Day: April 29, 2022

Can Public Clinics Be Fixed with The Right Technology?

Male doctor with smartphone
Photo by Ivan Samkov on Unsplash

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 the Mint 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.

By Daniel Steyn and Vusi Mokoena

Republished from the original at GroundUp under a Creative Commons Licence

New Drugs for Cryptococcal Meningitis Sorely Needed in SA

Brain scan image
Image source: Mart Production on Pexels

Despite the greater safety and efficacy of a new short course treatment for HIV-related cryptococcal meningitis (CM), access to the treatment in South Africa will be a challenge, according to a pair of articles by Spotlight.

Following positive results of a trial, the World Health Organization last week announced new recommendations for the treatment of CM, with a single high dose of L-AmB followed by two weeks of flucytosine and fluconazole.

Using L-AmB (AmBisome) and flucytosine for the treatment of CM will be a welcome change for South Africa, which has the world’s highest burden of the condition. This shorter course with fewer side effects than the current treatment involving amphotericin-B could save lives as well as clinical resources in the public sector, but at present the treatment is hamstrung by pricing and availability uncertainty, with a course of L-AmB currently only available at a steep cost.

Amphotericin B [deoxycholate] is a drug that doctors and nurses used to call ampho-terrible,” Amir Shroufi, Médecins Sans Frontières (MSF) Southern Africa board member told Spotlight.

He explained that “it’s a really nasty drug, doctors and nurses don’t like it because it can cause severe anaemia. It’s toxic to the kidneys, so it can cause kidney damage and even kidney failure… and the infusion line used for the drug can often become infected and it can cause inflammation of the veins where it’s going into the body.”

L-AmB is a “much better drug”, he said, with great benefits of administering it for one day as opposed to a week or two. The seriousness of CM meant hospitalisation will still be required, pointed out Dr Jacqui Miot, division director of the Wits Health Economics and Epidemiology Research office, but means that patients won’t be tethered to a drip and may be able to go home sooner.

Under the treatment regimen, a patient receives a single high dose of L-AmB on the first day of treatment, followed by a 14-day course of flucytosine and fluconazole pills.

For a 60kg patient at the recommended dosage, twelve 50mg vials of L-AmB are needed, which at Gilead’s promised access price would be R2 880. Key Oncologics’ currently charges R34 560 for 12 vials.

Even given the availability of L-AmB, Shrouifi warns that “whatever you’re doing, you have to have flucytosine. That’s your baseline, even if you’re giving liposomal amphotericin B, you have to have the flucytosine”.

Flucytosine is an old, off-patent medicine developed in the 1950s. Despite its age and its demonstrated efficacy in the landmark ACTA trial four years ago, flucytosine was only recently authorised for use in South Africa and is only slowly being rolled out.

Amir Shroufi warned that access to the life-saving medicine remains a major issue. “Doctors are not being given the tools they need to treat [CM],” he said. “The first tool they have to have is flucytosine and they still don’t have flucytosine. So, that’s the thing that needs to happen urgently, you know, tomorrow! Everyone with cryptococcal meningitis must get access to flucytosine.”

Like L-AmB, Mylan’s 250mg and 500mg flucytosine tablets were only registered recently, in December 2021. The Department of Health’s target price for a pack of 100 tablets is R1 500. Fortunately, it appears that the Clinton Health Access Initiative (CHAI) will be able to secure packs of 100 at R1 470 each for use in South Africa’s flucytosine access programme.

The next steps for rollout of flucytosine will be inclusion on the national essential medicines list and in CM treatment guidelines before tenders can be put out.

Source 1: Spotlight

Source 2: Spotlight

In Finger Osteoarthritis, Lipofilling Reduces Pain, Improves Function

Hand osteoarthritis
Source: Pixabay CC0

For patients with painful finger osteoarthritis, lipofilling  a nonsurgical procedure where a patient’s fat is transferred into the arthritic joints, may result in lasting improvements in hand function and especially pain, according to a study in Plastic and Reconstructive Surgery.

Researchers reported their experience with 18 patients undergoing fat transfer procedures for finger osteoarthritis.

“Even over a long-term follow-up, the transfer of fatty tissue to arthritic fingers joints appears to provide a safe and minimally invasive alternative to conventional surgery for patients with osteoarthritis,” commented the study’s lead author Max Meyer-Marcotty, MD, PhD.

In the lipofilling procedure, a sample of the patient’s own fatty tissue was obtained by liposuction from another part of the body: the upper thigh or hip area. Tiny volumes of lipid cells (< 1mL) were injected into the arthritic finger joints. For recovery, patients wore a splint around the treated finger and took pain relievers for a week. No infections or other complications were recorded.

The researchers analysed follow-up outcomes in a total of 25 finger joints treated by lipofilling. Hand function, pain scores, and patient satisfaction were evaluated an average of 44 months (maximum 50 months) after treatment.

Assessment showed a “highly significant clear improvement” in pain score: from a median of 6 points (on a 10-point scale) before treatment to 0.5 points at follow-up. “We believe that for our patients the reduction of pain represents the most striking and important result, which also has the most pronounced and highly significant effect,” Dr Meyer-Marcotty et al. wrote.

On functional evaluation, pinch grip strength of the treated fingers increased from a median of 2.0kg before lipofilling to 4.3kg at follow-up. Non-significant improvements were seen in fist closure force and score on a standard assessment of hand function during everyday tasks.

In severe cases of osteoarthritis, surgery is effective in relieving arthritis pain, but is associated with potential complications and lengthy recovery time.

Fat transfer procedures have been introduced in recent years for a growing range of purposes in plastic and reconstructive surgery. Animal studies have suggested that mesenchymal stromal cells found in fatty tissues can regenerate tissue in arthritic joints.

“The chance to preserve the joint with a minimally invasive procedure is of particular interest in the early, albeit painful, phases of finger osteoarthritis,” Dr. Meyer-Marcotty added. “Since the lipofilling procedure is nondestructive, conventional joint surgery can still be performed later, if needed.”

Larger long-term follow-up studies are needed to further corroborate these initial positive findings, the researchers said.

Source: EurekAlert!

Seven Hours’ Sleep is Optimal in Middle Age and Older

Sleeping woman
Photo by Cottonbro on Pexels

According to research published in Nature Aging, seven hours is the ideal amount of sleep for people in their middle age and upwards, with too little or too much little sleep associated with poorer cognitive performance and mental health.

Sleep plays an important role in enabling cognitive function and maintaining good psychological health, and also removes waste products from the brain. Alterations in sleep patterns appear during ageing, including difficulty falling asleep and staying asleep, and decreased quantity and quality of sleep. It is thought that these sleep disturbances may contribute to cognitive decline and psychiatric disorders in the ageing population.

Scientists from the UK and China examined data from nearly 500 000 adults aged 38–73 years from the UK Biobank. Participants were asked about their sleeping patterns, mental health and wellbeing, and took part in a series of cognitive tests. Brain imaging and genetic data were available for almost 40 000 of the study participants.

The researchers found in their analysis that both insufficient and excessive sleep duration were associated with impaired cognitive performance, such as processing speed, visual attention, memory and problem-solving skills. The optimal amount of sleep was found to be seven hours per night for cognitive performance and good mental health. More symptoms of anxiety and depression and worse overall wellbeing were associated with sleeping for longer or shorter durations.

The researchers say one possible reason for the association between insufficient sleep and cognitive decline may be due to the disruption of slow-wave — ‘deep’ — sleep. Disruption to this type of sleep has been shown to have a close link with memory consolidation as well as the build-up of amyloid — a key protein which, when it misfolds, can cause ‘tangles’ in the brain characteristic of some forms of dementia. Additionally, lack of sleep may hamper the brain’s ability to rid itself of toxins.

The amount of sleep was also linked differences in the structure of brain regions involved in cognitive processing and memory, again with greater changes associated with greater than or less than seven hours of sleep.

Consistently getting seven hours’ sleep each night was also important to cognitive performance and good mental health and wellbeing. Interrupted sleep patterns have previously been shown to be associated with increased inflammation, indicating a susceptibility to age-related diseases in older people.

Professor Jianfeng Feng from Fudan University in China said: “While we can’t say conclusively that too little or too much sleep causes cognitive problems, our analysis looking at individuals over a longer period of time appears to support this idea. But the reasons why older people have poorer sleep appear to be complex, influenced by a combination of our genetic makeup and the structure of our brains.”

The researchers say the findings suggest that insufficient or excessive sleep duration may be a risk factor for cognitive decline in ageing. This is supported by previous studies that have reported a link between sleep duration and the risk of developing Alzheimer’s disease and dementia, in which cognitive decline is a hallmark symptom.

Professor Barbara Sahakian from the Department of Psychiatry at the University of Cambridge, one of the study’s authors, said: “Getting a good night’s sleep is important at all stages of life, but particularly as we age. Finding ways to improve sleep for older people could be crucial to helping them maintain good mental health and wellbeing and avoiding cognitive decline, particularly for patients with psychiatric disorders and dementias.”

Source: University of Cambridge

People with Blue Eyes Share a Single Ancestor

Eye
Source: Daniil Kuzelev on Unsplash

New research published in Human Genetics shows that people with blue eyes trace their ancestry back to a single individual. Researchers tracked down a genetic mutation which took place 6–10 000 years ago and is the cause of the eye colour of all blue-eyed humans without albinism alive on the planet today.

While blue eyes evolved only once, blonde hair has evolved at least twice: in Melanesian populations, blonde hair evolved independently to European populations, involving a mutation in a different gene.

“Originally, we all had brown eyes,” said Professor Hans Eiberg from the University of Copenhagen. “But a genetic mutation affecting the OCA2 gene in our chromosomes resulted in the creation of a ‘switch’, which literally ‘turned off’ the ability to produce brown eyes.” The OCA2 gene codes for the P protein, which is involved melanin production. This ‘switch’, located in the gene next to OCA2, does not completely shut off production but instead is limited to reducing the production of melanin in the iris, effectively ‘diluting’ brown eyes to blue. The switch’s effect on OCA2 is very specific therefore. If the OCA2 gene is completely destroyed or turned off, albinism would be the result.

Eye colours from brown to green depend on the amount of melanin in the iris, but blue-eyed individuals only have a small degree of variation in the amount of melanin in their eyes. “From this we can conclude that all blue-eyed individuals are linked to the same ancestor,” said Professor Eiberg. “They have all inherited the same switch at exactly the same spot in their DNA.” Brown-eyed individuals, by contrast, have considerable individual variation in the area of their DNA that controls melanin production.

Professor Eiberg and his team studied mitochondrial DNA and compared the eye colour of blue-eyed individuals in countries as diverse as Jordan, Denmark and Turkey. His research stretches back to 1996, when he first implicated the OCA2 gene as being responsible for eye colour.

The mutation of brown to blue eyes does not confer any evolutionary advantage, as with others such as hair colour.

As Professor Eiberg explained, “it simply shows that nature is constantly shuffling the human genome, creating a genetic cocktail of human chromosomes and trying out different changes as it does so.”

Source: University of Copenhagen