iTOO Special Risks, a specialty risk underwriter and EthiQal, a medical professional indemnity provider for specialist doctors, have announced an exciting strategic partnership. This collaboration, backed by Hollard, one of South Africa’s largest non-life insurers, aims to bolster EthiQal’s mission to protect healthcare professionals with robust, reliable coverage and medico-legal support.
Together, the partnership reinforces the comprehensive suite of medical malpractice insurance cover available across the spectrum; iTOO’s focus on allied professionals, General Practitioners, institutions and clinical trials continues and EthiQal remains focussed on specialist practitioners.
Together this partnership unlocks valuable opportunities to achieve the shared vision of strengthening the protection of the medical profession, without which the delivery of high quality healthcare is not achievable.
EthiQal Reinforced
EthiQal’s dedication to safeguarding specialist practitioners aligns perfectly with iTOO’s extensive network and expertise in specialty insurance. This partnership, ‘EthiQal Reinforced,’ aims to leverage the strengths of both entities to enhance their offerings and deliver world-class products and services to their clients.
“We are saying this partnership is ‘EthiQal Reinforced’ because while EthiQal is already a strong entity, together with iTOO, it becomes even bigger and stronger,” says Justin Naylor, CEO at iTOO. “iTOO’s extensive network and resources bring additional and complementary skills and capabilities to support EthiQal and its customers.”
Naylor further elaborates, “We have a 20-year track record and well-established risk underwriting capability with a market-leading diverse product range, backed by a complete cradle-to-grave infrastructure. This partnership combines the expertise and track records of both iTOO and EthiQal, reinforcing their excellent offerings.”
EthiQal’s Vision and Strengths
Alex Brownlee, CEO of EthiQal, highlights the alignment of principles and vision that initially brought the two parties together. “iTOO brings a legacy of deep insurance expertise, an extensive network, and additional skills that complement our own. This partnership provides enhanced financial backing, stability, and reliability,” says Brownlee.
Brownlee emphasises the focused and niche market that EthiQal serves, which requires leading risk management support. “Medical malpractice, particularly in fields like obstetrics, spinal surgery, neonates and neurosurgery, involves high risks and long-duration claims. This has driven us to develop deep expertise and understanding of the medico-legal landscape,” he notes.
EthiQal’s team includes a dedicated clinical team, an in-house legal team available for urgent advice and legal support, and personalised quality service. Brownlee assures that the partnership will not change the way EthiQal does business, nor change its products or services, but will reinforce and support the dedicated and steadfast EthiQal team in their commitment to support doctors.
Financial Resilience and Support
EthiQal has strong financial capacity, with a Solvency Capital Requirement above 120%, well beyond the regulatory 1-in-200-year event solvency requirement. The firm enjoys continued financial backing from Dr. Christo Wiese’s Titan Group and reinsurance cover from Lloyd’s of London. Along with iTOO and Hollard, this combination offers improved financial support, stability, and reliability “for our clients’ benefit”, Brownlee stresses.
“EthiQal offers incredible value for medical specialists, and Titan will continue to invest significant resources to build EthiQal’s capacity to measure, mitigate and absorb medical malpractice risk. Alex Brownlee and the team’s drive and capability is what attracted us to the business and what will ensure EthiQal continues to offer value to its policyholders and broker partners”, says Titan’s investment executive Zac Pitsillis.
Engagement and Education
Brownlee also confirmed that EthiQal will remain actively involved in the medical community through conferences, presentations, and educational grants. “Over the last 2 years in particular we have been extremely active in sharing our knowledge and insights, aiming to support doctors and their medical societies.”
Commitment to Quality and Service
“This partnership with iTOO, backed by Hollard, reinforces the quality and value of EthiQal’s products and people, demonstrating confidence in EthiQal’s future and the team that makes it happen,” Brownlee concludes. “The alignment in our values, vision and approach to clients is a critical reason why this partnership is ideal.”
Scientists at ADA Forsyth Institute (AFI) have identified a critical factor that may contribute to the spread of hospital-acquired infections (HAIs), shedding light on why these infections are so difficult to combat. Their study reveals that the dangerous multidrug resistant (MDR) pathogen, Klebsiella, thrives under nutrient-deprived polymicrobial community conditions found in hospital environments.
According to the World Health Organization, HAIs pose significant risks to patients, often resulting in prolonged hospital stays, severe health complications, and a 10% mortality rate. One of the well-known challenging aspects of treating HAIs is the pathogens’ MDR. In a recent study published in Microbiome, AFI scientists discovered that Klebsiella colonising a healthy person not only have natural MDR capability, but also dominate the bacterial community when starved of nutrients.
“Our research demonstrated that Klebsiella can outcompete other microorganisms in its community when deprived of nutrients,” said Batbileg Bor, PhD, associate professor at AFI and principal investigator of the study. “We analysed samples of saliva and nasal fluids to observe Klebsiella‘s response to starvation conditions. Remarkably, in such conditions, Klebsiella rapidly proliferates, dominating the entire microbial community as all other bacteria die off.”
Starvation environments
Klebsiella is one of the top three pathogens responsible for HAIs, including pneumonia and irritable bowel disease. As colonising opportunistic pathogens, they naturally inhabit the oral and nasal cavities of healthy individuals but can become pathogenic under certain conditions. “Hospital environments provide ideal conditions for Klebsiella to spread,” explained Dr Bor. “Nasal or saliva droplets on hospital surfaces, sink drains, and the mouths and throats of patients on ventilators, are all starvation environments.”
Dr Bor further elaborated, “When a patient is placed on a ventilator, they stop receiving food by mouth, causing the bacteria in their mouth to be deprived of nutrients and Klebsiella possibly outcompete other oral bacteria. The oral and nasal cavities may serve as reservoirs for multiple opportunistic pathogens this way.”
Additionally, Klebsiella can derive nutrients from dead bacteria, allowing it to survive for extended periods under starvation conditions. The researchers found that whenever Klebsiella was present in the oral or nasal samples, they persisted for over 120 days after being deprived of nutrition.
Other notable findings from the study include the observation that Klebsiella from the oral cavity, which harbours a diverse microbial community, was less prevalent and abundant than those from the nasal cavity, a less diverse environment. These findings suggest that microbial diversity and specific commensal (non-pathogenic) saliva bacteria may play a crucial role in limiting the overgrowth of Klebsiella species.
The groundbreaking research conducted by AFI scientists offers new insights into the transmission and spread of hospital-acquired infections, paving the way for more effective prevention and treatment strategies.
While physical activity, especially aerobic exercise, is known to reduce depressive symptoms, the processes behind this have been poorly understood – until now. In a new review article published in Translational Psychiatry, researchers propose a novel hypothesis to understand the antidepressant effects of exercise. They believe that the process may hinge on motivation, which is very important for alleviating a number of symptoms of depression, such as anhedonia (a lack of interest or joy in life’s experiences), low energy and ‘brain fog’.
The team summarised research papers that explored the mechanisms of depression in both humans and animals and concluded that depression, especially anhedonia, is associated with elevated inflammation (caused by the body’s immune response). Importantly, inflammation is also linked to disrupted dopamine transmission. These biological changes may represent key processes leading to changes in motivation, and in particular a lower willingness to exert physical or mental effort.
Meanwhile, exercise reduces inflammation, boosts dopamine function, and enhances motivation. The researchers believe that this could be an important reason as to why exercise exerts an antidepressant effect.
Lead author, Dr Emily Hird (UCL Institute of Cognitive Neuroscience) said: “The antidepressant effect of aerobic exercise has been convincingly demonstrated through randomised controlled trials, but its mechanism is not well understood. This is, in part, because it likely involves a variety of biological and psychological processes.
“For example, alongside its positive effect on inflammation, dopamine and reward processing, exercise also reduces oxidative stress and improves self-esteem and self-efficacy.
“However, we are proposing that exercise – particularly aerobic activities that make you sweaty and out of breath – decreases inflammation and boosts dopamine transmission, which in turn increases the desire to exert effort, and therefore boosts motivation generally.”
The team hope that this understanding of how exercise reduces symptoms of depression will help to inform the development of new treatment strategies – such as personalised exercise programmes.
Dr Hird said: “Understanding the mechanisms that underly the antidepressant effects of physical activity in depression could also inform our understanding of the mechanisms causing depression and the development of novel intervention strategies, in particular personalised intervention, and social prescribing.”
To further test their hypothesis, the researchers advise that large randomised controlled trials need to be conducted that assess the antidepressant effects of exercise, whilst also measuring the effect on variables including inflammation, dopamine transmission and motivation.
It would also be important to investigate any potential barriers to exercise.
Dr Hird said: “Addressing barriers to exercise – particularly in people with depression – is crucial, as regular physical activity may be able to alleviate symptoms, enhance mood and empower individuals on their path to recovery. As part of this, finding strategies to encourage exercise is key.”
The team are now running a trial based on the hypothesis proposed in the review, which will involve 250 participants aged 18 to 60 and is funded by a Wellcome Mental Health Award.
Although South Africa has the largest number of people living with HIV worldwide, strides have been made in controlling the epidemic, especially in the reduction of HIV incidence, testing, and treatment. Researchers from the South African Medical Research Council (SAMRC) and University of KwaZulu-Natal (UKZN) are inching closer to finding the answer to the natural control of HIV infection, leading to improved health outcomes and quality of life amongst South Africans.
According to the latest survey by the Human Sciences Research Council, in 2022, there were approximately 7.8 million people afflicted with HIV in South Africa, the highest absolute number of people living with HIV globally. Yet despite having the largest genetic diversity in the world, African human genome sequences represent the lowest of all the human genomes that have been sequenced worldwide. There is a dire need to leverage genomics to back up and scale targeted intervention programs to put more people living with HIV on effective treatment.
Of particular interest in the global investigations into HIV is “elite controllers” (ECs), a rare group of HIV‐1‐positive individuals whose immune systems can seemingly suppress the infection from developing without taking antiretrovirals (ARVs). For every 200 people living with HIV, around one may be an elite controller (0.5%). In South Africa, with its high rate of HIV infection, the prevalence of ECs also appears to be higher. By “unmasking” the secrets of ECs through research, clues can be revealed, and new therapies potentially developed to benefit broader groups of people living with the disease.
In order to identify the polymorphism and mutations within individuals of African descent, and understand how they are associated with HIV disease progression, Dr Veron Ramsuran, Associate Professor at UKZN, and Prof Thumbi Ndung’u, Director for Basic & Translational Science at the Africa Health Research Institute, joined hands with SAMRC, MGI and local South African clinics in 2019 to take their 20+ years of work in EC research to the next level using whole genome sequencing (WGS).
“The HIV Host Genome project was started at the same time as we launched SAMRC’s African Genomics Centre in Cape Town with the support from MGI,” said project co-investigator Rizwana Mia, also co-founder of the SAMRC Genomics Centre and Senior Program Manager in Precision Medicine at SAMRC. “The partnership saw MGI putting down a high-throughput sequencing workflow and assisted us with the specialised scaled infrastructure design in our lab. This was at a time when there was no real infrastructure for large-scale next generation sequencing in Africa.”
“More importantly, by moving our laboratory workflow to scale, we are hoping to develop genomic research to address this quadruple burden of disease that South Africa faces,” explained Mia. “Our project looks at a unique cohort of patients that have the ability to control the HIV virus to ascertain how disease progresses and the host-directed mechanisms for innate immune control. In addition, we included family sets to help us better understand the relationship between pediatric non-progressors and their parents who are also HIV positive, to uncover and genetic differences that may contribute to host immune control of HIV.”
“We’ve identified new genes and polymorphism that are playing a role with HIV disease through new data generated from Whole Genome Sequencing,” said Dr Veron Ramsuran, principal investigator of the HIV Host Genome project. “Traditionally, there is a list of mutations or genes that are known to associate with HIV, yet they are largely based on studies on Caucasian populations. Our HIV research is adding to the general pool of knowledge pertaining to individuals of African descendent, which will thereby inform new treatment and new vaccine opportunities.”
“What’s important is also understanding how drugs interact with the individual,” added Ramsuran. “We’ve found in the past that certain polymorphism is associated with drug metabolism in genes. Building on this understanding of drugs in combination with the genetics of the individual, we can develop prediction tools to inform clinicians on drug type or dosage depending on the presence of the polymorphism to facilitate a more rapid metabolism of the drug.”
Encouragingly, investigations into Africa’s diseases will continue beyond this point. The HIV Host Genome project has laid the groundwork for the ambitious National 110K Human Genome Project. This large-scale population study will involve 110 000 participants from the South African population, aiming to understand more about of their genomic diversity, address various health challenges, and pave the way for personalized medicine in the country. Furthermore, the data collected will be incorporated into a national population database, enhancing research outcomes and deepening disease understanding for Africa.
Given South Africa’s diverse population, limited human genomics data and significant healthcare burden from diseases such as HIV, understanding pathogenesis and inherent mutations is important for implementing targeted treatments and public health programs. With its lower sequencing cost, high quality data, and efficient all-in-one workflows, MGI’s equipment play an instrumental role , will continue to drive progress in studying rare HIV phenotypes, which holds great promise in advancing the development of targeted interventions and cures– not only for HIV – but many other diseases.
“Looking at the genetic variation and its impact on HIV is a gamechanger, because it will shed light on some of the best immune responses that can be generated against the HIV virus,” stated Prof Thumbi Ndung’u, principal investigator of several of the project’s cohort studies. “And actually, this knowledge will be widely applicable and could have an impact on other diseases – infectious and non-infectious – as well as their drug interventions. It will make sure that Africans, just like everybody else, are at the centre of drug and vaccine development.”
Researchers share insights from US reduction of cigarette, sugar, and opioid consumption
Photo by Sara Kurfess on Unsplash
A case definition of market-driven epidemics (MDEs) could help address critical barriers to timely, effective prevention and mitigation, according to a study published this week in the open-access journal PLOS Global Public Health by Jonathan Quick from Duke University School of Medicine, US, and colleagues.
The misuse and overconsumption of certain consumer products have become major global risk factors for premature deaths at all ages, with their total costs in trillions of dollars. Progress in reducing such deaths has been difficult, slow, and too often unsuccessful. To address this challenge, Jonathan Quick and colleagues introduced a case definition of MDEs, which arise when companies aggressively market products with proven harms, deny these harms, and actively oppose mitigation efforts. To demonstrate the application of this concept, the researchers selected three MDE products: cigarettes, sugar, and prescription opioids. Based on the histories of these three epidemics, the researchers described five MDE phases: market expansion, evidence of harm, corporate resistance, mitigation, and market adaptation.
From the peak of consumption to the most recent available data, US cigarette sales fell by 82%, sugar consumption by 15%, and prescription opioid prescriptions by 62%. In each case, the consumption tipping point occurred when compelling evidence of harm, professional alarm, and an authoritative public health voice or public mobilisation overcame the impact of corporate marketing and resistance efforts. Among the three epidemics, the gap between suspicion of harm and the consumption tipping point ranged from one to five decades – much of which was attributable to the time required to generate sufficient evidence of harm. Market adaptation to the reduced consumption of target products had both negative impacts (eg, geographical shift of corporate marketing efforts) and positive impacts (eg, consumer shift away from sugar-sweetened beverages).
According to the authors, this is the first comparative analysis of three successful efforts to change the product consumption patterns of millions of people – and, over time, some of the associated adverse health impacts of these products. The MDE epidemiological approach of shortening the latent time between phases provides the global health community with a new method to address existing and emerging potentially harmful products and their health, social, and economic impacts.
While the specific product and circumstances are unique to each MDE, understanding the epidemiology of consumption and health impacts, and epidemic milestones, should help public health leaders combat current MDEs and more swiftly recognise future MDEs. Given the similar patterns among different MDEs, public health leaders, researchers, civil society and others can apply the mitigation strategies presented in the review article to save lives and lessen the impact of continuing and emerging MDEs.
The authors add: “The use of cigarettes and other unhealthy products costs the world millions of lives and trillions of dollars each year. An analysis of U.S. progress against three such market-driven epidemics demonstrates that we can save lives through earlier, more decisive action by public health leaders, researchers, and public mobilization,” concluding: “The use of cigarettes and other unhealthy products often follow patterns similar to infectious disease epidemics, causing widespread harm before any public health response. We can save lives by recognizing these market-driven epidemics earlier and acting more decisively to control them.”
A new paper surveying advances in diabetes pathogenesis and treatment explores the complex factors contributing to the onset and progression of the disease, suggesting that an understanding of these dynamics is key to developing targeted interventions to reduce the risk of developing diabetes and managing its complications.
In a paper in a special 50th anniversary issue of the peer-reviewed journal Cell, the authors surveyed hundreds of studies that have emerged over the years looking at the causes underpinning types 1 (T1D) and 2 (T2D) diabetes and new treatments for the disease. They examine the role that genes, environmental factors, and social determinants of health play and diabetes’ effect on cardiovascular and kidney disease.
What they found shows there are many advances in treatments that could stem the tide of a disease that has struck millions of people around the globe and continues to grow. In addition, some of these advances could be used to treat other disorders. But there are still challenges ahead.
“As the prevalence of diabetes continues to grow around the world, it is important to understand the latest advancements in research so that clinicians can provide the best care to their patients, and patients can make informed choices that support improved health outcomes,” said lead author Dr E. Dale Abel, chair of the UCLA Department of Medicine. “This is an educational resource that integrates the latest research and trends in diabetes management, which may have implications for clinical practice as the diabetic patient population continues to grow.
“This review will be the go-to reference for physicians and researchers, providing a state-of-the-art update of where the field is currently, and where it is headed,” Abel added.
Most people are affected by type 2 diabetes, for which inadequate diet and obesity are important underlying causes. Type 1 diabetes accounts for fewer than 5% of all cases. As of 2021 about 529 million people around the world were diagnosed with diabetes, representing about 6.1% of the global population, or about one in 16 people. Prevalence in some regions is as high as 12.3%. Type 2 diabetes comprises about 96% of cases, with more than half due to obesity. Some 1.31 billion people are projected to have the disease by 2050, with prevalence rising as high as 16.8% in North Africa and the Middle East and 11.3% in Latin America and the Caribbean, the researchers write.
Genetics, the central nervous system, and the interplay between various organs as well as social and environmental factors such as food insecurity and air pollution play a role in development of diabetes.
But some recent discoveries represent significant strides toward managing and perhaps even reversing the disease. For instance, a 2019 study found that a 14-day course of the antibody teplizumab delayed the progression of type 1 diabetes from stage 1 to stage 3 by 24 months. A follow-up analysis in 2021 showed that the delay could be up to 32.5 months.
Based on these results, the U.S. Food and Drug Administration approved teplizumab as the first disease-modifying therapy for type 1 diabetes, the researchers write.
Advances in insulins with optimised pharmacokinetics, algorithm-driven subcutaneous insulin pumps, continuous glucose monitoring, and improved tools for self-management have significantly improved the quality of life and outcomes for people with stage 3 type 1 diabetes.
In addition, stem cells could replace insulin-producing cells that are lost in type 1 diabetes, Abel said.
For type 2 diabetes, three classes of glucose-lowering medicines that were introduced in the last 20 years – GLP1RAs (glucagon like peptide-1 receptor agonists), DPP-4 inhibitors, and SGLT-2 inhibitors – have enabled people to control their glucose levels without gaining weight and with a low risk of developing hypoglycaemia. Personalised and precision medicine approaches are being explored to target the molecular mechanisms behind diabetes. However, they must demonstrate that benefits are clinically superior to standard care and are cost-effective. Also, it remains to be seen if precision approaches can be implemented in all settings worldwide, including those with few resources.
Combinations of GLP1Ras and with molecules that target other receptors such as GIP have shown even greater efficacy in treating diabetes. Recent trials have also shown that they are very effective in treating obesity, certain types of heart failure and even sleep apnoea, in part because of their potency to induce weight loss and reduce inflammation. Clinical trials are now underway to test their efficacy in treating other disorders such as Alzheimer’s disease, Abel said.
“Advances in therapy now raise the hope of preventing or curing T1D and treating T2D in ways that not only improve metabolic homeostasis, but also concretely reduce the risk and progression of cardio-renal disease,” the researchers write. “Finally, as we understand and develop tools for discerning the underlying heterogeneity leading to diabetes and its complications, the stage will be set for targeting therapies and prevention strategies to optimize their impact, in ways that will be broadly applicable across diverse populations and availability of health care resources.”
Researchers at UCLA Health uncovered new information about the role inflammation plays in mitigating liver fibrosis, which is associated with metabolic-associated fatty liver disease (MAFLD). While inflammation in the liver has long been considered a prerequisite to developing liver fibrosis, the scarring and thickening of tissue that can impair the liver’s ability to function, this new research, published in the Journal of Clinical Investigation, suggests that reducing inflammation may not influence the extent of fibrosis.
“Liver fibrosis is the critical feature that creates chronic liver disease and liver cancer. If we can keep fibrosis in check then we can meaningfully impact liver disease,” said Tamer Sallam, MD, corresponding author of the study and vice chair and associate professor in the department of medicine at the David Geffen School of Medicine at UCLA.
“For decades we have believed that targeting inflammation is one of the most important ways to reduce MAFLD. But this new research indicates that inflammation, while still important, may not be the main driver of fibrosis.”
The studylooked specifically at a protein called lipopolysaccharide binding protein (LBP), which is involved in the body’s immune response, and how LBP functions in mice. Findings showed that mice without LBP in their liver cells had lower levels of liver inflammation and better liver function but no change in fibrosis.
In addition to mouse models, the researchers also studied genetic analyses from large human datasets and human tissue samples from MAFLD patients at different stages in the disease, to examine the consequence of loss of LBP function. The evidence combined showed that the LBP does not alter scar tissue markers.
Sallam indicated a need to further explore how LBP influences inflammation and whether other factors can offer a more potent reduction in inflammation and have an impact on reducing fibrosis.
“Reducing scar burden is one of the holy grails in the treatment of advanced liver diseases,” Sallam said. “These results suggest that certain ways of targeting inflammation may not be a viable option and that more directed therapies against other pathways could help us better target fibrosis and improve outcomes for patients.”
Review of research suggests patients feel better when providers sit or crouch during bedside conversations
Photo by National Cancer Institute on Unsplash
Doctors and other healthcare workers, you may want to sit down for this news. A systematic review of studies suggests that getting at a patient’s eye level when talking with them about their diagnosis or care can really make a difference.
Their findings, published in the Journal of General Internal Medicine, revealed that sitting or crouching at a hospitalised patient’s bedside was associated with more trust, satisfaction and even better clinical outcomes than standing, according to the review of evidence.
The study’s authors, from the University of Michigan and VA Ann Arbor Healthcare System, note that most of the studies on this topic varied with their interventions and outcomes, and were found to have high risk of bias.
So, the researchers sat down and figured out how to study the issue as part of their own larger evaluation of how different nonverbal factors impact care, perceptions and outcomes.
Until their study ends, they say their systematic review should prompt clinicians and hospital administrators to encourage more sitting at the bedside.
Something as simple as making folding chairs and stools available in or near patient rooms could help – and in fact, the VA Ann Arbor has installed folding chairs in many hospital rooms at the Lieutenant Colonel Charles S. Kettles VA Medical Center.
Nathan Houchens, MD, the U-M Medical School faculty member and VA hospitalist who worked with U-M medical students to review the evidence on this topic, says they focused on physician posture because of the power dynamics and hierarchy of hospital-based care.
We hope our work will bring more recognition to the significance of sitting and the general conclusion that patients appreciate it.”
-Nathan Houchens, M.D.
An attending or resident physician can shift that relationship with a patient by getting down to eye level instead of standing over them, he notes.
He credits the idea for the study to two former medical students, who have now graduated and gone on to further medical training elsewhere: Rita Palanjian, M.D., and Mariam Nasrallah, M.D.
“It turns out that only 14 studies met criteria for evaluation in our systematic review of the impacts of moving to eye level, and only two of them were rigorous experiments,” said Houchens.
“Also, the studies measured many different things, from length of the patient encounter and patient impressions of empathy and compassion, to hospitals’ overall patient evaluation scores as measured by standardised surveys like the federal HCAHPS survey.”
In general, he says, the data paint the picture that patients prefer clinicians who are sitting or at eye level, although this wasn’t universally true.
And many studies acknowledged that even when physicians were assigned to sit with their patients, they didn’t always do so – especially if dedicated seating was not available.
Houchens knows from supervising U-M medical students and residents at the VA that clinicians may be worried that sitting down will prolong the interaction when they have other patients and duties to get to.
But the evidence the team reviewed suggests this is not the case.
He notes that other factors, such as concerns about infection transmission, can also make it harder to consistently get to eye level.
“We hope our work will bring more recognition to the significance of sitting and the general conclusion that patients appreciate it,” said Houchens.
Making seating available, encouraging physicians to get at eye level, and senior physicians making a point to sit as role models for their students and residents, could help too.
A recently launched VA/U-M study, funded by the Agency for Healthcare Research and Quality and called the M-Wellness Laboratory study, includes physician posture as part of a bundle of interventions aimed at making hospital environments more conducive to healing and forming bonds between patient and provider.
In addition to encouraging providers to sit by their patients’ bedsides, the intervention also includes encouraging warm greetings as providers enter patient rooms and posing questions to patients about their priorities and backgrounds during conversations.
The researchers will look for any differences in hospital length of stay, readmissions, patient satisfaction scores, and other measures between the units where the bundle of interventions is being rolled out, and those where it is not yet.
Like statins, cholesterol absorption inhibitors are linked with a lower risk of developing liver cancer.
Photo by Towfiqu Barbhuiya on Unsplash
Past studies have suggested that taking cholesterol-lowering statin drugs may lower the risk of developing liver cancer. In a new study of non-statin cholesterol-lowering medications, one type was linked to lower risks of liver cancer. The findings are published by Wiley online in CANCER, a peer-reviewed journal of the American Cancer Society.
Cholesterol absorption inhibitors, bile acid sequestrants, fibrates, niacin, and omega-3 fatty acids are types of non-statin cholesterol-lowering medications prescribed to manage cholesterol and lipid levels. The different classes of drugs work in different ways. A team led by Katherine A. McGlynn, PhD, MPH, of the National Cancer Institute, looked for associations between these five types of non-statin cholesterol-lowering medications and risk of liver cancer, the sixth most commonly occurring cancer globally and the third leading cause of cancer mortality.
The investigators used information from the Clinical Practice Research Datalink (CPRD), a primary care database that covers approximately 7% of the United Kingdom population. Their analysis included 3719 liver cancer cases and 14 876 matched controls without cancer. Additional matches were also made based on individuals’ type 2 diabetes and chronic liver disease status.
Use of cholesterol absorption inhibitors was associated with 31% lower odds of liver cancer risk in the overall analysis. These medications were also linked with a lower risk of liver cancer in analyses based on diabetes and liver disease status. The study also confirmed that statins were associated with 35% lower odds of liver cancer.
No associations with liver cancer risk were observed for fibrates, omega-3 fatty acids, or niacin. While bile acid sequestrant use was associated with higher odds of liver cancer risk in the overall analysis, the results of analyses based on diabetes and liver disease status were inconsistent, suggesting that replication of these observations is important.
“As few studies have examined the effects of non-statin cholesterol-lowering drugs on liver cancer risk, the results of our study require replication in other populations. If our findings are confirmed in other studies, however, our results may inform liver cancer prevention research,” said Dr. McGlynn.
Photo by Miguel Á. Padriñán: https://www.pexels.com/photo/syringe-and-pills-on-blue-background-3936368/
By Nthusang Lefafa
Despite some improvement over the past three years, the North West province continues to experience medicine shortages, according to a survey by a community clinic monitoring initiative. We unpack the latest findings and ask why shortages persist in the province.
Some people in need of HIV or tuberculosis (TB) medicines were sent home empty handed after visiting clinics in the North West. This is according to the latest survey of public healthcare services in the province published by community-led clinic monitoring group Ritshidze. The survey data was collected in April and May this year.
Of the roughly 490 000 people living with HIV in North West, around 380 000 (77%) are on antiretroviral treatment, according to figures from Thembisa, the leading mathematical model of HIV in South Africa. Antiretroviral treatment is recommended for everyone living with the virus.
According to Ritshidze, besides HIV and TB medicines, other commonly reported stockouts at clinic-level include pain medicines (such as Paracetamol and Ibuprofen), cardiac medicines (such as Aspirin), contraceptives, dry stock (gauze, bandages, needles), maternal health medicines, psychiatric medicines, and different vaccines.
Out of the 72 facilities surveyed in the province, medicine stockouts lasting one to three months were reported at 20 and stockouts lasting three to six months were reported at six.
‘Failed to comply’
The North West health department, according to Ritshidze, has failed to comply with national guidelines recommending that people living with HIV should be provided with a three or more month supply of antiretrovirals at a time. They found that 71% of people surveyed in 2024 received antiretroviral refills of three to six months – in each of the previous three years this number was below 30%. There was large differences between districts, with 97% of people surveyed in Bojanala district reporting getting a 3 month supply of ARVs — compared to 37% in Dr Kenneth Kaunda.
Giving people longer antiretroviral refills like this means people do not have to visit health facilities as often to collect their medicines.
Various factors influence giving more people longer antiretroviral refills, Tebogo Lekgethwane, Director of Media and Communications in the province’s health department, told Spotlight.
A crucial factor, he said, is that patients must have a good track record of collecting their medication as well as a history of a documented undetectable viral load. “There’s therefore a criteria for multi-month supply which includes the fact that patients should have been on treatment for six months, they are compliant and clinically stable,” said Lekgethwane.
No “crisis” of medicine shortages
While the year-on-year comparisons should not be overinterpreted – Ritshidze themselves advise caution – the numbers nevertheless provide some indication that when it comes to medicines stockouts things are trending in the right direction. The total number of stockouts in the province reported to Ritshidze plunged from 895 in 2021 to 148 in 2024 – over the same period stockouts of HIV medicines went from 115 to 19 and stockouts of TB medicines from 28 to 7.
Lekgethwane was at pains to point out that Ritshidze’s findings do not necessarily represent the actual picture of the entire province. He said that the department believes that the Ritshidze report is subjective and relies on isolated incidents. These incidents, Lekgethwane said, are often quickly addressed.
“The current provincial medicine availability report shows that medicine availability has stabilised above 80%. As at the end of June 2024, ARV stock was at 89.5%, Expanded Programme on Immunisation and Contraceptives remained above 90%, TB treatment at 79%, Oncology treatment at 81.7% and Diabetes Mellitus at 85.8%. Therefore the province does not have a crisis of medicine shortages,” he said.
Asked what exactly these percentages mean, Lekgethwane said that it indicates the actual medicines stock available in the province in relation to what is required.
A pharmacy expert consulted by Spotlight further explained that the percentage indicates the percentage of medicines on a list or in a class that is available in the province.
The way these numbers are tracked is somewhat tricky. Firstly, if a clinic is supposed to have 10 different HIV medicines in stock, but they only have 8 in stock, then its HIV medicines availability would be at 80% (having a single pack of a medicine counts as having it in stock). When many facilities are considered together, as with an entire province like North West, the key indicator looks at what percentage of those facilities have medicines availability above 90%. We thus understand the figures shared by Lekgethwane to mean that 89.5% of facilities, depots and so on in the province have HIV medicines availability above 90%.
Catching up with payments
Past medicine shortages in the province were partly attributed to companies ceasing delivery of medicine due to non-payment of invoices. While the North West health department was under National Department of Health administration in 2020, the offices at the Mmabatho Medical Depot was raided. The search uncovered a number of unpaid invoices worth millions, some dating back to 2014. One unpaid invoice was for more than R16 million.
Bolstered by a Pharmaceutical Intervention Team to address medicine shortages, Lekgethwane said the department’s payments system is now in top shape.
“Payment of suppliers has remained a priority and the finance unit has assisted the team by making good progress on payments of supplier accounts. The unit continues to investigate and intervene when suppliers indicate their account status to the pharmacies.
“This has led to an increased number of deliveries from suppliers to the depot and increased direct deliveries to pharmacies from contracted companies as well as deliveries of main orders, allocation of orders and emergency orders from the depot to the pharmacies,” he said.
“The Department can confidently confirm that the financial management of pharmaceuticals has been improved resulting in 97% of 2024/2025 accruals being paid and remaining with only two accounts that are on hold. The two accounts that are on hold will only be paid once their compliance requirements are sorted,” said Lekgethwane.
He said that the intervention team has the capacity to assess and intervene, in among others, pharmaceutical supply chain issues, system effectiveness, distribution and delivery processes, storage capacity, human resource capacity and safety issues.
Lekgethwane said the team’s first priority was to assess the Mmabatho Medical Depot before moving onto pharmacies in hospitals and clinics across the province.
Getting medicines to rural areas
While Ritshidze also raised concern around transportation for the delivery of medicines, the department said transportation has never been a challenge.
“There are contracted service providers who deliver to the Mmabatho Medical Depot and the depot delivers to hospitals. Clinics receive their medicine from their referral hospital,” said Lekgethwane.
“However, the department is currently implementing the bulk pharmacies for districts to bring medicines closer to facilities”, he added. A bulk pharmacy is a medicine storage facility which serves as a medical depot. It is situated in the districts and helps with bringing medicines closer to rural areas so that medicines do not have to be transported from major towns.
In this regard, Lekgethwane said the Dr Kenneth District Bulk Pharmacy was recently opened and soon the General De la Rey Bulk Pharmacy will open.
He said the department is confident that the use of these bulk pharmacies will improve medicine storage and distribution capacity.
Shortage of pharmacists and pharmacy assistants
The Ritshidze report found that only 9% of surveyed facilities had a pharmacist and only 18% had a pharmacist assistant. Government regulations state that either pharmacists or pharmacy assistants should be responsible for stock receiving orders and updating the stock visibility system. However, Ritshidze found that enrolled nurses, enrolled nurse assistants, facility managers, and even cleaners acted in that capacity at some clinics.
The province has a 6% vacancy rate for pharmacists while 342 are currently employed, according to the 2024/2025 health department annual performance plan tabled in the North West Provincial Legislature earlier this month. The plan states that the department’s organisational structure makes provision for 10 pharmacists to be appointed in the province for every 100 000 uninsured individuals.
The DA’s Hendriette van Huyssteen says there is a challenge of pharmacists and pharmacy assistants where there are clusters of less than 10 000 uninsured individuals (where one pharmacist would be allocated for 10 000 uninsured individuals) and the clinics servicing them are far removed from one another.
“With the NHI [National Health Insurance] being signed into law, the number of pharmacists will become only a greater challenge. The cost per pharmacist employee stands at R765 000.00 per annum. It is unclear as to where the funding would come from for the remuneration of the additional pharmacists needed under the NHI, as even the NHI Act is unclear in this regard,” she said.
Notwithstanding the issue of budget constraints, the training of more pharmaceutical staff is integral to having fully functional health systems, said Professor Andrew Robinson. He is a deputy dean in the Faculty of Health Sciences at North West University (NWU). He was previously a deputy director general in the North West health department.
“To improve the pharmaceutical skills in the province, the NWU must ensure it aligns its pharmacy training to address the skill needs of the provincial health department to ensure equitable health service delivery to all, which is necessary for successful implementation of the NHI,” he said.
