Day: November 13, 2024

Categories : Healthcare Politics and RegulationsTags :

The NHI Act: a Flawed Execution of a Laudable Idea

On By ModernMedia

By Prelisha Singh, Partner, Martin Versfeld, Partner and Alexandra Rees, Senior Associate, Webber Wentzel

Robust contestation on how to best fulfil the fundamental rights of South Africans complements and strengthens our constitutional democracy. Recent debate has centred on the effective realisation of the right to access healthcare, which the state is required progressively to realise for all South Africans, irrespective of their background and income.

The right to access healthcare came into sharp focus on 15 May 2024, when President Cyril Ramaphosa signed the National Health Insurance (NHI) Act into law, prompting the initiation of constitutional challenges by concerned stakeholders. The most recent of these was filed on 1 October 2024 in the North Gauteng High Court, Pretoria by the South African Private Practitioners Forum (SAPPF), represented by Webber Wentzel.

According to the government, the NHI Act is intended to generate efficiency, affordability and quality for the benefit of South Africa’s healthcare sector.

An assessment of South Africa’s current healthcare landscape shows a stark difference between private and public healthcare. The country has a high quality, effective private healthcare offering. However, it is currently inaccessible to the many South Africans who cannot afford private care or medical aid payments. Public healthcare, on the other hand, is understaffed, poorly managed and plagued by maladministration and limited facilities.

The NHI Act has been positioned as the vehicle to address this disparity and a desire to take steps towards achieving universal healthcare in South Africa. But a closer reading of the Act highlights numerous problems with its content and implementation design. The absence of clarity, detail or guidance contained in the Act makes it impossible to assess how the Act will actually be implemented (or, by extension, what the effects of this implementation will be).

This is particularly concerning given that years have passed since the economic assessments, on which the Act was based, were undertaken. Also problematic is the apparent lack of consideration given by the government to submissions made by affected stakeholders during multiple rounds of constitutionally required public participation.

SAPPF underscores these deficits in seeking both to have the President’s decision to assent to the Act reviewed and set aside, and the Act itself declared unconstitutional.

President Ramaphosa was obliged, in terms of sections 79 and 84(2)(a) to (c) of the Constitution, not to assent to the Act in its current form. Section 79 requires the President to refer back to Parliament any bill that he or she believes may lack constitutionality. In this case, it is difficult to conceive how the President, or any reasonable person in the President’s position could not have had doubts regarding the constitutionality of the NHI Bill. The decision by the President to sign unconstitutional legislation into law, instead of referring it back to Parliament for correction, is also irrational.

The President’s duty properly to have referred the NHI Bill back to Parliament is affirmed by the fact that the President is enjoined, by section 7(2) of the Constitution, to respect, protect, promote and fulfil the rights contained in the Bill of Rights.

SAPPF’s application demonstrates that the NHI Act, in its current form, infringes upon the rights to access healthcare services, to practice a trade, and to own property. Patients, including those using private healthcare, will be forced to use a public healthcare system that currently fails to meet its key constituents’ needs. Practitioners’ rights to freedom of trade and profession will be infringed upon, and the property rights of medical schemes, practitioners, and financial providers will be unjustifiably limited.

On its current text, the Act could make South Africa the only open and democratic jurisdiction worldwide to impose a national health system that excludes by legislation private healthcare cover for those services offered by the state – notwithstanding the level or quality of case.

Concerns regarding the rights infringements in the NHI Act are exacerbated by its lack of clarity and the fact that crucial aspects of its implementation are relegated to regulations, with no clear guidance provided in the Act itself.

For example, section 49 provides that the NHI will be funded by money appropriated by Parliament, from the general tax revenue, payroll tax, and surcharge to personal tax. However, this stance does not reconcile with section 2, which provides that the NHI will be funded through ‘mandatory prepayment’, a compulsory payment for health services in accordance with income level. Crucially, the extent of the benefits covered by the NHI’s funding mechanism and its rate of reimbursement, which impact affordability and the provision of quality healthcare, remain unknown.

The Act is, at best, a skeleton framework, seemingly assented to in haste. It is conceptually vague to the extent that the rights it seeks to promote will, in fact, be infringed if implemented. This renders the Act irrational, in addition to its other constitutional defects.

The NHI Act represents a radical shift of unprecedented magnitude in the South African health care landscape. This should be – and is required to be – underpinned by meaningful public participation, up-to-date socio-economic impact assessments and affordability analyses and final provisions that provide a clear and workable framework for implementation.

It is not sufficient for these vital issues to be addressed after the fact. Further engagements with stakeholders and the solicitation of proposals by the government cannot be used to splint broken laws. Collaborative engagement, including the solicitation of inputs for meaningful consideration, should take place during the law-making process, not after its conclusion.

A shift of the magnitude proposed by the Act, absent compliance with the structures of the law-making process and adherence by the state to constitutional standards, including rights protections, would be detrimental to the entire healthcare sector – public and private – and not in the best interests of patients and practitioners.

Notwithstanding the legal contestation surrounding the Act, it and the laudable goals underlying it can also be a watershed. The achievement of universal health coverage is an opportunity for the different stakeholders in South Africa’s healthcare system to meaningfully collaborate and inform well-supported, factually informed, rational and genuinely progressive legislative steps by the state.

Given the questions surrounding the Act and the evident need it seeks to address, the space exists for healthcare stakeholders to align around shared goals and values. They can leverage their available resources to design a healthcare system that serves all of South Africa’s people fairly and equitably, using the significant existing resources invested in the country’s healthcare sector.

Categories : Cardiovascular Disease PaediatricsTags :

Adequate Sleep Significantly Reduces Hypertension Risk in Teens

On By ModernMedia
Photo by Eren Li

Adolescents who meet the recommended guidelines of nine to 11 hours of sleep per day were shown to have a significantly lower risk of hypertension, according to a new study from UTHealth Houston.  

Recently published in the Journal of the American Heart Association, the research revealed that adolescents had a 37% lower risk of developing incidents of high blood pressure by meeting healthy sleep patterns, and underscoring the importance of adequate sleep behaviour. The research further explored the impact of environmental factors potentially impacting sleep.  

“Disrupted sleep can lead to changes in the body’s stress response, including elevated levels of stress hormones like cortisol, which in turn can increase blood pressure,” said first author Augusto César Ferreira De Moraes, PhD, assistant professor in the Department of Epidemiology at UTHealth Houston School of Public Health. 

De Moraes and his team analysed data from 3320 adolescents across the US to investigate incidents of high blood pressure during nighttime sleep cycles. Scientists identified a rise in hypertension incidents over two data periods, 2018-2020 and 2020-2022, showing an increase from 1.7% to 2.9%. The data included blood pressure readings and Fitbit assessments, which measured total sleep time and REM sleep duration at night. The study’s design analysed covariates such as Fitbit-tracked sleep, blood pressure, and neighbourhood noise by residential geocodes, allowing for a thorough examination of environmental noise exposure for each participant. 

Neighbourhood/community noise was not significantly associated with the incidence of hypertension. Environmental factors, such as neighbourhood noise, point to the need for longer-term studies to investigate the relationship between sleep health and hypertension, particularly in relation to socioeconomic status, stress levels, and genetic predispositions. 

The study emphasises the importance of improved sleep behaviours and meeting recommendations. “Consistent sleep schedules, minimising screen time before bed, and creating a calm, quiet sleep environment can all contribute to better sleep quality,” advises Martin Ma, MPH, second author of the study and recent graduate of the school. “Although environmental noise didn’t directly affect hypertension in this study, maintaining a quiet and restful sleep environment is still important for overall well-being.” 

Source: University of Texas Health Science Center at Houston

Categories : Cancer NeurologyTags :

Early Radiotherapy Treatment of Vestibular Schwannomas Prevents Problems

On By ModernMedia
Photo by National Cancer Institute on Unsplash

Patients with a small cranial nerve tumour that can cause hearing loss, vertigo, imbalance and ringing in the ears have typically been watched rather than proactively treated, as the risks of early intervention were thought to outweigh the benefits. Now a study shows that even those patients benefit significantly from non-invasive stereotactic radiosurgery, led by UVA Health physicians has found. The findings were reported in Neurosurgery.

Doctors typically treat larger forms of the tumours, called vestibular schwannomas, while taking a “watch and wait” approach to smaller tumours that aren’t causing appreciable problems. But the new research, from UVA Health neurosurgeon Jason Sheehan, MD, PhD, and collaborators, could change how asymptomatic schwannomas are managed. Their findings demonstrated that stereotactic radiosurgery – a highly targeted form of radiation therapy – can prevent small tumours from growing over time while at the same time sparing patients from potentially irreversible problems in the future.

“This study and our recent Vestibular Schwannoma International Study of Active Surveillance versus Stereotactic Radiosurgery [VISAS] trial demonstrate that radiosurgery affords effective and durable tumour control while more often avoiding the neurological complications that come from watching a vestibular schwannoma,” Sheehan said. “Over time, Gamma Knife radiosurgery bends the curve of growth and problems that commonly arise from watching even the smallest of vestibular schwannomas.”

About vestibular schwannomas

Vestibular schwannomas are growths on a cranial nerve that connects the brain and inner ear. This nerve transmits information about head movements, helps us control our balance and allows us to hear. The growths, however, can disrupt the nerve’s important functions, causing hearing loss, unsteadiness, headaches, tinnitus (ringing in the ear), facial numbness/paralysis and other problems. 

Seeking to improve care for patients with these tumours, Sheehan and his team performed a trial through the International Radiosurgery Research Foundation looking at 261 adults with the smallest category of vestibular schwannomas. These were usually picked up early, and the patients often were high functioning and had the most to lose from tumour growth over time. Of the study participants, 182 received stereotactic radiosurgery, while 79 did not. 

The patients who underwent radiosurgery using the Gamma Knife system showed consistently better tumour control over time. In this group, 99% of the patients’ tumours either stayed the same size, grew very little (less than 25%) or shrank. This was true at 3 years, 5 years, and 8 years. Only one patient’s tumour significantly increased in size.

Tumour control was much worse among those who didn’t receive radiosurgery: 37% saw their tumours grow significantly at 3 years, 50% at five years, and 67% at eight years.

That difference was seen plainly in the symptoms the patients experienced. Radiosurgery was associated with a 54% lower rate of tinnitus, a 51% lower rate of cranial nerve deterioration and an 83% lower rate of vestibular dysfunction that causes dizziness and loss of balance. 

Even with Gamma Knife radiosurgery to treat the tumour arising from this very delicate neural structure, hearing was preserved similarly in both groups.

Sheehan, an expert in stereotactic radiosurgery and brain tumours, urges physicians to take note of the findings because tumour symptoms are often irreversible as the tumour grows. Acting early, before symptoms develop, could greatly improve patients’ long-term quality of life, he says.

“In brain surgery, particularly involving the hearing and balance nerve, our approach must be exceedingly refined,” he said. “This study shows that Gamma Knife radiosurgery substantially improves the future trajectory of vestibular schwannoma patients.”

Source: University of Virginia Health System

Categories : Emergency MedicineTags :

CPR with Breaths Essential for Cardiac Arrest after Drowning

On By ModernMedia
Photo by Kampus Production

Updated guidance reaffirms the recommendation for cardiopulmonary resuscitation (CPR) and highlights the importance of compressions with rescue breaths as a first step in responding to cardiac arrest following drowning, according to a new, focused update to Special Circumstances Guidelines from the American Heart Association and the American Academy of Pediatrics. The recommendations were published simultaneously in Circulation (focusing on adults) and Pediatrics (focusing on children).

Drowning is the third-leading cause of death from unintentional injury worldwide. The World Health Organization estimates there are about 236 000 deaths due to drowning each year globally. According to the CDC, it’s the number one cause of death for children ages 1-4 years old in the US.

“The focused update on drowning contains the most up-to-date, evidence-based recommendations on how to resuscitate someone who has drowned, offering practical guidance for health care professionals, trained rescuers, caregivers and families,” said writing group Co-Chair Tracy E. McCallin, M.D., FAAP, associate professor of paediatrics in the division of paediatric emergency medicine at Rainbow Babies and Children’s Hospital in Cleveland. “While we work on a daily basis to lower risks of drowning through education and community outreach on drowning prevention, we still need emergency preparedness training that can be used in tragic circumstances if a drowning occurs.”  

Detailed in the new guideline update:

  • Anyone removed from the water without showing signs of normal breathing or consciousness should be presumed to be in cardiac arrest.
  • Rescuers should immediately initiate CPR that includes rescue breathing in addition to chest compressions. Multiple large studies over time show more people with cardiac arrest from non-cardiac causes such as drowning survive when CPR includes rescue breaths compared to Hands-Only CPR (calling 911 [10111 in South Africa] and pushing hard and fast in the centre of the chest).

Drowning generally progresses quickly from initial respiratory arrest (when a person is unable to breathe) to cardiac arrest, meaning that the heart stops beating. As a result, blood cannot circulate properly throughout the body, and it is starved of oxygen.

“CPR for cardiac arrest due to drowning must focus on restoring breathing as well as restoring blood circulation,” said writing group Co-Chair Cameron Dezfulian, MD, FAHA, FAAP, senior faculty in paediatrics and critical care at Baylor College of Medicine in Houston.

“Cardiac arrest following drowning is most often due to severe hypoxia, or low blood oxygen levels,“ Dezfulian said. ”This differs from sudden cardiac arrest from a cardiac cause where the individual generally collapses with fully oxygenated blood.”

The updated guidance advises untrained rescuers and the public to:

  • Provide CPR with breaths and compressions to all people who have a cardiac arrest after drowning. If a person is untrained, unwilling, or unable to give breaths, they can provide chest compressions only until help arrives. 
  • In-water rescue breathing should be given only by rescuers trained in this special skill if it doesn’t compromise their own safety. Trained rescuers should also provide supplemental oxygen if available.
  • The initiation of CPR should always be prioritised and begin as soon as possible as early lay responder CPR has been shown to improve outcomes from drowning.
  • The writing group recommends an automated external defibrillator (AED) should be placed in public facilities where aquatic activities are present such as swimming pools or beaches. They can be used once the person is removed from the water, if available, yet should not delay initiation of CPR. If available, the AED should be connected to the patient to assess for shockable rhythms once CPR is ongoing. Although most cases of cardiac arrest following drowning do not have shockable rhythms, if a primary cardiac event such as a heart attack occurs while in the water, the best outcomes are when defibrillation is done quickly. AED use is safe and feasible in aquatic environments.
  • All individuals requiring any level of resuscitation following drowning, including those who only need rescue breaths, should be transported to a hospital for evaluation, monitoring and treatment.

In addition to the recommendations on drowning resuscitation, the guideline update also highlights the Drowning Chain of Survival, which includes the steps needed to improve chances of survival: prevention, recognition and safe rescue.

Prevention

It has been estimated that more than 90% of all drownings are preventable. Research has found most infants drown in bathtubs, and the majority of preschool-aged children drown in swimming pools. The American Heart Association and the American Academy of Pediatrics recommend being water aware and practicing water safety. See: Prevention of Drowning and other guidelines.  

Recognition

Recognition of drowning may be challenging because someone who is drowning may not be able to verbalise distress or signal for help. Drowning happens quickly. People in distress will rapidly submerge, lose consciousness and may be hidden from anyone not actively seeking them.

Safe Rescue and Removal

The guideline update recommends that appropriately trained rescuers, such as lifeguards, swim instructors or first responders, should provide in-water rescue breathing to an unresponsive person who has drowned if it does not compromise their own safety. Previous studies have proven this leads to more favourable survival outcomes. A drowning person who is unconscious and likely in cardiac arrest should be removed from the water in a near-horizontal position, with the head maintained above body level and airway open. If the drowning individual is conscious, a more vertical position may be preferable to reduce the risk of vomiting.

In summary, “These updated guidelines are based on the latest available evidence and are designed to inform trained rescuers and the public how to proceed in resuscitating people who have drowned. Drowning can be fatal. Our recommendations maximise balancing the need for rapid rescue and resuscitation, while prioritising rescuer safety,” Dezfulian said.

Source: American Heart Association

Categories : PaediatricsTags :

More than a Quarter of New Mothers have Fallen Asleep while Breastfeeding

On By ModernMedia
Photo by Wendy Wei

More than a quarter of new mothers have fallen asleep recently while feeding their babies, putting the infants at increased risk of sudden infant death syndrome (SIDS), research published in Pediatrics reveals.

More than 80% had not intended to fall asleep, and many had chosen to feed in chairs or on sofas rather than in a bed. Unfortunately, the cushions and confines of those locations can be very unsafe for babies, raising the risk of death by 49 to 67 times.

The researchers, with UVA Health and UVA Health Children’s, are urging care providers to provide additional guidance for new parents on safe feeding practices, such as informing new moms that a hormone naturally released during breastfeeding will make them feel sleepy.

“While falling asleep while feeding young infants is not in itself too surprising, what is very alarming is that the majority of mothers did not plan to fall asleep, so the sleep space was potentially unsafe for the baby while both slept,” said researcher Fern Hauck, MD, MS, a safe-sleep expert at UVA Health and the UVA School of Medicine. “This highlights the need for parents to be educated about the potential risk of falling asleep while feeding and to plan for that possibility by making the space around the baby as safe as possible. That would include removing pillows and blankets to ensure an open airway for the baby.”

Safe infant feeding

Hauck and her collaborators, including UVA’s Ann Kellams, MD, and Rachel Moon, MD, analysed survey results collected from more than 1250 new mothers as part of the Social Media and Risk-reduction Training (SMART) study conducted at 16 US hospitals in 2015 and 2016. Most respondents completed the survey when their infant was between 2 and 3 months of age.

Among the respondents, more than 28% said they had “usually” or “sometimes” fallen asleep during feeding in the prior two weeks. Of those, a whopping 83.4% said falling asleep was unplanned.

Women who fed in bed were more likely to fall asleep (33.6%) than those who fed on a chair or couch (16.8%). The American Academy of Pediatrics (AAP) recommends mothers at risk of falling asleep while breastfeeding should do so in an adult bed rather than a chair or couch.

Many of the women who fell asleep on chairs or sofas said they chose those locations specifically to avoid falling asleep, to avoid locations (such as a bed) they had been told were unsafe or to avoid disturbing someone else. (The AAP warns moms against sharing a bed or other sleep space with an infant because of the risk the parent might accidentally roll over and smother the child, or that the child could become tangled in bedding. But the group also says that beds are safer than chairs and sofas if falling asleep while feeding is a possibility.)

“We need to meet families where they are and come up with a nighttime plan for sleeping and feeding their baby that works for them and is as safe as possible,” said Kellams, a paediatrician and breastfeeding and lactation medicine specialist at UVA Health Children’s. “Our data suggest that too many of these falling asleep incidents are not planned, so discussions about how to plan for feeding your baby when you are very tired are important.”

The researchers note that providing parents with information about safe sleep and feeding has been shown to reduce risk of unexpected death significantly. But this educational outreach needs to be expanded, they say. Care providers should acknowledge that moms face a very real risk of falling asleep while feeding, even if they are trying not to, and provide practical advice on how to reduce that risk. Further, the researchers are urging additional studies to find ways to assist parents in both safe-sleep practices and breastfeeding.

“We hope that parents of young infants will think proactively about what might happen in the middle of the night,” said Moon, a paediatrician and safe-sleep expert at UVA Health Children’s. “Feeding your baby in your bed is safer than feeding on a couch or armchair if you might fall asleep.”

Source: University of Virginia Health System

Categories : Substance UseTags :

Objective Study Shows that Cannabinol does in Fact Increase Sleep

On By ModernMedia
Photo by Cottonbro on Pexels

Research by scientists at the University of Sydney has identified cannabinol (CBN), a constituent in the cannabis plant that improves sleep. Their report is the first to use objective measures to show that (CBN), while not intoxicating, does increase sleep in rats. The study, which has been published in the leading journal Neuropsychopharmacology, found that CBN was comparable in efficacy to zolpidem.

“For decades, cannabis folklore has suggested that aged cannabis makes consumers sleepy via the build-up of CBN, however there was no convincing evidence for this,” said lead author Professor Jonathon Arnold, Director of Preclinical Research, at the Lambert Initiative for Cannabinoid Therapeutics and the Sydney Pharmacy School.

“Our study provides the first objective evidence that CBN increases sleep, at least in rats, by modifying the architecture of sleep in a beneficial way.”

CBN is an end-product of the main intoxicating constituent of cannabis, delta9-tetrahydrocannabinol (THC). THC in cannabis is slowly converted to CBN over time, which means older cannabis contains higher levels of this compound. It has been suggested that the consumption of older cannabis is associated with a sleepier cannabis “high”. 

In the United States, highly purified CBN products are being sold as sleep aids, but there has been little high-quality scientific evidence to support this application.

The research team at the Lambert Initiative for Cannabinoid Therapeutics tested the effects of purified CBN on sleep in rats. Using high-tech monitoring, the experiments provided insights into the rats’ sleep patterns including the amount of non-rapid eye movement (NREM) and rapid eye movement (REM) sleep. 

NREM is deep sleep that promotes physical recovery and strengthens memories, while REM sleep is associated with dreaming and processing of emotions. 

Professor Arnold said: “CBN was found to increase both NREM and REM sleep, leading to increased total sleep time, with a comparable effect to the known sleep drug zolpidem.”

Non-intoxicating

Unlike its parent molecule THC, CBN did not appear to intoxicate rats. THC intoxicates by activating CB1 cannabinoid receptors, which are present in the brain. The study showed that unlike THC, CBN only weakly activates these receptors. To their surprise, the researchers found that a metabolite of CBN had significant effects on cannabinoid CB1 receptors. 

A metabolite is a chemical produced via the metabolism of a larger molecule in the body.

They also found that the 11-OH CBN metabolite had some impact on sleep architecture, which might contribute to the overall effects of CBN on sleep.

“This provides the first evidence that CBN indeed increases sleep using objective sleep measures. It was a surprise that CBN metabolism in the body can yield a much greater effect on cannabinoid CB1 receptors than the parent molecule CBN, which has much more limited activity,” Professor Arnold said.

“At this stage our results are confined to testing in rats. Further research is needed to see if this translates to humans.”  

Further study

In a parallel study, yet to be published, Professor Iain McGregor, Director of Clinical Research at the Lambert Initiative, initiated a placebo-controlled randomised human clinical trial in insomnia patients. This was led by PhD student Isobel Lavender with leading sleep researcher Dr Camilla Hoyos from the Woolcock Institute of Medical Research. The trial has now been completed with very promising results that were recently announced at the International Cannabinoid Research Society and Sleep DownUnder scientific conferences.

“Our research encourages further basic and clinical research on CBN as a new treatment strategy for sleep disorders, including insomnia. Our clinical study only administered CBN on a single occasion. A trial on a larger scale, that includes repeated dosing, is the logical next step,” Professor McGregor said.

Professor Arnold said: “The team has now commenced a preclinical drug discovery program around CBN, as well as observing whether the pro-sleep effects of CBN can be further amplified by other molecules found in cannabis, or by conventional sleep aids, such as melatonin.”

Source: University of Sydney