While herbal supplements may be natural, they may not always be harmless. In Heart Rhythm Case Reports, doctors report on a patient who experienced dizziness and fainting and was diagnosed with a dangerous cardiac arrhythmia after taking hemp oil containing CBD and CBG and berberine supplements.
“More and more people are taking herbal supplements for their potential benefits. Yet their ‘natural’ character can be misleading, since these preparations can have serious adverse side effects on their own or if combined with other supplements or medications,” said Elise Bakelants, MD, Department of Cardiology, University Hospital of Geneva. “Their use should not be taken lightly, and dosing recommendations should always be respected.”
The reported case involves a 56-year-old woman who was admitted to the emergency department after experiencing dizziness and fainting without warning. She was diagnosed with a life-threatening cardiac arrhythmia after an ECG showed short runs of torsade de pointes, a rapid heartbeat originating in the ventricles, and a markedly prolonged QT interval, which means the heart’s electrical system takes longer than normal to recharge between beats.
Apart from low blood pressure, the patient’s physical examination and blood work were normal. The doctors were able to identify the cause as the herbal supplements she was taking to help her cope with a stressful work-life balance. She had started a regimen of six times the recommended dose of hemp oil four months earlier and had recently added berberine to the mix. All supplements were stopped during her hospital stay, resulting in a gradual decrease of her QT interval until it normalized after five days. At her three-month follow-up, she reported no new episodes of dizziness or fainting, and her ECG remained within normal range. With no other causative factors, her return to normal strongly validated that the diagnosis linked the supplements to the arrhythmia.
Herbal supplements has increased in popularity in recent years, especially those containing CBD (cannabidiol). Available without prescription, CBD has been shown to have anti-inflammatory, antiepileptic, analgesic, anxiolytic, antipsychotic, and immunomodulatory properties. Supplied as raw material or as ready-to-use products (eg, cosmetics, tobacco substitutes, scented oils), it does not contain THC (tetrahydrocannabinol), which causes the psychotropic effect of cannabis. Therefore, it is not subject to control by drug regulatory agencies. Berberine, found in the roots, rhizomes, and stem bark of many medicinal plants, is frequently used in traditional Chinese and ayurvedic medicine to treat infections, diarrhoea, type 2 diabetes, high cholesterol, and high blood pressure.
The e preparation of herbal supplements is largely unregulated and are widely perceived as safe. Exact composition can vary greatly from one distributor to another, and the pharmacodynamic and pharmacokinetic properties of these substances are not well known. Limited data are available regarding their effectiveness, toxicity, and potential for interactions. As a result, it is not always possible to foresee their negative consequences.
Dr Bakelants cautioned patients and physicians to be aware of possible side effects, respect dosing recommendations and consider possible interactions with other medications, particularly in patients with underlying cardiac disease or those already taking QT-prolonging medication.
Investigating the state of affairs in public clinics, Spotlight’s Daniel Steyn and Vusi Mokoena investigate whether the right technology could help them out of their predicament.
“I never look forward to clinic day,” says Nomtsato Tsietsi, 74, on a Monday morning while standing in the queue at Kayamandi Clinic in Stellenbosch, which she visits up to three times a month to collect pills, consult with a doctor, and have her blood tests taken.
Tsietsi has several diseases including diabetes and hypertension (high blood pressure). “We sit there for too long, sometimes all day,” she says.
Her experience is typical for people visiting state clinics. But for about 80% of South Africans, this is the only option: for most people private healthcare is unaffordable and public clinic services are free.
Some patients in the Kayamandi clinic queue said they sometimes pay people up to R80 to stand in the queue for them. One man, who had been paid by someone to stand in the queue, said that he had been there since 5am.
For employed people, a day at the clinic typically means taking a day off work, often without pay.
The pubIic health system is beset with problems: long waiting times, insufficient record keeping, poorly maintained infrastructure, and poor service delivery.
A 2018 study of nurses and doctors in Cape Town found that of 16 essential skills, ten were not performed in more than half of the consultations. In more than 60% of consultations, nurses and doctors in Cape Town did not greet patients, and in 90% of consultations, they did not attempt to understand the patient’s perspective. In nother study, 76% of Cape Town-based doctors in primary care reported that they are suffering from burnout.
During our visit to Kayamandi Clinic, we asked patients whether they would embrace technological solutions to make the experience more efficient. They all said they would. Almost all of them are smartphone users and some said they could not understand why appointments cannot be made and managed digitally, or why they cannot communicate with health workers online rather than in person.
Innovative technology solutions for primary care exist in South Africa.Phukulisa Health Solutions, for example, offers a platform that mimics a consultation with a healthcare practitioner. Equipped with Bluetooth sensors, the platform can screen patients for a range of health issues, focused specifically on HIV, TB, diabetes, and heart diseases.
Phukulisa’s CEO Raymond Campbell says that this testing and screening platform offers a more efficient screening service with a faster turnaround time. For example, the platform has been tested at an antenatal unit in Mamelodi, where the platform provided test results within 14 minutes, opposed to the usual 23 hours.
But Campbell says there is little interest from the public sector in his technology. Instead, he is finding more success licensing the platform to players in the private sector.
There have been some attempts to use innovative computer technology in public sector clinics. In Limpopo, the deputy director-general of the health department, Dr Muthei Dombo, has the vision to create a “clinic in the cloud”.
In 2018, Dombo partnered with theMint Group to conduct a trial funded by Microsoft at Rethabile clinic. Dombo provided the team at Mint Group with several problems to solve.
The team, led by Peter Reid, developed a technology to alleviate the high rate of fraud at medicine dispensing points, the difficulty of transferring medical records between different clinics, and the long waiting times.
When a patient entered the clinic, they would register at reception. Their identity document would be scanned and a picture would be taken of the patient. At every station in the clinic visited by the patient, a camera would identify the patient and the patient’s records would pop up on the screen. When the patient left the station, the profile would automatically lock.
This ensured that only patients due for specific medication would receive that medication, thereby eliminating fraud. Because the records were all kept in the cloud, the records could easily be transferred to another clinic. Without this technology, patients need to return to the same clinic every time they need to restock their medication.
The trial also assisted with queue management. Upon entering the clinic, patients would choose a “journey” based on their reason for visiting the clinic. The system would then guide the patient from one station to the next on big screens on the wall. This made the journey more seamless while also providing visual feedback to officials at the clinic helping them to manage the queues more effectively.
The trial ended shortly before the start of the Covid pandemic. The project has not yet been restarted.
One project that has been implemented widely in the public sector is Vula Mobile. Founded by Dr William Mapham in 2014, Vula aims to bridge the gap between health workers and specialists.
There is a shortage of specialist doctors in the public sector and health workers at the primary care level often lack the information to refer patients to a relevant specialist.
With the Vula app, a nurse seeing a patient can be linked with the closest specialist. Through the built-in chat function, the nurse can provide the specialist with all the necessary info and refer the patient.
The app is available in six provinces with an emphasis on the Eastern Cape. More than 24,000 health workers are registered on the system.
But other innovators in the health space, frustrated by the public sector, are focusing on providing affordable private healthcare. This follows a growing trend in South Africa, as medical aid providers increasingly offer more affordable packages targeted to lower-income earners.
At the Kayamandi clinic during GroundUp’s visit, Mcoleseli Mlenze, a 34-year-old father who often visits the clinic for hypertension medication or when his son is sick, said that while he uses the clinic to collect medication, he has started seeing a private doctor when he is sick.
He says he cannot really afford the private doctor, which costs upwards of R350 per consultation. If there was some middle-ground where he could pay R150-R200 for a consultation at a clinic that is faster and more efficient, he would happily do so.
Others in the queue said they would pay up to R50 for a better healthcare experience.
Saul Kornik, the founder of Healthforce and the Kena App, aims to lower the cost of quality primary health care so that millions of people have access to it.
Available in almost 500 pharmacies throughout the country, Healthforce’s technology enables nurses to conduct all necessary screenings and diagnostic procedures. If and when a doctor becomes necessary, the nurse presses a button to start a video call with one of the doctors in the Healthforce network.
The nurse and patient can both see the doctor and the doctor, with the help of the nurse, can consult the patient. This reduces the amount of time that the doctor is needed, thereby reducing the cost.
The patient ends up paying on average R70 to R90 for the nurse and R115 to R250 for the doctor. If needed, the doctor can prescribe medication that the patient can purchase at the pharmacy or pick up from a government dispensary.
There are Healthforce doctors available to speak any of the 11 official languages and they are available seven days a week.
In March, Healthforce launched the Kena Health app, through which patients can have consultations with nurses, doctors and mental health practitioners via chat, voice or video. The first three consultations per year are free.
After the consultation, if necessary, the doctor can provide a script for medication and a sick note.
At Kayamandi clinic, Gcobisa Malithafa, a 30-year-old mother of a toddler told GroundUp that although she would pay a small amount for a better experience, it should not have to come to that.
Malithafa suggests that instead, the clinic’s management should consult the community on a regular basis and make immediate improvements to the running of the clinic. “This thing of having one doctor at the clinic is not right,” she says.
She is struggling to get her child immunised, having visited the clinic many times without success.
Whether they use technology or not, she says, something has to change.
Having to cope with the strain of COVID on an already fragile healthcare system, a few hospitals in the Western Cape have been introducing robotics for specialised tasks – but are they worth the hype?
Robotics was able to fill an unprecedented need during the COVID pandemic – the ability to remotely conduct ward rounds from remote locations. Tygerberg Hospital made use of ‘Quintin’, a robot that is essentially a tablet on a mobile stand that allows users to remotely communicate and inspect the area, but it can’t physically interact with its environment.
Robotics offers greater surgical precision, which may translate into reduced healthcare load. IOL reported that the provincial Department of Health plans to use a pair of new robotic surgery machines installed at the Groote Schuur and Tygerberg hospitals to fast-track surgeries and address the province’s surgical backlogs caused by COVID. These robotic surgery units will be used for procedures on colorectal, liver, prostate, kidney and bladder cancers, and women with severe endometriosis. In the province’s private sector, Netcare Christiaan Barnard Memorial Hospital also makes use of robotic-assisted surgery.
Robotic surgery has a number of advantages. The small robotic arms allow for smaller incisions and faster recovery times, reducing the strain on hospitals. A liver resection that would have a patient in hospital for a week can be reduced to one or two days with robotic surgery. More complex surgery becomes possible, eg in difficult to access areas or in patients with obesity. Robotic surgery allows surgeons to be off their feet, easing an extremely fatiguing job, and the software automatically compensates for any tremor in the surgeon’s hands.
However, robotic surgery still has drawbacks – chief among them is cost and the need to have trained personnel to operate them. There is also some latency between the surgeon’s hands movements and the corresponding movement of the robot, leading to possible errors. Shorting of the electrical current running through the robotic arms can also cause burns to the patient’s tissue, and there is also the possibility of nerve compression injuries due to the positioning of the patient. Furthermore, operator errors, especially when operators are inexperienced or robotic surgery is performed in lower volumes, is always a possibility.
Robotics have promising applications in sanitation – they can easily disinfect areas using UV light, for example – and can also assist nurses with certain tasks, such as making a 3D vein map prior to a venipuncture. Some robots can even assist the elderly, conversing with them and can perform simple tasks like calling a nurse. Other applications include the much simpler technology of exoskeletons, a wearable frame which amplify users’ strength (though nowhere near that of the fictional Iron Man) and are useful in rehabilitation and for enhancing mobility in the elderly. Other applications include increasing strength of care staff for assisting patients, freeing up other staff.
Some exoskeletons are even purely mechanical, merely readjusting loads without any sophisticated electronics or motors. Yet even these are prohibitively expensive: the Phoenix Medical Exoskeleton goes for about US$30 000 each.
While promising, robotic systems are at present still hugely expensive, limited in function and can only assist with a small fraction of the tasks that healthcare workers perform. Even if the cost could be reduced enough to help ease healthcare worker burden in South Africa to help, that still leaves the problem of enough experienced and motivated healthcare workers, beds and neglected rural areas.
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.
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.
Damage has been sustained to the roofs, floors and fencing of healthcare facilties, the KwaZulu-Natal health department said. Water shortages from infrastructure damage had forced some hospitals to divert patients elsewhere. Environmental health practitioners are monitoring clinical data for early identification of any waterborne diseases.
Health MEC Nomagugu Simelane said there had been an influx of patients due to the torrential rains.
“We can confirm that our hospitals and clinics have been seeing a higher number of trauma and emergency patients than usual, particularly in the densely populated districts,” she said.
Simelane thanked the courage and dedication of the province’s healthcare workers, noting that many had simply put in extra hours to compensate. Damage to infrastructure such as roads meant that some healthcare workers have had to sleep at the facilities, she noted. Other facilities will try and provide accommodation for them.
To cope with the strain on morgues, KZN Premier Sihle Zikalala said: “We have mobilised additional resources, including seven doctors, to ensure that post mortems are completed speedily, in order to avoid congestion and to enable those who are grieving to bury their loved ones. Our officials are constantly monitoring the situation and sending bodies to those facilities that do have space.”
“All the resources allocated for flood relief and the recovery and rebuilding process will be utilised in line with fiscal rectitude, accountability, transparency and openness. We want to emphasise the fact that, having learnt lessons of Covid-19, no amount of corruption, maladministration and fraud will be tolerated or associated with this province,” Premier Zikalala said.
A study from Australia’s scientific organisation CSIRO has revealed that antimicrobial resistant (AMR) bacteria in urinary tract infections are more lethal, especially Enterobacteriaceae. The findings are published online in Open Forum Infectious Diseases.
Antimicrobial resistance (AMR) bacteria can be passed between humans: through hospital transmission and community transmission. While hospital acquired resistance is well researched, there are few studies focusing on the burden of community transmission.
To address this, the study analysed data from 21 268 patients across 134 Queensland hospitals who acquired their infections in the community. The researchers found that patients were almost two and a half (2.43) times more likely to die from community acquired drug-resistant UTIs caused by Pseudomonas aeruginosa and more than three (3.28) times more likely to die from community acquired drug-resistant blood stream infections caused by Enterobacteriaceae than those with drug-sensitive infections. The high prevalence of UTIs make them a major contributor to antibiotic use, said CSIRO research scientist, Dr Teresa Wozniak.
“Our study found patients who contracted drug-resistant UTIs in the community were more than twice as likely to die from the infection in hospital than those without resistant bacteria,” Dr Wozniak said. “Without effective antibiotics, many standard medical procedures and life-saving surgeries will becoming increasingly life-threatening. “Tracking the burden of drug-resistant infections in the community is critical to understanding how far antimicrobial resistance is spreading and how best to mitigate it.”
The study’s findings will provide further guidance for managing AMR in the community, such as developing AMR stewardship programs that draw on data from the population being treated.
CEO of CSIRO’s Australian e-Health Research Centre, Dr David Hansen, said the magnitude of the AMR problem needs to be understood to mitigate it. “Tracking community resistance is difficult because it involves not just one pathogen or disease but multiple strains of bacteria,” Dr Hansen said. “Until now we haven’t been using the best data to support decision making in our fight against AMR. Data on community acquired resistance is an important contribution to solving the puzzle. “Digital health has an important role in using big data sets to describe patterns of disease and drive important population health outcomes.”
When patients kept at a body temperature of 37C with aggressive warming during surgery, there was no reduction cardiac complications compared to patients kept at 35.5C, finds a large new study reported in The Lancet. No differences was seen in number of infections or required blood transfusions in patients kept at cooler body temperatures.
An unintentional drop in body temperature is a normal side effect during surgery, due mostly to anaesthetic medications’ interference with the body’s temperature regulation processes. In Western countries, nursing staff typically use forced-air heaters to keep patients warm during surgery, with a target temperature of 36C. This trial, one of the largest to date, sought to determine whether even greater warming, to 37C, would reduce the risk of cardiac complications, a major cause of mortality in the first 30 days after surgery.
Results showed no significant differences between groups for the trial’s primary endpoint, a composite of troponin elevation due to ischemia (an indicator of heart injury), non-fatal cardiac arrest or death from any cause within 30 days after surgery. Researchers also reported no differences for any of the trial’s secondary endpoints.
“This trial tells us that there is no benefit to aggressively warming patients to 37 C during surgery. It is simply unnecessary, and it doesn’t improve any substantive outcomes,” said Daniel I. Sessler, MD, Michael Cudahy professor and chair of the Department of Outcomes Research at Cleveland Clinic and the trial’s lead author. “Also, the results show that 36C should not be considered the threshold for defining mild hypothermia since there was no harm at 35.5C.”
The researchers enrolled 5050 patients, mostly in Chinese centres. Participants had various major noncardiac surgical procedures, with a minimum duration of two hours and an average duration of four hours. Half of the patients were randomised to routine care, with a target body temperature of 35.5C, and the other half randomised to aggressive warming, with a target body temperature of 37C.
For patients assigned to routine care, nursing staff put a warming cover in position but did not activate it until the patient’s body temperature decreased to less than 35.5C, resulting in an average group body temperature of 35.6C. With the more aggressive warming protocol, nurses covered patients with a heated blanket for 30 minutes before surgery and then used two forced-air heaters to keep patients warmed to a mean of 37.1 C during surgery.
In addition to seeing no benefit in terms of the composite primary endpoint, the trial reported no significant differences between groups in terms of serious wound infections, length of hospitalization, hospital re-admissions or the need for blood transfusions. The investigators were surprised that rates of wound infections and transfusions were similar to previous studies, which suggested that both were more common in patients maintained at lower body temperatures.
While most patients were enrolled in China, Dr Sessler said, the results should still be generalisable to patients and health care settings in other countries.
“This study shows that it is reasonable to keep patients warm, but we saw no evidence whatsoever that it makes a difference if they’re just above or just below 36C,” Dr Sessler said. “Surgical patients should still be warmed, but there’s no need to be super-aggressive about the warming.”
Less serious or non-medical outcomes, such as patient comfort or shivering was not assessed. Dr Sessler said that patients maintained at a lower body temperature may shiver or feel cold after surgery, but both are temporary and unlikely to have a meaningful health impact.
Factors such as anaemia and anticoagulants have more impact on hospitalisation time after breast reconstruction than “common” risk factors according to a new study published in the Journal of Clinical Medicine.
The study investigated the impact of different factors on postoperative blood loss and drainage fluid volume, two factors which can lengthen hospitalisation time of patients after breast reconstruction after breast cancer surgery. The findings of the study allow for an improved risk assessment and planning of reconstructive breast surgery to offer patients personalised and improved treatment.
Partial or total mastectomy is often necessary in breast cancer surgery, and reconstructive breast surgery lessens the psychological stress on the patient. Fast wound healing after surgical breast reconstruction is crucial to not delay subsequent cancer treatments. Factors influencing the length of hospital stay (LOS) or wound healing are therefore particularly significant in cancer treatment. This study identified previously unrecognised risk factors.
Blood loss and drainage fluid volumes after breast reconstruction due to breast cancer were recorded, parameters which are closely linked to the healing process and LOS .Lower loss equals earlier patient discharge and early start of subsequent treatment. “We analysed factors that might affect blood loss and drainage fluid volumes after surgery – but can be identified before the surgery,” explained lead author Dr Tonatiuh Flores, plastic surgeon. “These factors included age, body mass index and smoking status – factors that are known to have a strong impact on the course of disease.” Additionally, haemoglobin levels and possible antithrombotic prophylaxis were reviewed – two parameters that are particularly significant in oncological treatment.
Surprising results emerged from the evaluation of a total of 257 breast reconstructions in 195 patients. Professor Konstantin Bergmeister, senior author of the study explained that “the classic risk factors did not significantly influence postoperative blood loss and drainage fluid output. Haemoglobin levels and anticoagulant concentration, however, did.” The analysis revealed a close relation between low haemoglobin values or anaemia and fluid loss after reconstructive breast surgery. Co-author Prof. Klaus Schroegendorfer, elaborated on this: “Especially breast cancer patients often show perioperative anaemia, caused by the frequently required neoadjuvant chemotherapy which can affect blood values, in particular haemoglobin.”
There were similar findings regarding low molecular heparin used in cancer patients as antithrombotic prophylaxis. Patients receiving heparin tended to have increased drainage fluid output after surgery, though the effect was not as strong as with perioperative anaemia.
The study authors recommend that, to cut LOS and continue the necessary cancer treatment after reconstructive breast surgery in cancer patients as early as possible, patients should preoperatively be screened for anaemia and administration of low molecular heparin should be adapted to the patients’ risk. In correlation to the results, follow-up treatment can be improved, patients can be discharged earlier and cancer treatment can be continued.
The prospect of an exodus of doctors and other key healthcare personnel from South Africa ahead of the planned introduction of the National Health Insurance (NHI) scheme has prompted concern among healthcare stakeholders.
In addition to the loss of skilled healthcare professionals, there is also a growing concern that the country could lose valuable training skills as professionals look to leave.
Thirteen years on from its inception, the NHI continues to suffer from the same criticisms. A May 2021 research paper [PDF} found that South Africa’s per capita spending on public healthcare was higher than even wealthier developing countries, yet it ranked near the bottom for measures of healthcare outcomes.
An informal poll on the QuickNews website in March showed that 81% of respondents had at least considered emigrating due to the planned introduction of NHI.
Professional associations are also warning of an exodus with the start of NHI. The South African Medical Association (SAMA) has said that its members cannot support the NHI in its current form.
This stems from a deep-rooted lack of confidence in the capacity of government and its financial ability to ensure the service is successful, the association said. Other concerns that members have raised include only providing emergency treatment to refugees and illegal immigrants, as well as their children.
SAMA conducted a survey which showed that up to 38% of its members plan to emigrate from South Africa due to the planned introduction of the NHI.
6% of members said that they plan to emigrate for other reasons, while 17% of doctors said that they were unsure about leaving the country. Many doctors have said that the aim should rather be to get the public sector to a state where it can appeal to private sector patients.
They added that there should be engagement with private doctors to provide additional services funded by the state. The group also called for a proper pilot of the proposed systems and payment mechanisms.
The Department of Health noted these concerns in a parliamentary briefing this week, noting that skilled personnel will be needed for the NHI to work. It added that this was not limited to healthcare professionals, but that general skilled human resources will be central to the health system going forward.
It added that the complex interactions between training, registration compliance and employment can all be greatly improved.
“This is a big ship that will need to be turned, but the framework is in place,” said acting director-general of health Dr Nicholas Crisp. “We have heard the threats that there will be an exodus of personnel if the NHI is implemented and a brain drain.”
The department is actively responding to this, he said, with a framework in place to ensure the country retains the necessary skills. A ‘Human Resources for Health strategy’ before was already under development before the start of the COVID pandemic, he added.
This framework sets out a multi-work implementation plan, but it requires money and investment in the health workforce to ensure the country is ready for universal health coverage, Dr Crisp said.
“Every health professional has a place in the National Health Insurance – whether you choose to work in the public portion of the delivery system or the private portion of that delivery system.
“We do not think there needs to be a threat on anybody, or their viability, or their role to be played.”
The study supports the use of widely available CEAA supplements to promote recovery and preserve function in patients undergoing surgery for repair of major fractures. “Our results suggest that this inexpensive, low-risk intervention has considerable potential to improve outcomes after fracture fixation,” according to the report by Michael Willey, MD, and colleagues of University of Iowa Hospital and Clinics, Iowa City.
The study included 400 patients undergoing operative fixation of fractures in the limbs and/or pelvis at the researchers’ trauma centre. In equal numbers and stratified by fracture severity, patients were randomises to either standard postoperative nutrition or standard nutrition plus CEAA supplementation.
CEAAs are termed “conditionally essential” because the body doesn’t usually require them. However, during times of illness or stress, the need for these conditional amino acids increases dramatically. Previous studies have reported that CEAA supplementation can improve wound-healing and other outcomes in patients with a variety of conditions, including postoperative recovery. In the new trial, patients assigned to the CEAA group received a standard supplement that included arginine, leucine, and glutamine.
At follow-up, the overall complication rate was significantly lower for patients who received CEAA supplementation (30.5%) compared with those who did not receive CEAA (43.8%). The CEAA group also had a lower rate of nonunion (5.1 vs 13.2%, respectively). Some other types of complications, including surgical-site infections, were similar between groups.
Patients who undergo operative fracture fixation are at risk of skeletal muscle wasting, which often results in weight loss as a result of reduced muscle mass. In the new study, patients receiving CEAA supplements had little or no change in fat-free body mass. In contrast, patients receiving standard nutrition had a 1kg reduction in fat-free mass at 6 weeks postoperatively, which took until 12 weeks to return to normal.
An unexpected finding was a sharply reduced mortality rate in the CEAA group (0.5% compared to 4.1 % for the control). Although the authors could not explain the lower risk of death in patients receiving CEAA, they suggest it might result from “unidentified confounding factors.”
Despite advances in surgical techniques, trauma patients undergoing operative fixation of extremity and pelvic fractures remain at risk of complications and prolonged loss of function. “Malnutrition is a potentially modifiable risk factor for mortality, fracture nonunion, wound complications, and increased length of stay,” the authors wrote.
CEAA supplementation therefore appears to be a simple, risk-free, and inexpensive means of promoting good nutrition after fracture fixation surgery. Controlling for other factors, the relative risk of complications is about 40% lower in patients receiving CEAA, with no reduction in fat-free mass during the early weeks of recovery. The researchers concluded: “This study will serve as the foundation for multicentre [randomised controlled trials] that are designed to assess the impact of CEAA nutrition supplementation in reducing complications and loss of functional muscle mass in high-risk populations.”