A new Cochrane review has found that insulin can be kept at room temperature for months without losing potency, offering hope to people living with diabetes in regions with limited access to healthcare or stable powered refrigeration. This affects millions of people living in low- and middle-income countries, particularly in rural areas, as well as people whose lives have been disrupted by conflict or natural disasters.
Insulin is an essential medicine for people with diabetes and current guidance states that before use it must be kept refrigerated to preserve its effectiveness. For millions of people with diabetes living in low- and middle-income countries, however, the harsh reality is that electricity and refrigeration are luxuries that are unavailable to them. Vulnerable populations in war-torn areas, disaster-prone regions, and climate crisis-affected areas, including those enduring extreme heat, also need solutions that don’t rely on powered fridges.
The new Cochrane review summarises results of different studies investigating what happens to insulin when stored outside of fridges, including previously unpublished data from manufacturers. The review found that it is possible to store unopened vials and cartridges of specific types of human insulin at temperatures of up to 25°C for a maximum of six months, and up to 37°C for a maximum of two months, without any clinically relevant loss of insulin activity. Data from one study showed no loss of insulin activity for specific insulin types when stored in oscillating ambient temperatures of between 25°C and 37°C for up to three months. This fluctuation resembles the day-night temperature cycles experienced in tropical countries.
The research team, led by Bernd Richter from the Institute of General Practice, Medical Faculty of the Heinrich-Heine-University in Düsseldorf, Germany, conducted comprehensive research to investigate insulin stability under various storage conditions. The review analysed a total of seventeen studies, including laboratory investigations of insulin vials, cartridges/pens, and prefilled syringes, demonstrating consistent insulin potency at temperatures ranging from 4°C to 37°C, with no clinically relevant loss of insulin activity.
Bernd stressed the significance of this research, particularly for people living with type 1 diabetes, where “insulin is a lifeline, as their very lives depend on it. While type 2 diabetes presents its challenges, type 1 diabetes necessitates insulin for survival. This underscores the critical need for clear guidance for people with diabetes in critical life situations, which many individuals lack from official sources.
“Our study opens up new possibilities for individuals living in challenging environments, where access to refrigeration is limited. By understanding the thermal stability of insulin and exploring innovative storage solutions, we can make a significant impact on the lives of those who depend on insulin for their well-being.”
These findings can help communities facing challenges in securing constant cold storage of insulin. They provide reassurance that alternatives to powered refrigeration of insulin are possible without compromising the stability of this essential medicine. It suggests that if reliable refrigeration is not possible, room temperature can be lowered using simple cooling devices such as clay pots for insulin storage.
The researchers have also identified uncertainties for future research to address. There remains a need to better understand insulin effectiveness following storage under varying conditions. Further research is also needed on mixed insulin, influence of motion for example when insulin pumps are used, contamination in opened vials and cartridges, and studies on cold environmental conditions.
Photo by FOX: https://www.pexels.com/photo/brown-tabby-cat-scratching-head-1265613/
Toxoplasma gondii, a common, cat-borne parasite already associated with risk-taking behaviour and mental illness in humans may also contribute to exhaustion, loss of muscle mass, and other signs of frailty in older adults, suggests a study published in theJournal of Gerontology: Medical Science.
The research, by an international team of scientists including University of Colorado Boulder, University of Maryland School of Medicine and the University of A Coruña in Spain, is the latest to explore how the tiny, single-celled organism T. gondii could have big impacts on human health.
“We often think of T. gondii infection as relatively asymptomatic, but this study highlights that for some people it may have significant health consequences later on,” said co-author Christopher Lowry, a professor at CU Boulder.
Some 11%–15% of people in the US have been infected with T. gondii at some point and rates tend to be far higher in older individuals. In some countries, more than 65% have been infected. Once infected, people can unknowingly harbour the parasite for life.
For the study, the team examined the blood of 601 Spanish and Portuguese adults over 65, along with measures of a common geriatric syndrome known as frailty – which includes unintentional weight loss, tiredeness, loss of cognitive sharpness and other indications of declining health.
A whopping 67% of study subjects were “seropositive” showing markers in their blood of a latent infection.
The researchers did not, as they originally hypothesized, find an association between any infection to T. gondii and frailty. But they did find that, among those infected, those with higher “serointensity” or a higher concentration of antibodies to the parasite, were significantly more likely to be frail.
Higher serointensity could reflect a more virulent or widespread infection, multiple infections or recent reactivation of a latent infection, the authors said.
“This paper is important because it provides, for the first time, evidence of the existence of a link between frailty in older adults and intensity of the response to T. gondii infection,” said co-author Blanca Laffon, a professor of psychobiology at the Interdisciplinary Centre of Chemistry and Biology at University of A Coruña.
How cats spread T. gondii
Wild and domestic felines are considered the definitive host of the parasite, while warm-blooded animals like birds and rodents serve as secondary hosts: When cats eat infected animals, T. gondii takes up residence and multiplies in their intestines, shedding eggs in their faeces.
People are typically infected via exposure to those eggs (via litter boxes, contaminated water or dirty vegetables) or by eating undercooked pork, lamb or other meat that’s infested.
Most people never know they’ve been infected, with only about 10% initially having brief flu-like symptoms. But T. gondii tends to linger dormant for decades, cloaked in cysts in muscle and brain tissue (specifically the emotion-processing region known as the amygdala) with some insidious impacts, mounting research suggests.
In a creepy evolutionary trick seemingly designed to benefit the parasite’s favourite host, rodents infected with T. gondii tend to lose their fear of felines, making it easier for cats to catch rats and mice. In the wild, infected chimpanzees have been shown to actually grow attracted to the smell of the urine of their feline predator, the leopard.
People who have been infected also tend to engage in risky behaviour, with research showing they tend to be more impulsive, more entrepreneurial and more likely to get in a car accident. They also have higher rates of schizophrenia, certain mood disorders, cognitive problems and are more likely to attempt suicide, according to research by Lowry and Dr Teodor Postolache, a professor in the Department of Psychiatry at University of Maryland School of Medicine and senior author on the new study.
A declining immune response?
The authors caution that the new study does not prove causation, but suggests the association should be researched.
They found that frail people with high T. gondii seropositivity also had higher levels of certain inflammatory markers, suggesting that infection with the parasite could exacerbate inflammation that already occurs with aging – aka. “inflammaging.”
Because latent T. gondii tends to hide out in muscle tissue, Postolache suspects it could also play a role in hastening sarcopenia.
Lowry’s research focuses on the impact microorganisms have on the immune system and, thus, mental health. He notes that many microbes that humans have evolved with impact health in a positive way – a theory known as the ‘Old Friends’ hypothesis. Even T. gondii may have health benefits we aren’t yet aware of, he said. But in some cases, a switch flips, and friends become enemies.
In the case of T. gondii, certain medications or immune compromising diseases like HIV or cancer can enable a latent infection to escape suppression and reactivate, with adverse effects. Even in people with healthy immune systems, Lowry notes, immune function can decline with age, potentially wakening dormant dormant T. gondii.
The researchers hope their study will inspire more research into the relationship between T. gondii and frailty, and ultimately lead to new ways of keeping the parasite from doing harm.
For now, they encourage people – especially pregnant and immunocompromised people – to take steps to avoid infection.
Tips for preventing infection:
Change litter box daily, and wash hands afterward.
Avoid eating undercooked meat.
Rinse fruits and vegetables.
If pregnant or immunocompromised:
Avoid changing the litter box if possible (T. gondii infection during pregnancy can cause serious problems to a developing foetus).
A team of University of Michigan researchers developed a method that measures water loss from the skin to predict anaphylaxis during oral food challenges before it becomes clinically evident. The results are published in The Journal of Clinical Investigation.
Oral food challenges – when a patient ingests increasing doses up to a full serving of the suspected food allergen under supervision of a medical provider – are the diagnostic standard as skin and blood allergy tests have high false positive rates.
Although a highly accurate diagnostic test, patients often experience anaphylaxis during oral food challenges necessitating an epinephrine injection.
“This method could enhance the ability to detect and predict anaphylaxis during oral food challenges prior to the need for epinephrine, greatly improving patient safety and comfort,” said Charles Schuler, M.D., lead author of the study and an immunologist at Michigan Medicine.
Building on existing research
During anaphylaxis, the dilation or widening of the blood vessels increases heat and water loss from the surface of the skin.
Previous research has assessed facial thermography, which uses a specialized camera to detect heat patterns emitted from the skin, as a method to predict anaphylaxis.
However, this method requires optics expertise, tightly controlled conditions and for the patient to sit still for an extended period – making this an impractical choice, especially for assessing food allergies in children.
The researchers validated the use of transepidermal water loss, a measurement that represents the amount of water that escapes from a given skin area per hour, by comparing its ability to detect anaphylaxis with biochemical and clinical observation methods.
They found that transepidermal water loss increases during food allergy reactions and anaphylaxis.
The rise in skin water loss correlated with biochemical markers of anaphylaxis and substantially preceded clinical detection of anaphylaxis.
“Transepidermal water loss measurement can be done in office without specialized equipment, affixed to the skin and works in children making it a vast improvement from previous attempts at early anaphylaxis detection methods,” said Schuler.
Schuler’s research group is currently recruiting participants aged six months to five years old for a pilot clinical trial, Predicting Peanut Anaphylaxis and Reducing Epinephrine, that monitors transepidermal water loss from the forearm during a peanut allergy food challenge.
Results will help pinpoint values associated with anaphylaxis to determine “stopping rules” to end oral food challenges, hopefully reducing the need for epinephrine injections.
Already long surgical waiting lists in the Northern Cape appear to have ballooned in recent months. In May, the province’s MEC for Health Maruping Lekwene told the province’s legislature that surgical waiting lists in the province stood at just under 4000. According to more recent figures from the Northern Cape Department of Health’s 2023/24 First Quarterly report, the surgical backlog stands at 6373 – an increase of more than 50% on the figure given in May.
Lulu Mxekezo, Northern Cape Department of Health Spokesperson, confirmed to Spotlight last week that the surgical backlogs had indeed increased from around 4000 to around 6000. She said that the numbers fluctuate as the need continues to increase on a daily basis.
“The shortage of specialised theatre staff makes it impossible for us to utilise all theatres daily to perform the procedures,” said Mxekezo, adding that the department will not compromise the safety and lives of patients and operate in theatres with no specialised theatre staff.
The increase in the backlog came despite the outsourcing of some surgical services in the province. Lekwene told the legislature that the Northern Cape Department of Health pays Gauteng-based Medicomed (captured as Medicore-Mets in the legislature minutes) R400 000 per month to assist with orthopaedic surgeries at Robert Mangaliso Sobukwe (RMS) Hospital in Kimberly on a month-to-month basis. He said the company supplies the department with specialised theatre nurses which is a scarce skill in the province. In May, Lekwene told legislators that the company had assisted with 57 surgeries over a two-week period.
Lack of theatre staff
The quarterly report stated that the backlog is fuelled by the lack of theatre staff at RMS hospital, and that the private sector was called in to fill this gap.
When asked by Izak Fritz, Democratic Alliance member of the Provincial Legislature, why the department does not appoint specialist nurses instead of outsourcing these services, Lekwene answered that there are unfortunately not enough theatre specialist nurses in the province.
“For us to take this route, it means that we need to have internal capacity. For instance we will have a neurosurgeon but we will not have an anaesthetist. We have nurses, but we do not have theatre specialist nurses,” he said.
He said they do not enjoy outsourcing, but that because of the urgency and the growing backlog the department has to act swiftly. “However as soon as the backlog has been reduced, we will then try to use our internal staff,” he said.
Lekwene also told the legislature that the backlog was mostly caused by the Covid-19 pandemic. “Remember that for two years during Covid-19, hospitals were closed,” he said.
Left stranded
Some workers at RMS said the long waiting list has left many patients frustrated and stranded. One doctor described the situation to Spotlight as “dire”. “The hospital has four fully equipped theatres but patients do not get help,” he said. He asked not to be named for fear of losing his job.
“Yes, we do have a shortage of nurses, but it is not as bad as they say. We are available as doctors, but without the help from nurses we are unable to perform surgeries at all,” he said.
The doctor said that currently the list of patients that need to receive emergency surgery is longer than 30. He said that for ordinary surgeries such as hip replacements there are patients who have been in hospital for more than 18 months, while some have been waiting for cataract surgery for five years.
A strain on staff and patients
Dennis Segano, provincial chairperson of Health and Other Services Personnel Trade Union in South Africa (HOSPERSA) said the surgery backlog is putting a strain on both nurses and patients.
He said the main problems that they see at RMS is the shortage of specialised theatre nurses and a lack of equipment. “When you enter the theatres there are enough doctors but not enough nurses,” he said. “We have a problem with our theatre nurses who are often outsourced by the service provider to work during their surgery marathons at the RMS hospital but have to wait three months or sometimes even six months before they can get paid.”
Spotlight asked Mxekezo about the late payment allegations but had not received a response by the time of publication.
“We don’t know why the government is not appointing the nurses instead of paying a service provider,” Segano said. “The system is burdened, the nurses in orthopaedic wards are burdened and we feel sad for the patients who have to spend months in hospital. “As a patient when you have a fracture, you must be able to go to theatre immediately, but in this province, you have to wait months before you receive help.”
“Stakeholders are also assisting us in performing theatre marathons to deal with the backlog,” Mxekezo said.
For example, in October last year, disaster relief organisation Gift of the Givers sent a team of theatre nurses and anaesthetists to assist with the backlog at RMS. According to Ali Sablay, the organisations project manager, they performed 72 operations on 72 patients during the catch-up drive.
Long-term solution
When asked what the department’s long-term plans are to reduce the pressure, Mxekezo explained that the operationalisation of theatres in district hospitals with specialised theatre staff will assist in minimising the backlog at RMS as many patients are transferred from districts.
Segano agreed that a long-term solution is to equip district hospitals with decent theatres and specialised theatre nurses.
“Minor fractures must be dealt with at district hospitals. RMS Hospital must only perform serious surgeries,” he said. “If the department can prioritise Harry Surtie Hospital and De Aar Hospital with theatre staff and equipment, RMS Hospital will operate much better and the patients will be helped. It is incorrect to send all patients of the Northern Cape to one hospital in Kimberly. They will not succeed.”
“Permanent employment of theatre staff will also assist in stabilising the surgical backlogs,” Mxekezo said.
Sceptical opposition
Fritz told Spotlight the DA is very concerned about the growing backlog in the Northern Cape and that they have repeatedly highlighted surgery backlogs at the provinces only tertiary facility (RMS).
“When one looks at nursing appointments at the RMS hospital, we see a trend whereby more nurses’ contracts are terminated each year than the amount of nurses who actually get appointed,” he said. “In effect, the hospital only operationalises four of its nine theatres.”
“Despite agreements with private agencies for surgery marathons to help tackle the backlogs, this only has a limited impact because of the inability to operationalise more theatres and to ensure there is an availability of more beds for recovery,” he said.
Fritz said the reality is that the people who require elective surgery often have to wait years to be attended to while their condition progresses. “Only when their case becomes an emergency can they be bumped up the list, and by that time their disease has become worse and their hopes of a full recovery is minimised,” he said.
Wynand Boshoff, the Freedom Front Plus’s (FF+) Northern Cape Provincial Leader, said in an interview with Spotlight last week that the problem with the department is that it is an entity that is riddled with mismanagement and a culture which aims for anything but service delivery.
He said the FF+ is not only approached by patients, but also by doctors on a regular basis who want to leave the health department because of management that he said has completely abandoned services.
“It is clear that more is needed than the appointment of a new minister or a new Head of Department, as the legacy of mismanagement overwhelms individual role players. A comprehensive investigation and steadfast disciplinary action is needed,” he said. “Repeat offenders should not be tolerated in the department, not even in the most humble of positions.”
As Spotlight previously reported, the Northern Cape Department of Health has had several acting heads in the last three years and several senior officials have and are facing charges in court. The current Head of Department is Dr Alastair Kantani, who has been acting in the position since 8 September following the arrests of seven officials, including former head Dr Dion Theys who now occupies the post of Medical Director in the department. In a statement issued by the department on 13 September Lekwene said this action is informed by the constitutional responsibility to ensure relative stability in the delivery of healthcare services in the province.
