sharp knife, has
bones broken, is sawed
or drilled and stitched’
Medical Chronicle welcomes
D-Days
medical congress announcements.
Please email to [email protected].
To view a comprehensive list of congresses,
please visit www.medicalchronicle.co.za
June
International Confederation of Midwives
19-23 June, Durban ICC. Contact Nina Freysen-Pretorius, 031-303-9852, [email protected]
International Surgical Trainees Congress (SASSiT)
21-24 June, Steve Biko Pretoria Academic Hospital - Surgery Department. Contact Martie Nawn, 012-354-1721,
[email protected]
2nd Ndiyeva Audiology and Auditory-Verbal Conference
23-25 June, Protea Hotel, Stellenbosch. Contact Marieta van der Sandt, 082-725-9399, [email protected]
July
Board of Healthcare Funders (BHF) Conference
3-5 July, Sun City. Contact Zola Mtshiya, 011-537-0200, [email protected]
Child and Adolescent Psychiatry and Allied Professions - Incorporating PANDA and SAISI
17-20 July, Wits Medical School, Johannesburg. Contact Tanya Schmidt, 041-374-5654, [email protected]
World Congress of the World Federation of the Deaf
18-24 July, Durban ICC. Contact Wilma Newhoudt-Druchen, 011-482-1610, [email protected]
Pain, Interventions and Regional Anaesthesia (PIRA) Congress
23-24 July, Birchwood Hotel, East Rand. Contact Dr Lynette Bester, 083-656-3639, [email protected]
or [email protected]
SA Podiatry Association 8th Biennial Congress
29-31 July, Khaya iBhubesi, Parys. Contact Ken Richards, 083-753-2937, [email protected]
page 20 | medical chronicle | June 2011
// News
Pharmaceutical Giant Reconfirms Confidence in SA
Global pharmaceutical and chemical company
Merck recently solidified its confidence in the South
African market when it celebrated its 40th year in
the pharmaceutical sector and 100 years in the
chemical field in the country.
Merck South Africa MD, Klaus Boehm, said
the celebrations were proof of the company’s renewed commitment to grow its pharmaceutical and
chemical sectors in the
country.
According to Dr
Frank
StangenbergHaverkamp,
chairman of the company’s
Board of Partners and
vice chair of the executive board and family
board, SA is pivotal for
Merck’s growth strategy into Africa.
Dr Frank
“We don’t have imStangenbergmediate plans to open Haverkamp,
up more branches in the vice chairperson of
rest of Africa but SA’s Merck’s board of
good
infrastructure directors
enables us to use the country as a platform to expand
our business to the rest of sub-Saharan Africa,” he
stated.
Last month, the company sold its pharmaceutical
manufacturing operations, Merck Pharmaceutical
Manufacturing (MPM), to black-owned investment company Nkunzi Investment Holdings, with
the black women’s investment company, Omame,
also acquiring a significant stake. The existing
management team of MPM, who also acquired
shares, and all other employees will be transferred
to the new company, which will be called Nkunzi
Pharmaceuticals. The sale of MPM forms part of
Merck’s global efforts to optimise its manufacturing
site network, Boehm said.
A proud history
Started in 1668 in Germany, the company is still
controlled by descendants of the founding Merck
family. A trusted name in over-the-counter and innovative prescription medicine, its main focus is the
development and manufacturing of treatments for
unmet medical needs.
Apart from its diabetes and cardiovascular portfolios, Merck Serono is also a market leader in the field
of biopharmaceuticals and oncology. It is especially
active in the research and development of treatments
aimed at personalising cancer treatments such as
Cetuximab for patients with epidermal growth factor
receptor-expressing advanced or recurrent colorectal
cancer who carry the KRAS wild-type gene. Other
potential cancer treatments include a therapeutic
cancer vaccine for the treatment of a variety of indications. In addition, the company develops and
manufactures fertility treatments and drugs for neurodegenerative diseases such as multiple sclerosis.
New trends in drug development
“The global perspective on drug development is
that it is getting more complex with ethical questions
pertaining to funding for the development of new
drugs getting more topical, particularly in relation
to very expensive drugs that only prolong life for a
short time,” explained Stangenberg-Haverkamp.
“The new development that is being brought into the
market is to carefully monitor patients to determine
if an expensive drug is going to be effective or not,
such as testing patients with colorectal cancer for the
KRAS gene.
“With this type of testing, we select patients on
the basis that there is a 70%-80% chance that they
will positively respond to the treatment. This narrows the market and brings down the costs incurred
for treating patients that are not really going to benefit from the treatment in the long term.”
The drug registration challenge
One of the major challenges pharmaceutical companies such as Merck is facing globally is the delay in
the registration of new drugs.
Currently the research and development budget is
close to 1.5bn euros (R15bn) to bring a new drug to
market. If registration is delayed, it gives a company
less time to market and sell the drug in a country
before its patent protection expires, making it more
difficult to receive a return on the investment that
was put into the development of the therapy, while
it also prevents access to top, potentially life-saving
drugs, Boehm said.
“In SA, we work with the Pharmaceutical Industry
Association of SA (PIASA) to find ways of supporting the Medicines Control Council to speed up registration. Solutions such as mutual recognition where
drugs that have been available in other countries for
several years could be beneficial,” said Boehm.
Managing Cultural Differences when
Dealing with Terminal and Dying Patients
As SA continues to strive towards a fully integrated and multicultural society, more and more significant (previously poorly
managed) health issues come to the fore. This article in the series by specialist physician, Dr Huntley Mendelsohn and
clinical psychologist, Dr Melanie Krasin, aims to provide a basic framework around which these issues may be addressed.
We are all shaped to some degree by the cultural background we grow up in, and so death and
dying are both a personal as well as a cultural experience. Despite death and dying being universal
pheno­mena, human beliefs, feelings and practices
in this regard vary widely between different religions and cultures.
Culture may impact on aspects such as:
• Patients’ perception of what is suffering and
what is health.
• Patients’ perception of dying and death.
• Patients’ perception of the roles of health care
providers.
• Complying or not with treatment regimes.
• Forms of expression of pain (physical and
emotional), grief, fear and anxiety.
• Communication patterns and communication channels - who speaks to whom, how and
when.
• Involvement and role of the family and/or significant others.
• Decision making in terms of the patients’
treatment plan.
It is challenging to resist the temptation to
make generalisations and assumptions that all
individuals from the same culture, ethnic or religious group are exactly alike.
It is also natural to want to project or impose
your own cultural reality onto the patient and/or
family - a tendency health care professionals need
to be vigilant about.
In each culture, death is surrounded by rituals and customs which help people to grieve and
mourn. Rituals offer people ways to express their
grief and the opportunity for community members to offer support.
Despite the diversity of cultural approaches to
death and dying, there are two common underlying themes that extend across cultures, namely:
function and integration.
Function, in the sense that things need to get
done in a certain manner and integration in ensuring that the integrity of the cultural group remains intact and the death is integrated into the
cultural framework.
Some pointers to assist medical professionals in
managing cultural diversity are:
• Being aware of your own perceptions, assumptions and prejudices about other cultural
practices.
• Establishing rapport with the patient and/
or family and being willing to take time to
converse about their needs and concerns. It
may be necessary to use an interpreter in these
cases.
• Possessing a degree of openness toward the
patients’ and/or families’ unique needs.
• Working with a multidisciplinary team.
• Being acutely aware of what is culturally
appropriate.
Quality health care should embrace culturally
appropriate care where different cultural views are
respected and accommodated.
Some guidelines to the religious and cultural
traditions encountered in SA include:
African
• Refer to the deceased as ‘having left us’, not as
‘died’.
• Family may elect to wash the body of the patient prior to removal to the mortuary.
• Xhosa/Zulu culture refers to the ‘collection of
the soul’.
• Patients’ clothes given to the family might be
buried with the body.
Jewish
• Ask the family if they would like a visit from a
rabbi.
• Reciting of prayers.
• During the last minutes of life, no one in the
presence of the deceased may leave, excepting
those whose emotions are uncontrollable, or
the physically ill.
• Watching over a person as he/she passes is a
great respect.
• Eyes and mouth are closed by children or family members.
• The body is laid on the bed or floor with feet
towards the door.
• The deceased should not be touched or moved.
• Body must not be washed or wrapped in
plastic.
• Remove all apparatus from the body.
• Death certificate to be signed as soon as
possible.
• The deceased will be removed by a watcher.
• Eight minutes to lapse before body is removed.
• The body will not be taken to the mortuary.
• Watchers stay with the body until burial.
• To be buried within 24 hours.
• Cherva Kadisha (Jewish helping hand) arranges the funeral.
• Jewish helping hand removes the body from
the ward and arranges the autopsy if needed.
• Family do not view the body.
• Orthodox Jews do not allow autopsies.
Quality health
care should
embrace culturally
appropriate care
Hindu
• Wears a good luck ring, medal or necklace,
which shouldn’t be removed until the family
agrees.
• Body is placed on the floor while the family
prays.
• Gloves should be worn while preparing the
body.
• If the body is touched by a non-Hindu, the
family may be upset.
• The body is not washed in the hospital.
• The eyes of the diseased is closed, the limbs
straightened and the body is wrapped in a
shroud.
• Religious objects must not be removed.
The authors, Drs Melanie Krasin and
Huntley Mendelsohn
• Autopsy disliked, but permissible.
• Organ donation acceptable.
Muslim
• Recite the Quran or pray while the patient is
dying.
• Imam to visit.
• Patient laid on the right side facing the Kabah
or on the back with the feet towards the
Kabah.
• Cover the face and the body with a sheet.
• Do not strip the body naked.
• Death certificate must be produced as soon as
possible.
• Body collected soon after death, will not be
taken to the mortuary.
• Body should lie with the head pointing towards Mecca.
• Should be washed by another Muslim of the
same sex.
• The body is not to be left alone between death
and burial.
• Ideally not to be touched by non-Muslim.
• Autopsy, cremation and organ donation is
unacceptable.
Buddhist
• Considered dead when loses body temperature and consciousness.
• Considered a lack of respect if the body is disturbed during this process.
• Body should not be disturbed for eight hours.
• Remove all apparatus attached to the body.
medical chronicle | June 2011 | page 21
News //
Professional Indemnity: What Are the Options?
All health practitioners in private practice will soon be required by law to have professional indemnity cover.
In this series of articles supplied by the Medical Protection Society, the many issues around professional indemnity
are discussed to ensure that practitioners are well informed about this type of cover when it becomes mandatory.
Not all professional indemnity is the same. There
are differences between the two main types of
cover; short-term insurance and membership of
the Medical Protection Society (MPS).
Understanding the differences will help doctors
to make an informed
decision.
Insurance is a contract. If the terms are
met, the policy will
pay out. This is a familiar concept. The
contract terms will
specify what is and
is not covered. That’s
straightforward if you
are insuring a car, but
clinical negligence is Simon Kayll,
MPS Finance Director
more complex.
How do you define what clinical activity is allowed and what is not allowed? Also, who reads
the small print? Additionally, medicine is forever
changing and it’s difficult to continually update
contracts for these changes.
MPS indemnity is not subject to the terms of a
contract, as in an insurance policy. An individual
pays a subscription, not a premium, to become a
member of MPS. A member is entitled to apply
for assistance with professional matters related to
his or her work. Assistance is granted at MPS’s
discretion.
It may seem strange that an indemnity should
be discretionary and not enforceable under a contract. But there is much in favour of discretionary
indemnity and it is no coincidence that discretion
has stood the test of time for about 60 years in SA.
The majority of doctors in SA rely on discretionary indemnity, as is the case in the UK, Hong
Kong, Singapore, Canada and Ireland, among
other places.
Discretion gives flexibility to decide how best
to respond to a situation - not all requests for assistance are the same. Not having to define the
terms of indemnity in a policy means that MPS
assistance keeps pace with the changing nature of
medicine.
By contrast, insurance allows little flexibility to
respond to the requirements of a specific request.
However, discretion is not a lottery as there are
safeguards under common law determining how
discretion can be exercised.
Insurance and MPS indemnity respond in different ways to a negligence claim. Insurance contracts tend to be claims made and MPS indemnity
are claims incurred.
An insurance policy will only respond if the
insured had a valid policy at the time of the adverse incident giving rise to the claim and when
the claim is made. It can be many years between
the date of an incident and the making of a related
claim.
There is a risk that the insured fails to maintain
insurance cover over this period, so that when the
resulting claim is made, it is rejected.
A MPS member can seek an indemnity, provided they had valid membership at the time the
claim was incurred, the time of the adverse incident, irrespective of when the claims is made or
whether the doctor is still a member. Claims incurred means that there is no risk of a failure to
maintain cover.
Run-off is associated with the difference between claims made and claims incurred, and applies solely to insurance.
Insurance needs to be in force when an adverse
incident happens and when the resulting claim is
made. Thus, doctors need to keep a policy ongoing for many years. In clinical practice this is rarely a problem, however when they stop work due to
illness, retirement, sabbatical or any other reason,
they may forget or not realise they have to renew
an annual policy to maintain cover.
The solution is to buy ‘run-off cover’. This is an
agreement between the insured and the insurer
that the insured will make a single payment to effectively buy future insurance. The sum will depend on the insurer’s assessment of the risk.
Run-off cover is usually built into the pricing
for death, disability and retirement of the insured.
For all other incidents where doctors stop practice,
they may need run-off cover.
This is not applicable to MPS membership, as
an indemnity is provided for the claim no matter
when it is reported, provided the member was a
member at the time of the adverse incident.
MPS indemnity has no limit and no excess.
MPS will meet all claim-related costs. By contrast,
insurance policies tend to have indemnity limits
and excesses. It’s not only the absolute value of
the limit that is important, but whether it is index
linked, which is rarely the case.
MPS is a mutual, owned by its members and
run in their interest. It’s also not-for-profit, as surplus funds are retained for the benefit of members.
By contrast, most insurance companies are owned
by shareholders and run for profit in the interest
of the shareholders.
Most insurance companies only provide
an indemnity for clinical negligence claims.
Membership of MPS assists with matters other
than clinical negligence, resulting from the professional life of doctors, such as disciplinary matters and regulatory hearings.
This article is not anti-insurance, but points
out the pitfalls of insurance compared to MPS
indemnity.
page 22 | medical chronicle | June 2011
// News
Regulation of Medical Devices Will Benefit SA Patients
The impending regulation of medical devices in
SA and the recently implemented marketing code
for health products should be welcomed as major
steps towards ensuring that health technology and
diagnostics brought into the country meet required
safety and quality standards.
According to Waclaw Lukowicz, CEO of Siemens
Healthcare in the Middle East and Africa, the move
towards a tighter regulatory environment for medical devices in SA will not only benefit patients, but
also companies that have complied with the highest standards in their research and development of
innovative health care technologies and diagnostics.
Lukowicz was in the country for the African Health
Exhibition, the biggest exhibition of health care
products and services ever to be held in SA, of which
Siemens was one of the main sponsors.
Waclaw
Lukowicz,
CEO of
Siemens
Healthcare
in the
Middle
East and
Africa,
and Helen
Brown,
CEO of
Siemens
Healthcare
in SA, at
the African
Health
Exhibition
Commenting on the proposed registration of
devices in SA by the soon-to-be established new
regulatory body, the SA Health Products Regulatory
Authority, the CEO of Siemens Healthcare in SA,
Helen Brown said it will effectively stop companies
from using SA as a dumping ground for products that
don’t meet the required safety and quality standards.
However, she stressed that there isn’t much clarity yet on the way the registration of medical devices
will be conducted and whether it will also apply to
products that are already being used in the country.
“It is important that there should be extensive
discussions between large companies and the regulatory authority before regulations are implemented,”
Lukowicz noted.
Compliance programme
Siemens subscribes to a strict benchmark compliance programme that prevents the company from
any involvement in bribery, corruption and perverse
incentives. Before products are brought to market,
extensive research and evaluations are done and peerreviewed by leaders in the health technology field.
The company also offers extensive support and
training services with all its products to ensure that
they are correctly applied, used and maintained.
Stressing the company’s commitment to help
solve SA’s many health care problems through the
provision of integrated health care innovations, and
services and investment in education and training
programmes, Lukowicz emphasised the importance
of SA as a leader in the field of health care in Africa.
Alleviating the skills shortage
According to Brown, one of the biggest challenges
the country is facing, is the shortage of skills, particularly in health sciences and technology. To address
this, the company is proactively involved in training
and education initiatives that are aimed at marketing
these fields as career choices to students, and providing bursaries and internships to previously disadvantaged students. The largest provider of clinical diagnostics in the world following Siemens’ acquisition of
Dade Behring and Bayer Healthcare Diagnostics a
few years ago, the integration of these products and
services provides a myriad of benefits to both patients
and health care providers. Because it fully coordinates imaging technology and laboratory diagnostics,
it enables faster, accurate diagnosis, the detection of
diseases at an earlier stage and more efficient treatment and monitoring of patients, which contribute to
better management of diseases, outcomes and quality
of care, while also reducing the costs associated with
late diagnosis and treatment.
“Our main objectives in developing new diagnostics are tests that provide faster results, are more userfriendly and which can be conducted closer to patients, particularly those in rural ­areas,” said Brown.
Bringing health care to the patient
Particularly relevant to SA and the rest of Africa
was Siemens’ development of the Versant kPCR
Molecular System, which does viral load testing in a
very short time, allowing for more efficient monitoring of HIV/AIDS patients and which can be done in
a mobile laboratory.
Similar assays have been developed for the detection of other sexually transmitted diseases. Siemens’
point-of-care diagnostics produce results in minutes,
simplifying the work of health care practitioners and
allowing them to make accurate treatment decisions.
The company is also actively involved in the development of telemedicine solutions through its IT division that will enable access to specialised health care
to poorly resourced, remote areas. But, said Brown,
before it can be widely implemented in SA and the
rest of Africa, it is imperative that the infrastructure
required to support and utilise telemedicine is in place
because of the large amounts of data that need to be
transferred over networks. “We believe strongly in our
technology and have great IT solutions for the advancement of telemedicine in Africa, but to properly
implement it, we need to ensure that we have a telecommunication infrastructure in place that is able to
handle the data efficiently and reliably,” Brown said.
medical chronicle | June 2011 | page 23
Events //
Siemens Healthcare Participates
in First Africa Health Exhibition
Siemens was proud to participate in the inaugural Africa Health Exhibition as one of five founding
sponsors. The exhibition was held at Nasrec, Johannesburg from 9-11 May, and brought together
practitioners from around the African continent.
Andrew Forder, country division head, HIM
Southern Africa, was enthusiastic about the opportunities presented for the health industry by
the exhibition.
“Africa Health presented an opportunity to network with key government and other stakeholders
in the health care industry from the African continent,” he said.
Knowledge sharing
Forder added that this is important because
there is a growing need for collaboration between
specialists.
“With fewer professionals entering the industry,
we need to encourage knowledge sharing, because
we can all learn from each other. For instance, certain diseases are more prevalent in certain countries, so there are valuable lessons to be imparted
from practitioners in different countries on the
African continent.”
The exhibition further provided a showcase for
suppliers to display their offerings to the industry. Siemens, for instance, took advantage of the
platform to present the latest technologies impacting on the acquisition and distribution of digital
radiological images.
Leaders in Healthcare Conference
The company was also a platinum sponsor
of the Leaders in Healthcare Conference. Tom
Miller, CEO of Customer Solutions for Siemens
globally, was the keynote speaker. Siemens was
also a gold sponsor of the MEDLAB and Imaging
and Radiology Conferences.
Juanita Ward, marketing manager of Siemens
Southern Africa Healthcare Diagnostics, reported
that their booth garnered attention from health
care officials within the South African government
as well as delegates tasked with overseeing spend on
health care from funders operating in Africa.
“Our HIV disease management tools attracted
special interest, especially those focusing on decentralised and point-of-care testing,” said Ward.
Siemens also enjoyed a presence through
Julian Pillay, sales and marketing manager for
Automation and Healthcare Consulting Services,
who informed delegates about laboratory workflow efficiencies. His presentation was attended by
numerous laboratory managers.
Scope for growth
“This was the first event of its kind in Africa,
and it has enormous scope for growth,” Forder
commented.
“We look forward to greater attendance as the
Africa Health Exhibition becomes a recognised
scheduled meeting on the African continent.”
* Content supplied by Siemens Healthcare
Official opening ceremony at Africa Health
From left to right: Allyson Towle, managing director, IIR SA; Phila Mazamisa, hospital
support directorate, Gauteng Department of Health; Abdul Rahman, chief operations
officer, Gauteng Department of Health; Simon Page, managing director: Life Sciences
Exhibitions, IIRME; Waclaw Lukowicz, head of Siemens Healthcare, Middle East and
Africa; Tom Miller, CEO Customer Solutions, Siemens Healthcare; Helen Brown, head
of Siemens Healthcare in SA; Dr Norman Mabasa, chairman, South African Medical
Association and John Wallace, Group: Marketing, IIRME.
Left to right: Waclaw Lukowicz, head of Siemens Healthcare, Middle East and Africa;
Tom Miller, CEO, Customer Solutions, Siemens Healthcare and Helen Brown, head of
Siemens Healthcare in SA
Juanita Ward, marketing manager at Siemens Healthcare Diagnostics interacting with
Dr Norman Mabasa and the rest of the officiating team
Interested delegates at the Siemens stand
Siemens imaging, therapy and clinical products stand at Africa Health
page 24 | medical chronicle | June 2011
// Opinion
Practice
Matters
Doctor’s
Voice ...
Prof Morgan Chetty
Dr AM Levin
Issues around
Low-option
Medical Schemes
Managing the
Cost of Private
Health Care
Doctors are experiencing many problems with low-option schemes, and
patients belonging to these schemes
appear to be oblivious to the restrictions these health plans place on the spectrum and
quality of health services they can access. This, however, appears to be a worldwide phenomenon.
In recent meetings with GPs, a number of concerns
and questions around low-option schemes have repeatedly emerged. They all have the same pattern.
Several aspects of the current competitive managed care marketplace do not appear to be conducive
to achieving the goals of primary care. The restrictions
on doctors and patient choices have raised concerns
about the potential detrimental effect of managed
care on the patient-physician relationship.
Managed care is conceptualised as a set of organisational restraints and financial incentives that are
intended to focus and limit the doctor’s use of health
care resources.
Patients who purchase the lower-end options believe that the reduction in the premium will still afford
them the traditional spectrum of services. Many of us
are of the opinion that patients intentionally choose
low options; when, they in, fact are in a higher salary
bracket or have multiple comorbidities necessitating a
higher volume and intensity of care.
In fact, across the board, patients on low-option
plans believe that their entitlements are the same as
those of any traditional managed care patient. They
often abuse the system and the demand for care outweighs the need for care.
Patients believe in their entitlement of unrestricted
and demand-driven care.
However, the financial and organisational restrictions of a managed care plan does lead to huge problems for doctors. It also appears as if doctors are used
as a buffer between the scheme and the patient when
controversial issues with the plans arise.
These factors raise questions about the impact
of these plans on doctors’ time and their ability to
continue to deliver effective primary care. Physician
‘hassle’ is assessed in terms of increased administrative activities and management tasks generated by
the plan.
Grumback and colleagues found that 57% of doctors surveyed reported that they felt pressure from
the managed care organisation to limit referrals, 75%
felt pressure to see more patients per day and 17% and
24%, respectively, felt that limiting referrals and seeing
more patients per day compromised patient care.
Administrative hassles are also attributed to added
administrative burden such as the need to make
phone calls, write letters and the length and repetition
of required forms, pre-authorisations and motivation
for additional use of essential drugs and services not
covered by the plan.
There appears to be a serious need for some meaningful legislative oversight that demands minimum
quality assurance, and a reduction of risk to the doctors with low-option schemes.
There must also be a continuous monitoring of the
quality of care delivered and to evaluate the restrictive
clauses contained within a plan option. There should
also be a salary band level for entry into lower plans
and the impact of patients with multiple comorbidities buying down into low plans when the volume and
intensity of care they need will be compromised.
There is a need for us to eradicate the hassle factors
and ‘diminished’ quality as it will impair the health
outcomes of most of the vulnerable members, the elderly, the critically ill and the poor.
However, in SA, the medical forums interfacing with
medical schemes are regularly working on eradicating
the above administrative issues and providing quality
in health care delivery. Our concern is those schemes
that work independently of any formal GP input.
The South African Medical
Association (Sama) has publicly
proclaimed that the nonhealth care
services of the medical schemes are
responsible for the escalation of medical service
costs in the private health sector. Of particular
concern was the question of managed health
care.
The purpose of managed health care is to
educate both patient and medical service
provider regarding the availability of medical
scheme funding for a given consultation or
procedure.
Surgical treatment, and certain investigative
evaluations, especially x-rays such as magnetic
resonance imaging, computed tomography and
positron emission tomography scans are the
important costly events affecting the patient’s
medical scheme’s ability to contain expenditure
within the ambit of the patient’s medical scheme
financial benefits.
Managed health care administrators, especially
through personal engagement with both patient
and doctor, endeavour to provide the correct
information to establish the affordability of those
requested undertakings so as not to embarrass
the patient, and to ensure that the medical service
provider receives the designated payment for
services rendered.
In this way, all three parties, namely patient,
medical professional and medical schemes are
satisfied regarding the monetary aspects of the
services rendered, and thus savings will accrue.
Two pertinent factors result in escalating costs
of private health care.
The first has already been alluded to, and
that is the lack of knowledge pertaining to
the availability of medical scheme funds as
prescribed to by the patient.
Any misinformation will jeopardise the patient’s
treatment expectations, as well as the medical
practitioner’s fee, which does not conform to the
availability of these funds. Managed health care
avoids these monetary catastrophes.
The second factor is the almost unlimited
charges levied by medical practitioners for
consultations, investigations and procedures
for ill health, which falls under the umbrella of
Prescribed Minimum Benefits (PMBs).
The patient should be advised, hopefully
through managed health care, that the PMB
tariff should also be negotiated to fall within
the guidelines of the patient’s medical scheme
benefits.
The solution to the private medicine financing
debacle is the implementation of the free market
principles of freedom of choice and especially
freedom of negotiation for services rendered.
This applies to both doctor and hospital fees.
Though this commercial ideology has been
vehemently opposed, it is interesting to note that
the new Consumer Protection Act advocates that
there must be negotiation of prices for products
and services with clients, which would also
include private medical attention.
Likewise, Prof Morgan Chetty, in a recent issue
of the Medical Chronicle, encouraged ‘enforced
consumer-driven health care plans’, which
would restore free market forces in the health
care industry. These suggestions are free market
principles.
It is evident that private medicine can only
survive in a free market. This is evidenced by the
Competition Commission’s rejection of a fixed
tariff structure. Negotiation of fees for services
is fundamental for successful private medical
practice.
The SA Proposal for
Health Sector Reform
lll Kathy Tyacke
Principle Advisor: KPMG Health Sector
Two key characteristics of the current health sector in SA have largely driven government’s decision to introduce a National Health Insurance
(NHI) system.
Firstly, inequitable access to quality health
services between those with health insurance
and those without. This continues to pose a challenge to government. Those with private health
insurance (15%) use internationally comparable
private hospital services, while those without
(85%) use the ailing and overstretched public
health system.
Secondly, medical costs in the private sector
have escalated to levels widely considered to be
unacceptable with medical inflation becoming
increasingly higher than the Consumer Price
Index (CPIX).
Between 2000 and 2008, overall medical inflation increased 3.65% per year more than the
CPIX (Schussler, 2008) and was 8% higher than
CPIX by 2010 (Jacobs, 2010).
Experience from countries such as Canada,
which has a well-established national health insurance system in place, demonstrates that the
creation of a single payer (one national) scheme
can substantially decrease medical costs.
This is because the central body has optimal
control of prices that may be charged by health
service providers (hospital and clinics), who
need to manage costs accordingly.
The decision to introduce the NHI is, therefore, an attempt to curtail the private sector cost
escalation and at the same time improve access
for the majority of the population to quality services. How has the proposed NHI been designed
to achieve this?
The NHI proposals According to the ANC’s 2010 NHI document, the defining features of the plan include:
• Compulsory membership of all citizens universal coverage.
• Cross-subsidisation of the unemployed by
employed taxpayers.
• A publicly funded, tax-based system, administered through both public and private
health facilities.
• A single-payer system with one central
health authority administering contracts
with service providers.
• Accreditation of both private and public
health facilities to enable participation in the
NHI, using a single set of standards.
• The option to continue with private medical
scheme over and above mandatory NHI
contributions.
• Provision of free service at the point of care
to all South Africans and other legal residents who need it - from primary health care
to highly specialised services.
Response to the proposal
Criticism of the proposed system has revolved
primarily around the question of affordability.
SA has high levels of unemployment (around
24% in the last quarter of 2010) and a large informal sector.
The costs involved in upgrading the public
health system are extensive and the small pool
of taxpayers, about seven million individuals in
2010, (14% of the population), are set to carry
much of the burden.
Concern has also been expressed about governance and accountability mechanisms. The shift
in the role of the national authority from provider of services to purchaser involves a significant role and skill shift - with little information
as to how this gap may be filled. Furthermore,
centralised buying is regarded to be conducive to
corruption, given the number of large contracts
awarded from a single office.
Finally, should government apply the principle
fundamental to the functioning of the Canadian
system - that no private health provider outside
of the NHI may charge for a service that is already offered by the NHI, both private hospitals and medical schemes could face substantial
shrinkage.
Private medical schemes would be limited to
covering ‘top ups’, specialised services such as
ophthalmology and plastic surgery, not covered
by the NHI. Private hospitals would, in turn, be faced
with the decision of either contracting into the
NHI, at prices controlled by the central authority, or offering ‘top up’ services only. Either way,
the sector is likely to face significant efficiency
challenges.
Perhaps central to government’s success in
taking the plan forward will be opening up the
detailed plans and costing to public scrutiny.
There is a wide range of health sector stake­
holders whose input and buy-in could substantially bolster taxpayer confidence in the changes
to come.
The president’s recent promise of the release
of a policy on NHI early in 2011 offers a long
overdue opportunity to rally support.
The views and opinions expressed in this article
are those of the author and do not necessarily represent the views and opinions of KPMG.
cardiac
medicine
Call Lynn on
084-400-1235
or email: [email protected]
The Link Between Posttraumatic Stress
Disorder and Cardiovascular Risk
Consulting
Editor ...
Posttraumatic stress disorder shown to negatively impact on cardiovascular
health, such as coronary artery disease and diabetes.
Correlations with
Cardiovascular
Risk Factors
Since the 1960s, psychiatrists from Krakow
studied and reported on a group of former concentration camp prisoners and described a specific syndrome they called ‘postconcentration
camp’ syndrome in which this disorder persisted
for years after the stressor disappeared. This has
evolved into the posttraumatic stress disorder in
its current diagnostic criteria as defined in the
Diagnostic and Statistical Manual of Mental
Disorders, 4th Edition (DSM-IV).
Studies of the adrenergic system in patients with
posttraumatic stress disorder have shown elevated
plasma noradrenalin levels and increased 24-hour
urinary excretion of noradrenaline metabolites as
compared to people without posttraumatic stress
disorder. Some authors have previously noted
higher overall cardiovascular risk in patients with
posttraumatic stress disorder (PTSD).1
71.3%
higher prevalence of
CAD in PTSD group
deported to Siberia
Walczewska Study2
The aim of this study was to investigate the current cardiovascular health in old age of patients
who were deported to Siberia in their childhood.
Study population
A total of 195 help-seeking people left for
Siberia during their childhood. These individuals
were born between 1928 and 1941 and they were
deported to a specific region in Siberia, where they
stayed for at least five years.
They underwent medical and psychiatric
evaluations between January 2004
and December 2005. This group of
people fulfilled the criteria for the
diagnosis of posttraumatic stress
disorder.
After exclusion criteria were applied, 80 people were enrolled in
this study. There was a matched
control group without a traumatic
history and without PTSD. In this
way, 70 matched control people
were selected from the general
practice of the University Hospital
of Krakow.
Measurements
The diagnosis of PTSD was
based on DSM-IV criteria. Clinical
examination and blood tests were
performed, evaluating all cardiovascular risk factors as well as
cardiovascular diseases. Each individual had a pulse wave velocity
measurement.
Result
The group with PTSD due to
their deportation to Siberia in childhood had:
• A higher prevalence of coronary artery disease
(CAD) (71.3% vs 44.3%) p<0.001.
• Diabetes (26.3% vs 11.4%) p<0.05; hearing
impairment (23.8% vs 2.9%) p<0.001 vs the
control group.
The PTSD group also had a significantly higher
prevalence of blood pressure, fasting blood glucose, lower levels of HDL-cholesterol and higher
levels of triglycerides. These PTSD patients also
had significantly higher aortic pulse wave velocity
which increased with the severity of the PTSD.
Conclusions
1. The patients with PTSD due to childhood deportation had elevated cardiovascular risk as
compared to a group of people who did not
have PTSD.
2. Possible mechanisms explaining the higher
cardiovascular risk are neurobiological changes such as increased adrenergic activation as
confirmed by elevated plasma and urinary
noradrenergic levels in people with PTSD.
This can lead to dyslipidaemia and hyper­
glycaemia, which may explain the higher
prevalence of cardiovascular disease.
3. In this study, there is an association between
increasing pulse wave velocity (reflecting
higher arterial stiffness) and increasing severity of PTSD.
4. This study yielded similar data and results
as some previous studies which also demonstrated increased prevalence of cardiovascular
disease such as hypertension.
References
1. Kang HK, Bullamn TA, Taylor JW. Risk of selected cardiovascular diseases and post-traumatic
stress disorder among former World War II prisoners of war. Ann Epidemiol 2006;16:381-386.
2. Walczewska J, Rutkowski K, et al. Stiffness of
large arteries and cardiovascular risk in patients
with post-traumatic stress disorder. Europ Heart J
2011;32:730-736.
Prof James Ker
// Comment
Sudden cardiac death, mainly due to ‘malignant’ arrhythmias
is a reality. The diagnosis can be difficult, sometimes requiring
a specialist in the field (electrophysiologist). Some diagnostic
techniques are mentioned so that one can see how much is
available.
Some therapeutic strategies are mentioned. The standard
12-lead electrocardiogram (ECG) still remains an important
diagnostic tool. Narrow complex tachycardias are mostly
supraventricular and broad complex tachycardias (≥3 small
blocks on ECG) are mostly ventricular in origin.
Importantly, the structural or functional abnormality of
the heart needs to be diagnosed as part of the treatment of
arrhythmias. Catheter ablation has solved many arrhythmias
and implantable cardiac defibrillators have reduced mortality
significantly.
Depression and stress have been shown to be important risk
factors in the INTERHEART case-control study of myocardial
infarction. The population attributable risk of depression/stress
was considerable.
An interesting article appeared on the cardiovascular risk
associated with posttraumatic stress in a well-described group
of people deported to Siberia in their childhood. They were
evaluated for cardiovascular disease many decades later and
compared to people from the same city who were not deported.
This association could be driven by adrenergic activation
as demonstrated by elevated serum and urine noradrenaline
levels. This group of people also had abnormal increased
pulse wave velocity due to more stiff aortas. This information is
another addition to the growing evidence of the importance of
depression/stress in cardiovascular disease.
It remains an important question - when should one
discontinue aspirin use before cardiac surgery - especially
coronary artery bypass grafting. Early or late discontinuation
made no difference in outcome, but late discontinuation
of aspirin was associated with increased blood transfusion
requirements.
In the management of hypertension, we know that reducing
blood pressure is all important. The problem is adherence to
antihypertensives. As a class, adherence is worst with diuretics
and beta-blockers and best with ACE-inhibitors and ARBs.
What we still don’t know is how to improve overall adherence
to antihypertensive drug therapy.
What we now need is a clinical trial of antihypertensive
therapy to evaluate the possible effect on microvascular
damage of the brain. Can we start to add microvascular
damage to the brain as a worthwhile goal to prevent with the
treatment of hypertension?
page 26 | medical chronicle | June 2011
Cardiac
Aspirin Discontinuation before
Coronary Artery Surgery - Late or Early?
Current guidelines differ in their recommendations with
some advising to stop aspirin three to five days before
surgery and others recommending seven to 10 days.
Antiplatelet therapy, especially the inclusion of
aspirin therapy, is one of the important therapies in the primary and secondary prevention
of stable and unstable coronary artery disease. It
is important after percutaneous coronary interventions (PCI). Stent thrombosis during PCI is
associated with many risk factors but the most
important risk factor is premature cessation of
dual antiplatelet therapy, but also premature cessation of aspirin therapy.1
It has also been shown that ±5% of patients
who have a PCI will have to undergo cardiac
or non­c ardiac surgery within the first year after
stenting.2
A previous meta-analysis has shown that up to
50% of patients on low-dose aspirin who underwent surgery, will have peri-operative bleeding
complications, but it did not translate into an
increased morbidity or mortality.3
Acute withdrawal of chronic aspirin therapy results in a prothrombotic state, potentially placing the peri-operative patient at excess risk.
The clinical question
Should aspirin be stopped before coronary artery bypass grafting (CABG) and if so, when?
The clinical problem
Aspirin is associated with bleeding in both
cardiac and noncardiac surgery, although the
absolute detrimental effects seem to be modest.4
Late discontinuation
of aspirin resulted
in no difference
in postoperative
outcome
Study by Jacob et al 5
At the Cleveland Clinic over a period of six
years, 4143 patients who underwent coronary artery bypass graft surgery (CABG) were all taking
pre-operative aspirin.
Of these patients, 2298 discontinued aspirin
six or more days before surgery (early discontinuation) and 1845 patients still took aspirin within
five days of surgery (late use).
Propensity score analysis and matching, based
on 31 variables, was used to compare the outcomes between these two groups: early discontinuation vs late discontinuation.
The results showed that there were no significant differences in outcome of mortality, myocardial infarction and stroke (1.7% vs 1.8%,
p=0.80).
Late use of aspirin was associated with more
intra-operative transfusions (23%) vs early discontinuation (20%) p=0.03 and postoperative
transfusions, but a similar number of reoperations for bleeding (3.4% vs 2.4%, p = 0.10).
Conclusion
1. Among patients undergoing CABG, late
discontinuation of aspirin resulted in
no difference in postoperative outcome.
However, there were increased transfusion
requirements.
2. A bigger question remains - whether or
not aspirin should be stopped at all. This
is evaluated in the current ongoing Aspirin
and Tranexamic Acid for Coronary Artery
Surgery trial.
3. Currently, clinicians should weigh the risks
and benefits of late use of aspirin based
on the specific patient’s risk profile before
CABG.
References
1. Möllman H, Net HM, Hamm CW. Antiplatelet
therapy during surgery. Heart 2010;96:986-991.
2. Vicenzi MN, Meislitzer T, et al. Coronary artery
stenting and non-cardiac surgery - a prospective
outcome study. Br J Anaesth 2006;96:686-693.
3. Burger W, Chemnitius JM, et al. Low dose
aspirin­ for secondary cardiovascular prevention - cardiovascular risks after it’s perioperative
withdrawal versus bleeding risks with its continuation - review and meta-analysis. J Intern Med
2005;257:399-414.
4. Myles PS. Stopping aspirin before coronary artery
surgery: between the devil and the deep blue sea.
Circulation 2011;123:571-573.
5. Jacobs M, Smedira N, et al. Effect of timing of
chronic preoperative aspirin discontinuation on
morbidity and mortality in coronary artery bypass
surgery. Circulation 2011;123:577-583.
page 28 | medical chronicle | June 2011
Cardiac
Sudden Cardiac Death Due to Arrhythmias
In the previous issue of Medical Chronicle, Prof James Ker discussed specific diagnostic methods used to
investigate arrhythmias. This article explores other diagnostic methods as well as the various therapeutic modalities.
Diagnosis
lll Exercise testing
Exercise can bring out some arrhythmias:
Commonly ventricular ectopic beats may
develop during exercise, but both tachy­arrhythmias
and bradyarrhythmias can be precipitated by stress
(exercise) electrocardiogram (ECG) testing.
lll Long-term ECG recording
• Ambulatory ECG recording (Holter): Typically
this ECG tape recorder records three ECG channels for 24 hours with the patient continuing
his/her daily tasks. One of the strengths of this
technique is the ability to correlate the symptoms of the patient with the ECG abnormality
as captured on the recording. The recordings can
also be used to monitor anti-arrhythmic drug
efficacy.
• Event recorder: These devices may be kept for 30
days and are patient activated.
• Implantable loop recorder: This device is inserted
under the skin and can produce either patientactivated recordings or event-activated recordings. These recordings are used where neither the
Holter nor the event recorded were useful.
lll Heart rate variability
Heart rate variability recordings evaluate the influence of the vagal and sympathetic tone on the action of the sinus node. There are frequency domain
analyses as well as time domain analysis available.
lll Quartile coefficient of dispersion
Heterogeneity of refractoriness as well as
hetero­geneity in conduction velocity can be measured. One measure is to determine the difference
between the longest and shortest Quartile coefficient (QT) intervals on a resting ECG - the larger
the difference, the more QT dispersion that has
been correlated with risk of arrhythmic death.
lll Signal average ECG
Signal averaging can detect cardiac signals of a few
microvolts in amplitude. Mapping techniques can record myocardial activation from damaged areas that
occur after the end of the standard surface ECG QRS
complex. These delayed signals have such low amplitude that they cannot be seen on a standard ECG.
lll T-wave alternans
Beat-beat alternation in amplitude and/or the morphology of the ST-segment or (T-waves) have been
found in conditions that favour the risk of ventricular
tachyarrhythmias.
lll Tilt-table testing
This test is useful to determine if there is a vasodepressor and/or cardio inhibitory response that is causing syncope. It is thus sensitive to establish a neurally
mediated syncope.
lll Invasive electrophysiological studies
This involves introducing multiple catheter electrodes into the circulation and positioning them at
various intracardiac sites to record and/or stimulate
cardiac electrical activity. The use of this technique
for diagnosis of and therapy of various arrhythmias is
a speciality in its own right.
Pharmacological therapy
lll General principles
Most anti-arrhythmia drugs have blocking actions
on sodium, potassium or calcium channels and beta
adrenoreceptors. The actions of these drugs are very
complex and this makes their classification difficult.
However, the Vaughan Williams classification (despite limitations) is a commonly used one:
• Class IA: Prolong action potential duration quinidine, procainamide, disoprymide.
• Class IB: Shorten action potential duration mexiletine, phenytoin, lidocaine.
• Class
II:
Block
beta
adrenergic
receptors - beta-blockers.
• Class III: Block potassium channels - sotalol,
amiodarone.
• Class IV: Block slow calcium channels - e.g. verapamil, diltiazem.
lll Therapy for supraventricular tachycardias
After failure of vagal manoeuvres or intravenous
adenosine, the specific therapy depends on a lowest
diagnosis. Long-term treatment of most supraventricular arrhythmias will be a choice between catheter
ablation or permanent drug therapy.
Long-term anti-arrhythmic drug therapy is also
discouraged in patients with infrequent sympto­
matic episodes and women considering pregnancy.
Catheter ablation is recommended as the treatment
of choice for many supraventricular arrhythmias.
Flecainide and propafenone may be used for prophylaxis of some of these arrhythmias. Amidiarone is an
option where other drugs have failed, but its toxicity
remains a problem.
lll Therapy for ventricular tachycardias
Ventricular Tachycardias (VT) can be recognised
by the broad QRS-complexes (> 3 small blocks) and
can be monomorphic or polymorphic.
Emergent cardioversion is necessary for sustained
VT causing symptomatic hypotension, pulmonary
oedema and myocardial ischaemia. An important
point is that patients with ventricular ectopic beats
and nonsustained VT should not be given anti-­
arrhythmic drugs merely to suppress it, because it will
not reduce mortality. Rather find the cause and treat
that. Class I anti-arrhythmic drugs (e.g. quinidine,
flecainide, propafeone) actually increased mortality
in patients with ventricular arrhythmias and prior
myocardial infarction.
lll Implantable cardioverter defibrillators
Implantable cardioverter defibrillators (ICD) effectively terminate VT and ventricular fibrillation
and reduce mortality. Specialist opinion is mandatory on the indications for implantation.
References available on request.
medical chronicle | June 2011 | page 31
Cardiac
Better Compliance to Antihypertensive
Medication Reduces Cardiovascular Risk
Many randomised clinical trials have demonstrated reductions in the risk of fatal and nonfatal
cardiovascular events with a hypertension treatment intervention. The problem is that effective
reductions and control are rare in the hypertensive
population and there are many people with uncontrolled blood pressure.
Although there may be several factors that contribute to the poor control of blood pressure in the
management of hypertension, many people would
agree that compliance with medication is a problem - patients either take their medication irregularly or permanently discontinue their medication
after a while.1
There are some data showing that poor com­
pliance with antihypertensive therapy is related
to poor blood pressure control and not ­reaching
the goal.2 The impact of compliance with antihypertensive drugs and the effect on cardiovascular
event outcome is not well known.
A study was conducted to assess the relationship
between long-term compliance to antihypertensive drug treatment and the risk of cardiovascular
events.3
Antihypertensive
Drug Class and
Adherence
A study was conducted and the aim of this metaanalysis was to evaluate and determine the impact
of antihypertensive drug class on adherence to blood
pressure medications. Articles were sought that measured adherence using medication refill data and included data that compared adherence between two
distinct antihypertensive drug classes and had sufficient data to calculate a measure of relative risk of
adherence and its variance.
Results
Seventeen articles met the inclusion criteria of
which five were rated excellent and 12 were rated
good. The included articles in the meta-analysis assessed adherence to antihypertensive medications in
935 920 patients. The mean overall persistence with
antihypertensives ranged from 35%-84%.
The pooled mean adherence by drug class:
• 28% adherence for beta-blockers.
• 65% adherence for angiotensin receptor blockers
(ARBs).
There was lower adherence to diuretics as compared
to all other drug classes. There was better adherence
with ARBs compared to:
• Angiotensin-converting enzyme (ACE) inhibitors: Hazard Ratio 1.33 [95% CI 1.13 to 1.57].
• Calcium channel blockers: Hazard Ratio 1.57
[95% CI 1,38 to 1.79].
• Diuretics: Hazard Ratio 1.95 [95% CI 1.73 to
2.20].
• Beta-blockers: Hazard Ratio 2.09 [95% CI 1.14
to 3.85].
After the publication bias was accounted for, there were
no longer significant differences between ACE inhibitors and ARBs or between diuretics and beta-blockers.
Conclusion
In clinical settings, there are important differences
in adherence to antihypertensive classes. The lowest
adherence is to diuretics and beta-blockers. The highest adherence is to ARBs and ACE-inhibitors.
However, in all the studies, adherence was suboptimal, regardless of drug class. Poor adherence
to antihypertensives remains an important cause of
poor blood pressure control. Poor adherence has been
associated with complications, such as increased cardiovascular events and health care costs.
References available on request.
Method
Data were retrieved from the National Health
Service in a specific region in Italy (nine million
people constituting ±16% of the population). All patients who received at least one anti­hypertensive
drug at any time during 2000/2001 were followedup until June 2007 (±six years follow-up). All cardio­
vascular events were recorded.
Results
There were 242 594 patients treated for hyper­
tension in 2001/2011. Of these, 12 016 experienced
an outcome. Those who continued treatment vs those
who discontinued therapy had a 37% risk reduction of
cardiovascular outcome (95% CI: 34-40%).
Conclusion
In a real-world setting, compliance to anti­hyper­
ten­sive medications is effective in the primary prevention of cardiovascular outcome. The longer patients
adhered to their treatment regimen, the greater the
reduction in risk, both for coronary heart disease and
stroke. There is evidence that even a single episode of
drug discontinuation has a negative effect on outcome.
References
1. Bourgault C, Sénécal M, et al. Persistence and discontinuation patterns of antihypertensive ­therapy
among newly treated patients: a population-based
study. J Hum Hypertens 2005;19:607-613.
2. Krousel-Wood M, Thomas S, et al. Medication
adherence: a key factor in achieving blood pressure
control and good clinical outcomes in hypertensive
patients. Curr Opin Cardiol 2004;19:357-362.
3. Corrao G, Rarodi A, et al. Better compliance to antihypertensive medications reduces cardiovascular risk.
J Hypertens 2011;29:610-618.
page 32 | medical chronicle | June 2011
Cardiac
Ivabradine Improves Quality of Life
and Survival in Heart Failure Patients
Results of a new analysis from the largest-ever
­morbidity-mortality study of treatments for ­chronic
heart failure show that the heart rate-­lowering agent
ivabradine (Coralan®) significantly improves health
related quality of life.1 The new data from Systolic
Heart Failure Treatment with the If Inhibitor
Ivabradine Trial (SHIFT), presented for the first
time at the Heart Failure Congress 2011, are particularly important as quality of life is greatly impaired
in patients with congestive heart failure.
“Improving survival and alleviating patient
suffering are the major goals in the management
of heart failure patients,” said SHIFT co-chairman, Prof Karl Swedberg from the University of
Gothenburg.
“However, currently prescribed heart failure
treatments that prolong life such as beta-blockers
only improve quality of life for heart failure patients
modestly, if at all, while therapies such as diuretics that significantly improve quality of life have
no demonstrable effect on survival. We need new
therapies such as ivabradine that improve quality of
life and survival.”
The SHIFT quality of life study involved 1944
patients with chronic heart failure from 24 countries
who were randomised to receive either ivabradine
or placebo on top of standard heart failure therapy. Health-related quality of life was assessed for
two years using the Kansas City Cardiomyopathy
Questionnaire (KCCQ), a validated, disease-specific
measure of functional status and quality of life.2
The KCCQ is a self-administered questionnaire that quantifies various aspects of day-to-day
life such as physical limitations, symptoms, selfefficacy, social interference in chronic heart failure
patients.
Figure 1: Clinical summary score
An improvement was observed in the ivabradine
group. In a specific analysis that excluded patients
who died, the increase in clinical summary score
(CSS) reporting on clinical symptoms and overall
summary score (OSS) including clinical and social
aspects, was up to twice more in the ivabradine
group (Figures 1 and 2).
Figure 2: Overall summary score
These new results complement the main findings
of the SHIFT study, which showed that ivabradine
reduced the risk of hospitalisation due to worsening heart failure by over a quarter (26%, p<0.0001)
and the likelihood of death from heart failure by the
same amount (26%, p=0.014).
Despite the fact that patients were already well
treated, these benefits were seen in just three months
of treatment with ivabradine.
Chronic heart failure affects 15 million patients in
Europe (2% to 3% of the overall population). It impairs the heart’s ability to pump effectively and maintain sufficient circulation to meet the body’s needs.
Heart failure has an enormous impact on the prognosis and lifestyle of patients and is a major health
care and economic burden. Heart failure impacts all
aspects of patients’ daily lives, but particularly their
mobility and usual activities such as housework and
socialising. Sadly, half of all heart failure patients die
within four years.
When compared with other major chronic illnesses, patients with chronic heart failure showed
the same pattern of reduced quality of life as patients
on chronic haemodialysis, depression and hepatitis.3
Along with therapeutic advances that increase the
longevity of heart failure patients, it is essential that
these patients are able to perform routine day-to-day
activities and have a better quality of life.
“These new results on quality of life further reinforce the main SHIFT results suggesting a need to
consider heart rate-lowering with ivabradine in heart
failure patients in sinus rhythm and heart rate above
70bpm,” concluded Prof Komajda.
References
1. Ekman I. Ivabradine is associated with improved
health related quality of life. Results from SHIFT,
presented orally at a late breaking trial session of the
Heart Failure Congress 2011.
2. Green CP, Porter CB, Bresnahan DR, Spertus
JA. Development and evaluation of the Kansas City
Cardiomyopathy Questionnaire: a new health status measure for heart failure. J. Am. Coll. Cardiol.
2000;35;1245-1255.
3. Juenger J, et al. Health related quality of life in patients with congestive heart failure: comparison with
other chronic diseases and relation to functional variables. Heart. 2002;87:235-241.
medical chronicle | June 2011 | page 35
Cardiac
Vascular Risk Factors Important in the
Search for Dementia Interventions
In the search for interventions to delay or prevent
dementia, vascular risk factors may be important.
Previous studies have shown an association between
midlife hypertension, especially if left untreated, and
the likelihood of developing dementia.1 Hypertensive
individuals are at increased risk of dementia, depression, physical disability and falls.2
22%
of hypertensive individuals
will develop mobility,
cognition or mood
impairments
Previously, it was shown that impaired mobility,
impaired executive cognitive function and change
in mood, constitute a triad of impairments which
reflects microvascular damage to the frontal subcortical region of the brain.3 Hypertension, on the other
hand, is associated with cerebral microvascular disease, which manifests as white matter hyperintensities (WMH) on brain imaging.4
Hypothesis in the Hajjar et al 5 study
The authors proposed that hypertension can lead
to poor cognitive function, depression and gait disturbances (impaired mobility) by causing a specific
microvascular effect, manifesting as WMH. They
used data from the Cardiovascular Health Study, a
population-based longitudinal study of adults aged
65 years or older. The study followed 4700 participants for >10 years.
Measurements
Cardiovascular risk factors were measured and
two seated blood pressure readings were taken at each
visit. Mobility was assessed by gait speed, cognitive
function measured by Digit Symbol Substitution
Test, and mood was assessed using a depression scale.
A total of 3600 people also underwent brain magnetic resonance imaging.
Hypertensive
individuals are at
risk of dementia,
depression, physical
disability
Results
At baseline, 498 subjects (11%) had concurrent impairments and 3086 (66%) were intact on all three
measures - mobility, cognitive function and mood.
In the next seven years, 651 (21%) became impaired
in all three domains.
Hypertensive individuals were more likely to be
impaired at baseline and to become impaired during the follow-up. A greater degree of WMH was
associated with impairments in the three domains
and mediated the association with hypertension.
Impairments in the three domains also increased subsequent disability with hypertension. Hypertension
mortality was also increased in those impaired compared to unimpaired hypertensive individuals.
Conclusion
1. Hypertension increases the risk of impairments
in mobility, cognition and mood.
2. The association between hypertension and these
impairments is mediated in part by microvascular
injury as seen with white matter hyperintensities.
3. The impairments in hypertensive individuals are associated with increased disability and
mortality.
4. Close to one quarter (22%) of hypertensive
individuals will eventually develop these impairments in the three domains, which may
constitute a hypertension-specific pattern of
impairment.
5. Future clinical hypertension trials need to assess the effects of antihypertensive treatments on
these impairments.
References
1. Stewart R, Xue Q-L, et al. Change in blood pressure
and incident dementia: A 32-year prospective study.
Hypertension 2009;54:233-230.
2. Terry PD, Abramson JL, Neaton JD. Blood pressure
and risk of death from external causes among men
screened for the multiple risk factor intervention trial.
Am J Epidemiol 2007;165:294-301.
3. Pugh KG, Lipsitz LA. The micriovascular frontalsubcortical syndrome of aging. Neurobiol Aging
2002;23:421-431.
4. Dufouil C, de Kersaint-Gilly A, et al. Longitudinal
study of blood pressure and white matter hyperintensities: the EVA MRI cohort. Neurology 2001;56:921-926.
5. Hajjar I, Quach L, et al. Hypertension, white matter hyperintensities and concurrent impairments in
mobility, cognition and mood: The Cardiovascular
Health Study. Circulation 2011;123:858-865.
page 36 | medical chronicle | June 2011
BHF
CareCross Group Turns a Healthy 13
The CareCross Group has turned 13 years old this
year. It is indeed a far cry from the humble beginnings in 1998 when founder Dr Reinder Nauta
contacted the first GPs to become part of what
would turn into the largest capitated provider network in southern Africa.
With the now familiar logo on more than 1000
GP practices, CareCross has stuck to its vision
of offering ’quality health care you can afford‘.
Millions of patient visits have been made possible
through the partnership approach between participating GPs and CareCross.
The group has reinvented itself and has diversified into several health care sectors. On
the provision side, it owns Occupational Care
South Africa. It also owns the provider network
The CareCross board, From left to right Dr Nhlanhla Mabaso, Mark Mawman, Keely Stevenson, Ian Black (chair) Dr Eveline
Schurink, Yaseen Bhayat and Dr Reinder Nauta
ONECARE, focusing very successfully on designated service provider contracts. More than
1500 specialists and 3000 GPs are the core of this
network. On the pharmaceuticals side, the company has acquired Akacia Healthcare (formerly
Thebe Pharmaceutics) that is headed up by Yaseen
Bhayat. According to Bayat, the company has
brought several new products to the South African
market in recent months, including, Lozaan, the
first 100mg angiotension receptor antagonist plus
diuretic.
Group chairperson Ian Black (who teamed
up with Dr Nauta two years after he started
CareCross) said, “Affordability is a need that
stretches across all facets of health care and with
the synergies between our providers and our products, we aim to be champions of that cause.”
With the corporate head office in Newlands,
Cape Town, and the headquarters of Acacia
Healthcare in the newly-acquired Roche plant in
Isando, Johannesburg, the group has a national
presence.
With a turnover just shy of a R1bn per annum,
it can look back at a very successful period in difficult times during the last 13 years. A substantial shareholding by BEE partners UFF (funded
by Future Growth), and Soweto GP group First
Care, makes CareCross a truly South African
company that is fully committed to transformation. Approximately 8% of the company was
bought in 2010 by a Swiss investment group,
which heralds the beginning of international interest in CareCross.
With National Health Insurance (NHI)a certainty in the near future, the CareCross Group
has positioned itself to be a certain partner when
the need for provider contracting and capitation
arises. Dr Nauta, who has worked in the UK
National Health System (NHS) as well as in the
Red Cross Children’s Hospital before he started
CareCross, is cautiously optimistic about the future of health care in SA.
“What we cannot afford is to alienate our GPs,
and force them into a system that has no perceived or real value for them,” he stated. “We have
learned that only through mutual respect and a
partnership approach, will doctors come to the
table to ensure affordable health care solutions.”
Nauta and his team have spearheaded capitation in SA, and have most of the leading medical schemes as their clients today. Modern and
custom-designed IT infrastructure, dedicated
staff and the ethos of sustainability have turned
CareCross into one of SA’s biggest success stories
in managed care.
A typical CareCross practice
medical chronicle | June 2011 | page 37
Board of Healthcare Funders (BHF) Conference
Sun City, North West
3 – 5 July
BHF
The BHF Conference: The Turning Point
The Board of Healthcare Funders’ (BHF) annual South African conference will take place from 3-5 July at
Sun City. The Minister of Health, Dr Aaron Motsoaledi, has been invited to officially open the conference
with a keynote address on providing insights into the health care policy direction for SA.
The conference theme, The Turning Point reflects
the potential opportunities and threats to the private health care industry prompted by current and
future changes to the industry. The conference programme has been structured to explore those issues
which address the continued viability and sustainability of the entire health care system, its ability
to offer efficient and affordable health care to consumers, and to position the industry in such a way
as to ensure a constructive and robust relationship
between funders and providers.
Pricing negotiating forum
One of the key topics of the conference will be
the proposed pricing negotiating forum - arriving
at fair and reasonable prices for all. It is envisioned
that this forum will help to address the history of
imbalanced and problematic price determination
in the private health care sector and address the
various recent developments which have exacerbated the disarray.
Industry experts will address the many aspects
related to arriving at prices, such as: reconciling
the moral and economic goals which co-exist
within one industry and will share insights into
the pricing models in other countries.
National Health Insurance
With the National Health Insurance (NHI)
White Paper in the offing, another key focus of
the event will be a session entitled The Industry
Proposal to NHI. This session will see members of
the BHF NHI Task Team, made up of industry
experts such as actuaries and clinicians, outlining
details of the industry proposal, which addresses
many aspects relating to the implementation of
the NHI.
Among these are issues relating to the benefit
package, mergers and consolidation, reserves, administration systems, data collection and analysis
as well as fraud prevention.
BHF believes that the private health care funding sector is an extensive repository of expertise
and sophisticated infrastructure - all attributes
which will be required under the new system.
Consumer Protection Act
The introduction of the Consumer Protection
Act (CPA) has a potentially enormous impact on
the health care industry, both as consumer and
supplier. The CPA aims, among other things, to
establish a legal framework for the achievement
and maintenance of a consumer market that is
fair, accessible, efficient, sustainable and responsible for the benefit of consumers generally, to
promote fair business practices and to protect
consumers from unconscionable, unjust or unreasonable business practices.
To fully examine the impact on the health care
industry, an invitation has been extended to a consumer law expert as well as the national Consumer
Commissioner, Mamodupi Mohlala.
Oncology care
The funding of oncology care presents one of
the largest cost drivers in the private funding sector. To examine ‘where, when and how’ the ­monies
are spent, as well as the consumer angle of this
vexed issue, industry and consumer experts have
been invited to share their insights with delegates.
Other highlights
Other
programme
highlights
include:
international benchmarking and pharmaco­
economic evaluation of drugs. the role of corporate
SA in health care funding, a preventative care
package for medical scheme members, the tools
and steps required in developing a formulary,
are we in danger of creating a medical scheme
oligopoly?, ­balancing the ethics of funding or
not funding, with the financial aspect and equity
in the ­financing of health care, which will be
addressed by renowned international expert,
Dr Ramon Castano-Yepes, from Colombia.
Dr Victor Ramathesele, well known for his
charismatic facilitation style and expertise in
health care funding issues, will ensure that the
sessions are interactive and constructive.
Register for conference
The BHF conference attracts upwards of 900
delegates from the health care industry, including
local, regional and international health care executives, health care professionals, policy makers
and regulators.
Should you wish to register, please log on to the
BHF website, www.bhfglobal.com
To take advantage of having your brand associated with this prestigious event please email
[email protected]
page 38 | medical chronicle | June 2011
BHF
Dynamic Coding and Tariff Structures
Vital for Private Health Sector
The unfortunate intervention by the
Competition
Com­
mission (CC) into the
activities of the private
sector in 2004, which
resulted in the SA
Medical Association
(Sama), the Hospital
Association of SA
and the Board of Dr Chris Archer,
Healthcare
Funders SAPPF CEO
(BHF) being fined for what was deemed to be collusive activities, created an anarchic situation from
which the introduction of the then Reference Price
List (RPL) was supposed to rescue the industry.
However, the RPL never achieved what it should
have. In July last year it was declared illegal and invalid by Acting Judge Pieter Ebersohn, which has left
the industry in a state of limbo.
An unfortunate and unanticipated consequence
of the interference by the CC has been that the
maintenance of the coding structure has been dislocated, and although new codes have been introduced
by Sama and other provider organisations, there has
been no mechanism by which these code revisions,
additions and deletions, could be communicated to
and accepted by the funding industry, for inclusion
in their tariff of benefit schedules.
Suffer the poor patients
Patients have been the unwitting and unwilling
victims in this unfortunate scenario, because doctors performing one of these new procedures has not
been made aware of the fact that the procedure has
not been accepted by the funders, with the result that
patients end up paying the full cost.
The RPL process was supposed to provide a new
and transparent mechanism for the introduction of
Application Form
The SAPPF has been established in
response to the extraordinary times we are
living through and the enormous competing
challenges facing the medical profession.
Please join and assist in establishing a
better deal for specialists in the long term.
2011 Annual Subscription Fee R1500 incl vat
Name:.....................................................
ID:...........................................................
Address:.................................................
Practice No. and Discipline:....................
...............................................................
HPCSA Reg. No.:...................................
Tel:..........................................................
Fax:.........................................................
Email Address:.......................................
Please return above completed form and
a copy of your bank deposit slip by fax to:
011‑782‑0270. Bank details: South African Private
Practitioners Forum, ABSA Bank - account
number 4072908323
new codes with the value of the procedure being
based on input costs.
The RPL therefore represented a radical departure
from what had preceded it. This earlier process had
been characterised by the unilateral application by
the profession, of a relative value unit to a new code
and descriptor, following which, discussions took
place between the profession and the funding industry on the application of an acceptable annually
adjustable Rand Conversion Factor (RCF) to arrive
at a fee.
Appropriate fee disparity
Over time, what the medical profession considered an appropriate fee for its services, began to differ
markedly from what the funding industry considered appropriate as a benefit. This increasing disparity increased tension between the parties, eventually
culminating in Sama threatening to interdict BHF
for copyright infringement with respect to the Sama
Doctors’ Billing Manual.
The BHF appealed to the Department of Health
to intervene, following which, the CC fined the warring parties and the RPL was introduced, to be run
initially by the Council for Medical Schemes (CMS).
Towards the end of last year, following the demise
of the RPL, the new Director-General of Health,
Malebona Matsoso, announced that the Minister
of Health, Dr Aaron Motsoaledi, had requested that
the CMS again lead the search for a replacement for
the RPL.
Subsequently, the CMS produced a discussion
document that all parties in the private sector were
asked to comment on. This document, dated 28
October 2010, was entitled Discussion Document:
Determination of Prices in the Private Sector and
called for comment before 15 December 2010.
The discussion document indicated that it was
aimed at the determination of service provider prices
as well as levels of medical scheme reimbursement
(rather than at the development of a RPL or other
guideline). The proposal that the determination of a
fee above which a practitioner may not charge, constitutes a dramatic inroad into the rights that service
providers, medical schemes and patients currently
have to contract freely.
Furthermore, it amounted to an infringement of
the constitutional rights to property and freedom of
trade, occupation and profession.
Price regulation not the solution
The South African Private Practitioners Forum
(SAPPF), in its response, submitted that such a system of price regulation for health professionals was
also likely to discourage entry into and participation
in the health care sector which would, in turn, negatively affect the provision of private health care in SA.
Price regulation was, the SAPPF believed, unjustified, particularly given that there was no good reason for the introduction of such a dramatic regime in
respect of health professionals, for there were other
effective legal and market mechanisms (including
competition and the downward pressure exerted
by medical schemes), which regulate the manner
in which health professionals are compensated, and
there was no evidence of market failure in the market
for the provision of services by health professionals.
Despite these misgivings, the SAPPF and other
respondents agreed to participate in the attempt to
find an acceptable alternative to the RPL.
Benefits of a guideline tariff
The SAPPF, in principle, supported the determination and publication of a RPL that would serve
as a guideline to reimbursement by medical schemes,
provided that:
• Such a guideline is properly determined and
covers the cost of providing the health care service and allowed the service provider to make an
appropriate return, and;
• That the coding, which underpins the guideline,
is medically appropriate and takes into account
new technology and recent developments in
health care practice.
The SAPPF is keen to support the negotiation process to establish a new benchmark for professional
fees because there is an absolute need for the industry
to move forward to a new paradigm with respect to
the reimbursement for professional service.
The now defunct RPL process should have
achieved this with the emphasis on the reference
price reflecting the cost of providing the service rather than on the much more problematic concept of
what a medical scheme could afford.
Wherever the fee
for service system
operates, a coding
and tariff system is
employed to ensure
the orderly application
of fees and the
reimbursement of
benefits
To date, the funding industry has not been prepared to come to terms with the notion that provider
input costs are another reality that is critical to the
success of a sustainable industry capable of attracting
new professionals to it and retaining them.
An industry based on the principle that a supplier
should adjust its fee according to what a third-party
payer believed it could afford to reimburse is on
‘shaky’ foundations.
Open debate required
The SAPPF therefore would welcome a situation
in which such an open debate between all parties
could be held - not with a view to setting noncompetitive prices, but rather to create an environment in
which a more realistic pricing policy that is fair to all
parties could be established.
Such a guideline would promote certainty in relation to levels of reimbursement and would provide
an all-important coding structure to facilitate efficient medical scheme reimbursement to service providers and patients.
The SAPPF is, in principle, not opposed to the establishment of such a guideline through an independent regulatory authority or voluntary negotiations
(subject to obtaining a suitable exemption from the
CC prior to engaging in such negotiations).
However, the SAPPF cautions that this is a complex matter and that the manner in which either of
these mechanisms is structured will require careful
consideration and will, in our view, take some time.
Throughout the world, wherever the fee for service
system operates, a coding and tariff system is employed to ensure the orderly application of fees and
the reimbursement of benefits.
This process of necessity requires that there is
agreement on what investigations and procedures are
appropriate to ensure that the current best practice of
medical care is possible.
Agreements need to be reached through discussions and negotiations not only on descriptors and
codes, but also on the relative value of procedures,
without which the code is rendered useless as a regulatory tool for an industry in which there are many
thousands of different procedures.
This subtlety seems to have been missed by the
CC for in the commission’s reply to the Sama request for an advisory regarding the Doctors’ Billing
Manual, it stated that that in its view, the linking of
a relative value to a descriptor code would be tantamount to direct or indirect price fixing.
The need for code ‘values’
It is essential to understand why there is a need
for a weighting or relative value to be applied to
each code. The orderly arrangement of procedures
in terms of their increasing complexity in terms of
time taken to perform the procedure, their degree of
difficulty and their relative risk, all require a relative
value to be applied.
Comparing the ranking of medical procedures in
terms of their relative value with the motor industry
may serve to illustrate the point.
In gynaecology, there are different types of hysterectomies with differing weightings that reflect their
differing complexities; such as a total abdominal hysterectomy, a subtotal hysterectomy, a radical hysterectomy, a vaginal hysterectomy, and so on.
In the motor trade, a manufacturer produces a
range of motor vehicles in different classes, e.g. an
A-class or a B-class or a C-class, whereas another
manufacturer may produce a similar range of vehicles but these may be called a one- or a three- or
a five-series.
These categories are weightings, which enable
a comparison that is not directly price related. But
unlike medical procedures, any visit to a showroom
floor or a test drive will immediately enable one to
discern the differences between these different classes and therefore enable a price/value comparison to
be made.
Such comparisons are not possible in the health
industry, which makes a comparison that is not related to price much more difficult in the absence of
a relative value unit. As in the motor trade, where
an A class may attract a slightly different rand value
between different dealers, the price for a vaginal hysterectomy in which the relative value unit is fixed,
may nevertheless (and almost always does) attract a
different price between competing gynaecologists.
Taking the comparison one step further, the application of a relative value to a code would allow
for comparisons between different disciplines, comparing hysterectomies with prostatectomies for example, in the same way that motor vehicle customers
could compare a three-series from one manufacturer
with a C-class from another. This type of interdisciplinary comparison would not be possible without
the application of relative value units.
That said, the envisaged process requires that the
Minister of Health and the Minister of Economic
Development approach the CC with the view to the
designation of the private health industry for an exemption from competition law to enable such negotiations to begin.
However, there is, to date, no indication that such
an approach has been made by the ministers concerned and, in consequence, the industry remains
stuck in limbo.
This is an unacceptable and unconscionable state
of affairs and has placed patients in a completely unacceptable position, in which there are no guidelines
to assist them with respect to what constitutes an appropriate fee for a procedure, or an appropriate level
of reimbursement from the funding industry.
The view of the CC with reference to their understanding of the need for relative value units is clearly
also of concern. What is called for is clear vision and
understanding together with strong and decisive
leadership, to enable the establishment of the proposed independent regulatory authority. We have
waited long enough.
medical chronicle | June 2011 | page 39
BHF
Subacute Care in the Managed Care Environment
Dr Hendrik Hanekom,
CEO, Intercare Group
and
Dr Belinda Richards,
Clinical Risk Management, Discovery Health
The challenge for health care reform is not unique to
SA. All over the world, fundamental assumptions are
being reassessed in the quest for greater efficiency. To
ensure future relevance, the subacute industry must be
prepared to take quantum leaps. It must have the courage to look beyond the status quo, and not be afraid
of the unknown. Definitions of subacute care have
been prepared by several organisations. The definition
developed by the International Subacute Healthcare
Association (ISHA), appears to contain the key components reflected in most other definitions.
The ISHA defines subacute care as follows: It is
a comprehensive and cost-effective inpatient programme for patients who have had an acute event
as a result of an illness, injury, or exacerbation of a
disease process, have a determined course of treatment and do not require intensive diagnostic and/or
invasive procedures. The severity of the patient’s condition requires physician direction, intensive nursing
care and significant utilisation of ancillaries, as well
as an outcomes-focused interdisciplinary approach
utilising a professional team to deliver complex clinical interventions (medical and/or rehabilitation).
Subacute care is offered as an alternative to con­
tinued hospitalisation or acute care. However, it
encompasses a multidisciplinary service model and
should be:
• Comprehensive: Subacute care programmes
should offer the full range of necessary medical,
rehabilitation and professional services required
to provide efficient and effective multidisciplinary care for the specific medical conditions
treated within a programme.
• Cost effective: Subacute programmes should provide added value to patients and funders of health
care by rendering a service with optimal results,
using cost-effective services and programmes.
• Outcomes orientation: Subacute programmes
should be designed to ensure that the patient’s reentry into the social and working environment is
without compromise in terms of clinical treatment
and physical functionality. It should achieve quantifiable and measurable outcomes such as, but not
necessarily limited to, functional restoration, clinical stabilisation and avoidance of medical complications or exacerbation of a disease process.
• Qualified professionals: Subacute treatment,
because of its duration, complexity and intensity, must be provided under the direction of a
medical practitioner. An interdisciplinary team
providing a coordinated programme of care may
include a medical practitioner, nurses, speech
therapists, physiotherapists, occupational therapists, social workers, psychologists, pharmacists,
dietitians, case managers and other professionals.
• Programme descriptions: Programmes should
be organised around patient populations with
similar treatment or service needs. This will result
in cohesion among patients, collective achievement of goals and efficient allocation of resources. Subacute programmes may include medical
rehabilitation, respiratory, cardiac, oncology and
wound care programmes. Levels of intensity for
specific disciplines will vary from programme to
programme but will generally range from four to
eight nursing hours per patient per day.
• Continuation of care: Subacute care is essential
to the development of a complete continuum
of care in a controlled environment. Subacute
programmes are necessary components of any
health care system.
Subacute care categories
In practice, the term subacute care is often used
as an umbrella term to describe a huge variation of
clinical and care services. This may range from rehabilitation to frail care, from specialist to nursing care
and from short-term to long-term care. One subacute
facility clearly cannot provide services across the entire spectrum of subacute care. This often results in
organisations/roleplayers compiling unique definitions to describe their own services.
The responsibility of a managed care company is
to allocate appropriate funding. This responsibility
is not limited to those members requiring health
care services, but to all members who contribute towards a medical scheme. It is therefore important for
funders to categorise services in a way which clarifies
the ‘product’ for which funding is provided.
The following categorisation addresses the spectrum of subacute services according to patient’s clinical/care needs:
• Severe disability with specialised needs:
Patients with severe functional impairment require specialised multidisciplinary care. Likewise,
specialised facilities and equipment is required to
manage such patients. The conditions requiring
such care typically include spinal cord injuries and
ventilated patients. In SA, these facilities are sometimes referred to as acute rehabilitation facilities.
• Severe disability with significant reversibility
and/or with significant comorbidities: Patients
require not only rehabilitation, but also secondary
disease prevention, which includes education and
addressing an adjusted lifestyle as well as discharge
planning. For this, multidisciplinary care by gene­
ralists in a less specialised environment is needed.
In SA, these services are typically offered in facilities registered as subacute rehabilitation facilities.
• Severe disability with ‘irreversibility’: Care
that includes planning for long-term convalescent, frail or terminal care for those with profound levels of impairment that may never recover. These patients mainly need nursing care.
In SA, these services are typically offered in facilities registered as general subacute facilities.
Keys to success for subacute providers
The keys to success in a managed care environment are as follows:
• The subacute facility must reflect the characteristics that the referring specialists, patients and families seek: The quality care of the acute hospital environment, an interdisciplinary, holistic approach
to care and the warmth and comfort of a facility in
which patients may stay for long periods ranging
from two weeks to three months or longer.
• The subacute programme should have clearly
defined protocols or programme outlines for
those programmes in which the institution specialises. The admission criteria, continuing stay
criteria and discharge criteria should be clearly
outlined for each programme.
In subacute facilities registered as rehabilitation
facilities: Clinical direction should be provided by a
doctor who is qualified to do so based on training
and/or experience in the programme being offered.
Dedicated clinical teams should be developed and
nurtured. This should consist of an interdisciplinary
team comprising nursing and medical staff as well
as social services, rehabilitation therapists, dietitians
and psychologists who should provide care to patients in the subacute facility.
Patient outcomes should be measured by means of
industry-compliant record-keeping and data collection
focusing on functional status and discharge placement.
• Service delivery to referral sources should include
timely admissions and a user-friendly administrative process. Procedures may involve pre-admission assessments of hospitalised patients, which
should be performed within two hours of the
receipt of the referral by the subacute provider.
• Financial reports must be adequate to provide detailed information about the cost of care and the
operating margins by individual patient type and
funder source. The subacute provider must thoroughly understand the financial interrelationships
among costs, payment rates and methodologies.
Managed care reimbursement
mechanisms
Traditionally in SA, payment to subacute facilities
was based on the Reference Price List (RPL) for subacute facilities with a ‘49’ practice number. Although
the RPL is not valid anymore, reimbursements are
still mainly based on this guide to billing with annual tariff increases being added.
Unlike acute health care facilities, subacute facilities in SA are not organised in large network groups.
For this reason, tariff negotiations between funders
and subacute facilities are not sophisticated and
structured processes. Providers of care in subacute
facilities also typically bill for services provided in
their own professional capacity.
Internationally, many different models of funding
exist. This can range from per diem fees to global full
risk-sharing agreements, which include the professional’s services. Per diem and global fee arrangements
in SA (including professional services) exist mainly
within the specialised/acute rehabilitation environment. Some ‘per case’ negotiations sometimes happen
around discounted bed rates for individual patients.
Ideally, however, managed care organisations would
strive to differentiate payment according to patient
need and according to appropriate services provided to
such patients. Due to the lack of standardisation and
definitions of levels of care in the subacute environment, such strategies and negotiations are complex.
During the past few years, some funders have
shown some interest and attempts to create appropriate structures, based on members’ needs, whereby
differentiated payments could be negotiated.
Such interest from the managed care environment will, no doubt, stimulate the subacute industry.
However, such movement towards alternative, more
sophisticated payment arrangements will imply a
change in risks for both the provider and the funder.
Cost-effectiveness and outcomes-based patient
management will thus become increasingly important. The providers of subacute services will need to
carefully assess their business models and ensure that
managed care contracts include protective mechanisms to ensure a sustainable subacute industry.
Conclusion
The subacute industry has rapidly evolved into a
recognised niche within health care. Its continued
growth will depend on clear demonstration of the
cost-saving potential of moving patients out of highcost acute care hospitals and into lower-cost subacute
care units. Savings of ‘replacing a higher acute ward
fee with a lower, subacute ward fee’ is not the only
bene­fit required by managed care organisations. The
real bene­fit for funders lies in what is being achieved
during the subacute stay. The interventions and care
patients receive during their subacute stay should
be aimed at maximising long-term health, which in
turn reduces long-term costs to the funder.
As health care providers move from competitors
to collaborators with funders and managed care administrators, the potential of developing win-win
programmes for patients/members, providers and
funders are within reach.
Some experts predict that national integrated
health care delivery systems will control the majority
of the market in the next 20 years. It is likely that each
integrated delivery system will include a variety of
subacute providers and that the role of each provider
will depend on the types and roles of other pro­viders acute, subacute, home health, and out-patient - within the integrated health care delivery system.
Reference: Griffin KM. Handbook of sub-acute health
care. Aspen Publishers Inc, 1995.
page 40 | medical chronicle | June 2011
BHF
Managed Care: A Benefit
to Patients or Just
Another Profit Source?
Dr Andrew Good
Lifechoice MD
and
Pierre Robertson
Lifechoice Informatics Director
Our beautiful country is filled with possibilities. We have a very bright future. But we do have
challenges.
Crime is arguably our greatest challenge but
South Africans have innovated to manage their
crime risk. These innovations include high walls,
electric fences, security systems, private policing
companies and armed response.
But are these measures addressing the underlying problem? Are they contributing to a drop in
our crime rate? Will these measures solve our crime
problem?
To address this crime challenge we need continued national debate. Companies with vested
Graph 1: Key parameters per life per annum in 2008 prices
Source: Prepared by Good and Childs using Council for Medical Schemes (CMS) data.
All graphs have been corrected for inflation using Consumer Price Index
interests in building high walls, supplying electric
fences and selling private policing services cannot
be relied on to lead this debate.
International experience suggests that engaging
communities, education, improving socioeconomic
conditions and grassroot initiatives (broken window
policies) are more likely to help us deal with this
challenge than higher walls and increased policing.
In SA’s private health sector, our greatest challenge is the increasing cost that makes belonging
to a medical scheme ‘unaffordable’. In research presented by Lifechoice and Lighthouse actuarial consulting at the 2010 Board of Healthcare Funders
(BHF) conference, we showed how the cost of
belonging to a medical scheme has increased by
400% in real terms in the last 30 years. See the blue
contribution line in Graph 1.
We need to keep medical schemes affordable.
We have innovated to manage this challenge by
­developing managed care solutions. Scheme investment in managed care began in earnest in 1996
and increased dramatically in the next few years.
See the blue contribution line in Graph 2.
Are these investments paying off? Many trustees
are unconvinced. Certainly the financial performance of the industry suggests these measures are
failing. Benefit expenditure continues to outstrip
inflation despite all these managed care interventions being in place. See the red benefit line in
Graph 1.
Clinically managed care has also battled to
demonstrate improved health. Testimony to this
is that only nine schemes out of an industry of
over 100 participated in the 2009 Health Quality
Assessment clinical quality survey. There are virtually no published, peer-reviewed scientific articles
showing that this R2bn industry is improving how
diseases are being managed.
So should this lack of performance surprise us?
Using SA’s response to the high crime rate as
an analogy, our current suite of managed care interventions are effectively ‘high walls’, ‘electric
fences’ and ‘private policing’. The current hospital
risk, medicine risk and oncology risk programmes
do not address the underlying causes of increasing
costs.
We are in serious need of national debate about
how to decrease the rising cost of private health
care. However, companies with vested interests in
supplying the ‘high walls’ and ‘private policing’
cannot be relied on to lead this debate. They should
be part of the debate, their input is valuable, but we
must not forget that their vested interests do not lie
in developing a health system that functions well
and has no need for managed care.
The leading authority on health matters, the
World Health Organization (WHO), in its annual
report of 2008, entitled “Primary Health Care:
Now More Than Ever” discussed three main trends
that undermine health outcomes:
1. A disporportionate focus on specialist, tertiary
care, often referred to as ‘hospital-centrism’.
2. Fragmentation as a result of mutiplication of
programmes and direct access to specialists.
3. Pervasive commercialisation of health care in
an unregulated health system.
... to page 42
medical chronicle | June 2011 | page 41
BHF
Making the Case for Managed Care
It is 16 years since managed care was introduced locally. The trend started in the US in the 1970s in response to the uncontrolled rise in
health care costs, and by 1995 it was clear that something had to be done in SA to transform the private health care sector and contain costs.
The introduction of a managed care system in SA
was not without its problems. In fact, in the 1999
South African Health Review, managed care was described as ‘a contact sport’ and ‘not for sissies’.
SA has come a long way since then, and, with
the maturing of the industry, new solutions have
been found. However, it is not out of the woods
yet, and with the introduction of a National Health
Insurance (NHI) system, there are new challenges
to be faced.
“Trustees and other medical scheme stakeholders
see their scheme costs escalating rapidly year after
year and conclude that managed care is not working. They do not realise that there are powerful
forces underlying these cost increases, and without
managed care, the situation would be a lot worse,”
said Metropolitan Health’s senior actuary, Taurayi
Chinowona.
Dr Ngubekhaya Gobinca, managing director
of Metropolitan Health Risk Management, pre­
viously Qualsa, agrees.
“Managed care is achieving the objective of reducing costs without compromising the quality of
care,” he commented.
“But it is restrained by industry dynamics. We
operate in an environment where the benefits are
seen as a basic social need. The legislation then defines the benefit in a generous manner, while the
price for procuring it is not regulated in an industry
where demand outstrips supply.”
Measuring the benefits
One of the problems facing managed care is that
its benefits are difficult to measure and this results
in scepticism from observers and stakeholders.
There is also a lack of availability of a comprehensive set of client risk information due to fragmentation of risk initiatives and inadequate links
with providers.
“The employer groups and employees are the ultimate funder of most health care costs, including
managed care, but they have minimal influence in
the way it is run,” Dr Gobinca said.
“This allows the most vocal interest groups to
disrupt the effectiveness of the cost-reduction measures. The fragmentation of health care initiatives
means that there is bound to be duplication of
health care expenditure.” There are often unreasonable expectations by
stakeholders on what managed care should or can
do due to the complicated nature of the industry.
“It is important to remember that the benefits of
some aspects of managed care are not immediately
obvious. The benefits of disease risk management,
for example, are not immediate, but may be realisable many years in the future. That makes measurement of the effectiveness of these programmes
even harder than for something like medicine risk
management,” Chinowona said.
The wellness programme debate
The 2010 Old Mutual Actuaries and Consultants
(OMAC) health care survey delivered some scathing commentary on the effectiveness of some aspects of managed care. A key finding in the survey is the perception that disease management
and wellness programmes fail to add significant
value - in spite of a dramatic increase in uptake by
employers.
The survey found that the implementation of
disease management programmes in the workplace
increased significantly from 26% of employers surveyed in 2005 to around 90% of employers surveyed in 2010.
The use of wellness programmes increased from
12% in the employer survey in 2005 to 63% of employers using open schemes and 18% of employers
using closed schemes in 2010. In spite of this, the
medical schemes surveyed did not attribute much
value to the effectiveness of these programmes.
According to the survey’s authors, this is due to
inappropriate communication methods being used
to educate members about their disease and generate interest in using wellness programmes. They
also conclude that providers should be more involved in the process.
Chinowona takes cognisance of the OMAC survey, but points out that it is difficult to measure the
effectiveness of these programmes.
“Another benefit of wellness programmes for
open schemes that is often overlooked is that they
help them to attract and retain younger members.
Their effectiveness, in this regard, is even harder to
quantify,” he said.
Dr Gobinca said that there are multiple examples
of successful and unsuccessful implementations,
mostly due to the fact that medical schemesare
often a ‘grudge purchase’, where clients may lack
capacity to monitor and evaluate the programme’s
impact.
In addition, they tend to appoint the cheapest
provider, which could result in limited experience
and fragmented initiatives with no global view of
the overall programme and data.
Measuring the savings
Metropolitan Health’s executive manager: clinical best practice, Prof Manie de Klerk, explained
that the exact measurement of managed care
­savings is not a simple exercise, but one that hinges
around the expenditure and the impact from time
of development.
“It is difficult to ringfence savings that are solely
achieved through the application of good medicine
practice protocols,” he said.
“The only way to come to a conclusion is to use
... to page 42
page 42 | medical chronicle | June 2011
BHF
Managed Care: A Benefit
to Patients or Just
Another Profit Source?
... from page 40
The WHO recommends a primary health care
approach to ensuring financial performance of a
health system and improved outcomes.
We need to listen to what the WHO is saying
and embrace this thinking in our private health
system. This will require engaging scheme members and their doctors, member education, disease
prevention, a coordination of care model, limiting
direct access to specialists and hospitals and constructive cooperation by all the market players.
So as we head into the planning cycle for 2012,
one needs to be asking: Is the managed care strategy based on ‘high walls’ and ‘private policing’? Is
your managed care supplier trying to sell you yet
another security system or is it time to start working with the provider community to build a health
system that doesn’t rely on these outdated managed
care interventions?
We are not suggesting that you do away with
your ‘high wall’ just yet but we need to start investing in relationships and initiatives with providers
that will eliminate the need for the ‘high walls’ and
‘private policing’. This calls for ground-level interventions to ‘fix broken windows’.
With medical scheme expenditure on managed care now running at R2bn compared to the
R5.67bn schemes spend on GP reimbursement
(CMS Annual report 2009); this change in approach is arguably long overdue. It’s time to take
a serious look on the return you are getting from
your managed care and your long-term managed
care strategy.
The future of the industry lies in working with
providers to keep South Africans healthy.
Graph 2: Nonhealth care costs in rand per life per annum (plpa) in 2008 prices
Source: Prepared by Good and Childs using CMS data
There are those who will disagree that provider
engagement and involvement is the answer to addressing our health challenge. Indeed, there are
those who still believe that the solution to our crime
problem is simply sending out the Caspirs, rounding up any suspicious-looking characters and liberally using sjamboks. The approach of some managed care interventions suggests that this thinking
is alive and well.
Our beautiful country is filled with possibilities.
We have a very bright future. The bright future will
depend on people working together to realise our
dreams.
References available on request.
Making the Case for
Managed Care
... from page 41
a multidimensional approach that recognises a
number of outcomes measures, such as clinical and
access outcomes, as well as customer satisfaction.
Ultimately, the processes to ensure that we maintain and improve outcomes will work best if the
road is travelled in partnership with the scheme.”
The results of research Metropolitan Health
carried out with its clients to measure the efficacy of managed care and the results have been
encouraging.
“We know that schemes where managed care
systems failed for some time experienced very high
increases in costs, especially in hospitals and medicines,” Prof De Klerk said.
“Disease management programmes that were
structured according to internationally accepted
standards (as defined by the Disease Management
Association of America) showed returns on
investment.”
The research also showed considerable reductions in costs quite early in the disease management
cycle in chronic disease and HIV/AIDS risk management for very large schemes.
Managed care in an NHI system
With an NHI system on the cards, managed care
is becoming all the more important.
“The need for effective management of providers, especially in terms of quality of service and
pricing, will require strong managed care expertise,” Dr Gobinca said.
“The standardisation of the clinical and financial
language to be used will require managed care expertise. There will still be a need to rationalise utilisation of benefits using modified case management
techniques. The strategic analysis of the risk of the
population under management and the response
will also require top-class managed care expertise.”
It is clear that managed care in isolation will not
have an impact in controlling health care costs. For
it to be truly effective, it needs clients who coordinate their health care initiatives well and consolidate all or most related information.
The NHI system will not reinvent managed care,
but all indications are that it will use combinations
of selected existing managed care initiatives, in particular those that are in line with the fund’s strategic focus, Prof De Klerk said.
medical chronicle | June 2011 | page 43
Oncology
The Effect of Low-dose Aspirin on Risk
and Survival of Colorectal Cancer
Worldwide, colorectal cancer (CRC) is responsible
for almost half a million deaths, ranking it as the
second most common cause of cancer mortality. The
implementation of screening programmes in most
health care systems is limited by cost, so the identification of drugs that may help to prevent colorectal
cancer may be particularly useful, especially for individuals at high risk, such as those with a genetic predisposition or those who have previously had CRC.
Observational studies have indicated that aspirin and nonsteroidal anti-inflammatory drugs
(NSAIDs) may protect against CRC. Furthermore,
randomised clinical trials have also demonstrated
that low-dose aspirin (81-325mg/day) reduces the
risk of colorectal adenomas in both average and
high-risk populations.
However, the most and least effective doses of aspirin and duration of treatment required are currently unknown, as are the ideal starting age for chemoprevention and the latency of effect. Studies suggest
that it may need to be administered for at least five
years and the latency of effect may be up to 10 years.
In order to investigate these issues, Farhat Din
from the University of Edinburgh and colleagues
undertook a large population-based case-control
study, including 2254 cases and 2907 controls from
a population in Scotland matched for age, gender
and area of residence.
The subjects completed lifestyle and cancer
questionnaires reporting their status one year
prior to diagnosis (cases) or recruitment (controls),
which included information concerning duration
and amount of aspirin intake, NSAIDs and other
analgesics.
Compared to nonusers, there was an approximately 30% lower incidence of CRC in those with
any use of NSAID, which remained significant after
adjusting for confounding factors, including age,
energy, alcohol and fibre intake, physical activity,
smoking, gender, body mass index and deprivation
index.
Aspirin was protective at low doses (75mg/day;
odds ratio (OR) 0.79; 95% CI 0.66-0.95) and the
protective effect increased with dose, but not proportionately (>525mg aspirin/week; OR 0.66; 95%CI
0.41-1.05).
The risk of colorectal cancer decreased with increasing duration of use of low-dose aspirin, which
was modest after one year and becoming statistically
significant after five years of use (see Table 1).
Table 1: Adjusted risk of CRC associated
with duration of use of aspirin 75mg
Duration of
use (years)
Cases
(n)
Controls
(n)
Odds ratio
(95%CI)
>0 & ≤1
53
78
0.87
(0.59-1.28)
>1 & ≤3
72
96
0.84
(0.59-1.18)
>3 & ≤5
51
91
0.75
(0.52-1.08)
>5 & ≤10
71
125
0.63
(0.45-0.87)
>10
62
101
0.82
(0.58-1.16)
P for trend
= 0.004
The inverse relationship between CRC risk and
aspirin use (dependent on dose and duration) was
observed in both male and female subjects, but a
cumulative dose effect was statistically significant
only in men, perhaps as a reflection of more men
being on 75mg aspirin for cardiovascular protection. Interestingly, the inverse association between
nonaspirin NSAID use and CRC was statistically
significant only for females.
No association was demonstrated between allcause mortality or CRC-specific mortality and
NSAID use. There were also no differences between
cases and controls in the incidence of deaths that
may have been due to NSAID-related complications,
including bleeding and cerebrovascular accidents.
This study is the first to show that low doses
of aspirin, as used for cardiovascular protection,
(75mg daily) have a protective effect against CRC
that is evident as early as one year after use, increasing up to 10 years’ use and becoming statistically
significant after five years of use. The results are
applicable to a general population and not only to
those at high risk for CRC.
While there was a trend towards a dosedependent association, risk reduction was not
proportional to dose.
Although the study found no association between NSAID use and mortality from CRC, it
may be that the sample size was too small, or the
duration of treatment was too short to show such
an effect.
Aspirin does fulfil some specific criteria that
make it attractive for use as a chemoprotective
agent. It is effective, convenient, inexpensive and
easy to take. Furthermore, many patients are already taking daily low-dose aspirin for cardiovascular protection.
However, daily aspirin may also be associated
with an increased risk of gastrointestinal bleeds
and patients who are candidates for daily aspirin
need to be assessed for bleeding risk. It is noteworthy that this study did not detect any difference
between cases and controls in the incidence of fatal
bleeding.
Reference
Din FVN, Theodoratou E, Farrington SM, et al. Effect
of aspirin and NSAIDS on risk and survival from colorectal cancer. GUT 2010;59:1670-1679.
* Content supplied by Reckitt Benckiser
medical chronicle | June 2011 | page 45
Oncology Forum
Dr
Adam Nosworthy
Mesothelioma: Systemic Treatment for
Irresectable Disease
Mesothelioma is a rare malignancy worldwide,
but with a significant geographic distribution in
SA. It arises most commonly from the mesothelial surfaces of the pleural cavity and occasionally
from the peritoneal surface. It has an extremely
poor prognosis with the median survival being
four to 13 months for untreated patients and six
to 18 months for treated patients, regardless of
the therapeutic approach.
Pleural mesothelioma
The development of systemic treatment for
pleural mesothelioma has been difficult because
of limited numbers of patients, challenges in
deter­m ining whether an individual patient is
­benefiting from treatment, and the poor prognosis associated with advanced disease.
In all the large surgical trials done to date,
histology has a significant impact on prognosis,
with sarcomatoid and biphasic subtypes having
worse outcomes. The small number of mesothelioma patients enrolled on clinical trials and the
heterogeneity of study populations has limited
the identification of molecular biomarkers for
prognosis, but new molecular technologies, such
as gene expression profiling, may eventually classify patients into distinct prognostic subgroups.
Response assessment
There are several ways of assessing clinical
benefit­ - response rate, disease control rate, progression-free survival and overall survival. Both
of the objective response rate and progressionfree survival have been used as surrogates for efficacy in phase III mesothelioma studies due to
the poor outcomes when attempting to measure
overall survival.
In malignant pleural mesothelioma studies,
there are two radiographic measurement systems
that are employed using thoracic computed axial
tomography (CT) scans - Response Evaluation
Criteria in Solid Tumors (RECIST) and modified RECIST. Modified RECIST measures the
pleural rind or tumour thickness in a perpendicular manner to the chest wall in two positions at
three separate levels on a chest CT scan.
Other imaging modalities are under investigation for use in mesothelioma tumour measurements. Positron emission tomography combined
with CT scanning (PET/CT) can detect a decrease in metabolic activity in the tumour and
may be a better predictor of time to progression
rather than objective response as determined by
computed tomography alone. The PET/CT endpoint has, however, not been validated in phase
III trials.
Benefit of chemotherapy
Three randomised clinical trials have established that cisplatin-based doublet chemotherapy
significantly prolongs survival compared to single agent chemotherapy or best supportive care
(BSC).
The only randomised trial that directly compared chemotherapy to ASC failed to demonstrate a significant improvement in survival
with either single-agent vinorelbine or an older
regimen of mitomycin, vinblastine, and low-dose
cisplatin.
The study was terminated prematurely because of poor accrual after 409 patients were
enrolled, and the two active chemotherapy arms
were combined for a survival analysis. Survival
in those receiving chemotherapy plus BSC was
marginally prolonged, but the difference was not
statistically significant (8.5 vs 7.6 months with
BSC alone).
Two trials comparing contemporary doublets combined with an antifolate (cisplatin plus
pemetrexed and cisplatin plus raltitrexed) both
demonstrated significant increases in survival
compared to cisplatin alone. The median survival
with cis­platin alone in both of those trials was
nine months, which is very similar to that observed with BSC alone in the other randomised
trial.
Although single-agent chemotherapy has not
been shown to prolong survival in previously untreated patients, these agents may have a role as
second-line therapy in some patients.
Agents that have shown substantial activity in
phase II include the following:
• Cisplatin - In a meta-analysis of virtually
all phase II trials published until 2001, cisplatin was the most active single agent.
Carboplatin may also have activity although
the data are much less extensive.
• Pemetrexed had significant activity as a single agent in phase II studies and an expanded
access programme.
• Gemcitabine has shown activity in phase II
studies and may be particularly useful in
combination with cisplatin.
• Anthracyclines - Multiple studies have shown
significant response rates with doxorubicin.
• Vinca alkaloids - Phase II studies have shown
objective responses with the vinca alkaloids,
vinorelbine and vinflunine.
Pemetrexed and
cisplatin, with
prophylactic folic
acid and vitamin
B12, is standard
treatment
Combination chemotherapy
The superiority of chemotherapy with a
cisplatin doublet compared to single-agent
chemo­t herapy has been demonstrated for pemetrexed plus cisplatin and for raltitrexed plus cisplatin. There are no randomised trials that directly compared these two regimens.
Pemetrexed with cisplatin is an active regimen
in mesothelioma, and the combination prolongs
survival compared to cisplatin alone in patients
with advanced mesothelioma.
In the single-blinded Evaluation of
Mesothelioma in a phase III trial of Pemetrexed
with Cisplatin (EMPHACIS), 456 patients were
randomly assigned to cisplatin plus either pemetrexed or a placebo, both given once every three
weeks. The median survival was significantly
longer for the combination (12.1 vs 9.3 months),
as was the time to progression (5.7 vs 3.9 months)
and the objective response rate (41% vs 17%).
In addition to the survival benefit, combination therapy was associated with improvements
in symptoms and quality of life. All parameters
favoured the combination therapy group, including global quality of life, pain, dyspnoea, fatigue,
anorexia and cough.
Differences in survival were most striking in
patients who received supplementation with folic
acid and vitamin B12 during therapy. Treatmentrelated toxicity was significantly less, and the
mean number of administered cycles of therapy
(both single-agent cisplatin as well as the combination) was significantly greater in supplemented
compared to nonsupplemented patients.
Based on these results, the combination of
pemetrexed and cisplatin, with prophylactic folic
acid and vitamin B12, has become the standard
of care for patients with malignant pleural mesothelioma whose disease is either irresectable or
who are not otherwise candidates for potentially
curative surgery.
The role of maintenance pemetrexed after four
to six cycles of the platinum-based doublet is still
under investigation.
In an effort to decrease toxicity, carboplatin has been substituted for cisplatin in conjunction with pemetrexed. In the larger of two nonrandomised phase II studies, 102 patients were
treated every 21 days with carboplatin (AUC 5)
plus pemetrexed, folic acid and vitamin B12 supplementation. Objective responses were observed
in 19%, with a median time to progression of 6.5
months and a median survival of 12.7 months.
The addition of raltitrexed to cisplatin prolongs survival compared to cisplatin alone in patients with previously untreated advanced mesothelioma. This was illustrated in a phase III trial
in which 250 patients were randomly assigned
to raltitrexed plus cisplatin or the same dose of
cisplatin alone. Raltitrexed is not commercially
available in SA.
A number of other combinations have been
evaluated in phase II studies. Randomised trials will be required to establish the role of these
regimens:
• Gemcitabine plus a platinum - Gemcitabine
has been combined with cisplatin, carboplatin, and oxaliplatin. Response rates for
these combinations have ranged from 15% to
48%, with acceptable levels of toxicity.
• Cisplatin has also been combined with a
number of older chemotherapy agents in
phase II studies. These include anthracyclines, the combination of fluorouracil, mitomycin, plus etoposide, and the combination
of metho­t rexate plus vinblastine. The results
from these studies do not suggest any advantage compared to combinations of cisplatin
plus either pemetrexed or gemcitabine and,
in fact, may be somewhat inferior.
Although data are limited, second-line chemotherapy may be useful in patients with malignant
pleural mesothelioma. The most extensive data
in the second-line setting are for pemetrexed,
either alone or in combination with cisplatin.
Other drugs that have been used include gemcitabine, vinorelbine and anthracyclines.
Immunotherapy and gene therapy
Immunotherapy with systemically administered interleukin (IL)-2 has limited efficacy and
substantial adverse effects. In a study of 29 patients with advanced mesothelioma who received
recombinant IL-2 as a single agent, there were
only two partial responses (objective response
rate, 8%).
Nevertheless, further studies of systemic IL-2,
as well as artificial upregulation of endogenous
IL-2 by gene transfer are underway, based on
data from murine models of mesothelioma.
One of the most attractive targets for therapy is mesothelin, a tumour differentiation antigen that is overexpressed by most epithelial
mesotheliomas, but not by normal cells. Three
mesothelin-­t argeted agents are in various stages
of clinical development. These include SS1P
(antimesothelin dsFv-PE38), a recombinant immunotoxin composed of an antimesothelin Fv
fragment linked to a truncated Pseudomonas
exotoxin, MORAb-009, a chimeric antimesothelin monoclonal antibody, and CRS-207, a
live-attenuated Listeria monocytogenes vector
encoding human mesothelin.
The rationale for mesothelin as a tumour vaccine is that mesothelin elicits a strong T-cell response in patients. Phase I trials have been completed with SS1P and MORab-009, and some
evidence of minor antitumour activity has been
observed with SS1P. Preclinical models suggest
significant synergy between these agents and
systemic chemotherapy, and trials of combined
therapy are underway.
Peritoneal mesothelioma
Peritoneal and pleural mesotheliomas share
somewhat similar biologic and clinical characteristics - both are associated with a history of
asbestos exposure, and both are characterised by
extensive local growth.
Morbidity and mortality are almost entirely
due to disease progression within the peritoneal cavity. Aggressive regional therapy using a
combination of cytoreductive surgery (CRS) and
intraperitoneal chemotherapy has been increasingly applied to patients with peritoneal surface
malignancies, including malignant peritoneal
mesothelioma (MPM). Some expert centres report median survival durations that approach
five years using this approach in appropriately
selected patients.
For patients with advanced (irresectable or
recurrent) disease who are not candidates for
aggressive regional therapy, palliative systemic
chemotherapy is identical to that noted above for
pleural-based disease. First-line treatment with
pemetrexed plus cisplatin has been associated
with dramatic responses in some patients and is
generally well tolerated.
page 46 | medical chronicle | June 2011
Surgery
Optimal Medical Therapy not Administered
to Patients Before and After PCI
Data from a cardiovascular registry indicate that less
than half of patients with stable coronary heart disease undergoing percutaneous coronary intervention
(PCI), balloon angioplasty or stent placement are receiving optimal medical therapy (OMT).
According to a study in the 11 May issue of JAMA,
approximately one-third are also not receiving OMT
at discharge following PCI.
Although PCI may improve outcomes for patients with acute coronary syndrome, OMT results
in ­similar rates of cardiovascular events when compared with PCI in patients with stable coronary
artery disease (CAD).
Findings of a meta-analysis of 11 trials concluded
that there was no benefit of PCI in preventing heart
attack or death in patients with stable CAD.
In addition, the Clinical Outcomes Utilizing
Revascularization and Aggressive Drug Evaluation
(COURAGE) study, which provided OMT to all
patients, demonstrated no incremental advantage of
PCI on outcomes other than angina-related quality
of life in stable CAD, suggesting that a trial of OMT
is warranted before PCI.
“It is unknown to what degree OMT is applied
before PCI in routine practice or whether its use
increased after the COURAGE trial,” according to
background information in the article.
Dr William Borden from Cornell University in
the US and colleagues conducted a study to examine
the use of OMT before and after PCI and to evaluate
whether the use of OMT changed after the publication of the COURAGE trial (March 2007).
The study included data from the National
Cardiovascular Data Registry of patients with stable
CAD undergoing PCI between September 2005
and June 2009. Analysis compared use of OMT,
both before PCI and at the time of discharge, and
before and after the publication of the COURAGE
trial.
Optimal medical therapy was defined as either
being prescribed or having a documented contraindication to all medicines (antiplatelet agent, betablocker, and statin).
44.2%
Patients
receiving OMT
before PCI
A total of 467 211 patients receiving PCI procedures were included in the analysis, with 173
416 patients (37.1%) and 293 795 patients (62.9%)
in the before and after COURAGE periods,
respectively.
The researchers found that 206 569 patients
(44.2%) received OMT before PCI and 303
864 patients (65%) received OMT at the time of
discharge.
Before the COURAGE trial, the rate of OMT at
the time of PCI was 43.5%. Although the increase
in the proportion of patients receiving OMT before
PCI after the COURAGE trial was statistically significantly higher, it was of little clinical significance
(131 188 patients [44.7%]).
One-third of patients
are not receiving
OMT at discharge
following PCI
The rates of OMT before PCI in each study period month showed a small increase during the 46
months of observation, with an OMT rate before
PCI of 43.4% in September 2005 and an OMT rate
after PCI of 45% in June 2009, the authors wrote.
The overall rate of OMT after PCI, a time at which
the diagnosis of significant obstructive CAD had
been confirmed, was 63.5% before the COURAGE
trial and 66% after the COURAGE trial.
“Our study demonstrated that less than half of
patients undergoing PCI are taking OMT before
their procedure, despite the guideline-based re­
commendations to maximise OMT and the clinical logic of doing so before PCI so that the need for
additional symptom relief from revascularisation
can be appreciated.”
Even after publication of the COURAGE trial,
little change in this practice pattern was observed.
Although clinicians did increase the use of OMT before discharge, with antiplatelet agents being almost
universally applied, almost a third of patients were
not treated with OMT, a pattern that also did not
change after the COURAGE trial was published.
Collectively, these findings suggest a significant
opportunity for improvement and a limited effect
of an expensive, highly publicised clinical trial on
routine clinical practice, the authors concluded.
Source
JAMA. 2011;305(18)1882-1889.
medical chronicle | June 2011 | page 47
Winter Ailments
Symptomatic Treatment of Colds and Flu
Should be Considered First-line Therapy
With the increasing concern about the emerging
antibiotic resistance, involving all classes of antibiotic drugs, it is clear that symptomatic treatment
should be considered as standard therapy when
dealing with colds and flu-like illnesses of an uncomplicated nature. The primary problems facing
doctors are the ability to distinguish between a bacterial and a viral infection, as well as ascertaining
when the illness is serious and complicated enough
to warrant an antibiotic.
“One of the main factors that drives anti­biotic
resistance is that anti­biotics are prescribed when
they are not indicated,” said Prof Charles Feldman,
professor of pulmonology and chief physi­cian,
Charlotte Maxeke Johannesburg Academic
Hospital. “Other issues exacerbating the situation
are problematic antibiotic prescriptions, i.e. the
way anti­biotics are prescribed, the incorrect anti­
biotics are prescribed for the wrong indications, incorrect doses are prescribed, such as too low doses
over prolonged periods of time, etc. And of course,
­patients don’t always comply with antibiotic use,”
he continued.
The common
cold has local
involvement,
while the flu has a
systemic effect
Colds and flu are completely different
Laypeople and patients erroneously refer to both
colds and influenza as the flu, when, in fact, they
are completely different entities. It is therefore important for the doctor to explain the difference to
the patient as this impacts on the management of
the illness.
In general, the common cold is caused primarily
by viruses such as the rhinovirus and it is characterised by symptoms that slowly creep up on the
patient causing some irritation, without being debilitating. These include a runny nose, sneezing,
watery eyes, nasal congestion, nasal itching, slight
cough, seldom a fever, no body aches. Viruses do
not respond to anti­biotics, therefore the cold almost
never requires this therapeutic option. Agents targeting symptoms will be useful in this situation.
There are a few instances where the cold does complicate, leading to a more serious secondary infection with a bacterial aetiology. One such complication of a cold is pneumonia, which necessitates
the use of an antibiotic but this is an uncommon
occurrence.
Influenza, on the other hand, is a much more serious and severe illness caused by influenza viruses.
Whereas the common cold has local involvement,
the flu has a systemic effect, involving the entire
body. “If you’ve ever had it, you will definitely
know, as you literally cannot get out of bed due to
the severity of the condition,” stated Prof Feldman.
It may consist of similar symptoms to the common
cold, in addition to having a sudden onset, high
fever, which is not a significant feature of the common cold; muscular aches, sore joints, asthenia, fatigue and malaise, a terrible sore throat, headache
and an inability to function normally. “The cluster
of symptoms primarily characterising flu is known
as the flu FACTS: fever, aches and pains, coughs,
sore throat and sudden onset. So, you may wake
up feeling fine but by lunch time you can have
what appears to be the flu,” said Prof Feldman.
“Symptomatic treatment is again useful in making
the patient more comfortable.” A potential consequence of influenza is that it often complicates into
pneumonia. Anti­biotics are not generally indicated
for influenza, unless the secondary complication
has a bacterial origin, the patient is in a high-risk
group susceptible to complications or the patient
is sick enough to be hospitalised, as he/she may be
prone to pneumonia.
“I always ask GPs to interrogate their decision
to prescribe anti­biotics when faced with a patient
exhibiting flu-like symptoms. Doctors need to stop
for a second and ask themselves whether they really
believe the patient needs an antibiotic. If there is
uncertainty but they would prefer to prescribe an
antibiotic or if the patient really needs one, then go
for it. But if the doctor is unsure that the patient
needs one, then discuss the reasons with the patient
and do not prescribe initially. The decision can be
re-evaluated if the patient deteriorates,” confirmed
Prof Feldman.
About complications
The first sign that a cold is becoming complicated is that it does not seem to settle. The patient
may begin to experience a fever and the secretions transition from being clear and watery to
thick and purulent. The patient feels more unwell.
Common causes of complications and secondary
infections include allergies, sinusitis, middle ear
infections, etc.
With regard to flu, serious complications such
as pneumonia, meningo-encephalitis, meningitis
or serious cardiac involvement may ensue. “The
latter complication is the primary reason we advise patients not to exercise or exert themselves
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page 48 | medical chronicle | June 2011
Winter Ailments
Symptomatic Treatment of
Colds and Flu Should be
Considered First-line Therapy
... from page 47
when they have colds and flu, as this may induce a
heart attack,” stated Prof Feldman.
Which symptoms indicate the presence of
complications?
This is seldom a straight-forward, clear-cut observation. With regard to pneumonia, which is
one of the more common complications, the patient generally has a fever and coughs up secretions, which appear to be infected. The secretions
are no longer clear and watery, but may consist of
purulent yellow to greenish sputum, which would
appear more viscous and opaque. The patient will
warrant hospitalisation. The more purulent the
sputum, the darker and greener it becomes - particularly in the presence of other associated features indicating a bacterial infection. Secondary
bacterial infections do not have clear mucus and
sputum.
The influenza virus may cause pneumonia on its
own; however, influenza may also be complicated
by pneumococcal pneumonia and in that situation the viral infection is complicated by a bacterial infection. GPs may confirm the presence of
pneumonia by taking a good clinical history and
referring to a chest x-ray. Sputum samples can also
confirm the presence of pneumonia.
Many GPs belong to the national surveillance
network - Viral Watch at the National Institute
of Communicable Diseases - and they often take
swabs to inform about the types of organisms circulating throughout the year, which can impact
on communities.
“However, nasal swabs are not routine practice
and the diagnosis is primarily a clinical diagnosis,” stated Prof Feldman. With bacterial infections, sputum sampling may be useful and more
extensive specialised testing can be performed,
e.g. blood cultures.
Who is at high risk of complications and
secondary infection?
This group includes children, the elderly, pregnant women, immunocompromised patients and
those with underlying conditions such as cardiorespiratory diseases. In the latter instance, anti­
biotics are administered earlier in combination
with the antiviral medication. “A group that is
often not thought of is the HIV-positive population. We know that these patients can acquire a
terrible flu and are at greater risk of getting complicated flu,” said Prof Feldman.
Treatment
With the common cold and uncomplicated flu,
symptomatic treatment is first-line treatment. This
includes agents such as cough mixtures, lozenges,
throat sprays, gargles and general cold and flu medications that have antipyretic and analgesic properties. Caution should be heeded when treating
children with certain agents. “It must be reiterated
that anti­biotics do not work in these uncomplicated
cases of viral origin,” said Prof Feldman. For pneumonia, however, a patient will receive an antibiotic
which covers the most likely causative organisms.
lll Guidelines
“There are no guidelines on how to treat the
common cold, but solid SA guidelines are in place
for managing influenza,” said Prof Feldman.
High-risk cases should receive special care and
anti­virals should be considered in these instances.
If the condition deteriorates and becomes more
serious, leading toward underlying complications,
an antibiotic may be indicated with or without
an antiviral. The two classes of antivirals available consist of neuraminidase inhibitors, such as
oseltamivir or zanamivir, and the adamantines, of
which only amantadine is available in SA.
25%
of patients
receive anti­biotics
unnecessarily
The guidelines cover all aspects in the overall
management of influenza, including the high-risk
groups, various strains such as H1N1, and different
complications such as the upper respiratory tract
infections (URTIs), middle ear, sinuses, pneumonias, etc. The guidelines and recommendations are
based on what is occurring in the country, resistance patterns and the international guidelines.
“Doctors are urged to access this information from
the Federation of Infectious Diseases Societies of
Southern Africa and Thoracic Society’s websites
(www.fidssa.co.za; www.pulmonology.co.za), which
elaborate on the guidelines for upper and lower
respiratory tract infections, paediatric and adult
pneumonias and antibiotic re­commendations for
acute exacerbations of chronic obstructive pulmonary disease (COPD), which include bronchitis,”
said Prof Feldman.
Nonpharmacological elements such as bed
rest, adequate fluid intake and traditional home
­remedies also have an important role, according to
Prof Feldman.
Focus on education
Education is vital in clarifying the distinction
between viral and bacterial infections. Doctors
need to be enlightened in this area. One suggestion is to raise the bar on antibiotic prescription.
“A survey was conducted in the UK to ascertain
GPs’ antibiotic prescribing habits. GPs were asked
to review the last 100 patients they prescribed anti­
biotics to for URTIs, and to establish whether the
patient definitely needed one, probably needed one,
definitely did not need or probably did not need an
antibiotic. In a quarter of the cases, the GP admitted that the patients definitely did not or probably
did not need an antibiotic,” noted Prof Feldman. It
is therefore imperative for doctors to ask themselves
whether an antibiotic is really needed in a particular situation.
Patient education is also important, as they
are often demanding. Many countries in the UK
and northern Europe have implemented awareness campaigns around antibiotic use, and this has
... to page 49
medical chronicle | June 2011 | page 49
Winter Ailments
Symptomatic Treatment of
Colds and Flu Should be
Considered First-line Therapy
... from page 48
made a marked difference to the GPs. It is definitely
a two-way discussion between the patient and doctor. The doctor can also revise the decision after
a few days if circumstances change, according to
Prof Feldman.
Patient education should include advice on maintaining a healthy lifestyle to boost immunity. People
should avoid people who are ill as a primary measure
in staying well. Therefore, it is important for people
to get vaccinated or stay at home when ill to prevent
people from infecting their colleagues. People should
be taught proper hygiene - wear masks, frequent
hand washing, sneezing into tissues, disposing of tissues after blowing one’s nose, etc.
Final message to doctors
• Not all respiratory tract infections need anti­
biotics, as many have a viral aetiology.
• Education and increased awareness is imperative in identifying the signs that suggest viral
or bacterial infection.
• Rather than automatically prescribing an antibiotic, consider whether it is really necessary in
this instance and individualise every case.
• Make a proper diagnosis.
• Ascertain if the complication is pneumonia, an
acute exacerbation or COPD, sinusitis, etc.
• Follow the guidelines for optimum
management.
Symptomatic
treatment is firstline therapy in
uncomplicated
cases
Why Colds and Flu are More Common
in Winter?
Many patients are fascinated by the fact that
colds and flu appear more prevalent in winter. The
question is why? The common cold viruses circulates throughout the year, however, people become
infected to a greater extent in winter. Influenza is
primarily a winter disease and the associated ­viruses
differ from those related to colds. Pneumococcal
infection commonly follows a viral infection that
may be initiated by influenza or a common cold, as
the latter two conditions are risk factors that predispose individuals to pneumococcal pneumonia,
therefore this ailment also increases in winter.
The influenza virus is much more active during
the winter season, as it thrives in colder temperatures, therefore the amount of circulating virus is
far higher in winter as opposed to summer. This
does not mean that the virus is not present the rest
of the year.
More interesting questions
What happens to the virus? Where does it go?
Research now indicates that South America is the
destination where all the viruses travel to and subsequently mix. This is a far cry from what was commonly believed previously. The virus is extremely
active in the winter months in the northern hemisphere, becoming active in the southern hemisphere
six months later. The word ‘active’ implies that the
virus itself becomes much more vigorous and more
likely to infect, with a much higher circulation in
terms of number of organisms.
Another reason is that people spend a longer
period of time indoors around a heater or television, in closer contact to each other. All it takes is
one individual with the sniffles to pass the viruses
onto the next person. This may culminate as a viral
infection which may complicate with pneumococcal infection or it may colonise in the individual
without being majorly symptomatic, waiting to be
passed onto the next individual.
All people are colonised with pneumococcus at
some stage in their lives, although it is more common in childhood. Additional risk factors, such as
the common cold, make a person more susceptible
to pneumonia. Influenza, however, can be contracted from others who are infected via aerosol
transmission.
Should Health Professionals be
Obliged to Have their Flu Shots?
The trend in influenza vaccination is that the
rationale and campaigns were always focused on
the public domain, especially high-risk population
groups. With dangerous strains circulating such
as the H1N1, as well as a large number of patients
at high risk of contracting influenza at hospitals,
should health professionals be vaccinated as a mandatory proceeding?
This issue as is a very controversial subject. From
the point of view of infectious diseases (of which,
influenza is one), vaccination is clearly an ethical
consideration.
The first fundamental principles of ethics, above
all, is to do no harm. This implies that doctors
should first protect themselves from contracting
influenza because they run the risk of passing it on
to their patients while working. This is especially
a sensitive issue when working with high-risk patients such as paediatrics, the elderly and immuno­
compromised patients.
In some US states, there has been an attempt
to legislate compulsory vaccination for health
care workers, which has been challenged in court.
Concern has been that compulsory vaccination
goes against an individual’s autonomy and therefore has been difficult to enforce.
The solution
Because of the incredible controversy fuelled by
those who are against vaccination, it is more advantageous to better educate, add encouragement and
make vaccination easier to implement rather than
legislating the concept and forcing health professionals to abide by it.
There are circumstances where one’s autonomy
may be overturned, e.g. small pox was eradicated
because it was compulsory for people to have the
vaccine, due to the immense overall societal bene­
fit. Small pox was a highly infectious, serious illness
with a high mortality. In this instance, the greater
societal benefit potentially outweighed individual
autonomy.
medical chronicle | June 2011 | page 51
Winter Ailments
Cell Culture-derived Flu Vaccine is as
Effective as Current Flu Vaccines
A flu vaccine derived from cell culture is as effective
as currently available flu vaccines, but would be less
susceptible to manufacturing problems. It would
also be possible to incorporate that year’s predicted
seasonal strains into the vaccine much later than
is currently possible, reducing the chances of error.
These findings appeared in an article published
online in February 2011 by The Lancet written by
Dr P Noel Barrett from Baxter BioScience based
in Austria and colleagues.
Vaccines derived from cell culture are produced
in state-of-the-art manufacturing facilities using
well-characterised cell lines, which are available in
unlimited amounts and allow reliable and flexible
vaccine supply.
Currently, most influenza vaccines are produced using embryonated hens’ eggs. This is a
cumbersome process and manufacturing difficulties have led to vaccine shortages in the past.
The use of cell culture overcomes these problems by utilising standardised, closed manufacturing systems, which allow for more reliable production and supply of influenza vaccines.
In this study, the authors analysed a vaccine derived from Vero cell culture. Vero cells are well
characterised and have been used for over 25 years
for the production of human vaccines such as
polio and rabies and more recently, also the rotavirus vaccine, of which hundreds of millions of
doses have been safely used.
A randomised controlled phase three trial was
carried out in 36 centres in the US, in which
healthy adults (aged 18-49 years) were assigned
in a 1:1 ratio to one injection of either placebo or
Vero cell culture-derived influenza vaccine during
the 2008/09 season.
A flu vaccine derived
from cell culture
is as effective as
currently available
flu vaccines
A total of 7250 participants were randomly assigned to vaccine (n=3626) and placebo (n=3624).
Overall protective efficacy for antigenically
matched influenza infection was 78.5%.
The authors claim that this compared well with
current egg-derived vaccines, with one recent review reporting average protective efficacy of 73%
when the vaccine strains matched circulating
strains.
The new vaccine was well tolerated with no
treatment-related serious adverse events. Adverse
events were mainly mild and transient. The anti­
body response (level of antibodies required for
protection) produced by the new vaccine was
similar to existing vaccines.
The authors said: “This study is the first published report of the clinical efficacy of a Vero cell
culture-derived influenza vaccine. Comparison
with previously published meta-analyses shows
that the Vero cell-derived seasonal influenza vaccine is at least as immunogenic and efficacious as
traditional egg-derived vaccines. Our data also
provide the first evidence that prove that the protection established for egg-derived influenza vaccines are also appropriate for cell culture-derived
vaccines.
“The data presented here show that a novel,
inactivated Vero cell-derived influenza vaccine,
which is safe, immunogenic, and efficacious, will
be a valuable addition to the currently licensed
vaccines for the prevention of seasonal influenza,”
they added.
In a linked comment, Dr Paul Glezen from
the Department of Molecular Virology and
Microbiology, Baylor College of Medicine,
Houston, Texas, US, said: “The key to influenza
control is the dependable availability of sufficient
quantities of vaccine early in the season, preferably in August in the northern hemisphere. This
schedule will allow more time for vaccine delivery.
Safe vaccines which contain antigens that closely
resemble the epidemic viruses will assure the likelihood of protection and increase the demand for
vaccine.”
The abstract may be accessed on
www.thelancet.com/journals/lancet/article/
PIIS0140-6736(10)62228-3/abstract
Source
www.eurekalert.org
page 52 | medical chronicle | June 2011
Winter Ailments
Influenza Immunisations are Invaluable
- SA Needs to Increase the Uptake
Prof Barry Schoub,
NICD
To put it rather bluntly, SA has a rather dismal
record when it comes to influenza immunisation.
Although SA is classified as an upper middle income country by the World Bank, immunisation
coverage falls quite well below many countries in
the world with lower per capita gross national income (GNI).
In 2000, SA peaked its vaccine usage at 2.3
million doses shortly after the aftermath of the severe A/Sydney influenza outbreak in the northern
hemisphere at the turn of the millennium. Since
then, usage has steadily declined with less than one
million doses used in 2009. This translates to 19
doses per thousand population compared to over
350 per thousand population in Korea.
Several studies have been carried out to investigate reasons for this poor uptake, abroad and in SA,
and also in both private and public sectors. Among
the most common reasons given is that the vaccine
doesn’t work (‘last year I got the shot, but still got
flu’), or because of the side effects of the vaccine
(‘last year the vaccine made me ill’, or even ‘last
year the vaccine gave me the flu’), or, simply, that
flu is a trivial disease and not worth the trouble of
going to get immunised.
To answer all of these immunisation barriers
would require a detailed, lengthy review article
with many supporting literature references. Suffice
to say that the efficacy of the vaccine has been established in a large number of studies in many parts
of the world, among children and the elderly, and
among both healthy and ill subjects.
A recent publication from the Centers for
Disease Control (CDC) in the US (Morbidity
and Mortality Weekly Report (MMWR), 6 August
2010; Vol 59/No RR-8) stated that the ‘effectiveness of influenza vaccine among healthy adults
against influenza-related hospitalisation measured
in the most recent studies was 90%’. However, the
effectiveness will vary according to a number of
factors.
Firstly, age is an important modifier of effectiveness. The vaccine is less effective in young children
and this is why children under nine years old who
have never been immunised require two doses, as
they are unlikely to have been primed by previous
infection.
Also, at the other extreme of age, in the elderly, the efficacy is also reduced because of
immunosenescence.
Secondly, immunocompetence is important clearly, patients whose immune system is depressed
by infections such as HIV or medications such as
for cancer or posttransplant patients will also respond less effectively.
Thirdly, strain similarity plays a role - it is important to match the strains incorporated into the
vaccine with those circulating in the community.
Children under
nine years old who
have never been
immunised require
two doses
For this reason, a surveillance network under the
World Health Organization of some 125 sentinel
laboratories throughout the world, including SA,
regularly characterise influenza virus isolates to
detect any antigenic changes and, if necessary, to
submit these for further characterisation and possible incorporation into the forthcoming vaccine.
Influenza vaccine is administered every year because strains keep evolving and also because the
duration of immunity is less than a year. We tend
to use the terms ‘efficacy’ and ‘effectiveness’ rather
loosely.
Efficacy refers to the serological response; e.g.
specific antibody production, whereas effectiveness means the protection against a predetermined
clinical outcome, be it a case definition of influenza
or outpatient visits, hospitalisations, etc.
How well the vaccine performs will therefore also
depend on what is being measured. But even when
measuring all-cause reduction of illness in the winter season, influenza vaccine has been shown to be
protective at levels exceeding 40%.
However, what needs to be emphasised is that
influenza vaccine protects specifically against infection with the influenza virus. It does not protect
against the myriad of other infectious agents responsible for upper respiratory tract infections. The
value of the vaccine is because it targets specifically
influenza that is the major cause of serious complications and even death.
With respect to side effects, yes, the influenza vaccine commonly causes injection-site
tenderness, which may last a day or two perhaps
with some surrounding inflammation and mild
lymphadenopathy.
Rarely, a mild pyrexial illness may follow a few
days after immunisation. Because the vaccine
is composed only of the proteins of the virus, it
... to page 54
page 54 | medical chronicle | June 2011
Winter Ailments
Influenza Immunisations
are Invaluable - SA Needs
to Increase the Uptake
... from page 52
cannot cause influenza. Unfortunately, it is often
the elderly and the debilitated who complain
about side effects from the influenza vaccine, but
these are precisely the risk groups who especially
need vaccine protection.
Complacency certainly does play a role in poor
vaccine uptake. It is true that with fit, healthy
adults, influenza is, in the vast majority of cases, a
relatively trivial disease with complications occurring only very rarely.
However, influenza is not always a trivial disease. In the US alone, influenza has been attributed to be responsible for 17 000 to 51 000 deaths
and close to 250 000 hospitalisations annually.
In the developing world, the mortality is considerably higher. A study in SA carried out last
year at the National Institute for Communicable
Diseases (NICD) showed that influenza-attributable deaths were 3.5 times greater than in the US
(Cohen C et al. Clin Infect Dis 2010;51;1362-1369).
Who then should and who should not get influenza vaccines? A comprehensive guideline to
influenza vaccines is published annually in the
February edition of the SA Medical Journal.
Essentially, one can divide up the indications
into three main groups. The first group comprises
those individuals where it is medically mandated,
simply because the vaccine is very effective in
reducing the incidence of severe complications.
This list includes patients with underlying pulmonary and cardiac conditions, metabolic and renal
­diseases and immunosuppressed people including
those with HIV.
More recently, two new risk groups were added
following on the H1N1 pandemic of 2009/2010.
These are pregnancy at all stages (previously firsttrimester was regarded as a contraindication, but
after a number of observations and studies have
provided reassurance that the vaccine has no ill
effects on the foetus, this has been changed now
to include all stages of pregnancy).
Also morbid obesity, with a body mass index of
greater than 40 is now recognised as a significant
risk factor.
South African recommendations include 65
years and over as the age for routine immunisation. Regarding paediatric immunisation, South
African recommendations differ somewhat from
those of the US. Universally, it is clear that all children who have the same risk factors with respect
to chronic pulmonary, cardiac and other conditions listed above should be immunised annually.
Also, children up to the age of 18 years who are
on aspirin therapy for various conditions are also
candidates for influenza immunisation because of
the risk of Reye’s syndrome. However, SA has not
adopted the US policy of routinely immunising all
children between six months (the vaccine is not indicated for infants less than six months) and four
years.
In fact, most recently, the CDC have gone even
further and now recommend immunising all individuals over the age of six months (MMWR, 6
August 2010; Vol 59 RR-8).
The motivation for immunising healthy children
is two-fold - firstly, the rates of complicated influenza and hospitalisation for influenza-related illnesses
are significantly higher in children than adults and
secondly, children serve as the major reservoir of
the virus in the community. Immunisation of children has been shown in a number of population
studies to have a significant, indirect effect conferring herd immunity in the community.
Influenza vaccine
doesn’t protect
against all agents
responsible for
URTIs
The second group of vaccine recipients consists
of individuals who come into close contact with the
high-risk people mentioned above. This includes
health care workers, people living in the same
household and carers of at-risk individuals.
The third group of vaccine recipients is people
who are not medically at risk, but are annually immunised because influenza immunisation has been
shown to play a significant role in reducing work
absenteeism. It is also a useful option for anyone
who would simply like to protect themselves from
an illness that can be debilitating and which may
result in quite a number of days off work.
There are very few contraindications to the influenza vaccine. The very rare individuals who have
experienced an anaphylactic allergic response to
egg protein (as there may be minute traces remaining in the vaccine) or to any of the preservatives in
the vaccine should, of course, not receive the vaccine. It is also recommended that individuals with
an acute pyrexial illness, (but not an apyrexial common cold), should preferably wait until recovery.
In conclusion, influenza is a vaccine-preventable
disease. Influenza vaccine is a relatively cheap,
very safe, and at least moderate to highly effective
vaccine. Its usage needs to greatly increase in SA,
which would make a significant impact on the burden of winter-related illness.
medical chronicle | June 2011 | page 55
Asthma / Allergies
Optimum Asthma Management - It’s
Primarily about Adherence and Delivery
Adequate education of doctors and patients has
been cited as the primary factor responsible for
patients achieving target levels of asthma control.
Patients have the erroneous belief that they will
always be plagued by symptoms, but they should
be made aware that asthma symptoms are not part
and parcel of the condition and that attaining a
symptom-free state is very achievable. Doctors
should increase patients’ understanding of asthma
control and treatment.
According to Dr Michael Levin, head of allergy
in the department of paediatrics and child health
at the Red Cross Children’s Hospital in Cape
Town, the goals of treatment are as follows:
• Patients should be free of symptoms.
• Patients should have a minimal need of reliever therapy as symptoms are minimal.
• Asthma attacks can be avoided.
• Patients no longer require hospitalisation.
• Patients are able to sleep without disruption.
• Patients have a normal or near-normal lung
function.
• Patients have no side effects from medication.
• Normal activity can be maintained - work,
school, sport or exercise.
“It is important for patients to understand that
the above goals translate into asthma control,
which will enable them to work toward it,” stated
Dr Levin.
Doctors should also assess asthma control by
obtaining proper insight into the patient’s history
and behaviour through asking relevant questions,
which elicit informative responses.
Increase patients’
understanding of
asthma control
and treatment
Question your patients
• How many times a week do you experience
asthma symptoms?
• How many times a week do you experience
asthma symptoms at night?
• Are you able to perform normal daily
activities?
• How many times a week do asthma symptoms
restrict your normal activities?
• How much reliever medication did you use in
the last week?
• Have you missed school or work because of
asthma in the last month?
Practitioners need to know how to translate
these questions and goals of treatment into a formal assessment to gauge the level of asthma control. This can be accomplished by referring to the
Global Initiative for Asthma (GINA) guidelines
(www.ginasthma.com).
These guidelines also contain criteria that divide asthma control into controlled, partly controlled or uncontrolled.
In controlled asthma, daytime symptoms occur
less than twice a week and subsequently require
less than two doses of reliever therapy (short-­
acting beta 2 agonists) a week, without any limitation of activities.
No night-time symptoms and sleep distur­
bances are present and the patient has normal or
near-normal lung function. An assessment of control is that if the patient is using his/her reliever
medication more than twice a week, adequate
control has not been established.
Partly controlled asthma is present when any
one of those criteria are violated in a week - the
patient may have daytime symptoms more than
twice a week (implying that rescue therapy is required more than twice), activity may be limited,
nocturnal awakening may occur or lung functions
(either peak flow rate or FEV1) of less than 80%
may be present.
Lung function criteria only apply to patients
older than five years old.
Completely uncontrolled asthma is cha­
r­ac­terised by three or more features of
partly-controlled asthma in any week. The action
for partly-­controlled and uncontrolled asthma is
the same.
“Simply pay attention to why the patient’s asthma is uncontrolled. A critical error doctors make
is that they presume the medication is incorrect
and prescribe a different increased level of medication,” warned Dr Levin.
The ideal response is to examine the case more
closely and investigate the logistics around adherence and technique for drug delivery before modifying the treatment regimen.
At least 95% of patients with problematic
asthma­ control can rectify the situation by looking at these factors.
In terms of adherence, ascertain whether the
patient is actually taking the medication.
“When you ask patients whether they are taking their medication, they might say they do so
twice a day, everyday. When you ask them how
many times a week they forget to take it, they
sometimes admit to being human and a degree
of non­adherence, so it opens the door for them
... to page 56
page 56 | medical chronicle | June 2011
Asthma / Allergies
Optimum Asthma
Management - It’s
Primarily about
Adherence and Delivery
... from page 55
to disclose that they are fallible and they reveal
a more accurate picture of the real situation,” advised Dr Levin.
More specific questions should then be asked,
such as whether the dose was skipped in the morning or night.
“Then try to get them to reveal how many times
they really take their medication each week. They
may eventually come clean and admit they only
take it twice a week. You have finally identified the
root cause of the problem, even though they told
you a few minutes ago that they use it everyday,
because they know what they are meant to do, but
don’t always follow through,” said Dr Levin.
The other component is to assess technique
through direct observation. The best way is to
ask the asthma patients to bring their pump and
spacers to every appointment and to demonstrate
how they use the device. If an error is identified,
the patient should be re-educated on the process,
which may be time consuming. A well-trained
asthma nurse and educator may prove invaluable
in the remediation context.
Assessing the technique is simple and specific
techniques are used for the various types of inhalers - metered-dose inhaler, metered-dose inhaler
with spacer, dry-powder inhaler. Furthermore,
different techniques and devices are required depending on the age of the patient, and these aspects change as the patient gets older, e.g. patients
younger than five years old usually need a mask
and then move onto a mouth piece when a little
older.
Who is responsible for managing a
patient’s asthma?
The type of practitioner managing a patient’s
asthma depends on the severity of the asthma.
The doctor who sees the patient first should assign
him or her to one of four levels according to the
assessment of severity. Asthma severity is used as
a guide to decide which initial therapy to start the
patient on (level one, two or three).
Asthma is divided into intermittent and persistent asthma, with the latter type subdivided into
mild, moderate and severe persistent asthma. The
categorisation of asthma severity depends on the
factors mentioned when assessing asthma control.
• Intermittent: Daytime symptoms occur less
than twice a week, night-time symptoms
occur less than once a month and peak flow
rate is more than 80%.
• Persistent, mild: Daytime symptoms occur
two to four times a week, night symptoms
occur two to four times a month, and peak
flow rates are greater than 80%. (The frequency of night-time symptoms holds greater value
in indicating severity).
• Persistent, moderate - there are more than
four incidences of daytime symptoms per
week, more than four occasions of night-time
symptoms per month, and peak flow rate of
60%-80%.
• Persistent severe: Daytime symptoms are almost continuous, night-time symptoms are
very frequent and peak flow rate is less than
60%.
All grades of asthma, including intermittent
asthma require reliever therapy and control over
the environment. Intermittent asthma does not
require any regular maintenance (controller)
­therapy. All patients with persistent asthma require regular anti-inflammatory controller therapy. Intermittent or mild, persistent asthmatic may
be comfortably managed by a GP. A patient with
severe, persistent asthma and those on level three
therapy may need referral. Other indications for
referral are when the diagnosis is in doubt, there
are multiple severe concomitant allergic diseases,
asthma that is difficult to control or where patients experience life threatening asthma, have
frequent attacks, require regular oral steroids or
immunotherapy is being considered.
70%
Of patients fall into
the mild persistent
asthma category
These patients as well as young children under
the age of two years should be seen by a pulmonologist, allergist, paediatrician, specialist paediatrician or a physician with a special interest in
asthma.
In general, about 70% of patients fall into the
mild persistent, 25% into the moderate persistent
and only 5% into the severe persistent categories.
Therefore, approximately 95% of patients can be
managed by primary care practitioners who have
been appropriately educated and trained.
“Severity is never re-assessed after the initial
assessment. Only control is assessed. You assess
whether the patient is controlled or not to decide
whether you should go to the next level of therapy
after you establish adherence and technique of delivery. If the patient has been fine for three to six
months, you can reduce the therapy by one step,”
stated Dr Levin.
Final message
The biggest challenge is to understand the
meaning of control. Doctors and patients should
be taught that assessing control is important and
that obtaining control is not about drugs - it is
about adherence and drug delivery. Educating patients on how to use the devices effectively also
implies the doctor should be au fair with the
techniques.
Dr Levin recently published an article in the
journal, Current Allergy and Clinical Immunology
that looked at errors in optimal drug delivery.
A national asthma certificate course is available
to guide doctors and nurses on how to manage
asthma and educate their patients adequately. The
website, www.asthma.co.za serves as a great source
of information for doctors, and patients can also
be referred to this resource.
medical chronicle | June 2011 | page 57
Asthma / Allergies
Children, Males and Blacks are Population Groups
at an Increased Risk of Acquiring Food Allergies
A new study estimates that 2.5% of the US population or about 7.6 million people have food allergies. Food allergy rates were found to be higher
for children, blacks and males, according to the
researchers. The odds of male black children having food allergies were 4.4 times higher than others in the general population.
The research, which was funded by the National
Institutes of Health (NIH) and appeared in the
October 2010 edition of the Journal of Allergy and
Clinical Immunology, is the first to use a nationally
representative sample, as well as specific immuno­
globulin E (IgE) or antibody levels to quantify
allergic sensitisation to common foods, including
peanuts, milk, eggs and shrimp.
The hallmark of food allergy is the production
of IgE antibodies to a specific food protein. Once
IgE antibody is made, further exposure to the
food triggers an allergic response. IgE levels are
often high in people with allergies.
4.2%
Food allergy rates
for children aged
one to five years
“This study is very comprehensive in its scope.
It is the first study to use specific blood serum
levels and to look at food allergies across the
whole life spectrum, from young children aged
one to five years, to adults 60 years and older,”
said Dr Darryl Zeldin, acting clinical director at
the NIH’s National Institute of Environmental
Health Sciences (NIEHS) and senior author on
the paper.
“This research has helped us identify some high
risk populations for food allergies,” he said.
In addition to the identification of race, ethnicity, gender and age as risk factors for food allergies,
the researchers also found an association between
food allergy and severe asthma.
Food allergy rates were highest (4.2%) for children one to five years. The lowest rates (1.3%) were
found in adults over the age of 60. The prevalence
of peanut allergies in children aged one to five was
1.8% and in children aged six to 19, it was 2.7%.
In adults, the rate was 0.3%.
The odds of patients with asthma and food allergies experiencing a severe asthma attack were
6.9 times higher than those without clinically defined food allergies.
“This study provides further credence that food
allergies may be contributing to severe asthma
episodes, and suggests that people with a food
allergy and asthma should closely monitor both
conditions and be aware that they might be related,” said Dr Andrew Liu from the National Jewish
Health and the University of Colorado School of
Medicine and lead author on the paper.
The data used for the study come from the
National Health and Nutrition Examination
Survey (NHANES) 2005-2006. NHANES is a
large nationally representative survey conducted
by the National Center for Health Statistics,
a part of the Centers for Disease Control and
Prevention.
Drs Zeldin and Liu noted more research is
needed to understand why certain groups are at
The lowest food
allergy rate (1.3%)
was found in adults
over the age of 60
increased risk for food allergy. The authors commented in the paper that food allergies may be
under-recognised in blacks, males and children
because previous studies relied on self-reporting
and not food-specific serum IgE levels.
“Having an accurate estimate of the prevalence of food allergies is helpful to public health
policy makers, schools and day care facilities and
other care providers as they plan and allocate resources to recognise and treat food allergies,” said
Dr Linda Birnbaum, NIEHS director.
Source
www.eurekalert.org
page 58 | medical chronicle | June 2011
Asthma / Allergies
Sticker to Encourage Patients to ‘Stick’
with Asthma Compliance Programmes
A new asthma awareness campaign to educate patients on correct inhaler technique as well as boost
patient compliance with their daily asthma management has been launched.
The campaign is centred on the Turbuhaler®,
which features an innovative design that allows for
accurate dosage of asthma medications Symbicord®
and Pulmicort® without any propellant gas or other
additives. “The campaign has two distinct aims: to
improve patient compliance by dispelling any patient uncertainty around using the inhaler through
the introduction of an innovative way for patients
to personalise their Turbuhalers and to help alleviate the stigma around asthma,” said Dr Jasvanti
Bhana, senior manager: medical, regulatory and
quality assurance for AstraZeneca.
When the Turbuhaler was introduced in 1987,
it was welcomed as a revolutionary inhaler design. It was the first powder inhaler synchronised
to operate with the patient’s breathing, thus replacing the need for propellant gas. “As with any
novel design, patients may be uncertain on how to
use the Turbuhaler correctly. Unfortunately, this
uncertainty can lead to poor administration of
medication, a lack of trust in the medicine’s efficacy
and poor compliance,” said Dr Bhana.
Dr Bhana explained that to combat this,
AstraZeneca Pharmaceuticals will be distributing
step-by-step instruction stickers to doctors’ rooms
and pharmacies. These stickers are to be applied to
the exterior surface of the Turbuhaler and provide a
quick and easy explanation of how to use the device
correctly.
These stickers
provide a quick and
easy explanation
of how to use the
device correctly
To meet the second objective of the campaign, AstraZeneca will be introducing ‘Style My
Turbuhaler’ at doctor’s rooms. Style My Turbuhaler
is a collection of removable, themed stickers that
allow patients to personalise their Turbuhaler. “The
concept draws on the trend of customisation by offering 25 bold designs in a variety of themes including sports, nature and the arts,” added Dr Bhana.
The stickers are easy to apply and remove, allowing
patients to swop as they please.
“The rationale behind Style My Turbuhaler is
that customisation allows patients to identify with
their inhalers and therefore encourages proactive
ownership of the disease,” said Dr Bhana. “Apart
from this, one of the aims of the campaign is to
encourage destigmatisation of the disease.
“We know so much more about treating asthma
effectively these days. The right medicines and
following the correct regimen should have a positive impact on both patients’ asthma and quality
of life. Using an inhaler correctly and as often as
prescribed is a key part of any such regimen,” concluded Dr Bhana.
About AstraZeneca
AstraZeneca is a leading global pharmaceutical company, which employs over 65 000 people
in more than 100 countries across the Americas,
Europe, Asia, Africa and Australasia. Its 2008 sales
totalled over $32bn (R227bn), with R&D budgets
of over $5bn (R35bn).
For further information, contact Christo Olivier,
product manager: respiratory, Astra­Zeneca on
011‑797‑6000 or at [email protected]
* Content supplied by AstraZeneca Pharmaceuticals
page 60 | medical chronicle | June 2011
Asthma / Allergies
Broadening Patient Access: Asthma Care
AstraZeneca Pharmaceuticals’ innovations in the
field of asthma treatment include the design of a
dry powder inhaler operated solely by a patient’s
breathing called the Turbuhaler®, and the development of adjustable maintenance dosing.
This is a treatment concept known as
Symbicord® (budesonide/formoterol) maintenance and reliever therapy, which allows patients
to quickly gain and maintain control of a variable
disease with the same inhaler.
“Respiratory remains one of AstraZeneca’s key
therapeutic areas and the company is committed
to providing a wide arsenal of asthma treatments
for medical practitioners and also enabling more
patients to access key AstraZeneca asthma medicines,” said Dr Jasvanti Bhana, senior manager:
medical, regulatory and quality assurance for
AstraZeneca.
Treatments offered include:
• Bricanyl® (terbutaline) is a short-acting beta2-agonist, which is indicated for the treatment of bronchial asthma, chronic bronchitis,
emphysema and other lung diseases where
bronchospasm is a complicating factor.1
• Pulmicort® (budesonide) Turbuhaler is an inhaled corticosteroid for the prophylaxis of the
symptoms of asthma.2
• Symbicord Turbuhaler, indicated in the treatment of asthma in adolescents and adults
where use of combination (inhaled corticosteroid and long acting beta-2-agonist) is
appropriate.3
“Pricing is an important factor in enabling
greater patient access to our medicines and is
especially relevant to daily, chronic medication.
We have therefore taken the strategic decision
to reduce the pricing on Pulmicort Turbuhaler,
a move that should enhance our competitiveness
and make the medication much more affordable
to patients,” added Dr Bhana.
Pulmicort Turbuhaler is the company’s inhaled
corticosteroids treatment for patients with moderate to severe asthma.2 While a well-established
treatment (budesonide was first developed in the
1970s), the product is still widely prescribed for
asthma worldwide.
According to the Global Initiative for Asthma’s
guidelines, inhaled corticosteroids, of which
Pulmicort Turbuhaler is an example, are the most
effective anti-inflammatory agents available in the
treatment of asthma.4
It is fast-acting and helps achieve asthma control, which is maintained over time.5
As alluded to previously, it is impossible to refer
to AstraZeneca’s contribution to asthma management without referring to the Turbuhaler, the first
powder inhaler on the market operated by a patient’s breathing, removing the need for chemical
propellants such as CFCs.
Not only is the Turbuhaler device easy to use
even by children,6 it is also an efficient method for
the delivery of the medicine. When budesonide is
inhaled from the Turbuhaler, approximately twice
as much of the metered dose (34%) is deposited
in the lungs compared with a pressurised metered
dose inhaler (pMDI; 15%).6
Lower pricing
enables greater
patient access
to daily, chronic
medication
The innovative design was first created by
Swedish designer Kjell Wetterlin in 1987 at the
then Astra Draco after his daughter complained
about the taste of additives from her asthma
medication.
Since then it has won numerous design awards
including the 2010 Good Design Award from the
Japan Industrial Design Promotion Organization.
“This award recognises AstraZeneca’s contribution to patient care - it is simple, user-friendly and
suited to all age groups (children from the age of
six to adults). It is a wonderful acknowledgment
of the company’s contribution to both asthma
management and reaffirms its ongoing commitment to the improvement of patients’ lives,” said
Dr Bhana.
While still a chronic condition, with the right
medicines and the correct asthma preventative regime, asthma should no longer be scary.
“We know so much more about treating asthma effectively these days. The right medicines and
complying with a regime should have a positive
impact on both patients’ asthma and quality of
life. We hope that the reduction in the price of
one of our key asthma treatments will allow more
patients to benefit from this drug,” concluded
Dr Bhana.
References:
1. Bricanyl Turbuhaler South African Registered
Package Insert.
2. Pulmicort Turbuhaler South African Registered
Package Insert.
3. Symbicord Turbuhaler South African Registered
Package Insert.
4. Global Initiative for Asthma (GINA) guidelines.
Updated 2008.
5. Kemp J, Wanderer AA, Ramsdell J, et al. Rapid
onset of control with budesonide Turbuhaler in
patients with mild-to-moderate asthma. Annals of
allergy, asthma and immunology. 1999;82:463-471.
6. Shapiro G, Bronsky EA, LaForce, CF, et al.
Dose-related efficacy of budesonide administered
via a dry powder inhaler in the treatment of children with moderate to severe persistent asthma. The
Journal of Pediatrics; 1998;132:976-982.
* Content supplied by AstraZeneca Pharmaceuticals
medical chronicle | June 2011 | page 61
Men’s Health
Understanding Testosterone Deficiency Syndrome
Dr Poobalan Pillay
Sports Physician, Ballito, KwaZulu-Natal
Testosterone deficiency syndrome (TDS) and men’s
health were the hot topics for discussion by urologist
Dr Riaan Venter, endocrinologist, Dr Sindeep Bhana
and sexologists, Drs Prithy Ramlachan, Lorraine
Becker and Etienne Kok, at the Men’s Health Forum,
hosted by Bayer Healthcare at the Selborne Country
Club in KwaZulu-Natal last month.
TDS is defined as the clinical and biochemical
syndrome associated with advancing age and characterised by symptoms and a deficiency in serum
testosterone levels. This condition may result in a decreased quality of life and can negatively affect multiple organ systems.
Table 1: TDS-related somatic changes in men
Androgen
target organ
Change
Clinical
signs
Bones
Osteopaenia/
osteoporosis
Pain in bones
Musculature
Atrophy
Neurasthenic
weakness
exhaustion
Erythropoeisis
Anaemia
Chronic
fatigue
Libido
Loss of libido
Decreased
sexual activity
Potency
Erectile
dysfunction
Impaired
potency
Adipose
tissue
Visceral
deposition
of adipose
tissue
Weight
increase,
obesity
Fractures
Lipomastia
Metabolic
effects
Table 2: Typical symptoms in older men
Osteoporosis
Backache, fractures,
decrease in height
Body
composition
Increase in adipose tissue,
lipomastia, gynaecomastia
Muscle
strength
Muscle atrophy, diminishing
strength, neurasthenic
weakness
Skin
Dryness, lack of sebum
production
Sexual function
Loss of libido, erectile
dysfunction
Anaemia
Chronic fatigue,
neurasthenic weakness
Vegetative
and subjective
symptoms
Hyperhidrosis, hot
flushes, lethargy, lack
of enthusiasm, apathy,
lack of self-confidence,
anxiety, depression, lack of
perspective, sleep disorders
Signs and symptoms of TDS include loss of libido,
increased visceral fat, decreased lean body mass, depression, lethargy/fatigue, sleep disturbances, irritability, regression of secondary sexual characteristics
and erectile dysfunction.
Signs and symptoms
In addition to the multiple aetiological causes of
TDS, presentation may vary from patient to patient,
therefore making an accurate diagnosis a challenge.
There are six clinical changes that should alert doctors to the possibility of TDS: decreased sexual desire,
decreased morning erections and quality of erections,
decreased cognitive function, decreased lean body
mass, body hair and skin changes, decreased bone
mineral density and increased visceral fat.
Restoring plasma testosterone levels to a normal
range alleviates the symptoms of TDS and improves
various aspects of wellbeing.
Investigations
Who are the potential candidates for treatment
and how can clinicians best evaluate the situation and
the success of treatment?
It is vital for doctors to work-up the patient fully.
This includes a detailed history and full physical examination. There are two questionnaires currently
available for evaluating men with low testosterone
levels. One of these is the Ageing Males’ Symptoms
Questionnaire, which the patient has to complete.
The health care professional then tallies the score in
order to classify the patient as normal, little, moderate
or severely symptomatic.
In addition to the routine blood tests, testosterone
profile, luteinising hormone, follicle-stimulating hormone and prolactin tests should be performed. In the
past, a total testosterone level above 8.0nmol/ℓ was
considered normal. However, the third Consultation
of Sexual Medicine refers to levels of more than
12nmol/ℓ that does not usually require replacement
and to 12-27nmol/ℓ as normal.
Management
Androgen replacement therapy can safely alleviate the detrimental effects associated with decreasing
androgen levels in ageing men. It serves to treat patients with consistently low testosterone levels and
symptoms associated with andropause.
Treatment in these patients may positively impact
on body composition, bone mineral density, angina,
exercise-induced ischaemia and other androgen-­
regulated physiological functions.
Several androgen replacement therapies are available for the treatment of andropause. In SA, these
include oral preparations and intramuscular injections. Efficacy of treatment is typically measured by
increases in serum testosterone levels. Vigilant monitoring of potential complications, such as increased
haematocrit and gynaecomastia, should take place.
As with any therapy, safety is of paramount
concern. The major issue surrounding androgen
replacement therapy is its potential role in prostate
carcinogenesis. As far as the relationship between
serum hormone levels and prostate cancer is concerned, there is no evidence that androgen supplementation increases the risk of cancer.
However, androgen replacement therapy does promote the growth of already existing carcinomas, thus
necessitating that patients undergo digital rectal examinations and prostate-specific antigen testing prior
to treatment and thereafter annually.
One of the latest treatment options is testosterone
undecanoate 1000mg which involves a 12-weekly
deep intramuscular injection administered for two
minutes. The first and second doses should be administered six weeks apart. Individualisation of therapy is
necessary to meet the patient’s needs.
medical chronicle | June 2011 | page 63
Dermatology
International Aesthetic Surgical Trends
Dr Anton Potgieter,
Consultant Plastic Surgeon
For the first time in many years, the annual
International Society Of Aesthetic Plastic Surgery
(ISAPS) SA congress was held at a new venue in
warm Cape Town weather at The Lord Charles
Hotel in Somerset West.
Delegates from around the country made the trip
to listen to lectures from international invited speakers as well as local experts in their respective fields.
The fat revolution
Twenty years ago, fat was considered to be a fairly
uninteresting tissue, primarily made up of swollen
adipocytes, quietly doing very little other than storing up excess calories and tending to look unsightly.
Well, the world has changed and plain, old, wobbly fat appears to be loaded with stem cells, which
under the right circumstances, seems to be capable
of the most remarkable feats of wound healing and
regeneration.
Dr Steve Ray from Oxford University provided
fascinating insights into cell banking of adiposederived mesenchymal stem cells, and their potential
uses in anti-ageing and regenerative medicine.
Dr Domenico de Fazio from the University of
Modena in Italy demonstrated the practical and re­
le­vant results of fat transplantation and liposculpture
in his practice.
Lipofilling of
‘deflated’ areas
results in a
remarkable,
‘youthful’ change
Every other invited speaker echoed similar themes
about the usefulness of fat. Dr Dirk Richter from
Germany gave a very interesting presentation on
periorbital rejuvenation combining classical skin
excision with fat redistribution, while Dr Michael
Sheflan from Israel impressed with his results of lipoaspirate and transfer.
Dr Patrick Tonnard from Ghent University in
Belgium provided some of the most compelling outcomes by showing the impressive results that can be
achieved by combining his minimal access cranial
suspension facelift procedure with microfat grafting.
The ultimate message was: Lipofilling of ‘deflated’
areas, especially the subtle regions of the ageing face,
will result in a remarkable, ‘youthful’ change.
Bariatric surgery
Weight reduction surgery, by means of gastric or
intestinal procedures, has been increasing worldwide over the past few years. Many experts predict a
‘flood’ of massive weight loss patients lining up at the
doors of aesthetic surgeons.
Dr Dirk Richter gave several very useful lectures
outlining his approach to managing patients who
had successfully lost tremendous amounts of weight
and required lower and upper body lifting procedures, abdominoplasty (tummy tuck) and thigh
lifting.
Polyurethane implants
Most plastic surgeons who have used polyurethane-coated breast implants, talk about them like
long-lost lovers. However, plastic surgeons over the
years, have been schooled to be cynical and wary of
these implants.
Dr Tonnard gave one of the most thoughtprovoking­ presentations of the congress by initially
critically evaluating the complication rates of the
current ‘state-of-the-art’ breast prostheses and reminding delegates of the criticisms, theory and virtues of polyurethane-coated implants. He concluded
by showing very low complication rates and excellent
results over 15 years.
Breast surgery
Dr Sheflan started his presentation by recounting anecdotes about the idiosyncrasies of practicing
in Tel Aviv, before reminding everyone to be cognisant of how female breasts will age over the years
and then provided ways to prevent and deal with the
problems that may arise.
Ethics
Elsabe Klinck, a legal consultant, gave a very
useful lecture covering issues such as informed consent, medical tourism, health law and the new, controversial Consumer Protection Act.
Jeremy Gardiner from Investec in Cape Town
spoke about the state of the local and world economy
as well as reminding delegates of the events of the
past year, which contributed to the current world
economic situation. His extremely polished presentation included stirring footage from the world cup,
which had a few members in the audience wiping
their eyes.
In addition …
Local speakers provided experience on some of
the emerging technologies and the trade exhibitors didn’t disappoint by launching other new and
potentially very useful devices.
Dr David Presbury updated the audience about
the various uses of lasers, while Dr Vernon Ching
discussed his experience with the Slim-Lipo system
and Dr Ewa Siolo described the use of assisted high
definition liposelection sculpture (VASER) in her
practice.
Dr Michael Colonna ran a workshop on the
Canfield VECTRA X3 Imaging System, which
performs amazing pre- and postoperative analyses of
patients’ results.
Clinical workshops were also held at the Somerset
West Aesthetic Clinic, where Dr Ching performed a
live Slim-Lipo demonstration, followed by Dr Vivien
Jandera who demonstrated advanced techniques of
Restylane injections.
page 64 | medical chronicle | June 2011
Vaccines
Improved Addition Offers Broadest Coverage
of Any Pneumococcal Conjugate Vaccine
Prevenar 13® (13-valent pneumococcal conjugate
vaccine, Pfizer Laboratories) was developed as a
successor to Prevenar® and includes the 13 most
prevalent serotypes in young children worldwide.
Prevenar 13 is based on the scientific foundation
of Prevenar and uses the same CRM197 carrier
protein and conjugation technology that has been
utilised in various paediatric vaccines.
Invasive pneumococcal disease remains a leading cause of morbidity and mortality in children
below the age of five years and accounts for approximately 11% of all deaths in this age group
throughout the world.
Pneumococcal infec­t ions remain the leading
cause of death from a vaccine-preventable illness in children younger than five years of age.
Prevenar 13 contains the seven serotypes already
included in Prevenar, plus six additional pneumococcal serotypes 1, 3, 5, 6A, 7F and 19A,
which will increase the percentage of vaccinepreventable cases of invasive pneumococcal disease by to up to 90% or more in most regions of
the world.
The paediatric serotypes, 6A and 19A, now included in this vaccine, are known to be major
causes of serious pneumococcal disease in a
number of countries, including SA and have a
tendency to develop resistance to commonly
used anti­biotics.
Increased serotype coverage of Prevenar 13 is
expected to have a substantial public health and
economic impact by preventing substantially
more pneumococcal disease and childhood mortality than currently licensed pneumococcal conjugate vaccines.
References
1. De Gouveia L, Von Gottberg A. Streptococcus
pneumoniae. Comm Dis Surveillance Bull
2010;8(2):38-41.
2. Duggan ST. Pneumococcal polysaccharide conjugate vaccine (13-valent, adsorbed) [Prevenar
13®]. Drugs 2010;70(15):1973-86.
3. PneumoADIP. Pneumococcal Global Serotype
Project. Available at: www.preventpneumo.org/
pdf /GSP%20Summary%20for%20S AGE%20
Nov6-8%202007_Oct%2019-07.pdf
4. Reinert RR, Paradiso P, Fritzell B. Advances
in pneumococcal vaccines: the 13-valent pneumococcal conjugate vaccine received market
authorization in Europe. Expert Rev Vaccines
2010;9(3):229-36.
* Content supplied by Pfizer Laboratories
Pneumococcal
Vaccination
Helps Prevent
Pneumonia
Preventing pneumococcal infection through vaccination curbs the incidence of pneumonia-related
cases, because most pneumonia is not caused directly by the influenza virus, but occurs as a secondary bacterial infection, according to National
Research Foundation A-rated scientist, Shabir
Madhi, professor of vaccinology at the University
of the Witwatersrand. However, there are instances
where influenza, in itself, can cause pneumonia.
High-risk populations groups are especially at
risk of acquiring pneumonia. The HIV epidemic
claims the lives of many South Africans, particularly children, as a result of pneumococcal pneumonia and influenza.
Streptococcus pneumoniae or pneumococcus is responsible for pneumococcal pneumonia. Examining and understanding the sombre
‘­shadow’ cast by this bacterium, Prof Madhi has
under­taken groundbreaking research internationally for years.
Streptococcus pneumoniae was first described
over 100 years ago and there are now effective
anti­biotics available for the treatment of pneumococcal infections in humans, however antibiotic
resistance is an issue and prevention strategies are
becoming increasingly important.
According to Prof Madhi, the massive increase
in HIV infection has led to a surge in the number
of patients succumbing to pneumococcal disease.
Many children and some adults, especially
those infected with HIV, harbour pneumococci in
their nose and throat and acquire these from other
carriers. The organisms may invade the body and
cause active disease which manifests differently in
the various parts of the body. Pneumonia is a common consequence, but serious blood infections
and even meningitis are possibilities.
“Although vaccines are widely available to most
children in developed countries, the challenge
remains in making these vaccines available and
affordable to children where childhood mor­tality
from pneumococcal disease is greatest,” stated
Prof Madhi, who has focused much of his research
on pneumococcal vaccines and the many issues
surrounding their use, especially in developing
countries.
“The battle against pneumococci is slowly being
won, but it remains to be seen whether this bacterium will adapt to the anti­biotics currently being
used and continue to be ‘the captain of death of
men’ in developing countries. Until then, prevention of pneumococcal disease needs to be coupled
with optimising the management and treatment
of individuals who become ill because of this
dreaded bacterium,” concluded Prof Madhi.
medical chronicle | June 2011 | page 65
Prof
Reid Ally
Dr
Keith Pettengell
Dr
John Wright
Gastroenterology Forum
Heartburn, Normal Endoscopy - What Next?
Gastro-oesophageal reflux disease (GORD) is becoming an increasingly common clinical problem.
The current prevalence is estimated to be between
10% and 20% in western countries and 5% in Asia.
Consultation rates have been estimated at only 20%40% of sufferers, as the majority self-medicate.
Heartburn and acid regurgitation are significantly
related to acid reflux episodes identified on 24-hour
oesophageal pH studies. Heartburn has a sensitivity
and specificity of around 70% for GORD. Other
symptoms such as the globus syndrome, hoarseness
and cough, chest pain, nausea and pain on swallowing may all be due to GORD, but the relationship is
not specific.
When further investigation of heartburn becomes
necessary, endoscopy is the first step, but unfortunately there is little or no correlation between heartburn,
its frequency and severity, and endoscopic findings.
Erosive oesophagitis and even Barrett’s oesophagus
may exist in the absence of heartburn and daily severe heartburn may be present in patients with a normal endoscopy. In a series of 149 consecutive patients
with heartburn, 71 had a normal endoscopy.
This group was then investigated with 24-hour
oesophageal pH monitoring. Approximately 52 had
abnormally high oesophageal acid exposure and can
be classified as nonerosive reflux disease (NERD)
while 19 had normal acid exposure. Of these 19 patients, seven had heartburn correlated with episodes
of physiological reflux. This group can be described
as having a hypersensitive oesophagus. The 12 other
patients had heartburn unrelated to any episodes of
acid reflux and for this group, the term ‘functional
heartburn’ is appropriate.
Functional heartburn
In patients with NERD, symptoms are similar
to those patients with erosive oesophagitis. Such
patients demonstrate an enhanced sensitivity to
acid within the oesophagus but also to mechanical
stimulation (balloon distension), and for this reason,
tend to have a suboptimal response to proton pump
inhibitor (PPI) therapy. In patients with functional
heartburn where symptoms are unrelated to episodes
of oesophageal acid exposure, the putative mechanisms include bile reflux, alkaline reflux, volume
distension, hyper-vigilance, abnormal central sensory
processing and psychological-related factors. Patients
with functional heartburn have little or no response
to PPI therapy.
Diagnosis
The diagnosis of NERD is not altogether straightforward, as it implies no recent treatment that might
heal erosive disease, prior to the endoscopy. However,
the condition cannot be diagnosed without endoscopy, as the range of symptoms is similar to those of
erosive reflux disease (ERD).
The quality of life in patients with NERD is
similarly impaired to that of GORD patients and is
equivalent to that found in patients with ischaemic
heart disease. In general, NERD occurs less frequently in the elderly.
Progression to ERD seems to be infrequent occurring in only around 10% or less of patients. NERD
sufferers are more likely to have functional dyspeptic
symptoms accompanying their heartburn, such as
bloating, burping and easy satiety than their ERD
counterparts.
However, NERD itself is not without pathology.
Recent investigations using the new generation of
high definition endoscopes and confocal endomicroscopy have shown evidence of micro-erosions
and vascular abnormalities (capillary dilatation and
increased capillary looping) at the junction where
the pale oesophageal squamous mucosa meets the
glandular.
In general, the response rate of NERD to PPI therapy in controlled clinical trials is lower than that of
ERD and it may take 10-12 weeks for complete relief
of heartburn on standard PPI therapy in NERD patients. Doubling the dose has not been shown to improve response. Many NERD patients may require
long-term maintenance therapy.
Management
So when confronted with a patient with heartburn
and a normal endoscopy, what should one do? Firstly,
think again of a cardiac cause for the patient’s symptoms and if necessary, actively exclude this.
Then it is time for a trial of PPI therapy in either
standard or double dose, and this may need to be
continued for 10-12 weeks. Where a good response
is achieved as it will be in NERD patients and some
with a hypersensitive oesophagus, this group can be
treated as any other GORD patient.
Where the response is inadequate, compliance and
dose scheduling should be checked, remembering
that most PPIs should be taken on an empty stomach.
If all is in order, the patient should be referred for
24-hour oesophageal pH monitoring. This will sort
out those patients with acid-related disease from
nonacid-related disease. However, such referrals will
be unusual.
processing of visceral stimuli would seem appropriate
and is well worth a three-to-four-month trial.
Treatment
Most patients with endoscopy-negative heartburn
will have NERD and will respond to treatment in
the same way as ERD patients. A small proportion of
patients will not improve on prolonged PPI therapy
and have either a hypersensitive oesophagus or functional heartburn.
PPI failures should be referred to 24-hour oeso­
phageal pH monitoring to establish the diagnosis
and guide therapy. The utmost care should be taken
to avoid referring patients with functional heartburn
or a hypersensitive oesophagus for antireflux surgery.
References available on request.
For the majority of patients with heartburn and a
normal endoscopy, PPI treatment (eventually) will
prove effective. For patients with functional heartburn, treatment remains empirical.
Alginates and sucralfate have their proponents.
Baclofen has recently been shown to reduce transient
lower oesophageal sphincter relaxations and to be
beneficial in patients with bile reflux.
Although convincing evidence is lacking, the use
of tricyclic antidepressants in a low dose to reduce
visceral hypersensitivity and modify the central
Conclusion
page 66 | medical chronicle | June 2011
Gastroenterology
Symptoms of Paediatric Oesophagitis
Abstract: Children and adolescents with symptomatic gastro-oesophageal reflux disease
(GORD) and erosive oesophagitis (EO) of grade
≥2 or nonerosive oesophagitis (NEO) were assessed to determine the relationship between
presenting symptoms, oesophagitis severity and
patient age. Overall, regurgitation/vomiting, abdominal pain and cough were the most frequent
symptoms.
The prevalence and severity of anorexia/feed refusal was significantly greater in EO vs NEO children. This symptom was also significantly more
prevalent in younger children (aged one to five)
(both NEO and EO groups) compared to older
children.
Cough was significantly less severe in NEO
adolescents than in younger children. Cough,
anorexia/feed refusal and regurgitation/vomiting
were more severe and heartburn was less severe in
EO children aged one to five years compared with
older patients.
In conclusion, GORD in children manifests
differently than in adults and symptoms vary
with patient age. Symptoms were not predictive of
­presence or lack of mucosal damage.
Discussion
Heartburn is often referred to as the hallmark
symptom of GORD among adults. In contrast,
regurgitation/vomiting, abdominal pain and
cough were the most common presenting symptoms seen in the paediatric patients with GORD
in this study; >60% of children and adolescents
reported these symptoms.
Interestingly, with one exception, no significant
differences were observed in the prevalence and/
or severity of the symptoms between children
with NEO and EO. The prevalence and severity
of anorexia/feed refusal, albeit a less frequently reported symptom, was significantly greater among
those with EO compared with those without erosive disease.
This seems understandable. EO is more likely
to be associated with odynophagia and/or dysphagia, although to date this has not been studied in
children. Several interesting trends emerge when
symptoms associated with NEO and EO are stra­
ti­fied by patient age.
Anorexia/feed refusal was more common
among younger children (one to five years) than
older patients. In patients with EO, the severity of
anorexia/feed refusal, regurgitation/vomiting and
cough as well as the prevalence of anorexia/feed
refusal were found to be significantly greater in
the younger children compared with their older
counterparts.
On the other hand, heartburn was less severe
in the younger patients with EO compared with
older children with EO. This is not surprising;
younger children may find it difficult to recognise
or articulate the symptom of heartburn.
The other manifestations of reflux in younger
children are physical signs rather than symptoms
and therefore do not require descriptive cognitive
ability by the child.
Symptoms of GORD
are considerably
different in
children from
those in adults
Making the diagnosis of GORD in childhood
is important for several reasons. Firstly, data suggest that some early childhood GORD persists
into adolescence and that GORD in children and
adolescents often persists into adulthood.
Although these studies are flawed in some respects, including their retrospective designs, their
conclusions are probably true for patients with
GORD that is severe and chronic or recurrent.
Secondly, it is reasonable to speculate that early
detection and treatment of GORD in children
and adolescents may result in fewer complications
such as growth failure or poor weight gain, severe
EO and peptic stricture.
This has been shown for peptic stricture in
adults, but not for the other complications in
childhood. Furthermore, early treatment intervention may also result in improved quality of
life and ultimately reduce the overall health care
burden.
However, there is no evidence to indicate that
the development of serious, rare complications
of GORD, such as Barrett’s oesophagus and oesophageal adenocarcinoma, can be prevented by
intervention with medical or surgical antireflux
therapy.
In conclusion, data show that the presenting
symptoms of GORD are considerably different in
children from those in adults, in whom heartburn
is the most common. In addition, symptoms of
GORD differ between age groups in children.
Regurgitation/vomiting, abdominal pain and
cough were the most frequently reported symptoms in children and adolescents in the study.
However, the presence and severity of these frequently encountered symptoms were not predictive for EO vs NEO in our study.
Cough and anorexia/feed refusal appeared with
greater frequency and severity in younger children. Although a less frequently reported symptom, anorexia/feed refusal was more prevalent in
EO than NEO patients. Evaluation for GORD
should be initiated when the above symptoms are
present, particularly the atypical symptoms that
occur in younger children.
Excerpted from: Gupta SK, Hassal E, Chiu Y-L, et al.
Presenting symptoms of nonerosive and erosive esophagitis in pediatric patients. Dig Dis Sci 2006;51:858-863.
medical chronicle | June 2011 | page 67
Gastroenterology
Older Colon Cancer Patients Have Less
Side Effects with Chemo after Surgery
Even though older patients with colon cancer are
less likely to receive chemotherapy following surgery because of concerns of adverse events, new
research indicates that when they do receive this
treatment, it is less toxic and of shorter duration
than therapy younger patients receive.
In addition, older patients experience fewer adverse events, according to a study published in the
March 2010 issue of the Journal of the American
Medical Association (JAMA) dedicated to cancer.
Dr Robert Fletcher from Harvard Medical
School in the US presented the findings of the
study at a JAMA media briefing.
Randomised trials
Randomised trials have shown reductions in
cancer death and recurrence in patients with
stage III colon cancer treated with adjuvant
(supplemental after surgery) chemotherapy, with
clinical trials also showing that surgery and adjuvant chemotherapy increases survival over surgery alone in selected patients with this stage of
colon cancer.
Average number
of unique adverse
events was higher
for adjuvant
chemotherapy users
vs nonusers
But, in practice, older patients with stage III
colon cancer are much less likely to receive this
treatment.
“Doctors cite the lack of randomised controlled trials evaluating the effectiveness of adjuvant chemotherapy for patients older than 80
years as well as comorbid (co-existing illnesses)
conditions and drug toxicities as the most common reasons for not treating older patients with
adjuvant chemotherapy,” the authors wrote.
Analysis
Dr Fletcher and colleagues analysed the use
of adjuvant chemotherapy and adverse events by
age, through medical records and surveys, in a
multiregional group of 675 patients diagnosed
with stage III colon cancer from 2003 through
2005, who underwent surgical resection (removal of part of the colon).
The patients, who were followed up for as long
as 15 months after their diagnosis, were from five
regions (Alabama, Iowa, Los Angeles County,
northern California and North Carolina), five
integrated health care delivery systems, and 15
Veterans Affairs hospitals.
Results
The researchers found that overall, 513 of 675
patients with stage III colon cancer (75%) received any adjuvant chemotherapy. Of the 202
patients 75 years and older, 101 (50%) received
supplemental chemotherapy compared with 87%
of younger patients.
Patients aged 65 years and older were more
likely than younger patients to discontinue chemotherapy at all follow-up times. For example,
by 150 days, 40% of patients at least 65 years
old had discontinued chemotherapy, compared
to 25% of younger patients.
Among patients receiving adjuvant chemotherapy, adjusted rates of late clinical adverse
events were lower for patients 75 years and older
vs for younger patients.
Regarding adverse events, 24% of patients had
at least one adverse event (defined as 31 days after
resection and 15 months after diagnosis). These
events occurred in more than twice as many patients receiving vs not receiving adjuvant chemotherapy. The average number of unique adverse
events was also higher for adjuvant chemotherapy users vs nonusers.
“Strategies to help clinicians who are uncertain about the safety of adjuvant chemotherapy
for older patients with comorbidity could increase the likelihood that evidence-based chemotherapy benefits are realised in population-based
settings. Using decision support tools built on
published trials and population-based analyses
such as these can help clinicians predict effectiveness of chemotherapy, even for patients with
comorbid conditions and advanced age,” the authors wrote.
“Systematic monitoring of symptoms and
signs among chemotherapy users, combined with
interventions to evaluate and treat these clues,
could help clinicians support patients in meeting
evidence-based treatment dosage and duration
goals.
“Clinicians who identify symptoms and signs
early and take steps to avoid serious adverse outcomes may enable their patients to complete
­recommended treatment courses while also improving quality of life.”
Source
JAMA 2010;303(11):1037-1045.
medical chronicle | June 2011 | page 69
HIV Forum
Dr
Fatima Laher
Understanding
HIV, HAART and Preterm Birth
A preterm birth is defined as birth before the 37th week (258 days to be exact) of gestation. Especially in the context of low birth
weight, preterm birth is associated with adverse infant outcomes, such as early neonatal mortality and a long list of morbidities.
The incidence of preterm birth is variable by region.
A World Health Organization (WHO) Bulletin in
January 2010 reported the highest incidence (17.5%)
in southern Africa and the lowest (3.8%) in eastern
and central Asia.
Multiple risk factors for preterm labour have been
identified, including low socioeconomic status, maternal age <18 or >40 years old, smoking, stress, low
zinc levels, maternal underweight and infections, to
name a few. The latter two may be seen more often
in untreated HIV cases.
In SA, is untreated HIV a risk factor for
preterm delivery, as compared to HIVnegative women?
To answer this question, Prof Eckhart Buchmann
from the Department of Obstetrics at the University
of the Witwatersrand, shared his re-analysis of a study
published in the journal Obstetrics and Gynecology in
2004 with his colleague Dr Karlyn Frank.
The study included women who had given birth
in 2002 at midwife-run clinics or at Chris Hani
Baragwanath Hospital in Soweto. At this time,
highly active antiretroviral therapy (HAART) was
not available in SA.
Results showed that in HIV-negative women, the
rate of preterm birth was 19.6% and in untreated
HIV-positive women, it was 25.4% (p=0.0015). This
phenomenon of a higher rate of preterm birth in
HAART-naïve HIV-positive women remained significant, even when women with pre-eclampsia, the most
common reason for iatrogenic preterm birth, were excluded: 17.6% vs 24.7% preterm in HIV negative vs
untreated positive women respectively (p<0.0001).
In 2011, untreated HIV during pregnancy is not
an option. The benefits of antiretroviral therapy for
mother and child are indisputable. The appropriate
use of HAART can reduce vertical transmission
to <1%. Current national guidelines firmly recommend HAART for those who qualify, e.g. a CD4
<350 cells/mm3, or those who have WHO Stage 4
disease, or tuberculosis (TB), and a short course of
azidothymidine (AZT) is advocated in pregnancy
for women who do not qualify for HAART.
Some studies report protease inhibitor HAART
regimens in pregnancy as a risk factor for low birth
weight, but not preterm delivery. My own work with
colleagues at the Perinatal HIV Research Unit confirms no difference in preterm rates when comparing
final trimester use of protease inhibitor vs efavirenz
vs nevirapine in patients also taking two nucleoside
reverse transcriptase inhibitors.
While no intervention has been proven to ob­
literate preterm incidence, here are some reasonable
suggestions for expectant HIV-infected mothers
worried about preterm delivery.
Firstly, treat HIV in pregnancy: Give the baby
the best chance of survival. Remember to provide
HAART to pregnant women who qualify (contrary
to the incorrect practice of some health care workers
who merely prescribe short-course AZT to all pregnant women).
Secondly, cotrimoxazole prophylaxis (two singlestrength tablets a day) should be given to pregnant
women with CD4 counts <200 cells/mm3, regardless of the trimester or breastfeeding status. This
(despite rumours) is not controversial. It is a WHOendorsed recommendation.
Even though the mode of action of cotrimoxazole
is inhibition of folate synthesis, there is no evidence
of an increased risk of adverse events in pregnancy.
The maternal-foetal benefits overwhelmingly outweigh any theoretical foetal risks.
A landmark Zambian study found significantly
improved outcomes in pregnant HIV-positive
HAART-naïve women with CD4<200 cells/mm3
who used cotrimoxazole - less chorioamnionitis (0%
vs 6%), less prematurity (18% vs 31%), and fewer
neonatal deaths (0% vs 9%) in those who had taken
cotrimoxazole through pregnancy compared to
those who had not.
Thirdly, treat all infections such as asympto­
matic bacteriuria, TB, opportunistic infections,
etc, timeously.
Finally, the importance of adequate nutrition
cannot be overemphasised. While the value of nutritional intervention has not been demonstrated
in a clinical trial, multiple observational studies link low maternal weight with preterm birth,
including one study published in the Journal of
Obstetrics and Gynaecology Research, 2009, which
reported weight gain <0.25 kg/week and body
mass index <20 kg/m 2 as independent risk factors
for preterm delivery.
Nutritional supplements, such as Ensure, may
be a valuable adjunct.
For more information, contact Dr Fatima Laher,
University of the Witwatersrand Donald Gordon
Medical Centre, on 011-482-8297/8, or visit www.
hivdoctors.weebly.com
page 70 | medical chronicle | June 2011
Pain Management
The Evidence for Tramadol/Paracetamol
as Add-on Treatment in Pain
Three randomised, double-blind, placebo-controlled studies and a subgroup analysis of one study
assessed the efficacy of tramadol/paracetamol
37.5mg/325mg fixed-dose combination as add-on
therapy in patients with moderate to severe rheumatoid arthritis pain, osteoarthritis pain or pain
associated with an osteoarthritis flare.
Patients had osteoarthritis pain with osteophytes (confirmed by radiograph within two years
of study), osteoarthritis flare pain for two to five
days or pain associated with symptomatic rheumatoid arthritis for ≥2 days before study entry.
Eligible patients had pain scores of ≥40 or
≥50mm on visual analogue scale (VAS) and at least
moderate pain on a four-point scale, symptomatic
osteoarthritis of the hip or knee for ≥1 year or rheumatoid arthritis (diagnosed according to American
College of Rheumatology criteria) for ≥6 months.
Patients also had to be receiving stabledose nonsteroidal anti-inflammatory drugs
(NSAIDs), cyclo-oxygenase (COX)-2 inhibitors
and/or ­disease-modifying antirheumatic drugs
(DMARDs) for two weeks or ≥30 days prior to
study entry.
Tramadol/paracetamol add-on therapy for up
to three months was effective in providing pain
relief and improving health-related quality-of-life
(HR-QOL) in patients experiencing moderate to
severe osteoarthritis flare pain, osteoarthritis pain
or rheumatoid arthritis pain.
In patients with osteoarthritis flare pain, mean
daily pain relief and pain intensity scores through
days one to five improved significantly with the
addition of four to eight tablets/day of tramadol/
paracetamol to ongoing treatment with NSAIDs
or COX-2 inhibitors (primary endpoint, with
improvements being sustained until study end
(day 10)).
A dose-dependent effect on pain relief was observed, with two tablets (but not one tablet) providing significant (p=0.037 vs placebo) pain relief,
as assessed by the sum of pain relief and pain intensity difference scores during the first four hours
after the initial dose. In addition, add-on treatment was assessed as ‘very good’ or ‘good’ by more
patients and doctors than ongoing treatment.
Tramadol/
paracetamol
add-on therapy for
up to three months
was effective in
relieving pain
HR-QOL parameters also improved with tramadol/paracetamol add-on therapy relative to
existing therapy in this study, as indicated by significantly (p<0.05) lower overall Western Ontario
and McMaster Universities osteoarthritis index
(WOMAC) questionnaire scores (table VIII) and
scores for the individual WOMAC items of pain
and physical function in tramadol/paracetamol
recipients. There was no significant betweengroup difference for the category of joint stiffness.
Furthermore, a subgroup analysis of this study
showed that the addition of tramadol/paracetamol
to existing treatment was also beneficial in elderly
patients (aged ≥65 years) with osteoarthritis flare
pain.
Significant (p<0.05) improvements in efficacy
outcomes and overall WOMAC scores, as well
scores for the WOMAC items of pain and physical
function (but not joint stiffness), were observed
with tramadol/paracetamol relative to placebo
add-on therapy in these patients.
Patients with rheumatoid arthritis or osteo­
arthritis pain also experienced significant pain
relief with the addition of tramadol/paracetamol
to ongoing treatment with NSAIDs, COX-2 inhibitors and/or DMARDs.
Add-on treatment with up to eight tablets per
day of tramadol/paracetamol for seven days in
patients with rheumatoid arthritis and for three
months in patients with osteoarthritis resulted in
significant improvements in mean daily pain intensity or VAS scores, as well as pain relief scores,
relative to existing therapy.
In addition, add-on treatment was assessed as
‘very good’ or ‘good’ by more patients and doctors
than ongoing treatment in both studies.
In both studies, HR-QOL parameters (as assessed by WOMAC and SF-36 scores or the
Health Assessment Questionnaire score) did not
differ significantly between patients receiving
tramadol/paracetamol add-on therapy and those
continuing on existing therapy, with the exception of significant (p<0.05) improvements with
add-on therapy in the WOMAC category of
physical function and the SF-36 category of rolephysical in patients with osteoarthritis.
Excerpted from: Dhillon S. Tramadol/Paracetamol
fixed-dose combination: A review of its use in the management of moderate to severe pain. Clin Drug Invest
2010;30(10):711-38.
* Content supplied by Janssen
medical chronicle | June 2011 | page 71
Pain Forum
Dr
Luc Evenepoel
The Impact of Genetics on Painkillers
The therapeutic effect of most drugs varies from
patient to patient. For example, some patients
find that pethidine makes them nauseous, but not
morphine (or vice versa), or that the one works
better than the other - yet both drugs act on the
same receptors.
There are several reasons for this inter-individual variability: age, comorbidities, interactions with
other drugs, ethnicity, etc. However, 20%-40%
of the perceived differences seem to be genetic.
In future, it will be possible to determine the
genetic code of all patients, and treat them with
the drugs that are the most appropriate for them
individually. This is in the distant future, but we
can already learn valuable lessons from the early
results of this new branch of pharmacology, called
pharmacogenetics.
Genetics can explain interindividual variability
of drug effects via, among others, differences in
drug absorption and their binding to receptors.
The most important seems to be the influence on
drug metabolism. The ‘cytochrome P450’ group
of enzymes responsible for drug metabolism is
rather heterogeneous and allows people to be categorised as ‘poor metabolisers’ (PM), ‘intermediate
metabolisers’ (IM), ‘extensive metabolisers’ (EM)
and ‘ultra metabolisers’ (UM).
Genetics can explain
interindividual
variability of drug
effects
What are the practical applications?
Some drugs are prodrugs: they need to be
­ etabolised into their active form (e.g. codeine,
m
tramadol). They will be effective in UM and EM,
but not in IM and PM. UM and EM experience
good pain relief with codeine, but might also suffer morphine-like side effects such as respiratory
depression.
On the other hand, codeine does not give any
pain relief to PM, but might still show adverse
effects such as sedation. Approximately 46% of
children studied have inadequate analgesia after
codeine, but do become sedated (as many mothers
know, codeine-containing preparations are sometimes used solely to keep children quiet).
Drugs that need not be metabolised to be active
(pethidine, morphine, fentanyl etc.), will be more
effective in PM and IM, and less so in EM and
UM because of their faster breakdown. Females
seem to metabolise pethidine, fentanyl and midazolam 40% faster than males.
PM have a decreased pain threshold and tolerance: They feel more pain, but are more responsive
to opioids such as morphine, pethidine, etc. The
reason is probably that they synthesise less endogenous opioids.
Genetic differences are not only responsible for
opioids’ inter-individual variability in analgesic
effect, but also for their side effects:
• A certain opioid might cause less nausea
and sedation than another for the same analgesic effect, allowing for a higher tolerance.
However, the respiratory depressant effect
may be the same. Traditionally, it was thought
that opioid-induced sedation precedes respiratory depression, and acts as a warning signal,
but this is not always the case.
• Red-haired, fair-skinned females (but not
males) seem to have a genetically increased
sensitivity for certain opioids, and a naturally
inhibitory mechanism against pain.
All of the factors mentioned are also applicable
to other analgesics, like nonsteroidal anti-inflammatory drugs (NSAIDs) and paracetamol, but
clinical studies are still lacking.
Anecdotally though, many patients who tried
different NSAIDs report that the one works better for them than another. Very little research has
been done about the variability in efficacy of local
anaesthetics, yet, again anecdotally, we know that
they seem to be less effective in some patients than
in others.
Routine access to every patient’s genetic code will
not happen for at least another decade or so, but we
can use the early findings of pharmacogenetics to
adjust our prescription habits in the following ways:
• One drug does not fit all, and one dose definitely does not fit all. Peri-operatively, intravenously titrate opioids to effect, either
manually (in the recovery room), or via patient-controlled analgesia pump in the ward.
• Ask your patients which opioids they received
previously, and what their effect and side effects were. Did morphine help? Or did it make
them so nauseous that it needed to be changed
to pethidine? Did tramadol help at all, or did
it have more side effects than analgesic effect?
• Ask which oral painkillers that they use at
home are effective for them. You might find
that diclofenac helps, but not ibuprofen,
or that mefenamic acid works well for their
menstrual pain, but not for anything else. Do
codeine-containing preparations give them
more relief than noncodeine ones? Or do they
only suffer the side effects (e.g. constipation)
without any extra analgesic effect?
• If there is no history available, try one analgesic and change to another one of the same
group if needed.
• Ideally, stay away from combination preparations, and prescribe paracetamol and the
NSAID separately. Explain to the patients
that the drugs work on different receptors in
the body, and that they themselves must try
out what works best for them: the one, the
other or the combination?
medical chronicle | June 2011 | page 73
Pain Management
Responsible Self-management of Pain,
Fever: Taking Patients Back to Basics
In the management of pain and fever, it is important
to remind patients from time to time of the side effects and dangers of using over-the-counter (OTC)
medicines in combination with other drugs, or if
they have underlying conditions. In the interests of
holistic patient care, there is also room for taking patients back to basics and advising them of the place
for nonmedicinal treatment, at least in certain stages
of pain and fever.
Fevers over 38°C are generally signs that the patient could benefit from some kind of medication to
reduce the fever. However, patients often rush to selfmedicate at the first sign of fever, without considering the important role that fever plays in fighting
infection. Fever serves as one of the body’s natural
defences against bacteria and viruses that cannot
live at a higher temperature. For that reason, low fevers should normally go untreated, unless they are
accompanied by further symptoms such as pain or
swelling.
41.6°C
The temperature
from which fevers are
considered high-grade
and dangerous
While values may vary according to different
clinicians and the condition and age of the patient, generally, low-grade fevers range from about
37.7°C-38.3°C while high-grade fevers range from
about 39.4°C-40°C and higher. Dangerous highgrade fevers­ range from over 41.6°C or higher (also
termed hyperpyrexia).
Pain can be classified as acute (short duration,
identifiable pathology, a predictable prognosis and
usually due to injuries) chronic nonmalignant (goes
on for longer, associated with progressive, debilitating diseases such as arthritis) and chronic malignant
(advanced, progressive diseases such as cancer).
Headaches are the most common cause of pain
and can be considered a separate class of pain, and
can generally be described under three categories:
muscle contraction, migraine or vascular, and sinus
headaches.
In all cases, OTC medications are a first line of
relief. However, people with chronic pain should be
warned against overuse, which can lead to side effects. Stronger prescription medications are usually
necessary for chronic malignant pain.
Paracetamol is the analgesic of choice for mild
to moderate pain and is also used to reduce fever.
It is suitable for both adults and children and is safe
for people who do not have stomach ulcers and who
cannot take aspirin.
Aspirin, the common name for acetylsalicylic
acid, is a nonsteroidal anti-inflammatory drug and
one of the most common OTC analgesic drugs in
use today, having been used since the 1890s.
Both of these medicines work by inhibiting prostaglandin in the brain. When injured, the body
produces prostaglandins, which are complex fatty
acids that act as hormones within body tissues.
Prostaglandins act by stimulating the dilation of
blood vessels and muscle contraction, which are the
beginning of pain.
Paracetamol products are suitable for most people
including the elderly and young children. It does
not interact negatively with other treatments and
can generally be taken by people who are sensitive
to aspirin. Paracetamol is also well tolerated by
people­ with peptic ulcers and generally, by asthma
sufferers. Because of its broad-spectrum usage, there
is a danger that it can be overused, leading, in extreme cases, to liver damage.
While highly effective, aspirin should not be
used by pregnant and breastfeeding women, people
who suffer from asthma or other breathing-related
disorders, who have a history of bleeding, gout or
ulcers, as well as chronic alcohol usage.
Just about every household contains aspirin; however, children under age 17 are never given aspirin
because of the concern about Reyes syndrome, a
potentially deadly disease affecting the brain and
the liver. In particular, adults and children should
not take aspirin before or during a viral illness. The
probability of contracting Reyes syndrome is small,
but there is no need to take the risk when other pain
relievers are available.
In addition to reminding consumers about the
possible side effects and dangers of combining medicines when self-medicating their pain and fever, it
is also useful to inform patients about alternative
methods of treating their symptoms.
For early treatment of fever, simple instructions such as the importance of maintaining body
fluid by drinking as much water as possible, rest,
­avoiding sudden changes in atmospheric temperatures and taking tepid baths constitute sound
advice.
The management of pain, especially chronic
pain, offers many alternatives that do not include
medication, including acupuncture, guided imagery, chiropractic treatment, yoga, hypnosis,
biofeedback, aromatherapy, relaxation, herbal
­remedies, massage and many others.
page 74 | medical chronicle | June 2011
Pain Management
Countering Abuse of Over-the-counter Drugs
André Esterhuizen
Pharmacist
With the increase in self-medication by patients,
awareness raising is vital to prevent abuse or misuse
of certain drugs. Although the most serious consequences of abuse of medicines occur with prescription drugs as these are usually more potent and
have a higher potential for abuse, the most common form of widespread abuse occurs with overthe-counter (OTC) drugs, as these are generally
much more accessible. Pharmacists and pharmacists’ assistants therefore have an important role to
play in enforcing the correct and safe use of OTC
drugs.
Abuse and misuse of medicines occur when they
are used for a purpose and/or in a quantity which
falls outside of its licensed indication. Almost any
medicine that can be purchased without a prescription can be abused. Even unscheduled preparations
of paracetamol and aspirin that can be purchased
from a supermarket are sometimes used in excessive
quantities and for a purpose outside of its licensing. The most commonly abused OTC drugs are
those that have stimulant, sedative or euphoric effects. Laxatives can also be abused for weight loss
purposes.
Stimulants are found in almost all cold and flu
preparations, as they have a decongestant effect in
the sinuses. The stimulant effect results from an
agonistic effect on the sympathetic nervous system which results in increased alertness, mental
performance and energy. Examples include ephedrine, pseudoephedrine and phenylpropanolamine.
Sedatives include opioid pain killers, of
which codeine is the only available OTC agent.
Antihistamines and cough suppressants are also
abused for their sedative, stress-relieving and euphoric effects. In excessive quantities, some formulas may even induce psychosis.
These drugs generally include the painkiller and
cough suppressant, codeine, the antihistamines,
diphenhydramine, doxylamine, cyclizine and promethazine, as well as cough suppressants, dextromethorphan, noscapine and pholcodine.
A number of measures are in place to curb the
abuse of drugs. It is the responsibility of the pharmacist and pharmacists’ assistants to enforce these.
A true addict will obviously find ways of purchasing the drugs by visiting different pharmacies and
fabricating a problem, but it is any pharmacist’s responsibility to ensure, as far as possible, that this
does not occur under his or her authority.
The various measures that are in place and are
required by law include the following:
1. Supervision
Any scheduled substance has to be purchased
under the supervision of a pharmacist. This is to
ensure that a sale can be refused should misuse of
any substance be suspected or that correct advice
can be given regarding the correct use of a
substance.
2. Accessibility
This ties in closely with the supervision requirement. Scheduled substances should be kept out
of reach of the general public behind a counter to
eliminate self-selection of drugs and force the sale
to go via a pharmacist.
3. Pack sizes or quantities
Unscheduled substances which can be bought
from a supermarket or via self-selection are available in small packs only. Examples of this is
paracetamol, which is unscheduled in small pack
sizes, but classified as schedule 1 in bigger packs, to
prompt intervention by a pharmacist, should larger
quantities be required.
Following widespread abuse and the manufacturing of illicit drugs from ephedrine and pseudoephedrine, all pure ephedrine-containing products
have been reclassified as schedule 6. It is still available in cold and flu remedies, provided it is combined with another substance and that it not sold in
a quantity exceeding 720mg.
Most pack sizes for products containing these
agents have been changed accordingly and it is illegal to sell more than that quantity to any given
customer.
4. Licensed indications
All products that can be bought without prescriptions are for symptomatic relief only and the
box or package insert will state that the treatment
period should not exceed a certain number of days
without consulting a doctor for a proper diagnosis.
It is important to enforce this, as some substances
such as codeine and certain antihistamine combinations are still available in large packs and are heavily
abused for purposes other than tension headaches or
cough suppression, for which they are indicated.
5. Record keeping
The details of the person buying any scheduled
substance must be recorded. This includes the
name and quantity of the drug purchased, the date,
as well as the name and address of the purchaser.
This obviously provides details of how regularly a
certain drug is purchased.
In SA, larger pharmacy chains have computer
systems that are linked within the company. Ideally,
there should be a system that links all pharmacies
across the country, which will help to identify addicts who purchase the various drugs at different
pharmacies.
Pharmacists can also choose not to sell certain
products over-the-counter if abuse is suspected in
certain instances. Measures such as not stocking a
product or keeping stock out of sight and only selling them on prescription are sometimes employed.
*Article written on behalf of Adcock Ingram
Healthcare
medical chronicle | June 2011 | page 75
Nutrition Forum
Nutritional Insights: Enteral Feeding
Acute pancreatitis creates a catabolic stress state
promoting a systemic inflammatory response and
nutritional deterioration. Adequate supply of nutrients plays an important role in recovery. Total parenteral nutrition (TPN) has been standard practice
for providing exogenous nutrients to patients with
severe acute pancreatitis.
However, recent data suggest that enteral nutrition (EN) is not only feasible, but safer and more effective. Therefore, the authors sought to update their
systematic review to re-evaluate the level of evidence.
2.5 days
Hospital stay was
reduced in EN vs
TPN groups
Objectives
To compare the effect of TPN vs EN on mortality, morbidity and length of hospital stay in patients
with acute pancreatitis.
Search strategy
Trials were identified by computerised searches
of the Cochrane Controlled Trials Register, the
Medical Literature Analysis and Retrieval System
Online and the Excerpta Medica Database.
Additional studies were identified by searching Scisearch, bibliographies of review articles
and identified trials. The search was undertaken
in August 2000 and updated in September 2002,
October 2003, November 2004 and November
2008. No language restrictions were applied.
Selection criteria
Randomised clinical trials comparing TPN to
EN in patients with acute pancreatitis.
Data collection and analysis
Two reviewers independently abstracted data
and assessed trial quality. A standardised form was
used to extract relevant data.
In patients with
acute pancreatitis,
enteral nutrition
significantly
reduced mortality
Main results
Eight trials with a total of 348 participants were
included. Comparing EN to TPN for acute pancreatitis, the relative risk (RR) for death was 0.50
(95% CI 0.28 to 0.91), for multiple organ failure
(MOF) was 0.55 (95% CI 0.37 to 0.81), for systemic infection was 0.39 (95% CI 0.23 to 0.65), for
operative interventions was 0.44 (95% CI 0.29 to
0.67), for local septic complications was 0.74 (95%
CI 0.40 to 1.35), and for other local complications
was 0.70 (95% CI 0.43 to 1.13).
Mean length of hospital stay was reduced by 2.37
days in EN vs TPN groups (95% CI -7.18 to 2.44).
Furthermore, a subgroup analysis for EN vs TPN
in patients with severe acute pancreatitis showed a
RR for death of 0.18 (95% CI 0.06 to 0.58) and a
RR for MOF of 0.46 (95% CI 0.16 to 1.29).
Conclusion
In patients with acute pancreatitis, enteral nutrition significantly reduced mortality, multiple
organ failure, systemic infections and the need for
operative interventions compared to those who
received TPN. In addition, there was a trend towards a reduction in length of hospital stay. These
data suggest that EN should be considered the
standard of care for patients with acute pancreatitis requiring nutritional support.
Cochrane Database Syst Rev Jan 2010;20(1):CD002837.
Enteral Nutrition and Cardiovascular
Failure
Cardiovascular failure and low flow states
may arise in very different conditions from both
cardiac and noncardiac causes. Systemic haemodynamic failure inevitably alters splanchnic blood
flow, but in an unpredictable way.
Prolonged low splanchnic blood flow causes
intestinal ischaemia, increased mucosal permeability, endotoxaemia and distant organ failure.
Mortality associated with intestinal ischaemia is
high.
Why would EN be desirable in these complex
patients when TPN could easily cover energy and
substrate requirements? Metabolic, immune and
practical reasons justify the use of EN.
In addition, continuous enteral feeding minimises systemic and myocardial oxygen consumption in patients with congestive heart failure.
Further, early feeding in critically ill mechanically
ventilated patients has been shown to reduce mortality, particularly in the sickest patients.
In a series of cardiac surgery patients with compromised haemodynamics, absorption has been
maintained, and 1000-1200kcal/d could be delivered by enteral feeding. Therefore, early EN in stabilised patients should be attempted, and can be
carried out safely under close clinical monitoring,
looking for signs of incipient intestinal ischaemia.
Energy delivery and balance should be monitored and combined feeding considered when
enteral feeds cannot be advanced to target within
four to six days.
Journal of Parenteral and Enteral Nutr 2009;33(6):702-709.
Excerpted from: Clinical nutrition highlights: Science
supporting better nutrition. 2010;6(1):16-17.
medical chronicle | June 2011 | page 77
Psychiatry Forum
Dr
Ian Westmore
Managing Depression in Pregnancy
Postnatal depression, often termed ‘baby blues’, is a well-documented condition. However, not as much is known about depression
in pregnancy - a common occurrence.
Although pregnancy is generally considered to be a
time of emotional wellbeing for most women, depression is a common occurrence and needs to be
adequately managed to ensure the sustained mental
and physical health of both the mother and unborn
baby. Unfortunately, the diagnosis is frequently not
made, and when identified, confusion exists as to
what constitutes appropriate treatment for unipolar
depression in pregnancy.
Meta-analyses have indicated that the range of
antenatal depression is between 6.5%-12.9%, and a
systematic review in 2004 estimated the prevalence
of depression as 7.4%, 12.8% and 12.0% for the
three consecutive trimesters of pregnancy, respectively.1,4 Of note is that the prevalence rates are even
higher than those reported for gestational diabetes
(4%-8%) or preeclampsia (3%).2 Women already
suffering from depression at the time of conception
are at risk for relapse, especially if they discontinue
their medication during pregnancy.
It is also known that depression during pregnancy
is considered to be an independent risk factor for
subsequent adverse obstetric, foetal and neonatal
outcomes. Patients suffering from untreated depression during pregnancy are inclined to do less well
with self-care, have impaired bonding with their
babies, abuse substances and self-medicate with potentially hazardous effects.1 Yet, statistics show that
many depressed pregnant women go untreated.3
Diagnosis
The criteria for unipolar depression during pregnancy do not differ from that outside of pregnancy.
However, some of the symptoms of depression such
as fatigue and energy loss, and changes in sleeping
and eating patterns, are known to occur during
pregnancy and could be considered to be normal
phenomena.
Patients who are at risk for developing depression during pregnancy are those who have a previous history of depression or premenstrual dysphoric
disorder, live alone, have limited social support, are
younger, experience marital problems and are ambivalent about their pregnancy.1
As is always the case, consideration should be
given to the possibility of the depression forming
part of a bipolar mood disorder, and patients should
be screened for previous manic or hypomanic episodes. Treatment of bipolar disorder in pregnancy is
complex, and should be undertaken by a psychiatrist.
Treatment
Nonpharmacological: These interventions are
particularly useful in women with mild depression
during pregnancy. Psychotherapy can, and should,
be considered for treatment of depression during
pregnancy, either as a single modality, or in combination with medication. Cognitive-behavioural
therapy (CBT) and interpersonal therapy are frequently used in depressed patients. However, there
are no studies to demonstrate the efficacy of CBT
in pregnancy.1
There are some case reports that suggest that the
use of bright light therapy is useful in treating depressed pregnant women, even in those who suffer
from a nonseasonal type of depression. Physical
exercise has been shown to be effective in reducing
depression and anxiety in pregnant women who exercised during the first and second trimester of pregnancy. Further research is needed to demonstrate
clearly whether omega-3 fatty acids are useful in
treating depression during pregnancy.1
Pharmacological: It has been estimated that
3% of pregnant women take antidepressants.2
Psychotropic medications remains the first-line
treatment for women suffering from severe depression during pregnancy. However, there are no studies to quantify the efficacy of antidepressants in
pregnancy.
Physicians are naturally concerned about the
use of psychotropic medications during pregnancy.
Warnings are in place, considering identified risks
of teratogenicity, perinatal syndromes and abnormal
postnatal development. The risks for development of
these problems is, however, generally small. Pregnant
women are cautious about taking medication during
pregnancy, and as is always the case, the risk-benefit
ratio needs to be considered.
Antidepressants that have been used in pregnancy
include the tricyclic antidepressants (TCAs); the
selective-serotonin re-uptake inhibitors (SSRIs) and
selective serotonin-noradrenalin re-uptake inhibitors
(SNRIs), and atypical antidepressants. The TCAs
are generally not considered to be safe for use, considering their risk of harm in the event of overdose.
The SSRIs are considered to be a safe option for
use during pregnancy. However, studies have shown
that maternal use of paroxetine during pregnancy
did result in an increased risk of cardiovascular
birth defects. A review has found that, compared
to infants who were exposed to other antidepressants during the first trimester, those who had been
exposed to paroxetine had a 1.5-two fold increased
risk of congenital cardiac malformations. However,
a recent review from unpublished prospective cases
found that infants who had been exposed to paroxetine during pregnancy did not have a higher rate of
congenital cardiac malformations compared to the
general population incidence of approximately 1%.1
Another concern with the use of SSRIs during
pregnancy has been the possible development of
persistent pulmonary hypertension of the newborn.
This could be associated with exposure of the foetus
during the last trimester. It has, however, been questioned whether this serves as an independent risk
... to page 78
page 78 | medical chronicle | June 2011
Psychiatry
So it Exists - What Does it Look Like? Defining adult ADHD
More and more evidence has accumulated that attention deficit hyperactivity disorder (ADHD) in adults is highly genetically
inherited. Many children with the condition grow up to become adolescents and adults with persistent features of dysfunction.
Despite the robust research findings, adult ADHD has been a controversial and unpopular diagnosis.
Dr Dora Wynchank,
Psychiatrist in Private Practice in Johannesburg
So, what does adult ADHD look like? As it has been
recognised for decades in children, ADHD presents
with a combination of three symptom clusters: inattention, impulsivity and hyperactivity.
By the time patients reach adulthood, these
symptom clusters have mutated. The presentation
of the disorder is quite different in adults. Barkley
has identified four possible areas of problematic
functioning: the ability to sustain attention, inhibit behaviour, resist distraction and regulate
one’s level of activity.
If we were to examine each of the symptom
clusters in more detail: poor attention occurs
often and is a hallmark feature.
On performing repetitive or boring tasks, focus
is noticeably lacking. Many adults with ADHD
can concentrate well in areas that fascinate them.
Only in very severe cases, would the inattention
be globally present.
Concentrating on protracted tasks is often disrupted by distraction. Patients with ADHD are
chaotic, disorganised and seem to react to novelty
more quickly than others. They experience difficulty in multitasking and are poorly motivated.
They struggle to persist with one mental activity;
they might move from one uncompleted activity to
another, without finishing what they set out to do.
They find it challenging to shift attention from task
to task. They are plagued with procrastination and
may only complete boring tasks under time pressure.
They struggle to sort out personal administration.
Some highly skilled individuals are unable to
work independently. They cannot complete assignments without direct supervision. They may battle
to stay alert, or even awake in boring situations
(incidentally, many adults with ADHD have sleep
disturbances too.)
Difficulty in inhibiting one’s impulses and behaviour is another key symptom cluster in adult
ADHD. These patients interrupt frequently in conversation. They may finish the sentence of the person they are talking to.
They battle to delay gratification. In the workplace, they may find it difficult to work for a
Managing Depression in
Pregnancy
... from page 77
factor, as many other maternal and infant factors
could play a role.1
Poor neonatal adaptation may occur in up to
30% of infants with exposure to SSRIs. This is
characterised by jitteriness, poor muscle tone, weak
cry, respiratory distress, hypoglycaemia, low Apgar
scores and seizures. These symptoms generally start
within hours after delivery, but in most cases require only supportive care and clear up within one
to two weeks.
Finally, other foetal malformations such as risk
for omphalocele, craniosynostosis and anen­ce­phaly
have been associated with SSRI exposure, but the
absolute risk has been found to be very small.
Combination of treatments
Although it probably follows that, as is the case
with nonpregnant women, a combination of pharmaco- and psychotherapy may be purported to be
superior to either treatment modalities alone, the
efficacy of concurrent therapy has not been ­studied
in pregnant women.
Which antidepressant should I choose
for pregnant women?
• When deciding on the use of an antidepressant
long-term reward as opposed to immediate gratification. They may be highly impatient. This may
manifest in irresponsible behaviours, such as driving fast and recklessly, promiscuous sex, drug taking
or gambling.
‘Hyperactive’ adults are rarely seen, but regulation of activity level is often dysfunctional. Patients
describe themselves as restless, fidgety or ‘on the go’.
They are always busy and driven. They may be observed tapping, shifting position, shaking and wriggling while performing boring tasks.
They may be workaholics, full of nervous energy,
unable to relax and easily bored. Their desire for constant activity may lead to family tension. They may
self-select highly active, stimulating jobs and avoid
sedentary situations, with little physical activity.
Not only do patients present with these types
of symptoms, but their thinking style or executive
function may also be affected. Barkley (1997) has
described two further areas of difficulty: these involve working memory and the ‘mind’s voice’.
Working memory is the capacity we have to
hold information in mind. We then allow this information to guide our actions. Difficulties with
working memory result in patients being labelled
as ‘forgetful’ or disorganised thinkers. They may
lose track of the goal of the activities.
They are unable to anticipate what may well happen and therefore they prepare poorly for future
events. This also translates into chaotic time management and planning. Patients may over schedule
themselves, underestimating how long planned activities will take. They are therefore often rushing,
late or reneging on promises to deliver.
In fact, one of the areas of greatest difficulty
that I observe in my adult patients is a faulty sense
of time and poor planning abilities. They cannot
estimate accurately how long a planned activity
will take. They procrastinate and then rush. They
are often late.
We use the mind’s voice for private conversations we have with ourselves when contemplating
events and directing our own behaviour. A delayed
development of internal rule-following interferes
with the ADHD adult’s ability to self-regulate.
Patients struggle to follow through on rules and
instructions. They find it difficult to persevere with
their own plans. They may even break rules, as the
ineffective mind’s voice stops them from acting with
legal or moral principles in mind.
A final area of difficulty in these patients is their
emotional regulation. Managing moods and feelings can be very disturbed in these adults. They
may appear emotionally immature, reactive or
quick-tempered. They seem to lack willpower or
self-discipline.
In order for patients to regulate their feelings,
they need to take time to reflect. They must distinguish emotion from fact. Without this ability, they
cannot judge the significance of what is happening
in relationships.
What is happening to brain function in adult
ADHD? Dopamine is the neurotransmitter that
has been implicated in ADHD. Dopamine action
is believed to be deficient in the link between the
frontal lobes and the limbic system - the emotional
regulator of the brain.
The limbic system controls our basic emotions of
fear, anger and pleasure and formulates long-term
memories. One theory of the causation of ADHD is
that there is weak frontal cortex inhibition (rational
thought) over the limbic area (emotional centre).
The prefrontal cortex controls an important brain
function known as ‘executive function’. Deficiencies
in executive function seem to mirror ADHD symptoms. Housed in the frontal and prefrontal cortices,
executive functions combine different brain activities in order to plan a response.
Memory functions (where we came from) are integrated with the ability to future plan (where we
want to go to, how to assess the consequences of our
actions). Appropriate, controlled behaviour is then
carried out. In this way, executive functions enable
us to prioritise the best action while keeping track
of time.
Adult ADHD patients experience difficulty with
thinking through their responses. Their foresight is
very poor. They are unable to inhibit present distractions and battle to keep the future in mind.
Consequences seem to catch them unawares.
They are also often unable to inhibit motor responses, organise information, plan and complex
problem-solve. In study situations, they may struggle to learn (boring) verbal material and to recall
in this population, factors such as previous response to an antidepressant, severity of illness
and patient preference need to be considered.
• If a patient is currently taking an antidepressant to which she has previously responded,
and relapses during pregnancy, a dose increase
should be considered. Studies have shown that
a dose increase might be necessary in the second half of pregnancy, from week 27 onwards.
• When an antidepressant is reintroduced, it
should be done so at therapeutic doses. Subtherapeutic doses increase the risk of relapse,
and also increase the risk of exposing the foetus to undertreated maternal illness.
• If a pregnant woman needs to take an antidepressant and has never been exposed to
one before, consideration should be given to
prescribing an antidepressant that genetically
linked family members have responded to.
When no such information is available, the
current drug of choice is sertraline - an SSRI
that shows low placental transfer, and has a
good safety record in pregnancy and in breastfeeding women.1
C: Adverse effects in animals and no human data
available.
D: Human foetal risk seen (may be used in lifethreatening situations).
X: Proved foetal risk in humans (no indication for
use, even in life-threatening situations).
FDA Rating of Drug Safety in Pregnancy
A: No foetal risks in controlled human studies.
B: No foetal risk in animal studies, but no controlled human studies or foetal risk in animals,
but no risk in well-controlled human studies.
Table 1: Rating of drug safety in pregnancy
Drug
FDA category
SSRIs
Fluoxetine
Sertraline
Paroxetine
Fluvoxamine
Citalopram
Escitalopram
C
C
D
C
C
C
NDRIs
Bupropion
B
SNRIs
Venlafaxine
Duloxetine
C
C
NASSAs
Mirtazapine
C
TCAs
Amitriptyline
Clomipramine
Desipramine
Imipramine
Nortriptyline
C
C
C
D
D
Other
Trazodone
C
Source: Medscape.com
it at a later stage. Problems may arise for them in
sustaining attention, planning, organising, prioritising, impulsive thinking and decision making.
These difficulties are, of course, independent of the
patient’s IQ.
Another aspect of executive function that is deficient is the ability to ‘self talk’. Adults use this process when working through different choices using
words and thoughts. It is an internalised, silent, automatic process. If one is unable to have an internal
discussion about the pros and cons of a reaction,
and simply responds impulsively, the consequences
may be serious.
In summary, ADHD symptoms form a constellation of poor self-regulation and self-motivation,
especially for the impulsive/hyperactive types. Adult
ADHD is so much more than poor concentration.
Patients may be affected in work, relationships, heeding the law, self-esteem … and the list continues.
References
1. Barkley RA. Behavioral inhibition, sustained attention, and executive functions: Constructing
a unifying theory of ADHD. Psychological
Bulletin 1997;121:65-94.
2. Biederman J, Faraone S, Spencer T, et al. Patterns
of psychiatric comorbidity, cognition, and psychosocial functioning in adults with attention
deficit hyperactivity disorder. American Journal of
Psychiatry, 1993;150:1792-1798.
3. Faraone SV, Biederman J, Mick E. The age-dependent decline of attention deficit hyperactivity disorder: a meta-analysis of follow-up studies. Psychol Med
2006;36:159-165.
4. Gualtieri CT, Johnson LG. Efficient Allocation
of attentional resources in patients with ADHD:
Maturational changes from age 10 to 29. Journal of
Attention Disorders 2006;9:534-542.
5. Marczinski CA. Subclinical ADHD, stress, and
coping in romantic relationships of university students. J Atten Disord 2005;8:182 -187.
6. Overbey GA, Snell WE, Kallis KE. Subclinical
ADHD, stress, and coping in romantic relationships
of university students. J Atten Disord 2011;15:67-78. 7. Woods
SP,
Lovejoy
DW,
Ball
JD.
Neuropsychological characteristics of adults with
ADHD: A comprehensive review of initial studies.
The Clinical Neuropsychologist, 2002;16:12-34.
Adapted from Kaplan and Sadock’s Synopsis of
Psychiatry 10th edition p867.
Refer to Table 1.
Conclusion
Treating unipolar depression during pregnancy
remains a challenge for most physicians. The above
serves as a guideline, but there are many factors to
consider in treating these patients, particularly the
‘risk-benefit ratio’. Successful treatment minimises
the risk of relapse in a vulnerable patient population.
A complete assessment includes screening for
mood disorders in pregnancy and treatment options
should be discussed with the patient as soon as possible. If possible, patients who are at risk should be
informed about the risks and benefits of treatment,
and relapse, prior to their falling pregnant.
References
1. Raudzus J, Misri S. Managing unipolar depression in
pregnancy. Curr Opion Psychiatry 2009;22(1):13-18.
2. Buck ML. Drugs in Pregnancy and Lactation:
Literature and Resource update. Pediatr Pharm
2010;16(1).
3. Flynn HA, Blow FC, Marcus SM. Rates and predictors of depression treatment among pregnant women
in hospital affiliated obstetrics practices. Gen Hosp
Psychiatry 2006;28:289.
4. Hackley B. Antidepressant Medication use in pregnancy. J Midwifery Womens Health 2010;55(2):90-100.
medical chronicle | June 2011 | page 81
Sexual Health Forum
Rory du Plessis
Sexual Health Myths: Ejaculate Volume
On reviewing a number of online forums
regarding sexual health, I am struck by how
many of the postings reflect concerns that bear no
relation to pathology, illness or aspects of mental
health. Rather, a large portion is based on sexual
myths propagated by the media. For the purposes
of this article, one sexual myth will be explored,
namely a concern regarding ejaculate volume.
2%-5%
The amount
of sperm
in semen
The majority of postings are described as
follows: “Is there anything I can do to increase
my sperm volume?” and “Are there any foods/
drinks that help build up sperm?” Although only
two quotes are provided, they reflect one of the
overarching themes shared by the majority of such
postings: a conflation and confusion with the
terms sperm, ejaculate and semen.
Rather, there are distinct differences between
sperm, semen and ejaculation. Biologically, sperm
makes up only between 2%-5% of a given sample
of semen. Semen is released through the penis
during ejaculation.
One result of this conflation is that semen
and ejaculation are imbued with the importance
allotted to sperm - its role in reproduction and
markers related to fertility.
A further aspect that is shared in the postings
is related to the fact that no actual volume of
ejaculate is recorded. As such, the issue of ejaculate
volume may not necessarily be about auditing the
amount of ejaculate.
Rather, I argue that it is primarily related
to the aesthetics of ejaculation as is evident in
porno­graphy. This argument runs parallel to Lisa
Moore’s (2007) belief that our understanding of
sperm is based on sociocultural representations of
human semen.
Therefore, to account for the sociocultural
context of sperm in the 21st century, one needs to
re­cognise the role of pornography. This account
is not solely based on academic analysis and
interpretation, but is explicitly acknowledged and
peddled­ in the marketing of supplements that
claim to increase ejaculate volume.
The role of pornography has been outlined
in numerous publications as a key influence
in contributing to ideas in society about sex from what constitutes sex or sex acts to what
is considered sexy. In particular, pornography
specialises in representing a variety of techniques
to animate ejaculation and semen (Moore 2007).
In other words, ejaculate becomes scripted
and framed just like the actors in the film, to
achieve certain narrative aims. This is so much so
that much of the scenes in a pornographic films
can be argued to be about the achievement and
impressive display of ejaculation - the force of
ejaculate, the amount and its aim (Moore 2007).
In this line of reasoning, we may consider that
pornography has cast ejaculation as a quintessential
role in the genre itself. This idea is supported by a
number of pornographic genres that focus solely
on semen as the central theme of the narrative and
the action (Moore 2007). Pornography frames
ejaculation as a focus point - and in doing so, the
more spectacular the ejaculation, the larger the
volume, the more eruptive and explosive the force,
the better.
The framing of ejaculate in the above terms is
also noticeable in mainstream films - these films
have adopted many of the stylistic conventions
related to displaying ejaculation in pornography.
Dr Etienne Kok is in agreement with the main
argument of this article that the importance
allocated to ejaculation volume ‘is very much
based on myth and false expectations’. To counter
these myths, it is important to consider the
scientific facts of ejaculation.
Most notably, ejaculation volume is established
as being between 2-5ml. The variations in
ejaculation volume are based on a number of
factors - time of abstinence as well as amount of
and duration of stimulation.
Furthermore, Dr Kok cautions that rather than
being a quality to be esteemed; a large ejaculate
volume poses a significant fertility problem.
If the ejaculate is constantly more than 6ml in
an individual, it is known as hyperspermia and
can lead to a fertility problem.
The high volume of ejaculate that mainly
consists of secretions from the seminal vesicles
and prostate gland can dilute the sperm and result
in an insufficient concentration of sperm that are
unable to find their way to the fallopian tubes for
fertilisation to take place.
Ejaculate constantly
more than 6ml
(hyperspermia)
can lead to
fertility problems
The central motivating factor of this article
has been that it is imperative to analyse the social­
structures that shape and influence sexuality.
This goal was approached through recognising
the influence that pornography has in defining and
representing male ejaculation - the very ­influence
of which leads to heightened levels of anxiety for
men regarding the volume of ejaculation.
References available on request.
Herpes and Relationships: How to Tell
Prof Elna McIntosh,
Getting the facts
Sexologist
The more emotionally charged an issue, the
more important it is to find out the facts. Most
people know little or nothing about herpes.
Frequently, what knowledge patients have is
coloured­by myth and misconception.
Some of the basic facts that could be provided
to them include:
• Herpes simplex virus (HSV) most often shows
up as small blisters or sores on either the face
or mouth (cold sores or fever blisters) or the
genitals.
• HSV can be passed on when one person has
the virus present on the skin or mucosa and
another person makes direct skin-to-skin contact with the live virus.
• The virus is likely to be present on the skin
from the first sign of prodrome (tingling or
itching where the outbreak usually occurs),
until the sores have completely healed and
new skin is present.
• There are likely to be certain periods of time
(possibly only a few days out of the year)
when the active virus might be on the skin,
even though there are no obvious signs or
symptoms.
• Always using latex condoms may possibly reduce the risk of transmitting the virus during
these times.
• Herpes is very frequently transmitted by infected persons who don’t know they are infected. Since they have not been diagnosed,
they are unaware that they may be contagious
from time to time.
• Once diagnosed, a person generally is able to
take the simple precautions necessary to protect partners - avoiding contact during prodrome or an outbreak, and practising safer sex
when no symptoms are present.
Additional educational materials will offer more
information. It is important for both partners to
find out as much as possible about the condition.
It would be helpful to provide the patient with
educational materials on genital herpes, which
Many people do not feel comfortable talking
about sexuality and sexual health issues. The
health professional can assist patients diagnosed
with genital herpes in coming to terms with their
condition by offering some practical advice to
help them feel more confident in sharing this vital
information with potential sexual partners. This
article will explore various aspects in this regard.
Facial herpes (including cold sores on the lips)
and genital herpes are medically the same condition at different sites.
The significant difference arises from the stigma
that tends to accompany an infection that is sexually transmitted.
While some people may experience an unsupportive response, in fact, most have found their
partners both supportive and understanding.
Fear of rejection runs deep, and it leads some
to question why they should risk talking about
herpes­. Instead, they abstain during outbreaks,
practice safe sex at other times, and hope for the
best.
This strategy has more disadvantages than advantages. It’s much harder to tell someone who has
just found out they’re infected, or for them to find
out elsewhere. For most people, the anxiety of not
telling is worse than the telling itself.
If a person enters into the relationship with
full knowledge of their partner’s infection, the
likelihood of them becoming infected is reduced.
When an outbreak occurs.
Failure to confide may lead to a person being
talked into sex, even during a possible outbreak.
On the other hand, if two people are able to discuss the situation openly and honestly, they can
negotiate around it.
Imaginative lovers find ways to weather temporary setbacks.
Self-esteem, adaptation and acceptance
People can, and do, tell potential partners
successfully. While there is no fail-safe method, a
number of approaches can make it much easier.
Firstly, it’s important to remember that herpes
doesn’t change all the good things about a person.
To some extent, likelihood of infection is like the
toss of a dice. It can happen to anyone. It has nothing to do with intelligence, social habits or bank
account.
Genital herpes is extremely common, with studies suggesting that in some countries, up to one in
five people are infected with this virus, whether
they know it or not. Despite the fact that it is so
common, negative stereotypical beliefs related to
herpes abound and have become subconscious beliefs for the herpes sufferer.
It is important for the patient to learn to recognise these and to consciously replace them with
positive statements and to continually reinforce
these. This aids acceptance by a person that he/she
has herpes, which will, in turn, make it easier to let
others into their life.
will give them further information and provide
them with something they can give to their partner to read.
Preparing to tell partners
Tips for telling partners include:
• Timing: Before sexual contact is initiated, ideally, when a degree of comfort and trust in each
other’s company has been achieved and when
the couple can enjoy undivided, uninterrupted
attention.
• Opportunities: Advise the patient to look for
logical opportunities to bring up the subject.
‘Safe sex’ and AIDS are common topics today.
• Place: Somewhere neutral, safe and comfortable, or while taking a walk. Ideally, where
partners feel free to share emotions.
• Be positive and confident: Expecting rejection
increases the chances of an unhappy outcome.
Telling one’s partner is the right thing to do for both parties.
• Delivery affects the message: They should
speak calmly and clearly, and look the person
in the eye.
• Avoid melodrama: This is not a confession or a
lecture, but simply the sharing of information
between two people.
• Practise: They might consider practising by
telling a friend first.
Realistic and unrealistic expectations
People may need a little time to think it through
or to gather more information. The majority of people will react well and negative reactions are often
the result of misinformation.
Whether or not the relationship works out, the
person has been enlightened with education and
experience.
Some of the myths about herpes that cause so
much harm have been corrected, while the barrier
of silence that makes it so difficult to speak about
herpes has been removed. The patient will have
confronted a difficult issue in his/her life with courage and consideration.
medical chronicle | June 2011 | page 83
Wound Care
Quicker Healing of Venous Stasis Wounds
Imagine a battlefield medic or emergency medical
technician providing first aid with a special wad
of cottony glass fibres that simultaneously slows
bleeding, fights bacteria, stimulates the body’s natural healing mechanisms, resists scarring and - because it is quickly absorbed by surrounding tissue may never have to be removed in follow-up care.
Alternatively, imagine diabetics with hard-to-heal
wounds finding a source of relief from the battle
against infections and limb amputation.
These scenarios are the hope of the developers
of a revolutionary borate glass nanofibre material,
which appears have sped up and helped the final
healing of long-term wounds in eight out of 12 venous stasis wound sufferers in a recent clinical trial
held at a medical centre in the US.
Details about the trials and the glass fibre material were published in the May issue of the
American Ceramic Society’s Bulletin magazine. The
story reports on the discovery of the fibres and on
an empirical study that began in late 2010, supervised by the internal review board of the Phelps
County Regional Medical Center (PCRMC). The
trial groups originally had 13 volunteers, but one
dropped out during the early stages.
The cottony glass
fibres slow
bleeding, fight
bacteria and
resist scarring
According to Peggy Taylor, the registered nurse
who administered the treatments, all of the volunteers who took part in the trial are enthusiastic
about the use of the glass fibre product, which she
said ‘looks like candy floss’.
“All of the participants had diabetes and several
of them had wounds that had been unhealed for
more than a year,” said Taylor, a specialist in wound
care.
“One patient had the same wound for three
years. After using the glass fibre product for a few
months, we were able to repair the skin in eight of
the patients. Remarkably, the other four have made
a lot of progress and all of their wounds should be
healed soon, too.”
The patients in the test group suffered from
problems associated with venous stasis, a condition
where blood circulation in extremities is poor. As
the blood pools, typically in the lower legs, fluids
accumulate causing unusually high pressure on
skin tissues. Sores and wounds can then develop
when the fluid ‘weeps’ from skin cracks, cuts or
abrasions.
Because of an enzyme in the weeping fluid, the
skin surrounding small venous stasis injuries can
quickly erode and turn into large and deep wounds.
Even small bruises can eventually develop into
bone-deep openings.
The goal of the trial was to provide an initial
evaluation of the effects of the novel fibrous glass
material. ‘Bioglass’ materials aren’t particularly new
to the medical field, but thus far all bioglass has
been formed from silica-based glass compositions,
and these primarily have been used in hard-tissue
regeneration, such as bone repair.
Glass scientist Steve Jung, who helped develop the new material, said he and co-developer,
Prof Delbert Day, had wondered whether a different type of bioactive glass material could be used
for soft-tissue regeneration.
“Our in vitro studies showed that bioactive
glasses containing boron should react to body fluids
much faster than silicate glasses,” said Jung.
“We also knew that another in vitro study of lithium borate glasses had showed it to have beneficial
effects against bacteria, such as E coli, salmonella
and staphylococcus microbes.”
Lastly, Jung and Prof Day recalled that they
were interested in a composition that was rich in
calcium.
“Previously, investigators have reported that calcium is important for wound healing. It appears to
assist the migration of epidermal cells and help the
body regulate the healing process of open wounds,”
said Jung.
Besides composition, Jung and Prof Day thought
the structure of the material may be important to
consider too and suspected that ­providing a healing
‘scaffold’ might be beneficial to skin reconstruction.
“We wanted to have a material that could mimic
the microstructure of fibrin that normally forms
the basis of a blood clot. We reasoned that if the
structure could imitate fibrin, it might trap blood
platelets and allow the formation of a wound cover
that could support the healing process.”
Jung and Prof Day finally settled on a particular
borate glass composition that could be formed into
cottony glass fibres, 300 nanometres to five micrometres in diameter. After animal tests showed no
adverse effects, the company approached PCRMC
about starting the small-scale human test. The trial
was approved in July 2010 and Taylor saw her first
patient one month later.
Once the study was underway, the company
provided Taylor with individual, foil-sealed packets containing pads made of the glass fibres. She
said the material was easy to apply and seemed to
disappear over time, a phenomenon that has been
observed with other bioglasses.
Taylor acknowledges that the wounds would
have probably required expensive vacuum-assisted
healing systems as an alternative. Besides low cost
and ease of use, Taylor said the glass fibres seem to
offer another stunning benefit: low scarring.
The next step is expanded human trials and Jung
and Prof Day are optimistic about a new era in
wound treatment.
Source
www.healthandbeautyreview.co.za
page 84 | medical chronicle | June 2011
Women’s Health
Exploring Bone Health Solutions - DXA
Hologic developed the first DXA bone densitometer, which remains the gold standard for spine
and hip bone screening around the world. Its densitometry systems are used by more leading medical schools, universities, osteoporosis opinion leaders and pharmaceutical trials than any other bone
densitometer.
Advantages of Hologic Discovery
Speed and image quality: The OnePass single
sweep scanning captures the hip and spine with
10-second scanning time. No other system comes
close to the combined speed and imaging resolution of Discovery, with better than 1.8Lp/min.
Automatic hip positioning: The AccuView
finds the bone edge for perfect positioning and automatically centres the hip the same way on followup exams for improved precision. It helps eliminate
common positioning errors, saving time and eliminating unnecessary rescanning.
Superior visualisation: The device’s imaging
technology provides superb image quality by eliminating the beam overlap errors and image distortion found in rectilinear systems.
A computer-aided fracture assessment is also
incorporated to quantify and display the degree of
vertebral compression and helps to confirm the existence and severity of deformities.
Consistency from exam to exam: The device
performs continuous, automatic calibration, ensuring precise measurements results from exam to
exam. Preferred scan protocols can be created and
automated to speed analysis and improve workflow.
Integrated structural analysis of the hip: The
technology enables a new dimension in bone health
assessment with Hip Structural Analysis (HSA),
which uses DXA measurements to calculate the
structural geometry of the hip.
HSA provides a better predictor of biomechanical strength than using bone mineral density
(BMD) alone.
This exclusive feature helps determine
whether bones are reduced in strength
to the point that they require treatment
and, if the patient is being treated, if the
bones are getting stronger.
Superior vertebral fracture assessment: Hologic pioneered the next generation of vertebral fracture assessment
(VFA) technology, high-definition instant
vertebral assessment (IVA-HD), which
dramatically improves the detection of vertebral fractures.
IVA-HD doubles the resolution of previously
available techniques with a safe low-dose, single
energy image. Discovery is the first system to integrate the definitive factors for osteoporotic fracture risk: BMD and VFA.
Heart disease detection through calcification visualisation: Using the enhanced visualisation provided by IVA-HD, Discovery can help
medical practitioners appreciate calcifications in
the abdominal aorta.
Clinical studies have shown that abdominal aortic calcification (AAC) is a significant indicator of
heart disease.
Patients who have osteoporosis are often at risk
for cardiovascular problems - the number one cause
of morbidity and mortality in older women and
men.
Whole body composition: Obesity is a growing
health concern worldwide. According to the World
Health Organization, there are an estimated 400 million obese adults worldwide.
In the last 20 years, morbid obesity
(BMI>40) has gone from one in 200
adults to one in 50 adults in
the US alone. One in five schoolage children (9.2 million) are either
overweight or obese.
The Body Composition Analysis accurately
measures fat mass, lean mass and total mass for
the entire skeleton and for up to seven user-defined
subregions.
This information provides one with a comprehensive analysis of fat distribution. It also allows
one to monitor results for your pediatric patients
to a variety of criteria (e.g. height vs weight, weight
vs age, Centers for Disease Control and Prevention
growth curves).
Paediatric bone health assessment: Discovery
uses advanced analysis algorithms to detect and
measure the low-density bone mass that is characteristic of paediatric patients.
Evaluate therapies with supine lateral BMD:
Discovery offers more clinical options for vertebral
assessment than any other bone densitometer available today. Supine lateral spine BMD provides a
more sensitive means of detecting bone loss or gain
than AP spine BMD measurement alone, especially in older patients. With the push of a button, the
Discovery C-arm automatically moves into position for highly precise supine lateral scanning.
The rotating C-arm eliminates patient repositioning, which means more precise lateral
and anteroposterior views. With Discovery’s
advanced fan-beam DXA, you get a clear
measurement and visualisation of
trabecular-rich vertebral
bodies, which are usually the first bone tissues to show degeneration as well as positive
response to therapy.
3D hip measurement
for more accurate
fracture assessment
Hologic is pioneering 3D hip
measurements, a breakthrough dimension in fracture risk assessment.
Analysing bone structure requires creating a
3D ­volumetric density model.
Combining low-dose ­tomographic technology
with the rapid image sequencing made possible by
a rotating C-arm, Discovery can capture multiple
views of the femur at different angles and mathematically construct a 3D rendering.
Three-dimensional hip measurement will
­provide a powerful new tool for measuring the true
strength of the femur and more accurately determining the risk of future fractures. (US Food and
Drug Administration clearance is pending).
Osteoporosis Screening - Just do it!
As people age, they accumulate a number of illnesses, which increases their risk of morbidity.
Osteoporosis is such a disease. Unfortunately, it is
a silent disease and patients seek medical attention
when it is too late. Most patients present with osteoporotic fractures, indicative of a more established
form of disease, which is more difficult to treat. It
is much more beneficial to the patient to treat the
illness as early as possible. Therefore, screening is
imperative for early detection.
According to Dr Brent Tipping, geriatrician
at the Wits Donald Gordon Medical Centre in
Johannesburg, osteoporosis in men is grossly
underdiagnosed.
“Women’s magazines are fantastic at raising
awareness of osteoporosis in women, but the same
does not apply for the media targeting men.”
It is not uncommon for men around 85 years old
to suffer from osteoporosis and men who sustain
fractures or break bones have a worse prognosis and
a higher mortality.
High-risk patients
High-risk patients need to be identified and
screened to manage the onset of the disease or detect
early signs of osteopenia. Identifying and treating
patients at risk of fracture, but who have not yet sustained a fracture, will substantially reduce the longterm burden of osteoporosis. Reducing the risk of
first fracture from 2% to 8% can reduce the five-year
fracture incidence from approximately 10% to 34%.
Risk factors
• Age (women 45 years and older; men from 65
years onward).
• Menopausal status.
• Specific illnesses that can accelerate bone loss,
e.g. thyrotoxicosis, parathyroid abnormalities.
• Family history of thinner bones.
•
•
•
•
•
•
Certain medications such as cortisone.
Testosterone deficiency.
Rheumatoid arthritis.
Smoking.
Excessive alcohol consumption.
Nutritional status (severe eating disorders,
malnutrition).
• Falling.
About bone densitometry
Traditionally, the dual energy x-ray absorptiometry (DXA) bone densitometer ascertains the bone
mineral density.
“These days, we also incorporate risk factors
to assess fracture risk and the DXA scan helps to
confirm who should start prophylactic strategies or
treatment,” affirmed Dr Tipping.
Computerised tomography, ultrasound and bone
biopsies are used more in the research arena and
are not available in clinical practice in SA. The frequency of screening depends on the results of the
scan and older women are advised to be screened
every three years.
“The procedure is quick, easy and painless with
a very low dose of radiation,” said Dr Tipping. “It
is vital that trained radiographers carry out the
procedure.”
Hospital x-ray departments generally carry out
these scans.
Final thoughts on screening
“Unfortunately, in my practice, I see very advanced cases. GPs promote primary health care
and should aim to prevent illnesses. In modern
times, the doctor’s role is to keep patients well.
Osteoporosis is a preventable, manageable disease and early screening helps ensure early detection, which clearly benefits patients,” Dr Tipping
concluded.
medical chronicle | June 2011 | page 85
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page 86 | medical chronicle | June 2011
// Periscope
Updates and New Products
Document Solutions for the Medical Industry Providing Quality
Surgical Products
without Compromise
Bytes Document Solutions’ Xerox division has appointed
Med-e-Mass as a value-added reseller to serve the
country’s medical industry. Med-e-Mass already services
over 9000 customers in the medical practitioner, hospital,
specialist, group, administrative bureaux as well as the
dental and auxiliary health services markets.
“Med-e-Mass, part of the Altron group, is an independent
software vendor, which means it owns its IP, and its footprint
extends throughout SA and into sub-Saharan countries,” said
Peter Vieira, national channel manager of Xerox system sales at
Bytes Document Solutions.
“Xerox is a world-renowned and quality brand associated with
printing, copying and document management,” said Jayesh
Reddy, general manager at Med-e-Mass.
“We want to pass on to our clients the certainty that they are
dealing with a solution of substance.”
Med-e-Mass offers product support through a national call
centre, backed by four regional offices and 48 dealers that deliver
further telephonic or on-site support. The national call centre,
which is the client’s first port of call, is staffed by skilled customer
service agents with years of industry and product knowledge.
They not only handle technical queries, but through a tailored call
logging system, they can map clients’ needs and support trends.
Med-e-Mass leases its product for a monthly fee and offers
regular updates, support and maintenance to ensure that clients
always comply with the latest regulations in the rapidly evolving
health care industry. This is the perfect platform to offer printing
solutions as a value-added service to Med-e-Mass’s existing
client base.
Med-e-Mass has already kick-started the partnership by
selling Xerox printers, multifunction devices and consumables
for Xerox devices and Xerox replacement consumables for HP
devices to its customers through a mail campaign.
“The Xerox hardware is fully integrated with Med-e-Mass’s
suite of products and doctors, pharmacies and hospitals will
enjoy benefits through the partnership in terms of price, delivery
and a three-year warranty,” said Vieira.
Xerox also has an international agreement with Aycan for its
x-ray printing solution that was recently cemented locally through
a partnership between Bytes Document Solutions’ Xerox division
and Shinda Medical, the local Aycan agent.
This has seen radiologists around the country realise millions in
savings.
lll For more information, contact Jayesh Reddy on
012‑347‑2323, at [email protected], or go to
www.medemass.com
Pharmaceutical Company Launches
New Dermatology Division
In line with its vision of being a leading, world-class,
focused health care company, Adcock Ingram has
established a new dermatology business unit which
offers a range of prescription dermatological products.
“Adcock Ingram Dermatology is committed to improving
the quality of patients’ lives and providing dermatologists
with additional solutions for their patients’ needs,” said
recently appointed head of Adcock Ingram Respiratory and
Dermatology, Gary Vine.
Vine said the establishment of Adcock Ingram
Dermatology will ensure therapeutic alignment across the
company’s product range. The products will be marketed
by an established national dermatology sales force and the
new structure will ensure a high level of focus within each
therapeutic area.
The therapeutic areas that the dermatology division will
focus on include eczema, acne, psoriasis and skin infections.
“Through strategic collaboration with our valued partners
including LEO Pharma, Novartis, MSD and Roche, we are
now able to offer health care professionals and our patients a
wide range of prescription dermatological brands,” said Vine.
Some of the key brands within these areas include Elidel,
Elocon, Roaccutane, Dovobet, Famvir, Fucidin, Fucidin H and
Quadriderm.
“We are extremely proud to introduce our full range of
dermatological products to the market for the effective
treatment of skin conditions,” said Vine.
lll For further information, contact dermatology brand
managers, Nicolette Kotze, on 011-635-0627 or Shakti Pillay,
on 011-635-0642.
Adcock Ingram Limited. Reg. No. 1949/034385/06
Private Bag X69, Bryanston, 2021 South Africa
Telephone + 27 11 635 0000
www.adcock.com
Legacy Medical, distributing for CHEX Healthcare,
Manufacturers of Frankenman International, features
products with high-quality design and high-quality
manufacturing. Products have the necessary quality
accreditation - full CE and ISO 13485, 9001 accreditation
and US Food and Drug Administration clearance since
June 2009.
All product design is tested as strenuously as possible.
Tests are performed in-house and by qualified outside
contractors. Continuous feedback is incorporated in the
manufacturing and design development process. The end
product received for patient use is thus quality without
compromise.
The process does not end there:
• The company receives feedback from surgeons who are
using the products.
• Surgeons’ reports are read.
• Surgeons are invited to brainstorm with the company.
The company chooses to put the patient ahead of the
manufacturing process.
lll For more information, call Legacy Medical on
012‑997‑2155, fax 012-997-2070, email [email protected]
or go to www.legacymedical.co.za
New Lease on Life
for Schizophrenic
Patients
Olanzapine (Olexar) has been launched as Cipla’s first
atypical antipsychotic agent in its extensive range of
psychiatric medicines.
Olanzapine is indicated for the treatment of psychotic disorders
including psychotic manifestations of schizophrenia and acute
mania in patients with bipolar disorder. It is also indicated for the
prevention of recurrence of a manic or depressive episode in a
patient with bipolar disorder.¹
From the results of the Clinical Antipsychotic Trials for
Intervention Effectiveness (CATIE) trial and Cochrane
Collaboration Comparison Study, it was concluded that
olanzapine is the most effective antipsychotic compared to
several other available agents since:²,³
• Patients who took it demonstrated a greater reduction in
psychopathology.
• It allowed for a longer duration of successful treatment (patients
continued with treatment for a longer period of time).
• Its use was associated with a lower rate of hospitalisation.
The medication is available at an extremely affordable price
and offers a 45% to 60% cost saving, compared to the originator.
It is priced as follows (SEP excluding VAT):4
* Olexar 2.5mg R250
* Olexar 5mg R390
* Olexar 10mg R500
lll For further information, contact Wouter Lombard, product
manager CNS, Cipla Medpro on 021-917-5620 or email wouter@
ciplamedpro.co.za
References
1. Olexar PI.
2.Lieberman JA, et al. September 2005. Effectiveness of antipsychotic
drugs in patients with chronic schizophrenia. N Engl J Med 2005;353:120923.
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3.Komossa K,
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medical chronicle | June 2011 | page 87
Updates and New Products
Periscope //
Taking the Itch
Vitamin D Key Treating Acute Mania
out of the Scratch to Fighting Flu in Bipolar Patients
The launch of two revolutionary new skin care products,
Cetaphil Restoderm Skin Restoring Body Wash and
Cetaphil Restoderm Skin Restoring Body Moisturiser, is
good news for atopic dermatitis sufferers, as they will do
much to reduce redness, dryness and irritation - common
symptoms of this skin condition.
Both contain patented ceramide and flaggrin technology,
which helps replenish the skin’s natural
lipids and restore moisture to help rebuild
the damaged skin
barrier. Clinically proven
to be nonirritating, these
products are highly
tolerable and fragrance
free, with studies
showing that they can
be used in children
as young as three
months with atopic
skin.
These products,
when included in
the daily cleansing
and moisturising
regimen, will do much
to provide increased
tolerability.
lll Product information and references available on request.
Galderma Laboratories South Africa (Pty) Ltd Co Reg No: 1996/000311/07.
Vitamin D may be the key to preventing winter colds and
flu. A recent study published in Nature Immunology found
that without vitamin D, T cells cannot activate and launch
an immune response.1 Recognition of an antigen, the
first step in the process of T cell mobilisation, signals the
transcription of vitamin D receptors.
Only once the new vitamin D receptors bind vitamin D, is
a signal sent to the T cell’s DNA to encode phospholipase
C gamma1, which, in turn, catapults the T cell into action.
If insufficient vitamin D is present then the whole process
comes to a standstill and the T cell never launches its immune
response.
There is far less sun in the winter months and,
consequently, vitamin D levels are low. Insufficient vitamin D
means less T cell activation and a poor immune response in
the face of a threat.
With this new understanding, it’s easy to see why winter
is synonymous with colds and flu, while lending additional
support to previous findings which found that supplementation
with 1200IU of vitamin D3 (the most active form of vitamin D)
lowered the incidence of seasonal flu by 42%.2
lll For more information, contact SOLAL Technologies on
011‑783‑3939 or email [email protected]
References
1.Von Essen MR, Kongsbak M, Schjerling P, et al. Vitamin D controls
T cell antigen receptor signaling and activation of human T cells. Nature
Immunology, 2010;11:344-349
2.Urashima M, Segawa T, Okazaki M, et al. Randomized trial of vitamin
PO Box 71150, Bryanston, 2021. Tel: (011) 706-2339. www.galderma.com
D supplementation to prevent seasonal influenza A in schoolchildren. Am J
CET 1006-5.
Clin Nutr, 2010;91:1255-60.
Supporting Epilepsy SA to
Combat Stigma
At the recent 2011 Neurological Association of SA
congress, Cipla Medpro once again showed its
commitment to creating awareness about the social
challenges of patients living with epilepsy.
Epilepsy SA has a programme consisting of five virtual
walls of ‘True Potential’ in support of, and representing, its
major service programmes. This project aims to decrease
discrimination towards people with epilepsy and raise funds
to ensure sustainable service delivery. At the congress, Cipla
Medpro made a large contribution to one of the walls - the
Wall of Empowerment - on behalf of the delegates, thus raising
additional funds.
Apart from manufacturing medicine to treat epilepsy (Epitec),
the company also understands the importance of providing
continued patient education and supports awareness campaigns
surrounding the management of the condition, hence its
involvement in Epilepsy SA.
lll For more information, contact Wouter Lombard, Cipla
Medpro, on 021-917-5620.
Collaborating to Save
Children’s Sight in Africa
To establish 10 paediatric eye-care clinics in 10 years
in sub-Saharan Africa - that was the commitment
from multinational sight-saving organisation, ORBIS,
a nonprofit organisation dedicated to saving sight
worldwide. The announcement was made at a
conference held in Cape Town
last month aimed at developing
strategies to prevent childhood
blindness in Africa. Eye-care
nongovernmental organisations,
ophthalmologists, health
department officials and
academics from 15 countries
attended the conference.
With a direct link between the
incidence of blindness and poverty,
sub-Saharan Africa carries the
Prof Colin Cook,
heaviest burden with 23% of the
head of
world’s blind population (India has
ophthalmology,
19% and China 13%).
University of Cape
“In terms of global blindness
Town
alleviation, southern Africa is a priority region,” said Lene
Øverland, programme director for ORBIS Europe, Middle
East and Africa.
At the meeting, she challenged stakeholders to add on to
the organisation’s pledge of $1m (R6.7m) to establish one
paediatric eye care clinic each year, over the next 10 years.
“There are fewer paediatric ophthalmologists and
paediatric eye centres in Africa than anywhere else in the
world. Correcting the tragedy of preventable blindness in the
region is an urgent public health priority,” Øverland said.
According to Prof Colin Cook, head of ophthalmology
at the University of Cape Town, Groote Schuur Hospital
and Red Cross War Memorial Children’s Hospital, 50% of
childhood blindness is avoidable.
The World Health Organization recommends one
paediatric ophthalmic centre per 10 million people. SubSaharan Africa is grossly under-catered for in this field with
just 11 centres across the 47 countries.
SA only has one dedicated children’s facility at the Red
Cross Hospital and many countries in the region do not even
have a paediatric ophthalmologist.
Olanzapine (Redilanz) is an atypical antipsychotic indicated
for the management of the manifestations of psychotic
disorders and for the treatment of acute mania in bipolar
disorder.
Olanzapine will be available as 2.5mg, 5mg and 10mg. It
should be administered on a once-a-day schedule without
regard to meals, beginning with an initial dose of 5-10mg/day,
with a target of 10mg/day being reached within several days.
Further dose adjustments, if indicated, should occur at intervals
not less than one week.
Dr Reddy’s Laboratories (Pty) Ltd. Reg no. 2002/014163/07. South Wing,
The Place, 1 Sandton Drive, Sandton 2196, South Africa. Tel: +27-11-783-0104.
Fax: +27-11-388-1262. www.drreddys.co.za
S5 Redilanz 2,5/5/10. Each tablet contains olanzapine 2,5 mg/5 mg/10 mg. Reg. No’s.
42/2.6.5/0813;0814;0815.
Toothpaste’s Solution
to Tooth Sensitivity
Colgate-Palmolive SA introduces Colgate Sensitive ProRelief toothpaste, a major advance in the treatment of tooth
sensitivity. With its patented, Pro-Argin formula, the product
offers relief to the 29% of South Africans who have claimed
to have suffered from sensitivity.
It is the first and only toothpaste to incorporate Colgate’s ProArgin technology and is clinically proven to deliver instant and
lasting sensitivity relief. While most of the sensitive toothpastes
currently marketed primarily numb sensitivity pain, this product
effectively plugs the channels that lead to sensitive tooth nerves,
thereby blocking the transmission of heat, cold, air and pressure
that stimulate pain receptors within teeth. “The product can be
directly applied to a sensitive tooth, using your finger tip to gently
massage for one minute, to deliver instant relief from sensitivity,”
said Dr William DeVizio, VP, Global Technology, Colgate-Palmolive.
Tooth sensitivity is an oral condition that affects up to 57% of
consumers worldwide. The touch of a dental instrument can
make routine dental visits unbearable. This discomfort may lead
sensitivity sufferers to avoid regular checks ups - neglect that can
result in a progression of oral care problems.
lll For more information, go to www.instantrelief.co.za
page 88 | medical chronicle | March 2011
Product & Service Listing
// Directory
Refer to Company Listing for contact details
Ambulances and Accessories
•3M
•Afrivent
•Afrox Medical Gases
•B Braun
•Dräger Medical SA
•Gabler Medical
•Live Wire Learning
•Myriad Medical
•Miracle Medical
•SSEM Mthembu Medical
Ambulance Equipment
•3M
•Afrivent
•Afrox Medical Gases
•B Braun
•Gabler Medical
•Myriad Medical
•Miracle Medical
•Respiratory Care Africa
•Sere-med
•SSEM Mthembu Medical
•Viking Medical
•Welch Allyn
Anaesthetic Equipment
•Afrivent
•Afrox Medical Gases
•CareFusion
•Clinical & Medical Services
•Covidien
•Dinaledi Medical
•Dräger Medical SA
•Edwards Lifesciences
•Gabler Medical
•Marland Medical
•Med Loyd
•Myriad Medical
•Respiratory Care Africa
•R. Moloney & Company
•Scientific Group
•Surgimed Hospital Supplies
•Viking Medical
Anaesthetic Masks,
Breathing Bags, etc.
•Afrivent
•Afrox Medical Gases
•Clinical & Medical Services
•Dräger Medical SA
•Intersurgical RSA
•Laurike Marketing
•Marland Medical
•Myriad Medical
•SSEM Mthembu Medical
•Surgimed Hospital Supplies
•Viking Medical
Anaesthetic Trolleys
•Kendon Medical
•Surgimed Hospital Supplies
Aneurysm Clips
•Viking Medical
Architectural Systems
•Dräger Medical SA
Archiving and
Documentation Equipment
Bandages
•3M
•Hartmann - Vitamed
•Health In Form
•Johnson & Johnson Medical
•Kendon Medical
•Laurike Marketing
•Med Loyd
•Miracle Medical
•Sere-med
•Surgical & Ophthalmic Supplies
•Surgimed Hospital Supplies
Bath Tubs and Showers
•Franke Kitchen Systems
Bed Pan Flushing Equipment
•Franke Kitchen Systems
•SAFMED
•Scientific Group
Bed Pans
•Health In Form
•Kendon Medical
•Miracle Medical
•Surgimed Hospital Supplies
Bedding
•Miracle Medical
•Restonic
Bedside Tables and Cupboards
•BioClin Solutions
•Cook Chill
•Medical Excellence
•Miracle Medical
•Respiratory Care Africa
•Scientific Group
•Surgimed Hospital Supplies
Biopsy Forceps
•Johnson & Johnson Medical
•Medequip
•Surgimed Hospital Supplies
Biopsy Needles - Bone Marrow
•Adcock Ingram Critical Care
•Philisa Biomedical
•Surgimed Hospital Supplies
Biopsy Needles - Soft Tissue
•Adcock Ingram Critical Care
•Philisa Biomedical
•Vertec Scientific
Blood Bank Equipment
•Clinical Sciences Diagnostics
•Hemocue South Africa
•Scientific Group
•Viking Medical
Blood Bank Refrigerators
•Surgimed Hospital Supplies
Blood Gas Analysis
•Hartmann - Vitamed
•Ilex
•Myriad Medical
Blood Grouping Equipment
•Ilex
•Tidy Files
Arthroscopy
•Flurovizion
Assistive Listening Devices
•Hearing Innovations
•Live Wire Learning
Audiology Diagnostic Equipment
•3M
•Amtronix
•HASS Industrial
•Hearing Innovations
•Medical Excellence
•Surgimed Hospital Supplies
•Viking Medical
•Welch Allyn
Automated External
Defibrillators
•Kendon Medical
•Live Wire Learning
•Medical Excellence
•Miracle Medical
•Sere-med
•SSEM Mthembu Medical
•Welch Allyn
Autopsy Tables
•Dinaledi Medical
•Franke Kitchen Systems
Baby Warmers
•BioClin Solutions
•Dinaledi Medical
•Gabler Medical
•Medical Excellence
•Miracle Medical
•Surgimed Hospital Supplies
Balance Assessment Equipment
•Amtronix
Bandage Trolleys
•Cook Chill
•Health In Form
•Surgimed Hospital Supplies
Blood Grouping Kits
•Ilex
Blood Pressure Monitoring
Equipment
•Alcomed Medical Supplies
•BioClin Solutions
•Clinical & Medical Services
•Dinaledi Medical
•Edwards Lifesciences
•Hartmann - Vitamed
•Kendon Medical
•Manta Medical
•Medical Excellence
•Miracle Medical
•Sere-med
•SSEM Mthembu Medical
•Surgimed Hospital Supplies
•Welch Allyn
Blood Transfusion Equipment
•B Braun
•CareFusion
•Clinical Sciences Diagnostics
•Viking Medical
Blood-warming Equipment
•Augustine Medical SA
•BioClin Solutions
•Clinical & Medical Services
•Covidien
•Dinaledi Medical
•Gabler Medical
•Medical Excellence
•Surgimed Hospital Supplies
Body Contouring
•Intamarket
•Radiant Healthcare
•Technolase
Bone Density Tests
•Mammography Centre
Bone Mineral Analysers and
Densitometers
•Vertec Scientific
Brachytherapy
•CR Bard
Breast Implants
•Conquest Surgical Supplies
•Genop Healthcare
Breast Self-Examination Gel
•Vertec Scientific
Building Administration
and Supplies Management
•Radiant Healthcare
Building Technical Management
•Radiant Healthcare
Cannulae, Rigid and Flexible
•Afrox Medical Gases
•Conquest Surgical Supplies
•Covidien
•Edwards Lifesciences
•Flurovizion
•Manta Medical
•Med Loyd
•Ophthalmic Precision Instruments
•Radiant Healthcare
•Respiratory Care Africa
•Surgical & Ophthalmic Supplies
•Viking Medical
Cardiology - Balloon Catheters
•B Braun
•Johnson & Johnson Medical
•Manta Medical
•Viking Medical
Cardiology Catheter Sheath Introducers
•B Braun
•Johnson & Johnson Medical
•Manta Medical
•Viking Medical
Cardiology Diagnostic Catheters
•B Braun
•Johnson & Johnson Medical
•Manta Medical
•Viking Medical
Cardiology - Guidewires
•B Braun
•Johnson & Johnson Medical
Cardiology High Pressure Syringe
•Covidien
Cardiology - Stents
•B Braun
•Johnson & Johnson Medical
•Viking Medical
Catering Equipment
and Contractors
•Cook Chill
•Franke Kitchen Systems
Catheters
•Alcomed Medical Supplies
•B Braun Medical
•Covidien
•CR Bard
•Edwards Lifesciences
•Manta Medical
•Medequip
•Med Loyd
•Miracle Medical
•Nu Angle Medical
•Philisa Biomedical
•Surgimed Hospital Supplies
•Viking Medical
Certification and
Testing of Medical Devices
•Myriad Medical
Chest Drains
•Covidien
•Dinaledi Medical
•Johnson & Johnson Medical
•Viking Medical
Children’s Cots and Basinettes
•Health In Form
•Surgimed Hospital Supplies
Cleaning of Buildings
•Manta Medical
Cleaning of
Health care Facilities
•Evolution Medical
•Mediguard Healthcare Services
Clinical Education and Support
•3M
•Afrivent
•B Braun Medical
•CareFusion
•Live Wire Learning
•Manta Medical
•Myriad Medical
•Viking Medical
Clinical Management
•BHG (SA)
•CareFusion
•SleepNet/BreatheNet
Clinical Pathology
•Abbot Laboratories
•Hemocue South Africa
Colorectal Solutions
•B Braun Medical
•Covidien
•Johnson & Johnson Medical
Complete Equipping of Hospitals
•Afrox Medical Gases
•CareFusion
•Clinical & Medical Services
•Live Wire Learning
•Miracle Medical
•Radiant Healthcare
Computer Hardware
•Delta 9 Hospital Software Solutions
•Pro Med Computer Services
Computerised Tomography (CT)
Equipment
•Philips Healthcare
•Pro Med Computer Services
•Vertec Scientific
Conference Venues
•CSIR Conference Centre
•Eskom Conference Centre
Conforming Gel Pads for
Ultrasound
•Alcomed Medical Supplies
•Vertec Scientific
•Viking Medical
Convention Centres
•Cape Town International
Convention Centre
•Durban International Convention
Centre
•Sandton Convention Centre
Cosmetics
•G A Active
•Lesmed Procucts
•Radiant Healthcare
Critical Care
•Ilex
•Viking Medical
Cryotherapy and
Cryosurgery Equipment
•Nitran Surgical Systems
•Radiant Healthcare
•R. Moloney & Company
•Sere-med
•Surgimed Hospital Supplies
Darkroom Equipment
•Imagex
•Lomaen Medical
Defibrillators
•Alcomed Medical Supplies
•Dinaledi Medical
•Medical Excellence
•Miracle Medical
•Philips Healthcare
•Sere-med
•SSEM Mthembu Medical
Dialysis Consumables
•Adcock Ingram Critical Care
•B Braun Medical
•Covidien
•SSEM Mthembu Medical
•Viking Medical
Dialysis Equipment
•Adcock Ingram Critical Care
•B Braun
•CR Bard
•SSEM Mthembu Medical
Dialysis Fluids
•Adcock Ingram Critical Care
•B Braun Medical
Diathermy Equipment
•B Braun Medical
•Clinical & Medical Services
•Covidien
•Laurike Marketing
•Medequip
•Medical Excellence
•Miracle Medical
•Nitran Surgical Systems
•Onemed
•R. Moloney & Company
•Scientific Group
•Sere-med
Digital Radiography/Computed
Radiography Equipment
•AGFA Healthcare
•Carestream Health
•Imagex
•Lomaen Medical
•Philips Healthcare
•Pro Med Computer Services
•Scientific Group
•Vertec Scientific
Disabled Access
•Evolution Medical
•JessenDakile
Disinfectant Cleaner for
Ultrasound Probes
•Alcomed Medical Supplies
•Evolution Medical
•Vertec Scientific
Disinfectants
•Alcomed Medical Supplies
•Evolution Medical
•Health In Form
•Johnson & Johnson Medical
•Kendon Medical
•Miracle Medical
•SAFMED
•Scientific Group
•Sere-med
•Vertec Scientific
Disinfecting Washers
•Evolution Medical
•Franke Kitchen Systems
•Johnson & Johnson Medical
•Miele
•SAFMED
•Scientific Group
Disinfection Preparations
•Laurike Marketing
Disposable Articles
for Hospitals
•3M
•AGFA Healthcare
•B Braun
•Coloplast
•Dinaledi Medical
•Dräger Medical SA
•Kendon Medical
•Laurike Marketing
•Myriad Medical
•Miracle Medical
•Ophthalmic Precision Instruments
•Respiratory Care Africa
•Viking Medical
Doctors’ Bags, Emergency Cases
•Miracle Medical
•Sere-med
Drug Tests
•Clinical Sciences Diagnostics
•Health In Form
•Kendon Medical
•Miracle Medical
•Philisa Biomedical
ECG Equipment
•BioClin Solutions
•Clinical & Medical Services
•Covidien
•Dinaledi Medical
•Imagex
•Kendon Medical
•Medical Excellence
•Miracle Medical
•Philips Healthcare
•Respiratory Care Africa
•Surgimed Hospital Supplies
•Welch Allyn
Educational Appliances
•Live Wire Learning
•Miracle Medical
EEG Equipment
•Kendon Medical
•Respiratory Care Africa
•R. Moloney & Company
•SSEM Mthembu Medical
EEG Monitoring Equipment
•Philips Healthcare
•Respiratory Care Africa
•SSEM Mthembu Medical
Electronic Healthcare Records
•BHG (SA)
•CareFusion
•Delta 9 Hospital Software Solutions
•Pro Med Computer Services
Electronic Patient
Record Software
•BHG (SA)
•CareFusion
•Delta 9 Hospital Software Solutions
•Pro Med Computer Services
Electrophysiology
•CR Bard
Electrosurgical Instruments
•B Braun
•Covidien
•CR Bard
•Flurovizion
•Johnson & Johnson Medical
•Laurike Marketing
•Nitran Surgical Systems
•Ophthalmic Precision Instruments
•Scientific Group
•Surgimed Hospital Supplies
Electrotherapy Equipment
•Alcomed Medical Supplies
•CR Bard
•Nitran Surgical Systems
•Radiant Healthcare
•Scientific Group
•Viking Medical
Emergency and Transport
Ventilators
•Afrox Medical Gases
•Clinical & Medical Services
•Dräger Medical SA
•Myriad Medical
•Miracle Medical
•Respiratory Care Africa
•Scientific Group
•SSEM Mthembu Medical
•Viking Medical
Emergency Room Equipment
•3M
•B Braun
•Myriad Medical
•Miracle Medical
•Respiratory Care Africa
•SSEM Mthembu Medical
•Surgimed Hospital Supplies
•Viking Medical
•Welch Allyn
Endoscopy Equipment - Flexible
•B Braun
•Covidien
•Imagex
•Medequip
•R. Moloney & Company
Endoscopy Equipment - Rigid
•B Braun
•Covidien
•Flurovizion
•Imagex
•Medequip
•Nitran Surgical Systems
•Onemed
•R. Moloney & Company
•Smith & Nephew
•Welch Allyn
Endotracheal Tubes
•Covidien
•Dinaledi Medical
•Laurike Marketing
•Med Loyd
•Miracle Medical
•SSEM Mthembu Medical
•Viking Medical
ENT Diagnostic Equipment
•Amtronix
•BioClin Solutions
•Clinical & Medical Services
•Dinaledi Medical
•Flurovizion
•Kendon Medical
•Medical Excellence
•Miracle Medical
•R. Moloney & Company
•Sere-med
•Surgimed Hospital Supplies
•Viking Medical
•Welch Allyn
Equipment Accessories
•B Braun
•Franke Kitchen Systems
•Kendon Medical
•Myriad Medical
Equipment for Day Wards
•Afrox Medical Gases
•BioClin Solutions
•B Braun
•Clinical & Medical Services
•Cook Chill
•Dinaledi Medical
•Medical Excellence
•Respiratory Care Africa
•SSEM Mthembu Medical
•Welch Allyn
Equipment for Neonatal Units
•3M
•Afrivent
•BioClin Solutions
•B Braun
•CareFusion
•Clinical & Medical Services
•Dräger Medical SA
•Gabler Medical
•Medical Excellence
•Myriad Medical
•Philips Healthcare
•Respiratory Care Africa
•Scientific Group
•SSEM Mthembu Medical
•Viking Medical
Ergometers
•Welch Allyn
medical chronicle | March 2011 | page 89
Product & Service Listing
Directory //
Refer to Company Listing for contact details
Exam, Treatment, ICU and
Recovery Rooms equipment
•Afrivent
•Afrox Medical Gases
•BioClin Solutions
•B Braun
•Clinical & Medical Services
•Dräger Medical SA
•Gabler Medical
•Health In Form
•Medical Excellence
•Miracle Medical
•Philips Healthcare
•Respiratory Care Africa
•SSEM Mthembu Medical
•Viking Medical
Examination and Medical Lamps
•BioClin Solutions
•Clinical & Medical Services
•Dinaledi Medical
•Dräger Medical SA
•Kendon Medical
•Medical Excellence
•Miracle Medical
•R. Moloney & Company
•Scientific Group
•Sere-med
•SSEM Mthembu Medical
•Welch Allyn
Exhibition Organisers
•Fair Consultants
Feeding Tubes
•Covidien
•Med Loyd
•Miracle Medical
•Respiratory Care Africa
•Viking Medical
Fibre-optic Equipment
•Kendon Medical
•Miracle Medical
•R. Moloney & Company
•Welch Allyn
First-aid Equipment
•B Braun
•Kendon Medical
•Miracle Medical
•Sere-med
Floor Coverings, Wall
Cladding and Ceilings
•Polyflor
Fluid Management Pumps
•B Braun
•Flurovizion
Foetal Monitoring Equipment
•Bioclin Solutions
•Clinical & Medical Services
•Medical Excellence
•Miracle Medical
•Nitran Surgical Systems
•Philips Healthcare
•Respiratory Care Africa
•SSEM Mthembu Medical
•Surgimed Hospital Supplies
Fontanelle Scanning Pads
for Ultrasound
•Vertec Scientific
Food Supplements
•Meri Brands
Forced Air Warming
•Augustine Medical SA
•Clinical & Medical Services
•Covidien
Gas and Compressed Air Systems
•Air Liquide
Gas Therapy Equipment
(oxygen, ozone, etc)
•Afrox Medical Gases
•Air Liquide
•Gabler Medical
Gaseous Exchange Monitoring
Equipment and Breathalysers
•Air Liquide
•Myriad Medical
Gases for Cold Sterilisation
•Air Liquide
Genetic Counselling
•Gknowmix Genetic Care Centre
Genetic Testing
•Gknowmix Genetic Care Centre
Gloves Examination and Protective
•Alcomed Medical Supplies
•Auckland Orthopaedics
•B Braun
•Covidien
•Hartmann - Vitamed
•Kendon Medical
•Laurike Marketing
•Manta Medical
•Med Loyd
•Miracle Medical
•Sere-med
Gloves - Surgeon
•Alcomed Medical Supplies
•B Braun
•Covidien
•Hartmann - Vitamed
•Kendon Medical
•Laurike Marketing
•Manta Medical
•Med Loyd
•Sere-med
Gynaecology
Diagnostic Equipment
•Afrox Medical Gases
•Alcomed Medical Supplies
•BioClin Solutions
•Dinaledi Medical
•Kendon Medical
•Medical Excellence
•Miracle Medical
•Nitran Surgical Systems
•Onemed
•Philips Healthcare
•R. Moloney & Company
•SSEM Mthembu Medical
•Viking Medical
•Welch Allyn
Hammers, Percussion and Reflex
•Alcomed Medical Supplies
•Miracle Medical
Hearing Aids
•Hearing Innovations
Hearing Instruments
•Oticon SA
Heart Valves (Aortic and Mitral)
•Edwards Lifesciences
•Viking Medical
Heart-Lung Machines
•Scientific Group
•Viking Medical
Heating Technology
•Edwards Lifesciences
•SSEM Mthembu Medical
Haemodynamic Monitoring
•Edwards Lifesciences
•SSEM Mthembu Medical
•Viking Medical
Hip Endoprotheses, Knee &
Shoulder Prostheses
•Auckland Orthopaedics
•B Braun
•Laurike Marketing
HIV Diagnosis & Management
•Dr Keyser & Marshall
HIV Testing
•Dr Keyser & Marshall
Hospital Beds
•BioClin Solutions
•Cook Chill
•Health In Form
•JessenDakile
•Medical Excellence
•Scientific Group
Hot-air Sterilisers
•Miracle Medical
Image Documentation Systems
•Nobel Biocare SA
•Pro Med Computer Services
Implantable Catheters
and Long-term Access
•CR Bard
•Manta Medical
Implants and Protheses
•Auckland Orthopaedics
•B Braun
•Conquest Surgical Supplies
•CR Bard
•Dinaledi Medical
•Genop Healthcare
•Johnson & Johnson Medical
•Nobel Biocare SA
•Surgical & Ophthalmic Supplies
•Synthes
Incontinence and Stoma Aids
•Coloplast
•CR Bard
•Holister SA
•Manta Medical
•Nu Angle Medical
Incontinence Products
•B Braun
•Hartmann - Vitamed
•Johnson & Johnson Medical
•Nu Angle Medical
Infant Incubators
•BioClin Solutions
•Clinical & Medical Services
•Dräger Medical SA
•Medical Excellence
•Respiratory Care Africa
•Scientific Group
Infusion Pumps
•Adcock Ingram Critical Care
•B Braun
•CareFusion
•Clinical & Medical Services
•Fresenius Kabi
•Gabler Medical
•Myriad Medical
•Scientific Group
Infusions Sets
•Adcock Ingram Critical Care
•B Braun
•CareFusion
•Fresenius Kabi
•Gabler Medical
•Kendon Medical
•Myriad Medical
•Scientific Group
•Sere-med
Inhaler and Aerosol Equipment
•Myriad Medical
Insect Repellent
•Acorn
•BioClin Solutions
Instrument and
Syringe Sterilisers
•BioClin Solutions
•Sere-med
Insulin Syringes and Injectors
•B Braun
•Health In Form
•Kendon Medical
•Manta Medical
•Med Loyd
•Sere-med
Intraoperative Drains
•Dinaledi Medical
•Johnson & Johnson Medical
Invasive Pressure
Monitoring Products
•Manta Medical
•SSEM Mthembu Medical
Laparoscopic Equipment
•B Braun
•Covidien
•Gabler Medical
•Johnson & Johnson Medical
•Medequip
•Nitran Surgical Systems
•Onemed
Laryngoscopes
•BioClin Solutions
•Clinical & Medical Services
•Dinaledi Medical
•Kendon Medical
•Live Wire Learning
•Medequip
•Medical Excellence
•Miracle Medical
•R. Moloney & Company
•Sere-med
•Welch Allyn
Laser Equipment - Aesthetic
•Intamarket
•Radiant Healthcare
•Scientific Group
•Technolase
Laser Imaging Equipment
•Carestream Health
•Scientific Group
Laser Surgery Equipment
•Radiant Healthcare
•Spectra-Medic
Laser Therapy Equipment
•Alcomed Medical Supplies
•Genop Holdings
•Radiant Healthcare
Laundry Equipment & Facilities
•Evolution Medical
Lifting Platforms
•JessenDakile
Lighting Equipment
•Dinaledi Medical
•Medical Excellence
•SSEM Mthembu Medical
•Welch Allyn
Linen
•Health In Form
Liposuction
•Radiant Healthcare
•Sound Aesthetics
Liposuction - Radio Frequency
•Radiant Healthcare
•Technolase
Lithotripsy Equipment
•Spectra-Medic
Lubricants - Sterile
•Johnson & Johnson Medical
Male Sling - Advance
•Marcus Medical
Mammo Pads
•Vertec Scientific
Mammography
•AGFA Healthcare
•Carestream Health
•Mammography Centre
•Philips Healthcare
•Vertec Scientific
Mattresses
•BioClin Solutions
•Health In Form
•Medical Excellence
•Respiratory Care Africa
•Restonic
Medication Safety Software
•CareFusion
Microdermabrasion
•Radiant Healthcare
•Technolase
Microscopes
•Carl Zeiss
•Clinical Sciences Diagnostics
•Medequip
•Nitran Surgical Systems
Minimally Invasive Surgery
•Medequip
•Radiant Healthcare
Mobile X-Ray Equipment
•AGFA Healthcare
•Imagex
•Lomaen Medical
•Philips Healthcare
•Vertec Scientific
Molecular Diagnostics
•Ilex
•Molecular Diagnostic Services
Monitoring Equipment Pulse, Respiration & ECG
•Afrivent
•BioClin Solutions
•Clinical & Medical Services
•Dräger Medical SA
•Medical Excellence
•Myriad Medical
•Miracle Medical
•Philips Healthcare
•Respiratory Care Africa
•Scientific Group
•SSEM Mthembu Medical
•Welch Allyn
MRI Equipment
•Afrivent
•Dräger Medical SA
•Philips Healthcare
Nebulizers
•Sere-med
Needle-free Disposable Devices
•Alcomed Medical Supplies
•B Braun
•CareFusion
•Gabler Medical
•Manta Medical
•Radiant Healthcare
•Viking Medical
Neonatal Care Equipment
•B Braun
•Clinical & Medical Services
•Dräger Medical SA
•Gabler Medical
•Medical Excellence
•Myriad Medical
•Scientific Group
•SSEM Mthembu Medical
•Viking Medical
Nephrostomy Sets,
Stone Baskets
•Philisa Biomedical
Neurology
Diagnostic Equipment
•Philips Healthcare
•SSEM Mthembu Medical
Neurosurgery Equipment
•Medequip
•Nitran Surgical Systems
•Viking Medical
Nuclear Medicine
•Covidien
Nuclear Medicine Equipment
•Philips Healthcare
Occupational Therapy Equipment
•Alcomed Medical Supplies
•Live Wire Learning
Ocular Diagnostic Equipment
•Genop Healthcare
•Ophthalmic Precision Instruments
Office Furniture
•CN Business Furniture
OMF Implants
•Marcus Medical
Operating Room Textiles
•Manta Medical
Operating Tables
•Clinical & Medical Services
•Dräger Medical SA
•Miracle Medical
•Respiratory Care Africa
•SAFMED
Ophthalmic Implants,
Artificial Eyes, Lenses
•Carl Zeiss
•Genop Healthcare
•Surgical & Ophthalmic Supplies
•Viking Medical
Ophthalmic
Instrumentation and Fluids
•Carl Zeiss
•Flurovizion
•Marcus Medical
•Ophthalmic Precision Instruments
•Viking Medical
Ophthalmic
Monitoring Equipment
•Amtronix
•Ophthalmic Precision Instruments
Ophthalmic Units
•Carl Zeiss
•Genop Healthcare
•Gerry van Winsen Optics
•Surgical & Ophthalmic Supplies
Ophthalmoscopes
•Dinaledi Medical
•Genop Healthcare
•Gerry van Winsen Optics
•Medical Excellence
•Sere-med
•Welch Allyn
Optometry Instruments
•Gerry van Winsen Optics
OR Lights
•Clinical & Medical Services
•Dräger Medical SA
•Medical Excellence
•Miracle Medical
•SAFMED
•Scientific Group
•SSEM Mthembu Medical
OR Technology and Equipment
•Dräger Medical SA
•Myriad Medical
•Respiratory Care Africa
•SSEM Mthembu Medical
Orthopaedic Prostheses - Hip
•Auckland Orthopaedics
•Laurike Marketing
Orthopaedic Prostheses - Knee
•Auckland Orthopaedics
•Flurovizion
•Laurike Marketing
Orthopaedic Prostheses
- Shoulder
•Flurovizion
•Laurike Marketing
Orthopaedic Prostheses Small joint
•Flurovizion
•Laurike Marketing
Orthopaedic Powertools
•Flurovizion
Orthopaedic Per systems
•Flurovizion
Orthopaedic Trauma Products
•Auckland Orthopaedics
•Flurovizion
•Laurike Marketing
•Marcus Medical
•Philips Healthcare
•Smith & Nephew
•Surgimed Hospital Supplies
Oximeters
•Alcomed Medical Supplies
•BioClin Solutions
•Clinical & Medical Services
•Covidien
•Dinaledi Medical
•Health In Form
•Laurike Marketing
•Medical Excellence
•Miracle Medical
•Respiratory Care Africa
•Scientific Group
•Sere-med
•SleepNet/BreatheNet
Oxygen Generating Systems
•Air Liquide
•Intaka Tech
•Medical Excellence
•Miracle Medical
Oxygen Therapy Equipment
•Afrivent
•Afrox Medical Gases
•Clinical & Medical Services
•Gabler Medical
•Intersurgical RSA
•Radiant Healthcare
•Respiratory Care Africa
•Sere-med
•SSEM Mthembu Medical
•Viking Medical
PA Catheters
•Edwards Lifesciences
•SSEM Mthembu Medical
Patient Care Trolleys
•BioClin Solutions
•Medical Excellence
Patient Lifting Equipment
•Kendon Medical
•Scientific Group
Patient Monitors
•BioClin Solutions
•Clinical & Medical Services
•Dinaledi Medical
•Dräger Medical SA
•Kendon Medical
•Medical Excellence
•Miracle Medical
•Nitran Surgical Systems
•Philips Healthcare
•Respiratory Care Africa
•Scientific Group
•SSEM Mthembu Medical
•Surgimed Hospital Supplies
•Viking Medical
•Welch Allyn
Patient Transfer Equipment
•Respiratory Care Africa
•Scientific Group
PCA Devices
•CareFusion
•Gabler Medical
•Viking Medical
Penile Prostheses
•Marcus Medical
•R. Moloney & Company
Pharyngeal Tubes,
Laryngeal Masks
•Dinaledi Medical
•Med Loyd
•Myriad Medical
•Scientific Group
•SSEM Mthembu Medical
Physiotherapy Equipment
•Alcomed Medical Supplies
•Nitran Surgical Systems
Plaster of Paris Bandages
•Kendon Medical
•Sere-med
Pregnancy Tests
•Clinical Sciences Diagnostics
•Kendon Medical
•Philisa Biomedical
•Sere-med
Premature Baby
Products & Services
•Little Miracle Products & Services
•Viking Medical
Prolapse Surgery Products
•Johnson & Johnson Medical
•Marcus Medical
•Onemed
Prostate
Thermotherapy Equipment
•CR Bard
Prostheses - Eyes
•Custom Eyes
Prostheses - Hip
•Auckland Orthopaedics
•Laurike Marketing
•Smith & Nephew
Prostheses - Knee
•Auckland Orthopaedics
•B Braun
•Laurike Marketing
•Smith & Nephew
Prostheses - Shoulder
•Laurike Marketing
•Smith & Nephew
Protective Clothing
•AGFA Healthcare
•Alcomed Medical Supplies
•Miracle Medical
•Vertec Scientific
page 90 | medical chronicle | March 2011
Product & Service Listing
// Directory
Pulmonary Function
Equipment and Spirometers
•Covidien
•Medical Excellence
•Respiratory Care Africa
•R. Moloney & Company
•SSEM Mthembu Medical
•Welch Allyn
Radiotherapy Equipment
•CR Bard
•Nitran Surgical Systems
•Vertec Scientific
Rebreathing Bags
•Clinical & Medical Services
•Covidien
•Intersurgical RSA
•Laurike Marketing
•Myriad Medical
•Miracle Medical
•Scientific Group
•SSEM Mthembu Medical
•Surgimed Hospital Supplies
Reconstruction Instruments
and Implants
•Synthes
Refer to Company Listing for contact details
Services - Financial Services
•PPS Insurance
Services - Lawyers
•Webber Wentzel
Services - Managed Healthcare
•Agility Global Health Solutions
Services Medical Administrators
•Health-Worx
•Status Medical Administrators
Services - Medical Aid Care
•Eternity Private Health
•Fedhealth
Services - Medical Scheme
•GEMS
•Genesis Medical Scheme
•Resolution Health Medical Scheme
Services - Medical Scheme
Managed Care Services
•Agility Global Health Solutions
Services - Ocularist
Rehabilitation Devices
and Equipment
•Alcomed Medical Supplies
Rescue Helicopters and Aircraft
•B Braun
•CareFusion
•Myriad Medical
•Miracle Medical
Respiration Masks
•Afrox Medical Gases
•Covidien
•Dräger Medical SA
•Intersurgical RSA
•Laurike Marketing
•Myriad Medical
•Respiratory Care Africa
•SleepNet/BreatheNet
•SSEM Mthembu Medical
•Surgimed Hospital Supplies
Respiratory
Monitoring Equipment
•Afrox Medical Gases
•Amtronix
•Myriad Medical
•Nitran Surgical Systems
•Respiratory Care Africa
•SSEM Mthembu Medical
•Surgimed Hospital Supplies
Rib and Sternal Fixation
•Synthes
•Custom Eyes
Services - Pathology Services
•Ampath
•Lancet
•Toga
Services Practice Revenue Management
•Quantum Revenue Management
Services - Recruitment
•Thymic Connections
Services - Smoking Cessation
•Dr Gavin Zipp & Associates
Services - Staff Outsourcing
•Quintiles Commerical Solutions
Services - Travel Agency
•Edenvale Travel
•Rosebank Travel Service
•Thompson’s Leisure Travel
•XL Travel
Sleep Disorders
Diagnostic Equipment
•Respiratory Care Africa
•SleepNet/BreatheNet
•SSEM Mthembu Medical
Slit Lamps
•Gerry van Winsen Optics
RIS/PACS Systems
•AGFA Healthcare
•Carestream Health
•Imagex
•Lomaen Medical
•Philips Healthcare
•Pro Med Computer Services
Scales
•BioClin Solutions
•Live Wire Learning
•Medical Excellence
•Miracle Medical
•R. Moloney & Company
•Scientific Group
•Sere-med
Scalpel and Surgical Blades
•B Braun
•Medequip
•Sere-med
Self-Retaining Retractors
•Marcus Medical
•Medequip
Self-Monitoring Equipment
•Dräger Medical SA
•Health In Form
•Sere-med
•Vertec Scientific
Sentinel Node
Detection Equipment
•Johnson & Johnson Medical
Services - BLS Training Centre
•Sere-med
Services Information Technology
•Switch
Services Insurance Underwriters
•Alexander Forbes Compensation
Technologies
Services - Financial Advisors
•First Health Finance
•Imperial Bank
Software
•AGFA Healthcare
•Amtronix
•Delta 9 Hospital Software Solutions
•Pro Med Computer Services
Specialised Skin Care
•Environ Skin Care
•Radiant Healthcare
Sphygmomanometers
•Alcomed Medical Supplies
•BioClin Solutions
•Dinaledi Medical
•Medical Excellence
•Miracle Medical
•R. Moloney & Company
•Scientific Group
•Sere-med
•Welch Allyn
Spinal Anaesthesia Products
•B Braun
•Manta Medical
Spinal Implants
•Astech
•Laurike Marketing
Splints
•Kendon Medical
•Miracle Medical
•Sere-med
Stapling Devices Open and Laproscopic
•Covidien
•Gabler Medical
•Johnson & Johnson Medical
Stents
•B Braun
•CR Bard
•Johnson & Johnson Medical
•Philisa Biomedical
•Viking Medical
Sterilisation Containers
•Marcus Medical
Sterilisation Indicators
- Biological
Swimming Goggles
and Dive Masks
•Danker Lenses
•3M
•SAFMED
Sterilisation Indicators
- Chemical
•3M
•SAFMED
Sterilisation Packaging
Syringe Drivers
•B Braun
•CareFusion
•Clinical & Medical Services
•Gabler Medical
•Myriad Medical
•Miracle Medical
•SAFMED
Sterilisers - Low Temperature
•3M
•SAFMED
Sterilisers - Steam (Autoclaves)
•3M
•BioClin Solutions
•Kendon Medical
Steriliser Ultra violet
•Sere-med
Stereotactic Biopsy Equipment
•CR Bard
•Johnson & Johnson Medical
•Vertec Scientific
Stethoscopes
•3M
•Alcomed Medical Supplies
•BioClin Solutions
•Dinaledi Medical
•Kendon Medical
•Medequip
•Medical Excellence
•Miracle Medical
•R. Moloney & Company
•Sere-med
•Welch Allyn
Suction Equipment
•Alcomed Medical Supplies
•BioClin Solutions
•Clinical & Medical Services
•Dräger Medical SA
•Gabler Medical
•Kendon Medical
•Medequip
•Medical Excellence
•Myriad Medical
•Miracle Medical
•Nitran Surgical Systems
•Radiant Healthcare
•Scientific Group
•Sere-med
Surgical Dilatators
•Onemed
Surgical Drapes
•3M
•AGFA Healthcare
•Hartmann - Vitamed
•SAFMED
•SSEM Mthembu Medical
Surgical Haemostat
•B Braun
•Dinaledi Medical
Surgical
Instruments and Devices
•BioClin Solutions
•B Braun
•Conquest Surgical Supplies
•CR Bard
•Dinaledi Medical
•Environ Skin Care
•Flurovizion
•Intamarket
•Johnson & Johnson Medical
•Marcus Medical
•Marketspace Medical
•Medequip
•Medical Excellence
•Nitran Surgical Systems
•Onemed
•Ophthalmic Precision Instruments
•SAFMED
•Scientific Group
•Sere-med
•Surgical & Ophthalmic Supplies
•Surgimed Hospital Supplies
•Synthes
Surgical Operating
Loupes and Lights
•Danker Lenses
Sutures
•Alcomed Medical Supplies
•B Braun
•Covidien
•Dinaledi Medical
•Flurovizion
•Gabler Medical
•Johnson & Johnson Medical
•Kendon Medical
•Laurike Marketing
•Sere-med
•Surgical & Ophthalmic Supplies
Syringes
•Alcomed Medical Supplies
•B Braun
•CareFusion
•Conquest Surgical Supplies
•Kendon Medical
•Laurike Marketing
•Manta Medical
•Med Loyd
•Miracle Medical
•Sere-med
Technical Service,
Training and Support
•AGFA Healthcare
•B Braun
•CareFusion
•Flurovizion
•Medical Excellence
•Myriad Medical
•Pro Med Computer Services
•Radiant Healthcare
Telemedicine Equipment
•AGFA Healthcare
•Carestream Health
•Welch Allyn
Telemetry Systems
•Dräger Medical SA
Testicular Implants
•Conquest Surgical Supplies
•Marcus Medical
•Nu Angle Medical
Thermal Ablation Equipment Women’s Health
•Johnson & Johnson Medical
•Radiant Healthcare
Thermometers
•Alcomed Medical Supplies
•Hartmann - Vitamed
•Kendon Medical
•Medical Excellence
•Miracle Medical
•Sere-med
•Welch Allyn
Thermotherapy Equipment
•Covidien
Topical Skin Adhesives
•Dinaledi Medical
•Johnson & Johnson Medical
Torniquet Machines
•Surgimed Hospital Supplies
Tracheostomy Tubes
•Covidien
Training Equipment
•Live Wire Learning
•Miracle Medical
•R. Moloney & Company
•Scientific Group
Transcutaneous
Nerve Stimulators
•Alcomed Medical Supplies
•Nitran Surgical Systems
Trial Lenses
•Gerry van Winsen Optics
Tubes for Anaesthesia
•Clinical & Medical Services
•Covidien
•Intersurgical RSA
•Myriad Medical
•Respiratory Care Africa
•Scientific Group
•SSEM Mthembu Medical
Tympanometers
•Hearing Innovations
•Medical Excellence
•Welch Allyn
Ultrasonic Cleaning Equipment
•Alcomed Medical Supplies
•BioClin Solutions
•Gerry van Winsen Optics
•Medical Excellence
•SAFMED
Ultrasonic Nebulizers
•Alcomed Medical Supplies
•Myriad Medical
•Miracle Medical
•Nitran Surgical Systems
Ultrasonic Surgical
Instruments and Devices
•Johnson & Johnson Medical
•Nitran Surgical Systems
Ultrasonic Therapy Equipment
•Nitran Surgical Systems
•Ophthalmic Precision Instruments
Ultrasound Equipment
- Diagnostic
Vision Aids
•Danker Lenses
Vision Therapy
•Danker Lenses
•Vertec Scientific
Walking and Mobility aids
•Vertec Scientific
Ward Equipment
•Imagex
•Kendon Medical
•Lomaen Medical
•Medical Excellence
•Miracle Medical
•Ophthalmic Precision Instruments
•Philips Healthcare
•Respiratory Care Africa
•Scientific Group
•Sound Aesthetics
•SSEM Mthembu Medical
•Vertec Scientific
•B Braun
•Cook Chill
•Dräger Medical SA
•Franke Kitchen Systems
•Health In Form
•Medical Excellence
•Miracle Medical
•Respiratory Care Africa
•Scientific Group
•SSEM Mthembu Medical
•Welch Allyn
Ultrasound Gel - High Viscosity
•Covidien
•Alcomed Medical Supplies
•Kendon Medical
•SSEM Mthembu Medical
•Vertec Scientific
•Solid Waste Technologies
•Wasteman Healthcare
Ultrasound - HIFU
•Intamarket
Ultraviolet and Infrared
Radiation Equipment
•Alcomed Medical Supplies
Ultraviolet
Germicidal Irradiation
•R. Moloney & Company
Urine Bags
•Adcock Ingram Critical Care
•B Braun
•Covidien
•CR Bard
•Holister SA
•Kendon Medical
•Laurike Marketing
•Med Loyd
•Nu Angle Medical
•Sere-med
Urology Bulking Agents
•Manta Medical
Urology Diagnostic Equipment
•CR Bard
•Philips Healthcare
•R. Moloney & Company
•SSEM Mthembu Medical
Urology Products
•AGFA Healthcare
•B Braun
•Covidien
•Medequip
•Med Loyd
•Nu Angle Medical
•Philisa Biomedical
•SSEM Mthembu Medical
Vaginal Specula
•BioClin Solutions
•Dinaledi Medical
•Kendon Medical
•Medequip
•Med Loyd
•Onemed
•Sere-med
•SSEM Mthembu Medical
•Welch Allyn
Vein Strippers
•Marcus Medical
•Scientific Group
Ventilation and
Respiration Equipment
•Afrivent
•Clinical & Medical Services
•Covidien
•Dinaledi Medical
•Dräger Medical SA
•Med Loyd
•Myriad Medical
•Respiratory Care Africa
•Scientific Group
•Sere-med
•SleepNet/BreatheNet
•SSEM Mthembu Medical
Video Endoscopes
and CCD Cameras
•Medequip
•Nitran Surgical Systems
•Smith & Nephew
Virtual Colonoscopy - Viatronix
•Vertec Scientific
Warming Blankets
Waste Processing/Treatment
Wheelchairs
•Alcomed Medical Supplies
•Miracle Medical
Working Clothes and
Protective Clothing
•Health In Form
•Manta Medical
•Vertec Scientific
Wound Care
•3M
•AGFA Healthcare
•Coloplast
•Covidien
•Dinaledi Medical
•Johnson & Johnson Medical
•KCI Medical SA
•Laurike Marketing
•Manta Medical
•Sere-med
•Smith & Nephew
Wound Drainage Equipment
•Coloplast
•Dinaledi Medical
•Filterworks
•Gabler Medical
•Johnson & Johnson Medical
•KCI Medical SA
•Manta Medical
Wound Management - Advanced
•3M
•Coloplast
•Covidien
•Dinaledi Medical
•KCI Medical SA
•Manta Medical
•Sere-med
•Smith & Nephew
X-ray Chemicals
•Afrox Medical Gases
•AGFA Healthcare
•Carestream Health
•Dinaledi Medical
•Radshield
X-ray Contrast Media
•AGFA Healthcare
•Radshield
X-ray Equipment
•AGFA Healthcare
•Carestream Health
•Imagex
•Lomaen Medical
•Philips Healthcare
•Scientific Group
X-ray Film Processors
•AGFA Healthcare
•Carestream Health
•Imagex
•Lomaen Medical
•Radshield
X-ray Films and Screens
•AGFA Healthcare
•Carestream Health
•Imagex
X-ray Protection Items
•AGFA Healthcare
•Imagex
•Lomaen Medical
X-ray Quality Assurance
Software, Phantoms
•AGFA Healthcare
•Radshield
medical chronicle | March 2011 | page 91
Company Listing
Directory //
ADCOCK INGRAM CRITICAL CARE
www.adcock.com
Bard Medical South Africa (Pty) Ltd
www.crbard.com
Carestream Health
www.carestream.com
Dräger Medical South Africa (Pty) Ltd
www.draeger.com/ZA/en/
Adcock Ingram Critical Care is a company which
has committed itself over the last 60 years to the
development of the health care community. Products
include intravenous solutions, minibags, SVPs, pour
bottles, IV anti­biotics, infusion pumps and administration
sets, dialysis equipment, theatre disposables and blood
collection systems.
CR Bard Inc is a leading multinational developer, manufacturer,
and marketer of innovative, life-enhancing medical
technologies in the product fields of vascular, urology,
oncology and surgical specialities. BARD’s core values of
quality, integrity, service, and innovation represent our reality
and our aspirations and prepare us for the challenges ahead,
guiding our everyday activities and aligning us to our mission.
CARESTREAM HEALTH is a leading provider of medical
and dental imaging systems including information
technology solutions, molecular imaging systems and
x-ray products for non-destructive testing. Carestream
Health’s medical digital imaging portfolio includes RIS,
PACS, CR, DR, Laser Printers, as well as Mammography
& Oncology Solutions.
Dräger Medical South Africa (Pty) Ltd is a solution provider for all
Care Areas like ER, ICU, Operating Theatres, NICU and Maternity.
We supply Patient Monitoring & IT Solutions, Anaesthesia Work
Stations, Ventilators, Incubators and Architectural Systems.
Dräger Medical South Africa has offices in Johannesburg,
Durban, Cape Town and Bloemfontein. Our local supplier
in the Eastern Cape is AD Medical.
PO Box 6888
Johannesburg
2000
PO Box 1977
Kelvin
2054
PO Box 1901
Cramerview
2060
PO Box 4676
Rivonia
2128
Tel: (011) 494-8000
Fax: (011) 494-8757
Email: [email protected]
Tel: 086-102-2273
Fax: (011) 444-6047
Email: [email protected]
Tel: (011) 794-8322
Fax: (011) 794-6979
Email: [email protected]
Tel: (011) 557-2300
Fax: (011) 557-2301
Email: [email protected]
EDWARDS LIFESCIENCES (Pty) Ltd
www.edwards.com
Genop Holdings (Pty) Ltd
www.genopholdings.co.za
Johnson & Johnson Medical
KCI Medical South Africa (PTY) LTD
www.kci-medical.co.za
Global leader in the science of heart valves and haemodynamic
monitoring, with more than five decades of experience in
developing life-saving innovations. Edwards treats advanced
cardiovascular disease with its market-leading heart valve
therapies, critical care and vascular technologies. Global brands
include Carpentier-Edwards, Cosgrove-Edwards, Edwards
SAPIEN, FloTrac, Fogarty, PERIMOUNT Magna and Swan-Ganz.
“Innovative products displaying world leading technologies,
coupled with good value pricing, passionate staff and professional
service. The Genop 4P’s. It’s what has kept our brand at the
forefront of our industry for over 80 years. And will continue
to do so for many years to come.”
L Abrahamson - CEO
Together we can fly the flag for eye care in South Africa.
Johnson & Johnson is the world’s largest medical devices
company, with leading businesses in minimally invasive surgery,
suture and mechanical wound closure products, interventional
and diagnostic cardiology, diagnostic equipment and instruments,
orthopaedic joint reconstruction and spinal products and
disposable contact lenses. Since 1930, the Company has been
serving the health care needs of all South Africans.
Kinetic Concepts, Inc. is a leading global medical
technology company devoted to the discovery,
development, manufacture and marketing of innovative,
high-technology therapies and products for the wound
care, tissue regeneration and therapeutic support
system markets.
20 Regency Drive
Route 21 Corprate Park
Irene, Centurion 0062
Genop House
53 Commercial Street
Cape Town
PO Box 273
Halfway House
1685
Building 24 Thornhill Office Park
94 Bekker Road
Midrand, 1685
Tel: (012) 345-2482
Fax: (012) 345-5848
Email: [email protected]
Tel: (021) 464-5400
Tel: (011) 538-4200
Email: [email protected].
Tel: (011) 265-1000
Live Wire Learning (Pty) Ltd
www.livewirelearning.com
R. MOLONEY & COMPANY
radiant healthcare
www.radianthealth.co.za
Live Wire Learning (Pty) Ltd distributes basic and advanced
medical training simulators and anatomical models for
universities, nursing colleges and emergency services.
We market advanced obstetric manikins, geriatric training
dolls, auscultation and X-ray models (among many others), as
well as CPR manikins, skeletons, anatomical charts and DVDs,
ideal for patient or advanced education.
Since 1990 as the exclusive distributor for Heine Diagnostic
Instruments in South Africa, we offer this German
equipment with a five-year warranty and after sales support
worthy of the name. New 3SLED headlamp and surgical
loupe for all disciplines of surgery. UltraViolet germicidal
irradiation systems. Protect your rooms and your staff area
against TB pathogens. Call for a demonstration.
Radiant Healthcare - suppliers of medical and aesthetic
equipment
•Servicing the fields of dermatology, plastic surgery,
aesthetic medical practitioners and medi-spas with
lasers, IPL, microdermabrasion, cellulite reduction
etc.
•New hospital and clinic turnkey consultation
PO Box 969
Rivonia
2128
46 Drysdale Road,
Sundowner Ext. 2
Randburg, South Africa
Tel: (011) 807-7716
Fax: (011) 807-7856
Email: [email protected]
PO Box 84375
Greenside 2034
Tel: (011) 327-1201, (021) 939-3070, (031) 266-9871
Fax: (011) 442-5863
Email: [email protected]
The Scientific Group
www.scientificgroup.com
Sere-med
www.seremed.com
Smith & Nephew (Pty) Ltd
www.smith-nephew.com/za
The Scientific Group is a distributor of niche products
for the electro medical, laboratory and surgical fields.
Our reputation is based on supplying and supporting
quality products into South Africa and Sub Saharan
countries. A BEE empowered healthcare company
with core values and a reputation to deliver innovative
technology for an improved patient outcome.
Sere-med is an established and trusted supplier to the medical industry.
Situated in Sandton, Sere-med provides the professional health care
market namely GP’s, specialists, pharmacies, clinics, mine hospitals and
the public sector with over 600 products. Our range includes medical
consumables, surgical dressings, medical equipment, instruments, first
aid and emergency care products. Sere-med provides products that
are innovative, affordable and at the forefront of medical technology.
Smith & Nephew is a specialist supplier of Orthopaedic
Trauma, Arthroplasty, Endoscopy and Advanced Wound
Management products that help healthcare professionals
treat patients more effectively. The company has been
committed to helping people regain their lives for over
150 years globally, and 75 years in Africa.
1 New Road
Midrand
1686
Unit 1, Eastborough Business Park
Cnr Olympia & Spartan Crescent
Eastgate Ext. 11, Sandton
30 The Boulevard
Westend Office Park
Westville 3629
Tel: (011) 635-0000
Fax: 086-553-0954
Email: [email protected]
Tel: (011) 262-2220
Fax: (011) 262-2226
Email: [email protected]
Tel: (031) 242-8111
Solid Waste Technologies SA (Pty) Ltd
www.swtsa.co.za
SSEM MTHEMBU MEDICAL (PTY) LTD
www.ssemmthembu.co.za
Vertec Scientific SA
www.vertecsa.co.za
Solid Waste Technologies SA (SWTSA) is one of the
leading players in the health care risk waste treatment
sectors in South Africa. SWTSA owns a 25 ton a day
electro thermal deactivation processing plant in Cape
Town with a month capacity of 1200 tons, as well as
a plant in City Deep, Johannesburg, with a monthly
capacity of 2540 tons.
SSEM Mthembu Medical (Pty) Ltd is a distributor of
electro-medical devices and medical consumables
throughout Southern Africa.  We provide an extensive
range of medical equipment for the ICU, high care,
emergency and  operating room as well as to the
specialist physician and home care market.
Vertec Scientific SA has built up an enviable reputation for
delivering and supporting quality products over a wide range of
modalities, including analogue and digital mammography, bone
densitometry, mini c-arms, digital radiography, dedicated head CT
and radiotherapy immobilisation products. We build and nurture
long-term relationships with our customers and offer outstanding
after sales service, including technical and clinical applications.
6 Hunt Road
Killarney Gardens
Cape Town, 7441
PO Box 5007
Tygervalley
7536
PO Box 2530
Johannesburg
2000
8 Charmaine Avenue
President Ridge
Randburg 2194
Tel: (021) 556-9167
Email: [email protected]
Fax: (021) 556-9168
Tel: (011) 430-7000
Fax: (011) 444-8171
Email: [email protected]
Tel: (011) 789-7177
Fax: (011) 789-7391
Email: [email protected]
Genop Centre
New Doornfontein
Johannesburg
Fax: (011) 265-1114
PO Box 590
Sundowner
2161
Tel: (011) 794-8253
Fax: (011) 794-8251
Email: [email protected]
Tel: (011) 315-0445
Fax: (011) 315-1757
Email: [email protected]
SOUTH AFRICAN MEDICAL DEVICE
INDUSTRY ASSOCIATION
www.samed.org.za
Expanding on the association’s maxim - ‘Advancing
Innovation Responsibly’ - SAMED’s mission is to achieve
‘the responsible and ethical advancement of the interests
of the medical devices industry within the South African
health care environment, while promoting better patient
outcomes’.
PO Box 651761
Benmore
2010
Tel: (011) 467-0855
Email: [email protected]
Fax: (011) 467-1697
Fax: (031) 242-8251
Call Lynn on
084-400-1235
Classifieds
Place a free ad in
Medical Chronicle’s classifieds!
Doctors only. Commercial
classifieds accepted - but not free.
Call Tarien on 011-787-4969 or
fax her on 011-787-1819 or
Email us: [email protected]
Taking
the Gap
Dr Ron Kemper
Doctors and
Discovery - Real
Partners at Last?
The medical profession has,
in the last few years, been sorely
stressed by the need for ICD-10
codes to define every contact that
they make with patients.
When the codes were introduced, doctors were
expected to buy the books and the software
containing the instructions as well as the codes.
Then they were expected to upgrade their software
to make provision for inclusion of those codes on
their invoices and statements.
They were left with no option but to upgrade
their hardware to cope with the more sophisticated
software packages and had to undergo training to
do it properly. Staff also had to be sent on training
courses to administer all of it.
Some doctors even had to take on extra staff.
The amount of time and money spent by doctors in
the interests of applying the coding system across
the country was astronomical. All of this, despite
the fact that the codes are of no use to doctors
whatsoever, and add no value to the doctorpatient relationship.
Not only that, but, as so many doctors’ columns
and letters have attested, ICD-10 coding takes
up a significant part of every day, what with
looking up obscure codes, trying to find codes to
replace those that have been withdrawn (without
warning), sorting out the interminable queries
from Discovery’s petty administrators and redoing
accounts to meet with Discovery’s very inflexible
requirements.
And, in my experience, it has only been
Discovery that has wasted my time and spoiled my
day with ICD-10 code hassles.
Now, with the National Health Insurance system
looming, it is rumoured that Discovery is set to
sell their database of accumulated ICD-10 coded
statistics to the South African government,
for purposes of planning primary health care
provision. And you can bet that it is going to be a
really good shakedown.
My question is: Does Discovery have the right
to sell our blood data? And, if it does, how will it
share the proceeds with the medical profession
who have both financed and provided the entire
database?
Discovery has merely collated and stored the
data, and their time and financial investment has
been minuscule by comparison with that of the
medical profession.
If we were to consider selling our database,
I would say that a fair split of the payout would
be 80% to the doctors, and 20% to Discovery. For
argument sake, let us attach a purchase price of
R50 million for the transaction. That leaves R40
million to be shared among the doctors.
If we assume that there are 10 000 doctors who
have contributed to the Discovery database, we
(let’s call us database shareholders) could each be
in for a R4000 dividend in recognition of our costs,
efforts and frustrations. That’s only fair.
Since Discovery is always so keen to call us their
partners in health, I would imagine they would
appreciate the opportunity to recognise us in this
small way. I mean, are there any other contributors
or shareholders who have bled more to produce all
that data?
lll PRACTICES FOR SALE
GP practice for sale in Port Elizabeth.
Rooms shared with GPs, dentists and a
psychologist. Full or half day.
Contact [email protected]
Well-equipped solo practice in spacious
rooms available in small mining town in the
Northwest province. Current practitioner
wishes to retire. No goodwill required. Modern
equipment including electrocardiograph and
lung function machine for sale.
Call Saul on 084-2080-935.
Well-established practice in fast-growing
Mpumalanga Highveld town needs an assistant
with a view to partnership. Wide spectrum GP
practice work done.
Contact [email protected] or
phone 082-416-4939.
lll POSITION AVAILABLE
Looking for an assistant/partner for a busy fiveman practice in the Northern Cape. Services
required from 1 July 2011.
Please contact 083-259-6929.
C H RONIC L E
© Copyright Medical Chronicle 2011
Site-based medical services manager
EDITORIAL
required in Paulshof, Johannesburg. MBChB
EDITOR-IN-CHIEF Marietjie van den Berg
email: [email protected]
qualification and being registered with
the HPCSA required, as well as five years’
management experience.
Key responsibilities include SBMS operations,
medical services, health and safety, HR,
Spacious consulting and examination rooms
are available on a sessional or full-time basis
in a GP’s consulting room in a busy medical
centre adjacent to Bedford Gardens Hospital.
Receptionist, security, furniture, off-street
parking, water and lights included.
This would be an excellent opportunity for
medical specialists, psychologist, dietician,
biokineticist, speech and hearing therapist,
podiatrist, occupational therapist or another
allied medical professional to establish a
practice in a thriving medical centre.
Please phone 011-616-1577 for more
information.
MEDICAL
finance and logistics, and sales & marketing.
Please contact Michael Emery on 011-803-7707
for enquiries.
Please forward your CV to
[email protected] using ‘SBMS Manager’ as a
reference.
DEPUTY EDITOR Nazli Jugbaran
email: [email protected]
Senior journalist René Bosman
email: [email protected]
PRODUCTION EDITOR Claire Smith
email: [email protected]
CONTRIBUTORS
Prof Morgan Chetty, Rory du Plessis, Andre Esterhuizen,
Dr Luc Evenepoel, Dr Andrew Good, Dr Hendrik Hanekom,
Dr Ron Kemper, Prof James Ker, Elsabé Klinck, Dr Melanie
Krasin, Dr Fatima Laher, Dr AM Levin, Prof Elna Mcintosh,
Dr Huntley Mendelsohn, Dr Adam Nosworthy, Dr Keith
Pettengell, Dr Poobalan Pillay, Dr Anton Potgieter, Prof Barry
Schoub, Mike Scott, Dr Belinda Richards, Dr Ian Westmore
FEATURE WRITERS
René Bosman, Nazli Jugbaran, Maggie Monsieur,
Marietjie van den Berg
lll POSITION REQUIRED
PHOTOGRAPHS
I am looking for a temporary or permanent
Unless previously agreed in writing, Medical Chronicle owns all rights to all contributions,
whether image or text.
position at a practice in Port Alfred. I have
extensive health care experience in reception,
office support and administration.
Call Samantha on 073-1238-913 or email
[email protected]
lll B
UILDING FOR SALE/
RENT
Building to rent or for sale. Call Saul on
084-2080-935.
SOURCES: Shutterstock, supplied images, editorial staff.
ADVERTISING
ADVERTISING EXECUTIVES
Dick White
Peter van Dyk
Tel: 082-896-1813
Tel: 082-555-9611
[email protected]
[email protected]
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Tel: 082-492-0229
[email protected]
Merinda de Kocks
Tel: 084-611-5632
[email protected]
Bonney Cinnamond
Tel: 082-338-2258
[email protected]
Chantal Adlard
Tel: 082-717-9051
[email protected]
Media 24 Magazines Business & Custom
PUBLISHER Werner Lindeque
email: [email protected]
June Treasure Hunt
PRODUCTION Tarien Lampen
email: [email protected]
LAYOUT & DESIGN Allison McCallum
email: [email protected]
REGISTRATION/circulation
Jenny de Beer
Tel: 011-787-4969
email: [email protected]
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