The Medical Week In Review
Episode 4: 5 March  2022



 

Links from this Podcast

 COVID-19 Data Repository by the Center for Systems Science and Engineering ( CSSE) at Johns Hopkins University
Population Immunity and Covid-19 Severity with Omicron Variant in South Africa | NEJM
Measures to prevent infection failed’ – study finds 85% of Gauteng residents were likely infected in first three Covid-19 waves (Daily Maverick)
Tracking covid-19 excess deaths across countries ( The Economist) 
Omicron's lasting mysteries: four questions scientists are racing to answer (nature.com)
Harmless or deadly? Examining the evolution of E. coli (phys.org) 
Scientists uncover 'resistance gene' in deadly E. coli (phys.org) 
Malawi intensifies response after wild poliovirus detected (WHO)
Association of the Gut Microbiota With Cognitive Function in Midlife | Lifestyle Behaviors | JAMA Network Open | JAMA Network 
Balanced Multielectrolyte Solution versus Saline in Critically Ill Adults | NEJM 
Liability of doctors based on negligence for culpable homicide: No need to change the law concerning medical negligence or to establish special medical malpractice courts – use mediation and medical assessors instead (SAMJ)  
Critical care - where have we been and where are we going?


Audio Transcript

Welcome to the Medical Week in Review.

I'm your host Linda Ravenhill. Each week in this podcast, I review a selection of clinical information and general healthcare stories that caught my attention, both internationally and here in South Africa. 

Links to all the content discussed in the podcast will be posted on the website – www.meded.co.za – under the "The Medical Week in Review" feature."

This Week's review takes place as the war on Ukraine enters its 11th day, a situation unimaginable less than 2 weeks ago. Where we'll be next week is anybody's guess, but we can only hope for a speedy resolution for the people of Ukraine.
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On that sombre note, here is your Week in Review for the week ending 3 March 22
 

So if you've been following this podcast, you'll know that each week, I take a quick look at matters COVID.

While the pandemic has understandably been pushed to the bottom of the laundry basket in the face of Ukraine events, we still need to keep it in our sights.
 
Last week I mentioned the global easing of restrictions juxtaposed against the surge of cases in Hong Kong. Sadly, that situation seems to be worsening. The 7-day rolling total for Hong Kong on the 3rd of March was 38,000 cases, and according to various sources such as Our World in Data, the country is currently sitting with the highest death toll in the world. The Hong Kong government is imposing ever-tightening restrictions as it has done in pursuit of its zero-COVID policy, but it seems that horse has bolted. The restrictions appear to be ineffective and yet are having a catastrophic impact on the people living in the country. Let's see how the next week rolls out.

Here at home, our 7-day average has again fallen week-on-week in South Africa. When this data was drawn on the 3rd of March, we were sitting at a 7-day average of 1 711 cases. Compared to our data pull last week that is a decline of 684 cases 

Again, however, I would like to edge a note of caution, as the day-on-day cases for the first three days of March are still sitting around the 1600+.   It is easy to forget we are not yet out of the woods as we attempt to get back to 'normal' – whatever form that takes. 

Professor Shabir Madhi - dean of the Faculty of Health Sciences and professor of vaccinology at Wits University - said in an interview this week in the Daily Maverick (an independent media source here in South Africa) that, and I quote "…. I think it is high time that we get back to normal – and our data support the case – but at the same time people must do what is required to keep themselves protected," he added."

He was being interviewed regarding a new South African study released in the NEJM, on Feb 23, entitled Population Immunity and Covid-19 Severity with Omicron Variant in South Africa.

The study – the second out of SA – took place between Oct and December 2021, and its objective was to determine the seroprevalence of SARS-CoV-2 IgG in the population of Gauteng (a province within SA), before the 4th wave, - which was dominated by the omicron variant – occurred. 

Samples were obtained from 7010 participants, 1319 of whom had received at least one Covid vaccination. The researchers observed a widespread underlying SARS-CoV-2 seropositivity before the omicron-dominant wave of Covid-19 occurred. 

Positioned against this finding, the incidence of the omicron variant rapidly increased and then declined more quickly than in the previous 3 waves. Furthermore, there was a decoupling of the incidence of Covid cases from those requiring hospitalisation and death, which they attributed to a possible cell-mediated immunity in the population that was induced by previous natural infection and vaccination.

Based on these results, the researchers conclude that this represents a turning point in the pandemic if the primary goal is protection against severe disease and death rather than prevention of infection. 

One point I noted was Prof Madhi's comment that the study provided a more realistic picture of the true Covid case burden within the country, stating that previous studies had underestimated its prevalence, a direct result he believes of the low testing numbers.

Again, this highlights the global debate regarding the transparency and accuracy of corona reporting we raised in last week's podcast.  The very low numbers reported by some countries may be viewed in relation to the various factors that impact that reporting, such as lack of testing, differing methodologies deployed, appropriate skills, and available resources. 

The Economist article we mentioned last week, which looked at the suspected under-reporting of COVID deaths in certain countries, concluded that such under or over-reporting may not be intentional, rather a reflection of the various factors that impact its recording. I've included a link to that article on this Week's podcast info.

With that in mind, as we do each week, let's look at our sub-Saharan neighbours - who are all reporting very low figures: Botswana has reported 185 (slightly up from last Week) Namibia 25, Zimbabwe 340. Further afield – Kenya reporting 29 and Nigeria 25 cases respectively. 

Again links to the data source, John Hopkins Novel Corona Data can be found on MedED

Link
COVID-19 Data Repository by the Center for Systems Science and Engineering ( CSSE) at Johns Hopkins University

Population Immunity and Covid-19 Severity with Omicron Variant in South Africa | NEJM

Measures to prevent infection failed’ – study finds 85% of Gauteng residents were likely infected in first three Covid-19 waves (Daily Maverick)

Tracking covid-19 excess deaths across countries ( The Economist) 

 

More on matters Covid, there is an excellent article in Nature by science journalist Amber Dance, entitled Omicron's lasting mysteries: four questions scientists are racing to answer.

The article notes that even as omicron is on the decline, in some regions, it's variant -BA.2- is rising in others. Scientists are now interested in understanding how the variant spread so rapidly, particularly in populations who possess antibodies against earlier SARS – COV-2 versions, whether acquired through infection or vaccinations   - which was what the SA trial looked at -  and secondly why Omicron causes less severe diseases. 
 
According to the article, Prof Salim Abdool Karim, an epidemiologist at the Centre for the AIDS Programme of Research in South Africa in Durban, says that the virus has changed in its MOA - "It enters cells differently, it infects lungs differently, it infects the nose differently."

Indeed one theory doing the rounds is that the omicron variant creates a higher concentration of viral particles in the nose, so that infected individuals release more virus with every exhalation. That said the data supporting this had been mixed.
The reduced severity of disease, however of interest. The variant's relative inability to colonize or damage the lungs appears to have resulted in fewer cases of pneumonia and severe respiratory distress but increased numbers of head colds and sinus infections.

The reasons may be, as Sandra Barclay, a virologist at Imperial College London, says that "….Omicron is very good at getting into the cells of the nose," she says. "Once it's in there, actually, I don't think that Omicron is a terrible fit virus." 

The article looks at what comes next for Corona and raises some additional concerns; some scientists think that Omicron could have passed through an animal host or hosts before it was first detected in South Africa last November.

Which segues neatly to my next story - the discovery earlier this year of a deadly, drug-resistant strain of E.Coli and the accompanying worrying rise of zoonotic pathogens

Link: 
Omicron's lasting mysteries: four questions scientists are racing to answer (nature.com)
 

Researchers at the University of Technology in Sydney reported in January this year that they had found a previously unnoticed gene in E.Coli bacteria, making it highly resistant to commonly prescribed antibiotics – particularly the fluoroquinolones.  

Apart from its resistant properties, this new bacterial variant – known as ST58 – can spread incredibly quickly.

According to the source article on the site Phys.org, ST58 has been isolated from bloodstream infections in patients around the world, including France, - where - I'm quoting here – the number of infections with this strain was shown to have doubled over a 12 year period. 

Here is the kicker. E. coli ST58 has been found in intensively farmed animals - pigs, cattle and chickens, which may account for its increased resistance and spread among humans.  

This again raises the issue of the increasing incidence of zoonotic pathogens as causative agents in human infectious diseases – Corona as a case in point. As the researchers in Sydney indicate - all three sectors of animal production - cattle, chickens and pigs - acted as backgrounds for the evolution and emergence of this latest deadly E.Coli variant.

Given our industrialised farming practices – including the indiscriminate use of antibiotics - and the globalisation of our food chain, it is not inconceivable that our next pandemic is just around the corner.

The scientists raise an additional point that relates to research I’ve mentioned \n previous podcasts namely, genomic sequencing technology. The question is whether, using these new technologies, it will be possible to predict pathogen emergence and inform effective interventions, meaning that future public health interventions will be more pro-active against infectious disease as opposed to our current retro-active approach. I will definitely find someone to interview around this new technology in a future podcast.

Link: 
Harmless or deadly? Examining the evolution of E. coli (phys.org) 

Scientists uncover 'resistance gene' in deadly E. coli (phys.org) 
 

Now I don't know about you, but I find the lack of follow-up on news stories in the mainstream media immensely frustrating.

So here is some feedback on a story I ran last week namely the reported case of wild poliovirus found in Malawi. There have been some critical developments here – all positive.

2 days ago, the WHO reported there was a ramped-up response in the country and surrounding regions, with polio emergency response teams increasing disease surveillance and deepening investigations. A mass supplementation polio vaccine programme has been scheduled, targeted at children under five. and the surrounding countries of Mozambique, Tanzania and Zambia are also all planning to conduct immunization campaigns.

We'll keep our eye on this story and report any significant developments. We can only hope that Malawi's commendable swift action in declaring a public emergency may have saved us all from the re-emergence of this dread disease.

Link
Malawi intensifies response after wild poliovirus detected (WHO)
 

Continuing my weekly focus on age, age care, and cognitive health, JAMA Network Open published a study on Feb 8th, which looked at the link between gut microbiota and cognitive health in mid-life. 

You may recall I discussed the Whitehall study last Week. That study looked at the presence of comorbidity and the incidence of cognitive decline over a 30 year period, reporting that those with comorbidities in midlife had a higher incidence of dementia when reviewed 30 years on?

This particular trial in JAMA looked to close the gap in knowledge between what had been evidenced in animal experiments - which supported the role of gut microbiota in cognitive functioning-  and the lack of studies investigating gut microbiota and cognition in large community human trials. Specifically, the researchers wanted to "examine associations of gut microbial composition with measures of cognition in an established population-based study of middle-aged adults."

They analysed data from the prospective Coronary Artery Risk Development in Young Adults (CARDIA) cohort in 4 US metropolitan centres between 2015 and 2016 and found that in this particular cohort ( middle-aged Black and White US Adults) microbial community composition, based on β-diversity, was associated with all cognitive measures in multivariable-adjusted analysis. The study goes on to report that "Several specific genera were also significantly associated with 1 or more measures of cognitive function after adjustment for multiple comparisons." This data contributes to a growing body of literature suggesting that gut microbiota may be related to cognitive ageing.

So that is another story to keep an eye on in the months and years to come. Meantime – it can't harm to start eating better and looking after your gut microbiota a bit more…


Link:
Association of the Gut Microbiota With Cognitive Function in Midlife | Lifestyle Behaviors | JAMA Network Open | JAMA Network 
 

In Critical Care Medicine, this week a new piece of research published in the NEJM looked at the challenging question of fluid management in critically ill patients. 

This particular study examined whether a balanced multi-electrolyte solution was more effective than a 0.9% saline infusion in avoiding acute renal failure and ultimately death in these patients.  

The trial was a double-blind, randomised controlled trial with a sample of 5037 patients. They primarily wanted to review the prevalence of death from any causes within 90 days after fluid randomisation. The secondary outcomes were whether patients received new renal replacement therapy or had a maximum increase in creatinine levels during their ICU stay.

Unfortunately, no good news to report here. The data showed no discernible difference in treatment outcome difference between the two solutions. So the search for optimal fluid regimens continues.

Link:
Balanced Multielectrolyte Solution versus Saline in Critically Ill Adults | NEJM 
 

Now my next story should make you sit up and take note.

A new paper published by Law Professor David McQuoid Mason in the latest edition of the South African Medical Journal, raises the question of the liability of doctors based on negligence for culpable homicide. 

This paper arises from the recent – and not so recent – calls by various medical organisations for special legislation regarding charging doctors for culpable homicide and for the creation of special medical malpractice courts to deal with the significant increase in the number of medical malpractice cases.  Indeed the South African Medical Association itself has been one of the vocal proponents of the establishment of these courts

I think everyone is familiar with Professor Beale's case, and the tragic circumstances around the death of Dr Abdulhay Munshi just as a reminder of what is at stake here in the worst-case scenario. That aside, there is a rapidly growing culture of filing medical negligence and malpractice suits in SA – the most frequently occurring in the Obs and Gynae professions. 

So I did a bit of digging. The most recent figures I could find were from the Medical Protection Society SA (MPS), who reported a 35%  increase in the number of claims made against healthcare professionals between 2011 and 2016. That is quite startling, given that that does not include malpractice cases raised against the Department of Health –  a thesis on its own.

What stood out for me in the paper was the statement that medical insurers say that the failure of doctors to communicate with their patients after a procedure or treatment has gone wrong is one of the main reasons why patients sue their doctors. I've been on both sides of this equation – and I concur entirely. Could we alter this criminal litigation trajectory by at least having a conversation with patients and their families?

That said, a recent amendment to the law, which allows payment of damages to be made in instalments rather than lump sums, may help reduce the number and extent of claims made by lawyers because the damages will not be paid out upfront.  McQuoid Mason indicates that in the past, lawyers have claimed damages for the period of the actuarially calculated future life expectancy of their clients even though that life expectancy might not be played out in real life.

He further goes on to state that the actual number of medical negligence cases that proceed to criminal cases is very low. It appears that prosecuting authorities generally accept that doctors do not intend to kill their patients, and act in good faith and in keeping with best standard of care.

Instead of establishing special courts,McQuoid Mason recommends appointing medico-legal assessors to medical cases to advise the court.  He further puts forward a robust case favouring mediation – the earlier, the better. 

Finally,  this statement may bring practitioners some comfort and aid in their decision to enter into mediation earlier rather than later. I'll read here from the paper -  that "doctors need not be afraid to make admissions during mediation proceedings before civil litigation, because if made while trying to negotiate a settlement, such admissions may be made 'without prejudice'. Furthermore, the legislation provides that such admissions and evidence may not be used in subsequent civil actions"

I will also keep my eye open for any developments in this space.


Link:

Liability of doctors based on negligence for culpable homicide: No need to change the law concerning medical negligence or to establish special medical malpractice courts – use mediation and medical assessors instead (SAMJ)  



Then for my last story - which is more of a comment -  this week was Rare Disease Week.

Over 7,000 rare diseases have been identified to date, affecting an estimated 350 million people worldwide.  Yet treatment exists for only a handful of these diseases, and they remain largely misunderstood and misdiagnosed by the majority of practitioners.

I have been writing and creating CPD programs focused on Rare Diseases since 2010, and what has been heartening in recent times is to see the increased attention paid to these conditions in the public sphere. 

However, we are still a long way from finding solutions for most of these patients, and this makes the work of the RD Association all the more important. 
 

And now it’s Medical Trivia time. 

How old do you think the concept of ICU or critical care is?  It may surprise you to know that is fairly recent. 

With a nod to the current Ukrainian situation – it was Florence Nightingale in the Crimean War in the 1850's who first demanded that the most seriously ill patients under her care were placed closest to the nursing station so they could be watched more closely. According to my source article - Critical Care - where have we been and where are we going - in 1923 – one Dr Dandy - "..opened a  three-bed unit for the more critically ill postoperative neurosurgical patients at the Johns Hopkins Hospital in Baltimore, MD, USA, using specially trained nurses to help monitor and manage them."

But it was really only in the 1950s, when there was a significant polio epidemic in Copenhagen, which saw the opening of dedicated respiratory units for patients on iron lungs, that ICUs became a permanent fixture in our hospitals. 

If you'd like to read more about the evolution of critical care units and critical care medicine – and indeed a fascinating story - you can as always, find the link to my source on MedED.

So, if you didn't know, now you do.


Link: 
Critical care - where have we been and where are we going?

And that is all for the Week in Review. 

Links to all the stories featured here can be found on the Medical Week in the Review page on MedED.  If you liked this podcast, please tell your friends about it. If there are stories you’d like me to focus on drop me a line using the contact details on www.meded.co.za

Wherever you are, stay safe, stay sane, and join us next week where we review the week in medicine.
 
This has been a production on the Medical Education Network – delivering quality medical education and information to Southern Africa since 2008. All thoughts and comments on this podcast remain that of its creators. Every effort has been made to fact check the information contained here. Any errors or misstatements that may occur are unintentional.
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