“I had always considered working for Doctors Without Borders (MSF),” says Dr Lindsay Demes, “but I didn’t expect to do more than one assignment.” Now, I’m on my third international assignment. It’s something that I love.” Lindsay’s first MSF assignment was in 2017 in Pakistan. Since then, he’s racked up some serious experience in several exciting projects across the African continent. In 2019, the Cape Town doctor spent seven months working with MSF in Maban county, an isolated area near the South Sudanese border with Sudan. Maban is home to thousands of refugees and internally displaced people who often face additional challenges like severe flooding. The camps they live in were constructed on a natural flood plain.

“In some places, the villages were only accessible using quad bikes, which meant that we had to pack the bikes with the day’s supplies and set out early in the morning and start vaccinating, often under a tree.”

On routine days, Lindsay would review the most critically ill patients with the medical staff, discuss optimisation of prescriptions and engage in bedside teaching related to patients’ conditions. Most afternoons were filled up with further staff training.

He faced more daunting challenges on not-so-ordinary days, like a sudden measles outbreak. “One Friday evening, three patients presented with measles,” Lindsay explains. “Within 30 minutes of the patients arriving, about 12 colleagues arrived from the compound and worked late into the night to set up an isolation ward with a 30-bed capacity. It really shows the amazing teamwork we have at MSF.”

Another highlight was running a crucial measles vaccination campaign to reach 7 000 children between six months and 15 years old. “In some places, the villages were only accessible using quad bikes, which meant that we had to pack the bikes with the day’s supplies and set out early in the morning and start vaccinating, often under a tree.” At the start of 2020, Lindsay was set to head off to his next assignment – a plan quickly derailed by the Covid-19 pandemic. With international borders closed, many South African MSF staff who typically work internationally were reassigned to projects within South Africa as part of the national response to the pandemic. In April, Lindsay joined our teams in Johannesburg, where they were providing primary healthcare at shelters for people experiencing homelessness.

“I appreciated the work in the shelters because it helped me to build a relationship with people that you usually only meet on a transient basis and you don’t usually take the time to get to know,” he says. “Hearing about life from a different perspective was very interesting and humbling.”

In July, he travelled to Kenema in the eastern region of Sierra Leone, where he is working in an MSF-built hospital focused on reducing the mortality of children under five years old and offering quality healthcare to pregnant and lactating women.

Sierra Leone’s two health indicators are among the worst in the world, and there is not enough medical staff to meet demands, partly due to the untimely deaths of 7% of the country’s healthcare workers during the Ebola outbreak from 2014 to 2016.

am, Kang et al (2021) analysed the asthma treatment outcomes, safety, and patient preferences using formoterol/beclomethasone (FORM/BDP), a pMDI with extra-fine particles, compared with formoterol/budesonide (FORM/BUD), another pMDI with non-extra-fine particles. It was independent, double-blind, double-dummy head-to-head randomised controlled trial, funded by the Korean Government. This study aimed to assess the treatment outcomes, safety, and patient preferences.

Inhaled drugs with extra-fine particles are more effectively distributed in the peripheral airway

METHODS

In this parallel group study, 40 adult asthmatics were randomised to FORM/BDP group (n=18; active FORM/BDP and placebo FORM/BUD) or FORM/BUD group (n=22; active FORM/BUD and placebo FORM/BDP). During the two visits (baseline and end of eight-weeks treatment), subjects were asked to answer questionnaires including asthma control test (ACT), asthma control questionnaires (ACQ), and Quality of Life Questionnaire (QoLQ) for adult Korean asthmatics (QLQAKA). Lung function, compliance with inhaler, and inhaler-handling skills were also assessed.

RESULTS

The increase in forced expiratory volume in one second/forced vital capacity and forced expiratory flow at 25% to 75% of the pulmonary volume in the FORM/BDP group was higher than in the FORM/BUD group. Regarding preference, subjects responded that the flume velocity of FORM/BDP was higher, but more adequate than that of FORM/BUD. They also answered that FORM/BDP reached the trachea and bronchus and irritated them significantly more than FORM/BUD.

The study results suggest that FORM/BDP, an ICS/LABA with extra-fine particles, may be intrinsically more effective in terms of lung function because it reaches the distal airways, consequently relieving airway constriction. Inhaled drugs with small particles are more evenly deposited in the lung after inhalation, which may suggest that asthma can be more effectively controlled using these medications.

Moreover, inhaled drugs with extra-fine particles are more effectively distributed, in the peripheral airway, which can contribute to more uniform therapeutic effects on the patient’s lung. In a clinical study, inhaled drugs with extra-fine particles resulted in better asthma treatment outcomes in elderly asthmatics compared with the same dose of drugs with non-extra-fine particles. Furthermore, ICS/LABA with extra-fine particles resulted in less frequent AE than other ICS/LABAs with non-extra-fine particles.  

However, there were no differences in other treatment outcomes, such as ACT, ACQ, QLQAKA, asthma control, AE, FeNO, FVC, or FEV1, during the study.

The relatively short study period and the small number of subjects in this study may have hampered sufficient evaluation of the potential therapeutic benefits of extra-fine formulations. Asthma control using pMDIs with extra-fine particles may relieve smaller airway obstruction more than that those with non-extra-fine particles despite no significant differences in overall treatment outcomes. In addition, asthma patients may prefer specific pMDIs for reasons that may not be consistent with health care providers’ expectations, such as high flume velocity.

CONCLUSION

The study suggests that inhaled drugs with extra-fine particles have better therapeutics advantages in treating inflammation and bronchoconstriction of small airways than those with non-extra-fine particles, despite no significant differences in overall treatment outcomes. This evidence further enriches the dataset regarding the benefits of extra-fine pMDIs in adult asthmatics when compared to non-extra-fine formulations.

REFERENCES: Nam T-H, Kang S-Y et al. Comparison of Two pMDIs in Adult Asthmatics: A Randomized Double-Blind Double-Dummy Clinical Trial. Tuberc Respir Dis 2022;85:25-36. Doi: https://doi.org/10.4046/trd.2021.0093.

Medical malpractice insurance is essential to medical practitioners. Equally as important is a financially secure and trusted medical malpractice (med mal) partner. Genoa Underwriting Managers director Michael John Damant tells Medical Chronicle what makes a good medical malpractice partner.

In the medical environment, we launched five years ago, taking care of the medical malpractice needs of over 7 000 medical practitioners.

Q. WHY IS IT IMPORTANT TO CHECK FINANCIAL BACKING OF YOUR MED-MAL PARTNER?

A: Medical malpractice is a highly specialist line of liability insurance associated with large value claims. As an insured it is essential to engage with an insurance company that has strong underwriting experience (thus avoiding cross-subsidisation of premiums between multiple claimants and non-claimants).

Due to the severe nature of the claims these insurance companies are also generally supported by reinsurance companies to ensure that they have the appropriate balance sheet to withstand the claims.  

Q. WHAT PERCENTAGE OF MEDICAL PRACTITIONERS FACE SOME TYPE OF LITIGATION DURING THEIR CAREERS?

A: It is imperative for a practice to maintain appropriate liability insurance coverage in the event of a medical malpractice event. Whilst claims are not seen frequently, when they do arise, they are often of a severe nature. Our claims team at Genoa

Underwriting Managers will be able to guide you through these difficult times. We will assist with both HPSCA matters as well as briefing top panel attorneys (including Norton Rose Fulbright, Werksmans, Clyde & Co, Mac Roberts and Garlicke and Bousfield) to represent your interests in the event of a valid claim.

Q. IF YOU ARE SUED AND YOUR MED MAL PARTNER HAS GONE INTO LIQUIDATION WHAT DOES THIS MEAN?

A: This could, amongst other things, mean that the Prudential Authority has been consulted and has suggested that the insurer be placed in liquidation. Now a legal process will commence to wind up the insurer. Insured practitioners may not receive the full claims benefit that they may have been previously entitled to.  

Q. HOW LONG HAS GENOA BEEN AROUND?

A: Established in 2005 and previously trading as Multiline Insurance Administrators, Genoa Underwriting Managers has well-established business in the attorney environment where we insure in excess of 650 law firms, including top law firms in South Africa. We have written the professional indemnity policies for business rescues including Ster Kinekor, Comair, Group 5, CNA, and Stefanutti Stocks, all of which require large levels of indemnification.

In the medical environment, we launched five years ago, taking care of the medical malpractice needs of over 7 000
medical practitioners.

Q. WHO BACKS THE GENOA MEDICAL MALPRACTICE PRODUCT?

A: This product is underwritten by Safire Insurance Company Ltd, and further backed by reputable global reinsurers (with whom our senior directors have worked with for numerous years).

These global specialists offer the necessary balance sheet protection when claims arise.  

Q. WHY IS HAVING A STRONG SA-BASED PROVIDER IMPORTANT?

A: Having access to a South African-based insurer is essential as they have first-hand knowledge and experience
of the local market and legislation. Further, should you as the insured be unhappy with a decision taken by the insurer, then youhave access to the ombudsman for short term insurance (OSTI).

The OSTI is essentially the ‘champion of the people’ and has the power to overturn a decision taken by the South African insurer,provided the insurer is a member of the OSTI and the dispute falls within the OSTI’s jurisdiction.  

University of Virginia School of Medicine researchers and their collaborators have solved a decades-old mystery about how E. coli and other bacteria are able to move. 

An international team led by a leader in the field of high-tech cryo-electron microscopy, has cracked the case of how bacteria can move.

Bacteria push themselves forward by coiling long, threadlike appendages into corkscrew shapes that act as makeshift propellers. But how exactly they do this has baffled scientists, because the “propellers” are made of a single protein. 

An international team led by UVA’s Professor Edward Egelman, a leader in the field of high-tech cryo-electron microscopy (cryo-EM), has cracked the case. The researchers used cryo-EM and advanced computer modelling to reveal what no traditional light microscope could see: the strange structure of these propellers at the level of individual atoms. 

“While models have existed for 50 years for how these filaments might form such regular coiled shapes, we have now determined the structure of these filaments in atomic detail,” said Prof Egelman, of UVA’s Department of Biochemistry and Molecular Genetics. “We can show that these models were wrong, and our new understanding will help pave the way for technologies that could be based upon such miniature propellers.” 

BLUEPRINTS FOR BACTERIA’S ‘SUPERCOILS’ 

Different bacteria have one or many appendages known as a flagellum, or, in the plural, flagella. A flagellum is made of thousands of subunits, but all these subunits are exactly the same. You might think that such a tail would be straight, or at best a bit flexible, but that would leave the bacteria unable to move. That’s because such shapes can’t generate thrust. It takes a rotating, corkscrew-like propeller to push a bacterium forward. Scientists call the formation of this shape “supercoiling,” and now, after more than 50 years, they understand how bacteria do it. 

Using cryo-EM, Prof Egelman and his team found that the protein that makes up the flagellum can exist in 11 different states. It is the precise mixture of these states that causes the corkscrew shape to form. 

It has been known that the propeller in bacteria is quite different than similar propellers used by hearty one-celled organisms called archaea. Archaea are found in some of the most extreme environments on Earth, such as in nearly boiling pools of acid, the very bottom of the ocean and in petroleum deposits deep in the ground. 

Prof Egelman and colleagues used cryo-EM to examine the flagella of one form of archaea, Saccharolobus islandicus, and found that the protein forming its flagellum exists in 10 different states. While the details were quite different than what the researchers saw in bacteria, the result was the same, with the filaments forming regular corkscrews. They conclude that this is an example of “convergent evolution” – when nature arrives at similar solutions via very different means. This shows that even though bacteria and archaea’s propellers are similar in form and function, the organisms evolved those traits independently. 

“As with birds, bats and bees, which have all independently evolved wings for flying, the evolution of bacteria and archaea has converged on a similar solution for swimming in both,” said Prof Egelman. “Since these biological structures emerged on Earth billions of years ago, the 50 years that it has taken to understand them may not seem that long.” 

In low- and middle-income countries (LMIC), BCa disproportionately affects young women (23% versus 10% in high-income countries). This is due to misconceptions about the disease, delayed detection, poverty, cultural and religious beliefs, and fear of breast removal.

The goal of screening is to detect preclinical disease in healthy, asymptomatic patients to prevent adverse outcomes, improve survival, and avoid the need for more intensive treatments.

Women in Africa present with BCa at a mean age of around 35- to 45 years, compared to their counterparts living in high-income countries (mean of 45- to 60-years) and present with more advanced disease (in South Africa, 50%-55% of women present with advanced BCa).³

Although mammogram screening from the age of 40 has been shown to save countless lives by reducing the incidence of advanced and inoperable disease with metastases, the uptake in LMICs is low with less than 2.2% of women between the ages of 40- to 69-years having undergone screening.^2,3

According to Prof Jennifer Moodley, Director Cancer Research Initiative at the Faculty of Health Sciences at the University of Cape Town, studies have shown that time to a cancer diagnosis may be influenced by several factors including women’s knowledge and awareness of cancer symptoms, whether women see themselves as being at risk for BCa, barriers in the health system, knowledge and attitude of health providers, and psychological, and socio-cultural barriers to healthcare.²

The downside of screening, writes Dr Shirley Lipschitz, considered one of South Africa’s most well- regarded and experienced breast-imaging specialists, is that it can result in overdiagnosis and overtreatment. The American Cancer Society (ACS) and the United States Preventive Services Task Force (USPSTF) consider mortality reduction as the only benefit of screening.⁴

Some studies show that BCa mortality can be reduced by between 30%–40%, while others show a reduction of 25% decrease in those invited to screening and a 38% reduction in those actually exposed to screening.⁴

Yet another study showed that mortality decreased by 44% in women aged between 40- to 49-years, 40% in those in the 50–to 59-year age group, 42% in women between 60– to 69-years and 35% in those in the 70–79 age group.⁴

According to Dr Lipschitz, overdiagnosis and overtreatment of a cancer are perceived as harms of screening.⁴

The American College of Obstetricians and Gynecologists (ACOG) states that reported rates of overdiagnosis range from 1% to 10% and expose women to unnecessary call backs and biopsies, which incurs great costs, and stress. The USPSTF found that one in eight women diagnosed with BCa with biennial screening from ages 50- to 75-years will be overdiagnosed.⁵

Furthermore, state the body, for every woman who avoids a death from BCa through screening, two to three women will be treated unnecessarily. Overtreatment, are in part, related to the management of ductal carcinoma in situ.⁵

According to Dr Lipschitz, improved technology, especially with digital breast tomosynthesis, will enable more screening detected cancers with less call backs and biopsies.³

Guideline screening recommendations

The goal of screening is to detect preclinical disease in healthy, asymptomatic patients to prevent adverse outcomes, improve survival, and avoid the need for more intensive treatments.⁵

Breast self-examination, breast self-awareness, clinical breast examination, and mammography all have been used alone or in combination to screen for BCa.⁵

The ACOG recommends regular screening mammography annually or biennially, starting at age 40 years in women at ‘average’ (see box 1) risk of BCa. The USPSTF recommends biennial screening from the age of 50.⁵

The ACS recommends screening from the age of 40- to 45-years and stopping if life expectancy is >10-years. The ACS recommends yearly screening for women between the ages of 40- and 54-years, and as an ‘option’ for women >55-years.⁵

The European Commission Initiative on Breast Cancer recommends mammography for women aged 50- to 69-years and with conditional recommendations for women in younger and older age groups.⁶

The European Society of Medical Oncology (ESMO) recommends regular (annual or biennial) mammography in women aged 50- to 69-years. Regular mammography may also be done for women aged 40- to 49-years and 70- to 74-years, although the evidence for benefit is less well established.⁶

In women with a strong familial history of BCa, with or without proven BRCA mutations, annual magnetic resonance imaging and annual mammography (concomitant or alternating) are recommended.⁶

The main focus of the South African clinical guidelines for BCa control and management, is to promote early detection and treatment. The guidelines state that all women irrespective of the reason for the visit to a public healthcare facility should receive provider initiated screening clinical breast examination.⁷

The examination should be done systematically, followed by the recording of the results. If any abnormality is detected irrespective of the severity, that woman should immediately be given a referral letter detailing the findings to the regional breast unit.⁷

The guidelines recommends annual mammography in women at high risk (>30%+ lifetime risk [see box 2]) of BCa from the age of 40 (or five years before the age at which a close relative was diagnosed if this calculated age is earlier than 40 years). Ultrasonography can be used for diagnostic follow-up of an abnormality seen on screening mammography. Furthermore, the guidelines recommend that screening should stop at age 70.⁷

The Radiological Society of South Africa and Breast Imaging Society of South Africa recommend annual screening from 40 to 70 and regular self- and clinical breast examination (CBE).⁴

How can we improve BCa detection?

Although BCa survival rates have increased in most developed countries, sub-Saharan Africa has the worst mortality-to-incidence ratios globally. This is partly due to the fact that 80% of women in the region present with advanced BCa as mentioned above.⁸

IN DEVELOPED COUNTRIES

Systemic mammography is accepted as the gold standard for effective screening, but in resource-limited setting, mammography is not considered cost effected and it is recommended that early detection focus on downstaging through improved BCa awareness.⁸

According to Lince-Deroche et al, lower-cost methods of breast disease detection, which are easily available, include breast self-examination, and a CBE performed by a healthcare provider [see box 3]).⁹

Lince-Deroche et al recommend the following to improve BCa detection in South Africa:⁹

• Incorporate breast-health education and awareness-raising, the early signs of BCa, and breast self-examination into existing health-education and outreach activities
• Increase the number of specialist breast centres nationwide and ensure that they are staffed with multi-disciplinary teams
• As a first step towards population-level screening, re-train primary healthcare nurses on how to perform CBE and begin screening of asymptomatic women above 35 years of age (in addition to offering screening for all symptomatic women)
• Strengthen existing referral systems, including through facilitated patient-transport systems
• Maximise the use of mammography and ultrasound for diagnosis by ensuring that the machines are placed in specialist breast centres with trained personnel
• Increase support for and links to patient advocates and counsellors in communities and within specialist breast centres to ensure comprehensive, full-spectrum care
• Establish strong monitoring and evaluation systems to track access to and utilisation of screening, diagnostic and treatment services nationwide
• Support and lead clinical, social, and economic research on BCa and breast-disease management in the country in order to address the current dearth of available information.

Conclusion

Finestone et al  developed a model that forecasts the incidence of five of the most commonly diagnosed cancers in South Africa. The aim of the model is to estimate the true underlying burden of cancer, as opposed to diagnosed cases only.¹⁰

The team found that the incidence of all cancers has been increasing over time. In South Africa, the total number of cases almost doubled between 2019 and 2030  (about 62 000 to 121 000 incident cases). This is a result of increases in the age specific incidence rate of cancer, as well as the growth and ageing of the South African population.¹⁰

This highlights the need for increases in resources available for cancer services, as well as rapid implementation of cancer prevention strategies, to reduce the number of future cancer cases, and thereby reduce the burden on the health system, concluded Finestone et al.¹⁰