Only 16% of South Africans can afford private healthcare, and many low-income earners cannot afford healthcare and must rely on community clinics. These facilities are under intense pressure as they often cannot cope with the demand. For many workers, getting medical attention at these facilities means waiting for hours and being unable to work for a day and therefore losing wages. However, things could change if the pioneering efforts of a dedicated nurse with the financial backing of Standard Bank reach their full national potential.
“We assist this sector by working longer hours than do local government clinics that only open five days a week. Our services are available seven days a week at R300 per visit. Those able to pay for primary healthcare often must travel long distances to get to pharmacy-based primary healthcare clinics, mostly in the suburbs. The Rapha Clinic has been strategically placed between the city and the townships so that it can be easily reached by people commuting from their homes to the city,” says Ntombi Skosane, founder of Rapha Healthcare Services.
For Skosane, the clinic, which is located in the Montana area of Pretoria, realised her dream of being able to fill a vital gap in providing primary and basic healthcare to her community.
“As a nurse with 30 years in both the public and the private sector, I believed that I could open a clinic where I could establish a community service offering quality healthcare at affordable rates. The growing success of our operation shows that I was correct,” she adds.
Using her experience of clinics as a guide, Skosane has opted to have Rapha offer nine core services ranging from antenatal care and family planning to assisting with immunisations and wound care, as well as helping those with chronic illnesses and HIV testing and counselling.
“The Rapha Clinic met the stringent guidelines for being considered for a grant. These included an assessment of the viability of the business by the Standard Bank Enterprise Development Funding Committee, the commitment and required personal investment of the owner, and the sector in which the business operates. Although the business was operating successfully, it needed financial assistance to reach its full potential. In this case, the company needed additional stock and equipment to deliver a full service. After considering the application, Standard Bank purchased the required equipment for Rapha,” says Naledzani Mosomane, Head of Enterprise and Supplier Development at Standard Bank.
Skosane says that acquiring additional medical and surgical stock, emergency trollies, a vaccine fridge, wheelchairs, and air-conditioning through Standard Bank meant that the clinic would be able to attend to more patients more efficiently.
Rapha may be just a single clinic, but new outlets are being planned for Gauteng and the North West Province. Ten new clinics are being considered, as are health assessment centres in partnership with gyms and medical aids.
“We believe that Rapha Healthcare Services has a bright future. We look forward to playing a central role in growing the nation’s small business sector and developing relationships with a new generation of entrepreneurs,” says Mosomane.
Women who have their ovaries removed before menopause, particularly before the age of 40, have reduced white matter integrity in multiple regions of the brain later in life. The findings appear online in Alzheimer’s & Dementia: The Journal of the Alzheimer’s Association.
“We know that having both ovaries removed before natural menopause causes abrupt endocrine dysfunction, which increases the risk of cognitive impairment and dementia,” said Michelle Mielke, PhD, professor at Wake Forest University School of Medicine. “But few neuroimaging studies have been conducted to better understand the underlying mechanisms.”
For the study, the research team examined data from the Mayo Clinic Study of Aging to identify women over the age of 50 with available diffusion tensor imaging, a magnetic resonance imaging (MRI) technique that measures white matter in the brain. The cohort was comprised of:
22 participants who had premenopausal bilateral oophorectomy (PBO) before age 40
43 participants who had PBO between the ages of 40 and 45
39 participants who had PBO between the ages of 46 and 49
907 participants who did not have PBO before the age of 50
“Females who had premenopausal bilateral oophorectomy before the age of 40 had significantly reduced white matter integrity in multiple regions of the brain,” said Mielke, the study’s corresponding author. “There were also trends in some brain regions such that women who had PBO between the ages of 40–44 or 45–49 years also had reduced white matter integrity, but many of these results were not statistically significant.”
Mielke said that 80% of participants who had their ovaries removed also had a history of oestrogen replacement therapy. Therefore, the study was not able to determine whether the use of oestrogen replacement therapy after PBO mitigated the effects of PBO on white matter integrity. She noted that the ovaries secrete hormones both before (primarily oestrogen, progesterone and testosterone) and after menopause (primarily testosterone and androstenedione).
“Having both ovaries removed results in an abrupt decrease in both oestrogen and testosterone in women,” Mielke said. “Therefore, one possible explanation for our results is the loss of both oestrogen and testosterone.”
Mielke said additional research is needed to further understand how white matter changes are associated with cognitive impairment.
“While these findings are important for women to consider before having premenopausal bilateral oophorectomy for non-cancerous conditions, we need a larger and more diverse cohort of women to validate these results.”
Pancreatic cancer. Credit: Scientific Animations CC BY-SA 4.0
Patients with pancreatic cancer who received chemotherapy both before and after surgery experienced longer survival rates than would be expected from surgery followed by chemotherapy, according to a new study from researchers at Yale School of Medicine.
The study, published June 20 in JAMA Oncology, included patients with pancreatic ductal adenocarcinoma (PDAC), an aggressive cancer with a high mortality rate which accounts for 90% of pancreatic cancers. The researchers say these findings are encouraging for the 15 to 20% of patients with operable pancreatic cancer.
The single-arm Phase II trial evaluated a modified form of the chemotherapy treatment FOLFIRINOX. This combination treatment consisting of leucovorin calcium, fluorouracil, irinotecan hydrochloride, and oxaliplatin received US Food and Drug Administration approval in 2011 as a first-line treatment for patients with metastatic pancreatic cancer. Patients in the trial received six cycles of the modified FOLFIRINOX before surgery, followed by an additional six cycles of the chemotherapy treatment after surgery. The modified regimen consisted of slightly lower doses of FOLFIRINOX to improve tolerability, which was previously shown in a 2016 publication not to impact outcomes negatively.
Of the 46 patients who started the modified treatment, 37 completed all six cycles of chemotherapy before surgery and 27 had successful tumour removal operations. For all enrolled patients, the 12-month progression-free survival rate was 67%, indicating significant progress in controlling the disease. Furthermore, 59% of all patients lived at least two years after completing the full chemotherapy treatment plan and surgery.
The study was the first of its kind for patients with PDAC when senior author and Yale Cancer Center member Jill Lacy, MD, started it in 2014. The study goal had been a 12-month progression-free survival rate of at least 50% of patients.
“When the study launched, even with operable pancreatic cancers, 90% of patients were still relapsing and dying from their cancer eventually,” said Michael Cecchini, MD, the first author of the study. “We sought to move chemotherapy up in their treatment regimen and give it before surgery to see if we could improve the outcome for our patients.”
The study used advanced techniques to monitor the progress of treatment, including analysing circulating tumour DNA (ctDNA) and using the cancer biomarker keratin 17 to help predict outcomes. For example, patients with detectable ctDNA four weeks post-surgery had significantly worse progression-free survival than those who had no detectable ctDNA.
Cecchini said larger randomised clinical trials are needed to continue to investigate the role of FOLFIRINOX before surgery for patients with operable PDAC.
“I think even though there have been changes in standard of care for patients with this aggressive pancreatic cancer type, we have here very promising data to justify a larger study,” said Cecchini.
Credit: Darryl Leja National Human Genome Research Institute National Institutes Of Health
A new study published in Neurology suggests that certain drugs commonly used to treat enlarged prostate may also decrease the risk for dementia with Lewy bodies (DLB). This observational finding may seem surprising, but it mirrors previous work by the University of Iowa Health Care team that links the drugs to a protective effect in another neurodegenerative condition: Parkinson’s disease.
The UI researchers think that a specific side effect of the drugs targets a biological flaw shared by DLB and Parkinson’s disease, as well as other neurodegenerative diseases, raising the possibility that they may have broad potential for treating a wide range of neurodegenerative conditions.
“Diseases like dementia with Lewy bodies, or Parkinson’s disease, or Alzheimer’s disease are debilitating, and we don’t really have any good treatments that can modify the disease progression. We can treat symptoms, but we can’t actually slow the disease,” explains lead study author Jacob Simmering, PhD, UI assistant professor of internal medicine. “One of the most exciting things about this study is that we find that same neuroprotective effect that we saw in Parkinson’s disease. If there is a broadly protective mechanism, these medications could potentially be used to manage or prevent other neurodegenerative diseases.”
Large observational study links prostate drugs to lower risk of dementia with Lewy bodies
DLB is a neurodegenerative disease that causes substantial and rapid cognitive decline and dementia. It affects about one in 1000 people per year, accounting for 3 to 7% of all dementia cases.
For the new study, the UI researchers used a large database of patient information to identify more than 643 000 men with no history of DLB who were newly starting one of six drugs used to treat benign prostatic hyperplasia (enlarged prostate).
Three of the drugs, terazosin, doxazosin, and alfuzosin (Tz/Dz/Az), have an unexpected side effect; they can boost energy production in brain cells. Preclinical studies suggest that this ability may help slow or prevent neurodegenerative diseases like PD and DLB.
The other drugs, tamsulosin and two 5-alpha-reductase inhibitors (5ARIs) called finasteride and dutasteride, do not enhance energy production in the brain and therefore provide a good comparison to test the effect of the Tz/Dz/Az drugs.
The team then followed the data on these men from when they started taking the medication until they left the database or developed dementia with Lewy bodies, whichever happened first. On average, the men were followed for about three years.
Because all the participants were selected to start a drug that treats the same condition, the researchers reasoned that the men were likely similar to each other at the outset of the treatment. The men were all propensity score-matched for characteristics like age, year of medication start, and other illnesses they had before starting the treatment, to further reduce the differences between the groups.
“We found that men who took Tz/Az/Dz drugs were less likely to develop a diagnosis of dementia with Lewy bodies,” Simmering says. “Overall, men taking terazosin-type medications had about a 40% lower risk of developing a DLB diagnosis compared to men taking tamsulosin, and about a 37% reduction in risk compared to men taking five alpha reductase inhibitors.”
Meanwhile, there was no statistically significant difference in risk between men taking tamsulosin and alpha reductase inhibitors.
Approved drugs show potential
Since this was an observational study, causation cannot be established, only an association. In addition, the study only included men because the drugs are prescribed for prostate problems, which means that the researchers don’t know if the findings would apply to women. However, Simmering and his colleagues are excited by the potential of these drugs, which are already FDA approved, inexpensive, and have been used safely for decades.
“If terazosin and these similar medications can help slow this progression – if not outright preventing the disease – this would be important to preserving cognitive function and quality of life in people with DLB,” Simmering says.
Is complementing in-person care with virtual care (hybrid care) a key part of the answer to South Africa’s NHI aspirations, asks Deon Bührs, Managing Director of Genie Health SA, who suggests that technology is the ‘unreasonable man’ in complementing decent universal healthcare and that self-empowerment is the only solution to sustainable wellness.
“The reasonable man adapts himself to the world: the unreasonable one persists in trying to adapt the world to himself. Therefore all progress depends on the unreasonable man.”
George Bernard Shaw
There is a school of thought that a young democracy can benefit from a well-considered blend of socialism and capitalism, particularly when it comes to healthcare and education. I would second that, to a degree. That South Africa requires a more equitable health system goes without saying though, as the apparent disparity and divisions between the haves and have nots is ever widening.
The status of our public healthcare system and the spiralling costs of the private offering need to find parity. A sad situation indeed, because at one stage, South Africa had one of the best public health sectors in the world, where groundbreaking heart transplants, for example, were done.
To the question of universal healthcare then. If it means that universal healthcare is a fundamental human right that everyone should aspire to, then it’s a yes, the NHI is essential. It should not be a matter of political affiliation, and let’s be clear, there is already healthcare for all in South Africa, through the public health system, free at the point of care for those who cannot afford care. But it is the quality of this care, and the effective management of these services that lie in stark contrast to that of the private healthcare system.
Signed in literally at the 11th hour before the country went to general elections, the National Health Insurance (NHI) bill is a polarising topic for many. The massive cost of providing a functioning NHI as per the bill, has been estimated conservatively at more than R200 billion a year, while some estimate closer to R1 trillion. With an already strained tax base, we must adopt new thinking as to how to deliver healthcare in a cost sensitive and effective way.
To my mind, one of the most effective ways of ensuring there is universal care that works, is recognising and supporting the role the patient plays in empowering their own health, recovery and wellness journey. They appear, however, to have been forgotten in the conversation that is the NHI bill to date.
For me, in its current guise, the NHI will unfortunately not bridge the quality divide. In fact, if we are not careful and if we do not find common ground, and hold government and the private sector to account, our entire healthcare system could well be in danger of failing – completely.
The unreasonable man test – laying the groundwork for new ways of healthcare delivery
Although expediently signed into law with little regard to comments or concerns raised from many sectors including health and business, the NHI does lay the groundwork for new ways of delivering healthcare and sets the scene for changing the mindset from the current sick-care system mentality to one of a patient-empowered HEALTHcare system.
Change must happen, but the extent of that change often depends on what Irish playwright and political activist, George Bernard Shaw, once stated as: “The reasonable man adapts himself to the world: the unreasonable one persists in trying to adapt the world to himself. Therefore all progress depends on the unreasonable man.”
At present, Prof Nicholas Crisp who has been tasked with helming the delivery of the NHI, could be seen as Shaw’s “unreasonable man” in his efforts to equalise and deliver universal healthcare. Ensuring that the lever of technology is utilised in an effective way is critical though, to ensure that we don’t try and replicate previous perceived successes, and not move forwards.
With a challenged healthcare system, both public and private, we are called to not give up hope, but to lean into the solution, and at the same time, avoid a defensive posture of that which only served the few. I believe that these circumstances force us to innovate, and to seriously consider new ways of providing healthcare for all. It should be seen as an exciting time of just where we can push the future of healthcare.
For instance, we already know that a traditional healthcare delivery system, with its associated costs and accessibility challenges for those living in remote parts of our country just won’t cut it. But unlocking technology as the new delivery channel of healthcare complimented by affordable and fast internet, could well be the solution to cracking the code of healthcare for all.
Through technology we can drive the patient-centric approach to health and open the door for patients to more easily access the multi-disciplinary team of healthcare professionals they need.
The best of both worlds – prevention, and when required, recovery
An example of doing things differently, is a new approach to musculoskeletal health that has been facilitated by digital transformation, and which is finding growing adoption in South Africa. With objective improvements in patient outcomes, satisfaction scores and recovery times, virtual care teams can support patients through their recovery programmes, ensuring improved compliance and ownership of their health journey. And empowering patients to embrace exercise and activity over surgery and pharmaceuticals where appropriate, has a dramatic impact on the overall healthcare spend.
Imagine patients having the choice to access a multi-disciplinary team of experts anywhere in the country – from the comfort and convenience of their own home or workplace, all at the tips of their fingers. No need to be transported to a clinic or hospital every time they need healthcare services. This is entirely possible, with platforms like Genie Health, that provide a hybrid approach in complimenting in-person care with virtual care.
NHI needs a strong front loader like these hybrid platforms that provide the full range of allied healthcare services, to reduce the burden of care and cost on an already strained system, by reducing unnecessary hospital admissions, surgeries, medication and travel costs and allowing for the existing framework to be brought up to date and even surpass expectations.
With ICASA reporting over 75% of the population having Internet access in South Africa and more than 90% smartphone penetration, pressure on Mobile Network Operators to provide zero rated data for healthcare applications (as they have done in education and other areas) mounts.
If measures like this can be implemented, they will have a tremendous impact on reducing the burden on the existing healthcare system through a self-health-empowered approach, with the backing of a full clinical team on the ready to assist the patient.
The ultimate question is how do we make healthcare more affordable and accessible to all South Africans, which is the core aim of the NHI?
The answer – we need to renew our focus on the key stakeholder, our patients – and empower them to drive their own health, by using technology as the backbone for sustainable wellness. It could well be, that with a renewed mindset and health-empowered citizens, the NHI is the true gamechanger for progress in HEALTHcare that we all need.
Brain-computer interfaces, or BCIs, promise life-changing benefits for people suffering from a range of neurological conditions, but implementation is for both the invasive and noninvasive methods is challenging. Researchers led by Bin He at Carnegie Mellon University used an innovative electroencephalogram (EEG) wearable. They successfully integrated a novel focused ultrasound stimulation to realise bidirectional BCI that both encodes and decodes brain waves using machine learning in a study with 25 human subjects.
This work, published in Nature Communications, opens up a new avenue to significantly enhance not only the signal quality, but also, overall nonivasive BCI performance by stimulating targeted neural circuits.
Noninvasive BCI is lauded for its merits of being cheap, safe, and virtually applicable to everyone, but because signals are recorded over the scalp versus inside the brain, low signal quality presents some limitations. The He group is exploring ways to improve the effectiveness of noninvasive BCIs and, over time, has used deep learning approaches to decode what an individual was thinking and then facilitate control of a cursor or robotic arm.
In their latest research, the He group demonstrated that through precision noninvasive neuromodulation using focused ultrasound, the performance of a BCI could be improved for communication.
“This paper reports a breakthrough in noninvasive BCIs by integrating a novel focused ultrasound stimulation to realise bidirectional BCI functionality,” explained Bin He, professor of biomedical engineering at Carnegie Mellon University. “Using a communication prosthetic, 25 human subjects spelled out phrases like ‘Carnegie Mellon’ using a BCI speller. Our findings showed that the addition of focused ultrasound neuromodulation significantly boosted the performance of EEG-based BCI. It also elevated theta neural oscillation that enhanced attention and led to enhanced BCI performance.”
For context, a BCI speller is a 6×6 visual motion aide containing the entire alphabet that is commonly used by nonspeakers to communicate. In He’s study, subjects donned an EEG cap and just by looking at the letters, were able to generate EEG signals to spell the desired words. When a focused ultrasound beam was applied externally to the V5 area (part of the visual cortex) of the brain, the performance of the noninvasive BCI greatly improved among subjects. The neuromodulation-integrated BCI actively altered the engagement of neural circuits to maximize the BCI performance, compared to previous uses, which consisted of pure processing and decoding recorded signals.
Following this discovery, the He lab is further investigating the merits and applications of focused ultrasound neuromodulation to the brain, beyond the visual system, to enhance noninvasive BCIs. They also aim to develop more compact-focused ultrasound neuromodulation device for better integration with EEG-based BCIs, and to integrate AI to continue to enhance the overall system performance.
“This is my lifelong interest, and I will never give up,” emphasized He. “Working to improve noninvasive technology is difficult, but I strongly believe that if we can find a way to make it work, everyone will benefit. I will keep working, and someday, noninvasive lifesaving technology will be available for every household.
Discovery Health had an “overwhelming case” against the Road Accident Fund (RAF) and its CEO Collins Letsoalo showing it was clearly in breach of a 2022 court ruling that the fund was not allowed to withhold payments for past medical expenses from road accident victims who had been paid out by their medical schemes.
This was the submission of Advocate Wim Trengove, on behalf of Discovery, at a special court hearing seeking to hold the fund and Letsoalo to account.
While initially Discovery, in its application before Gauteng Judge President Dunstan Mlambo and judges Ingrid Opperman and Noluntu Bam on Thursday, were seeking orders of contempt of court, Trengrove said it was now only seeking an order of “breach” and to compel compliance.
He said this would give Letsoalo a further opportunity to “have his say” as to why he should not be found in contempt and possibly jailed for it.
In 2022, Judge Mandla Mbongwe ruled in the Pretoria High Court that a new directive – effectively refusing to pay for past medical expenses of those claimants already paid out by medical aids – was unlawful.
The RAF was unsuccessful in its appeals to both the Supreme Court of Appeal and the Constitutional Court.
Read the original Pretoria High Court judgment here
Trengove argued that the RAF had continued to implement the directive, regardless of the court ruling.
“We have a list of about 20 cases, all of which are in line with the Mbongwe judgment,” he said.
After the apex court refused to grant the RAF leave to appeal the Mbongwe judgment, two further “directives” came to light in which the fund seemingly sought to side-step the legal implications of the Mbongwe judgment.
Trengove said “directive two” was also raised once in litigation and was rejected. Under this directive, the fund had argued that it should not have to compensate medically insured victims if they had been paid out in accordance with prescribed minimum benefits.
“Then it produced ‘directive three’ which is equally spurious,” he said.
This was based on a section of the RAF Act, which prohibited compensation to anyone who had agreed to share compensation with another person. The fund argued that the agreement between a medical scheme and its members fell foul of this.
“But that agreement is merely an agreement to avoid double-compensation. That the medical aid pays upfront and if the member recovers (from the fund), then that member will reimburse the medical aid,” Trengove said.
He said regardless, the new directive did not absolve the fund from complying with the Mbongwe ruling.
That ruling, he said, confirmed that a claim against the fund is a claim in delict: the fund steps into the shoes of the wrongdoer, and “the perpetrator is not entitled to benefit from the insurance proceeds of the victim”.
“Our courts have held that medical schemes, for the purposes of claims, are akin to insurance, and claims cannot be taken into account when determining the quantum of liability,” Trengove said.
RAF denial
But advocate Cedric Puckrin, who appeared with advocate Gerhard Cilliers for the fund, said Trengove had argued his case “with rose-coloured glasses”.
Cilliers said the fund was entitled to implement the first directive during the period when the appeal process had been underway.
He said Discovery was arguing a new case, not an enforcement of the Mbongwe ruling, and had based it on ten examples where the fund had responded to letters of demand by claimants, indicating that it would dispute liability for any claim for past medical expenses.
Cilliers suggested that Discovery had no standing in court, and that it was up to individual claimants to take their matters to court.
He also said the ten examples did not show that the fund was in breach.
“It is not Discovery’s case that RAF is enforcing the 2022 directive. It wants you to go further and ask you to find that the subsequent directives are the same. And we submit that is not the proper process to follow. It is an abuse of the process.”
Advocate Puckrin argued that while the third directive might be “entirely wrong”, it was a different directive which could only be set aside by a separate application to the court.
He said it could not be considered a “breach” of the Mbongwe judgment.
But Judge Opperman suggested that it was just a “new piece of paper” dealing with the same issue.
“But it’s based on a new principle,” Puckrin said. “It’s far more limited.”
In reply, Trengove said the Mbongwe judgment has set out a statement of “general principle” that the fund could not free itself from paying full compensation to medical aid members.
He said Letsoalo and other fund officials had made a series of public statements which reflected their “unlawful disdain” for the ruling.
“A delinquent public body cannot insulate itself against compliance with a court order by adopting a directive in effect not to comply with it. It is contrary to the rule of law.”
New research from Macquarie University’s Spinal Pain Research Group shows that walking has the potential to change the way low back pain is managed, making effective interventions accessible to more people than ever before. The results of the trial, which combined walking with education, are published in The Lancet.
About 800 million people worldwide have low back pain, which is a leading cause of disability and reduced quality of life. Recurrences of low back pain are very common, with seven in 10 people who recover from an episode going on to have a recurrence within a year.
Professor of Physiotherapy Mark Hancock and his research team have been investigating ways to shift the emphasis from treatment to prevention to improve the management of back pain, an approach that empowers individuals to manage their own health and reduces the cost to society and the healthcare system.
Far from the bed rest recommended for back pain in the past, current best practice includes the combination of exercise and education, both to treat current pain and to prevent future episodes.
While beneficial, some forms of exercise are not accessible or affordable to many people due to their high cost, complexity and need for supervision.
A simpler, more accessible method
The world-first WalkBack trial examined whether a programme of walking combined with education could be effective in preventing recurrences of low back pain.
The trial followed 701 adults who had recently recovered from an episode of low back pain, randomly allocating participants to either an individualised walking program facilitated by a physiotherapist and six education sessions across six months, or to a no-intervention control group.
The participants’ progress was then followed for between one and three years to collect information about any new recurrences of low back pain they experienced.
The researchers’ primary aim was to compare the two groups for the number of days before participants experienced a recurrence of back pain that impacted daily activities or required care from a healthcare provider.
They also evaluated the cost effectiveness of the intervention, including costs related to work absenteeism and healthcare services.
Longer pain-free periods
The paper’s senior author, Professor Hancock, says what they discovered could have a profound impact on how low back pain is managed.
“The intervention group had fewer occurrences of activity-limiting pain compared to the control group, and a longer average period before they had a recurrence, with a median of 208 days compared to 112 days,” Professor Hancock says. “The risk of having a recurrence that required seeking care was nearly halved in those in the intervention group.
“Walking is a low-cost, widely accessible and simple exercise that almost anyone can engage in, regardless of age, geographic location or socio-economic status.
“We don’t know exactly why walking is so good for preventing back pain, but it is likely to include the combination of gentle oscillatory movements, loading and strengthening the spinal structures and muscles, relaxation and stress relief, and the release of ‘feel-good’ endorphins.
“And of course, we also know that walking comes with many other health benefits, including cardiovascular health, improved bone density, maintenance of a healthy weight and improved mental health.”
Professor Hancock said the amount of walking each person completed was individualised based on a range of factors including their age, physical capacity, preferences and available time. Participants were given a rough guide to build up to 30 minutes, five times a week over a six-month period.
After three months, Professor Hancock said most of the people who took part were walking three to five days a week for an average of 130 minutes.
“You don’t need to be walking five or 10 kilometres every day to get these benefits,” Professor Hancock says.
A cost-effective option
The paper’s lead author, Postdoctoral Fellow Dr Natasha Pocovi, says in addition to providing participants with longer pain-free periods, they found the program was also cost effective.
“It not only improved people’s quality of life, but it reduced their need both to seek healthcare support and the amount of time taken off work by approximately half,” Dr Pocovi says.
“The exercise-based interventions to prevent back pain that have been explored previously are typically group-based and need close clinical supervision and expensive equipment, so they are much less accessible to the majority of patients.
“Our study has shown that this effective and accessible means of exercise has the potential to be successfully implemented on a much larger scale than other forms of exercise.”
To build on these findings, the team now hopes to explore how they can integrate the preventive approach into the routine care of patients who experience recurrent low back pain.
The quest to develop universal donor blood has taken a decisive step forward. Researchers in Denmark have discovered enzymes that, when mixed with red blood cells, are able to remove specific sugars that make up the A and B antigens in the human AB0 blood groups. The results appear in Nature Microbiology.
“For the first time, the new enzyme cocktails not only remove the well-described A and B antigens, but also extended variants previously not recognised as problematic for transfusion safety. We are close to being able to produce universal blood from group B donors, while there is still work to be done to convert the more complex group A blood. Our focus is now to investigate in detail if there are additional obstacles and how we can improve our enzymes to reach the ultimate goal of universal blood production,” says Professor Maher Abou Hachem, who is the study leader at Technical University Denmark (DTU) and one of the senior scientists behind the discovery.
He states that the discovery is the result of combining the expertise of DTU researchers in enzymes from the human gut microbiota and Lund University researchers in carbohydrate-based blood groups and transfusion medicine.
High demand for donor blood
Human red blood cells carry specific complex sugars structures (antigens) that define the four AB0 blood groups A, B, AB and 0. These antigens control compatibility between donors and recipients for safe blood transfusion and organ transplantation. Donor blood is screened for disease markers and the main blood groups. It can then be stored refrigerated for up to 42 days.
The need for donor blood is high due to the elderly making up a larger proportion of the population and more patients undergoing blood-intensive medical procedures. Successfully converting A or B blood types into AB0 universal donor blood can markedly reduce the logistics and costs currently associated with storing four different blood types. In addition, the development of universal donor blood will lead to an increased supply of donor blood by reducing the waste of blood approaching its expiry date.
The reason why it is necessary to remove the A and B antigens to create universal donor blood is because they can trigger life-threatening immune reactions when transfused into non-matched recipients.
The concept of using enzymes to generate universal donor blood was introduced more than 40 years ago. Since then, higher efficiency enzymes to remove the A and B antigens were discovered, but researchers are still not able to explain or abolish all immune reactions related to the blood, and therefore these enzymes are still not used in clinical practice.
Enzymes from the gut
The research groups from DTU and Lund University have gone new ways to find enzymes that can remove both the A and B blood antigens and the sugars that block them. The research teams discovered new mixtures of enzymes from the human gut bacterium Akkermansia muciniphila that feeds by breaking down the mucus, which covers the surface of the gut. It turns out that these enzymes are exceptionally efficient, as the complex sugars at the surface of the intestinal mucosa share chemical resemblance with those found at the surface of blood cells.
“What is special about the mucosa is that bacteria, which are able to live on this material, often have tailor-made enzymes to break down mucosal sugar structures, which include blood group AB0 antigens. This hypothesis turned out to be correct,” says Maher Abou Hachem.
The researchers in this study tested 24 enzymes, which they used to process hundreds of blood samples.
“Universal blood will create a more efficient utilisation of donor blood, and also avoid giving AB0-mismatched transfusions by mistake, which can otherwise lead to potentially fatal consequences in the recipient. When we can create AB0-universal donor blood, we will simplify the logistics of transporting and administering safe blood products, while at the same time minimizing blood waste” says Professor Martin L. Olsson, the leader of the study at Lund University.
The researchers from DTU and Lund University have applied for a patent on the new enzymes and the method for enzyme treatment and expect to make further progress on this in their new joint project over the next three and a half years. If successful, the concept needs to be tested in controlled patient trials before this can be considered for commercial production and clinical use.
The initial research project is funded by the Independent Research Fund Denmark (Technology and Production Sciences, FTP), the Swedish Research Council, ALF grants from the Swedish government and county councils as well as the Knut and Alice Wallenberg Foundation and Research Fund Denmark, Natural Sciences, FNU), while the new continued project is funded by the Novo Nordisk Foundation, Interdisciplinary Synergy Programme.
The AB0 blood group antigens found on the surface of red blood cells are also found on the mucosal layer that lines the surface of the gut. Researchers have harnessed a specialised human gut bacterium and its ability to use these antigens as nutrients to discover and develop two enzyme mixtures that convert group A and B red blood cells into universal donor blood. Graphic: Mathias Jensen, postdoc at DTU.
About Akkermansia muciniphila
Akkermansia muciniphila is a bacterium found abundantly in the guts of most healthy humans. This bacterium can break down mucus in the gut and produces beneficial compounds such as the short-chain fatty acid propionate, in addition to exerting beneficial effects on body weight and metabolic markers.
In an international phase III study, researchers have demonstrated the potential of tirzepatide, known to manage type 2 diabetes, as the first effective drug therapy for obstructive sleep apnoea (OSA), a sleep-related disorder characterised by repeated episodes of irregular breathing due to complete or partial blockage of the upper airway.
The results, published in the New England Journal of Medicine, highlight the treatment’s potential to improve the quality of life for millions around the world affected by OSA.
“This study marks a significant milestone in the treatment of OSA, offering a promising new therapeutic option that addresses both respiratory and metabolic complications,” said Atul Malhotra, MD, lead author of the study, professor of medicine at University of California San Diego School of Medicine and director of sleep medicine at UC San Diego Health.
OSA can result in reduced blood oxygen levels and can also be associated with an increased risk of cardiovascular complications, such as hypertension and heart disease. Recent studies, also led by Malhotra, suggest that the number of OSA patients worldwide is close to 936 million.
Conducted in two Phase III, double-blinded, randomised, controlled trials, the new study cohort recruited 469 participants from 9 countries with clinical obesity and living with moderate-to-severe OSA. Participants either used or did not use continuous positive airway pressure (CPAP) therapy, the most common sleep apnoea treatment which uses a machine to maintain an open airway during sleep, preventing interruptions in breathing. Patients were administered either 10 or 15mg of the drug by injection or a placebo and followed for 52 weeks.
Researchers found that tirzepatide led to a significant decrease in the number of breathing interruptions during sleep, a key indicator used to measure the severity of OSA. This improvement was much greater than what was seen in participants that were given a placebo. Importantly, some participants that took the drug reached a point where CPAP therapy might not be necessary. Considerable data suggest that a drug therapy that targets both sleep apnoea and obesity is beneficial rather than treating either condition alone.
Additionally, the drug therapy improved other aspects related to OSA, such as reducing the risk factors of cardiovascular diseases and improved body weight. The most common side effect reported was mild stomach issues.
“Historically, treating OSA meant using devices during sleep, like a CPAP machine, to alleviate breathing difficulties and symptoms,” Malhotra said. “However, its effectiveness relies on consistent use. This new drug treatment offers a more accessible alternative for individuals who cannot tolerate or adhere to existing therapies. We believe that the combination of CPAP therapy with weight loss will be optimal for improving cardiometabolic risk and symptoms. Tirzepatide can also target specific underlying mechanisms of sleep apnoea, potentially leading to more personalised and effective treatment.”
Malhotra adds that having a drug therapy for OSA represents a significant advancement in the field.
“It means we can offer an innovative solution, signifying hope and a new standard of care to provide relief to countless individuals and their families who have struggled with the limitations of existing treatments,” said Malhotra. “This breakthrough opens the door to a new era of OSA management for people diagnosed with obesity, potentially transforming how we approach and treat this pervasive condition on a global scale.”
Next steps include conducting clinical trials to examine longer term effects of tirzepatide.
