Day: April 22, 2022

A Check-up on Western Cape Healthcare

Image by Hush Naidoo from Unsplash
Image by Hush Naidoo from Unsplash

A report by IOL revealed mixed reviews by experts and patients for the Western Cape’s healthcare system, which, while providing mostly excellent service in certain hospitals, is seen to be especially lacking in rural areas, infrastructure and handling of patients.

Award-winning service

Along with receiving the highest marks for efficiency, Western Cape healthcare has earned recognition such as through the Batho Pele Excellence Awards, with a silver medal going to Dr Barry Smith who worked in frontline COVID hospitals in Cape Town, where as medical manager he organised efforts to deal with devastating COVID waves.

A total of R29.4 billion has been allocated to the province’s 2022–2023 budget to deal with a serious backlog of unmet TB, HIV and other medical care put off during the COVID waves, along with a new surge in mental health issues.

A critical view

The ANC’s Rachel Windvogel said that while Western Cape is said have the country’s ‘most efficient’ health-care system, it is deteriorating and “nearing collapse”.

Dilapidated infrastructure in hospitals such as Groote Schuur and Tygerberg Hospitals is a challenged, with “sections that are cordoned off and not functioning.”

The knock-on service pressure across all district hospitals has resulted in patients having to sleep in chairs or on the floor.

Windvogel said that the Khayelitsha District Hospital is a prime example, with R150 million allocated for upgrades by the hospital but with no provincial government funding forthcoming.

She said that the provincial government’s boasts about a leading healthcare system does not match the situation. This can be seen in rural communities where people wait days for an ambulance transfer to city hospitals, she said, and doctors only visiting rural clinics to issue prescriptions without examining patients.

From the wards

Speaking to IOL, on the condition of anonymity, a nurse with over 15 years of experience currently working at a local government hospital said that while they try their best to deliver a service to residents, the sector has so much lacking.

The quality of new nurses has been steadily declining, she said. “As nurses, we are inundated with work but we manage, however, as an experienced nurse seeing how the ‘latest intakes’ have no feeling towards patients is sad.”

There have been deaths from “incorrect triages” as well as problems with nurses not knowing how to speak to the community, resulting in “pissing off the very community we took an oath to serve,” she said.

While she believes nursing is her calling, she is considering moving over to the private sector, driven by a high workload, crime, poor pay and lack of experienced assistance.

A patient’s experience

Candice van der Rheede, director of the Western Cape Missing Persons Unit (WCMPU) has been through a string of hospitals since 2020 following a collapsed lung, and her experiences reflected problems with staffing and gender segregation.

She first stayed at Mitchells Plain District Hospital, and her ward was “spotless” with security “always there”. “If help was needed and you buzzed for help, nurses came immediately,” she told IOL.

The thoracic ward at Groote Schuur Hospital was also praiseworthy – except that her ward was in the middle of the men’s section.

“One night I woke up and saw one of the men standing and watching us ladies with no nurses on the inside,” Van der Rheede said.

However, entering the ICU ward after theatre, her experience took a turn for the worse, being roughly handled when check for bed sores, despite her having a large surgical wound.

In November, Van der Rheede had to overnight in the trauma section at Tygerberg Hospital due to a check-up. While she was generally satisified with the hospital and its staff, there was a major sticking point for her – in the trauma section, “we were men and women sleeping in one room which I had a big problem with. Using one toilet. I could not sleep that night.”

While she has her reservations about the state of hospitals in the province, Van der Rheede told IOL she commended the Mitchells Plain District Hospital for its impeccable service, and the Symphony Clinic in Delft which she currently attends is of the highest standard of service and cleanliness.

Source: IOL

WHO Panel Recommends Paxlovid for at-Risk Mild COVID

Image from Pixabay

Pfizer’s oral antiviral Paxlovid (nirmatrelvir/ritonavir) is strongly recommended for patients with non-severe COVID with greater hospitalisation risk, such as unvaccinated, older, or immunosuppressed patients, according to a WHO Guideline Development Group writing in The BMJ

The experts explained that Pfizer’s Paxlovid, a comnbination of nirmatrelvir and ritonavir tablets, is likely a better choice for these patients because it may prevent more hospitalisations than the alternatives, is safer than molnupiravir, and is easier to administer than intravenous options such as remdesivir and antibody treatments. 

Use in low-risk patients is not recommended due to trivial benefits. It is also not recommended for patients with severe or critical COVID, as there are currently no trial data on nirmatrelvir/ritonavir for this group.

Their recommendation is based on new data from two randomised controlled trials with 3100 patients.

In these trials, moderate certainty evidence showed that nirmatrelvir/ritonavir reduced hospital admission (84 fewer admissions per 1000 patients), low certainty evidence suggested no important difference in mortality, and high certainty evidence suggested little or no risk of adverse effects leading to drug discontinuation.

Additionally, WHO also makes a conditional (weak) recommendation to use the antiviral drug remdesivir for patients with non-severe COVID at highest risk of hospitalisation.

This is based on new data from five randomised controlled trials involving 2700 patients and replaces a previous recommendation against treatment with remdesivir in all patients with covid-19 regardless of disease severity.

Antiviral drugs should be administered as early as possible, but this may be challenging in low- and middle-income countries, the panel noted, and also that access to these drugs is tied to COVID tests.

The emergence of resistance is also an uncertain risk, they add.

This guidance adds to previous conditional recommendations for the use of molnupiravir for high-risk patients with non-severe COVID and for the use of sotrovimab or casirivimab-imdevimab (monoclonal antibody treatments) in selected patients; and against the use of convalescent plasma, ivermectin and hydroxychloroquine in patients with COVID regardless of disease severity. For patients with severe COVID, WHO strongly recommends corticosteroids, with the addition of IL-6 receptor blockers or baricitinib.

Source: EurekAlert!

Why Breast Cancer Metastases Spread to the Bones

A breast cancer cell
Scanning Electron Micrograph of a breast cancer cell. Credit: NIH

A team of biologists has discovered a factor that increases cellular plasticity can explain why, in breast cancer, metastases spread to the bones. Their findings appear in the journal Nature Communications.

The organs affected by cancer metastases depend in part on their tissue of origin – in the case of breast cancer, they usually form in the bones. No cure for metastatic breast cancer exists yet, and it is associated with a poor prognosis with a 5-year survival rate of 26%. However, treatments can improve and extend the lives of patients.

From the primary site of a tumour, cancer cells can invade their microenvironment and then circulate via blood and lymphatic vessels to distant healthy tissue to form metastases. In the case of metastatic breast cancer, the cancer cells primarily colonise the bones, but can also be found in other organs such as the liver, lungs or brain.

Plasticity of tumour cells

Although the mechanisms behind the different stages of the metastatic process are not yet fully understood, cellular plasticity plays an important role: tumour cells that become metastatic change their shape and become mobile.

Using mice, the researchers investigated the potential role of the protein ZEB1, known to increase cell plasticity, in breast cancer cell migration.

“Unlike in women, mice transplanted with human breast cancer cells develop metastasis to the lungs, not the bones. We therefore sought to identify factors capable of inducing metastasis in bone tissue and in particular tested the effect of the factor ZEB1.,” explained researcher Nastaran Mohammadi Ghahhari, first author of the study

Directing metastasis to bone

In in vitro migration and invasion experiments, the scientists found that cancer cells expressing ZEB1 moved to bone tissue, unlike cancer cells that did not express it. These results were later confirmed when human breast cancer cells were transplanted into the mammary glands of mice. If the cancer cells did not express ZEB1, metastasis occurred primarily in the lungs. In contrast, when ZEB1 was present, metastases also developed in the bones, as is the case in women.

‘‘We can therefore assume that this factor is expressed during tumour formation and that it directs cells that have acquired metastatic characteristics to the bones,’’ explained Didier Picard, the study’s last author. These findings confirm the importance of plasticity in metastases, and could help lead to new therapies.

Source: University of Geneva

Lasting Gains Achieved with Retinal Vein Occlusion Treatment

Source: Daniil Kuzelev on Unsplash

A treatment for retinal vein occlusion yields long-lasting vision gains, with visual acuity remaining significantly above baseline at five years – though many patients still require ongoing treatment, according to a report published in the American Journal of Ophthalmology. The report marked the five-year outcomes of the Study of Comparative Treatments for Retinal Vein Occlusion 2 (SCORE2).

Retinal vein occlusion (RVO) is caused by a blockage of the veins carrying blood away from the retina, causing macular oedema where fluid becomes trapped within and under the retina, leading to rapid and severe loss of visual acuity. Central retinal vein occlusion (CRVO) is an occlusion of the main retinal vein posterior to the lamina cribrosa of the optic nerve. CRVO has a better prognosis in younger patients. One-third of older patients improve without treatment, one-third stay the same, and one-third get worse.

The leading treatment for RVO is injections of anti-vascular endothelial growth factor (VEGF) drugs, helping to control blood vessel leakage and swelling.

“While anti-VEGF therapy is associated with significant improvement in both retinal swelling and visual acuity in patients with central or hemi-retinal vein occlusion, our findings show that most of the patients followed still required treatment to control the macular oedema for at least five years,” said the chair of the study, Ingrid U. Scott, MD, MPH, at the Penn State College of Medicine. “This demonstrates the importance of continued monitoring of these patients.”

In 2017, SCORE2 clinical trial investigators reported that two types of anti-VEGF treatment were equally effective at improving visual acuity in people with macular oedema due to CRVO or hemi-retinal vein occlusion (HRVO). CRVO affects the entire retina, while HRVO generally affects about half of the retina. Half of the study participants had received bevacizumab while the other half received aflibercept. Participants received monthly injections over six months. At the six-month mark, the vision of participants in both groups had, on average, improved over three lines on an eye chart.

The researchers followed SCORE2 participants for five years, collecting information about their visual acuity, treatments, and whether their macular oedema had resolved. After the initial 12-month study period, participants were treated at their physician’s discretion, most reducing the frequency of anti-VEGF injections and some switching their patients to the other anti-VEGF drug. At five years, many participants had lost some visual acuity compared to the 12-month mark, but they retained on average three lines of improvement compared to baseline.

“It was surprising to us that despite many participants still needing treatment after five years, their visual acuity outcome remained very good,” said Dr Michael Ip, MD, co-chair of the study from the University of California Los Angeles. “In comparison to this treatment for wet age-related macular degeneration, where initial vision improvements fade over time, these results are quite favourable.”

“This five-year study tells us a lot about what’s happening with retinal vein occlusion patients in the real world,” said Dr Scott. “Prior to this study, retinal vein occlusion was widely considered an acute illness. This study shows that RVO is a chronic disease. It also underscores the importance of disease monitoring and individualised treatment to achieve the best possible vision.”

Source: NIH/National Eye Institute

Children Must be Psychologically Assessed Before Mother’s Surrogacy, Court Rules

pregnant woman holding her belly
Source: Anna Hecker on Unsplash

The existing children of a woman who agrees to a surrogate pregnancy must be psychologically assessed before an agreement can be sanctioned. This is according to a recent ruling by Judge Brenda Neukircher at the High Court in Pretoria.

In her ruling, Judge Neukircher laid down further guidelines to be followed in surrogacy agreements which come before courts for approval. Some of the guidelines are in terms of the Constitutionally-entrenched principle of the “best interest of the child”.

Judge Neukircher ruled that, “Were it to be found that the surrogacy may have a harmful effect on their psychological well-being, this would be a factor that a court would be able to weigh up in the consideration of whether the agreement should be confirmed or not.”

Setting out the history of surrogacy laws in South Africa, Neukircher said that one provision was that a surrogate mother must have a documented history of at least one pregnancy, a “viable delivery”, and a living child of her own.

Neukircher noted the importance for the courts to consider the impact a surrogate pregnancy would have on the woman’s existing child or children. “How does a surrogate pregnancy affect the surrogate mother’s own child/children? Bearing in mind that they watch her pregnancy for nine months, know she is carrying a child and see her going to hospital to deliver a baby and then comes home without a baby in her arms. Is it important that the interest of these children be protected and, if so, how does a court do that?” she stated.

The applicants in the matter before Neukircher were financially stable. They already had a ten-month-old baby born through a previous surrogate arrangement with the same surrogate mother. The surrogate mother had previously been a surrogate for other couples and had once given birth to twins.

Neukircher said the couple had one frozen egg left and now wanted another child with the surrogate mother. “In all respects, they function as a stable family unit and I’m satisfied that they are able to care for a second child financially, emotionally, physically and educationally. Any child that will be born of this surrogacy will have his/her best interests catered to in every aspect of the (Children’s Act),” the Judge said.

Turning to the surrogate mother, Judge Neukircher said she was married and had two children of her own aged ten and seven years old. “At the time of the first surrogacy, they were six and three. Each time their mother carries a child as a surrogate, they are confronted by her pregnancy which does not end in a child being brought home to join their family. My concern was how healthy, psychologically, it is for children to go through this process?”

Neukircher said she had ordered that expert reports be compiled on the surrogate’s physical suitability to have another child, and the effect, if any, of her surrogate pregnancies on her own children.

She said the report revealed that both the surrogate’s children did not want her to have more children of her own. “Both were proud of the fact that she was helping others have a family and it seems both have adjusted to the fact that she acts as a surrogate….they do not see [the babies] as being part of their own family….they do not want their mother to bring baby home”.

She said the “invaluable report” highlighted the importance that the children of surrogate mothers needed to be prepared for the pregnancy “which goes a long way to alleviating any possible anxiety”.

The Judge said lawyers for both the commissioning parents and the surrogate mother and her husband had agreed that in not requiring such expert reports, the legislature had overlooked the “best interests” principle when it came to existing children. She said the Act laid down compliance factors for surrogacy agreements, including that a court must consider the personal circumstances and family situation of all concerned.

Going forward, Neukircher said, this must include an assessment of children already born. In this matter, she granted an order confirming the agreement.

Written by Tania Broughton for GroundUp.

Source: GroundUp