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19 June 2022
Welcome to the Medical Week in Review for the week ending June 19 2022.
We know you’re busy, and while we know you would love to read our full weekly edition, we realise that is not always possible. With that in mind this week we’ve introduced a quick access link guide, which will help you access sections within this review by simply clicking on the section you are interested in.
Happy reading!
Quick Access Links
Matters COVID
Infectious Disease Update
Ageing and Age care
Focus on Paediatrics
Ophthalmology
Tech Talks
Ethics,Legalities and Medical Practice
Medical Trivia
Matters COVID
1. COVID-19 Data Repository by the Center for Systems Science and Engineering ( CSSE) at Johns Hopkins University
2. How months-long COVID infections could seed dangerous new variants ( Nature, June 15 22)
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Infectious Disease Update
Last week we mentioned the possibility that monkeypox could soon have a new name. This was is in response to an appeal by global scientists, who said that the continued referral to the virus by this name was discriminatory and did not make allowances for the current variants' origins – thought to be in the global north.
It should be noted that, way back in May, the Foreign Press Association of Africa had expressed a similar concern, noting that "..western media were using photos of black people in stories on monkeypox, despite the current outbreak sustaining itself in predominantly white, western nations."3 The WHO has responded to these calls and is currently consulting with various experts and technical advisory groups regarding the best way forward. We could have a decision on the new name as early as next week.
In other matters monkeypox: the WHO will be holding a meeting next week to review whether the current outbreak should be deemed a public health emergency of international concern. Only swine flu, polio, Zika, Ebola and COVID-19 have ever received this classification. Given how devastating those diseases are, it is interesting to see monkeypox considered for this classification.
Confirmation of one case of monkeypox, in a country, is considered an outbreak. According to the situation update from the WHO, as of June 15, "..a total of 2103 laboratory-confirmed cases and one probable case, including one death, have been reported to WHO. The outbreak of monkeypox continues to primarily affect men who have sex with men who have reported recent sex with new or multiple partners."4
The fact that monkeypox is now occurring outside of its endemic areas and the new variant clade seems to be the driving force behind this latest development.
Links
3. Monkeypox: WHO to rename disease to prevent stigma (BMJ)
4. Multi-country monkeypox outbreak: situation update (WHO)
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Age and Age Care
A new paper published in the Journal of Applied Gerontology has determined that greater intensity of light exposure during the evening has a direct impact on the quality of sleep in patients with cognitive impairment and may result in the daytime sleepiness often seen in these patients.
The finding should be noted by acute care facilities, such as hospitals which treat these patients, and long-term care facilities, such as frail care, where these patients often reside. Improving sleep quality can only enhance their overall quality of life.
In other matters ageing, this week, JAMA Network Open published a study entitled 'Experiences of Everyday Ageism and the Health of Older US Adults.' 6
The study, which looked at 2035 US adults between the ages of 50 - 80 years old, set out to determine whether 'everyday ageism', defined as "…brief verbal, nonverbal, and environmental indignities that convey hostility, a lack of value, or narrow stereotypes of older adults.",6 had an impact on the physical and mental well-being of older adults.
While acts of ageism may be unconscious or unintended, the study found that the impact was considerable:
"A total of 1915 adults (93.4%) ages 50 to 80 years reported regularly experiencing at least 1 of 10 forms of everyday ageism (Figure 1). Internalised ageism was the most commonly endorsed category (1664 adults [81.2%]), followed by exposure to ageist messages (1394 adults [65.2%]) and ageism in interpersonal interactions (941 adults [44.9%])" 6
The impact of ageism on health was experienced via multiple pathways, including the hampering of interaction between the person and their clinician and the experience of interpersonal interactions, ageist cues and beliefs around ageing, resulting in the development of negative normative expectations associated with poor health outcomes. Older adults experienced everyday ageism as a chronic stressor, which in turn activated "..psychological, cognitive, behavioural, and biological stress responses, resulting in accelerated ageing and increased risk for chronic disease and premature mortality." 6
One interesting observation was that inverse associations were also applicable. In other words, older adults who suffered from ill-health were often exposed to more ageist messages and discrimination based on their state of health + disability. This resulted in a self-fulfilling prophecy of sorts. The researchers point out that the most entrenched stereotype is the belief that old age is frequently associated with poor health, despite evidence to the contrary. 82.3% of the participants in this study rated their physical health as good or better.
So words, it seems, really do matter. We've attached an additional paper for your interest which reviewed the existing ageism scales, so you are in the know.
Links
5. The Relationship Between Light Exposure before Bedtime and Daytime Sleepiness Among People Living With Cognitive Impairment ( Journal of Applied Gerontology)
6. Experiences of Everyday Ageism and the Health of Older US Adults (JAMA Network Open)
7. A systematic review of existing ageism scales (Ageing Res Rev. 2019)
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Focus on Paediatrics
This week we look at the continuing mystery of the current outbreak of acute hepatitis of unknown aetiology that has been reported in children from 33 different countries. According to a recent Disease Outbreak update by the WHO, "...as of May 26 2022, 650 probable cases fitting the WHO case definition have been reported to WHO from 33 countries in five WHO Regions, with 99 additional cases pending classification." 8
The majority of the cases (58%) are from 22 countries in the WHO European region. 34% of those cases were recorded in the UK and Northern Ireland. Cases have also been recorded in the US, the Western Pacific, South-East Asian and Eastern Mediterranean Regions.
Out of the 650 probable cases, at least 38 (6%) children have required transplants, and nine (1%) deaths have been reported to WHO.8 No reasonable explanation has been identified for this sudden increase in cases. Some evidence has supported the theory that previous infection by SARS-COV-2 and or adenovirus might be the missing link. A new study out of Israel, which reviewed a notably small number of cases (5 children) who had developed acute hepatitis, found that those same children had previously had mild COVID-19 infectious, leading the researchers to speculate on a possible link. Clinicians, in this case, have, however, stated the sample is too small to draw a definitive conclusion.10
Likewise, the WHO has reported that SARS-CoV-2 and/or adenovirus have been detected in a number of the cases reported to them, although the data are incomplete. They indicated that an increase in adenovirus activity, which is co-circulating with SARS-CoV-2 has been observed in the UK cases, but the role of these viruses in the pathogenesis of the current outbreak is not yet clear.8
We'll keep our eye on that story.
In yet another concerning finding related to COVID and Paeds, the preliminary findings of a new study suggest that infants born to mothers who tested positive for SARS-CoV-2 are more likely to receive a neurodevelopmental diagnosis within the first 12 months after delivery.11 The link between adverse neurodevelopment outcomes in infants & maternal infection in pregnancy, including other viral diseases such as influenza, has been well studied. The development disorders include"..autism spectrum disorders, schizophrenia, cerebral palsy, cognitive dysfunction, bipolar disorder, and anxiety and depression."11
This study looked at 7772 live births that occurred between March and September 2020 in 6 hospitals in Massachusetts, USA The overall rate of SARS- COV-2 positivity in pregnant mothers was 2.9 %, equating to 222 women.
The study determined that 4 of 222 exposed offspring (6.3%) received a neurodevelopmental diagnosis within 12 months, compared to 227 of 7550 unexposed offspring (3.0%).
Infants whose mothers were exposed to the infection in their third trimester were particularly affected. The disorders most commonly reflected were development disorders of motor function or speech and language. The researchers indicated that although mothers who had tested positive were more at risk for preterm birth, this did not account for the increased neurodevelopment disorders observed.
They concluded their study by noting that as infants born to mothers in the first wave of COVID are only approximately two years in age, additional findings may yet emerge.
Nonetheless, the findings of this study are in keeping with a large body of research that conclusively links maternal viral infection and the associated immune response to adverse neurodevelopmental outcomes in infants born to these mothers.
Links
8. Acute hepatitis of unknown aetiology in children - Multi-country ( WHO Disease Outbreak News)
9. Trends in Acute Hepatitis of Unspecified Etiology and Adenovirus Stool Testing Results in Children — United States, 2017–2022
10. Past COVID-19 Infection Could Play Role in Child Hepatitis (Medscape)
11. Neurodevelopmental Outcomes at 1 Year in Infants of Mothers Who Tested Positive for SARS-CoV-2 During Pregnancy (JAMA Open Network)
Ophthalmology
Advances in Therapeutic Ophthalmology has published a study which looked at changes to the macular microcirculation after a macula-off rhegmatogenous retinal detachment repair with Silicon Oil tamponade
Rhegmatogenous retinal detachment or RRD, is characterised by "… separation of the neurosensory retina from the retinal pigment epithelium (RPE) due to vitreous fluid, subretinal accumulation through a retinal tear or hole."12
Even after successful reattachment of the retina, in cases where RDD involves the macular, macular detachment is one the main reasons for a "guarded visual prognosis" 12, and functional results are often not as expected.
Silicon oil or SO is widely used as a retinal tamponade, especially in complex vitreoretinal disorders. However, the treatment has been associated with potential side effects including anterior segment complications and adversely affected retinal function.
The researchers of this study note that in addition to these well-established effects, a sub-set of patients suffer from unexpected visual loss following the use of SO tampondade for their RRD repair. Possible explanations for these phenomena include"…. SO-related retinal toxicity, inner retinal layer alterations, or retinal electrolyte homeostasis dysregulation"12
With advanced imaging techniques such as Optical coherence tomography angiography (OCT-A) it is now possible to visualise the retinal and choroidal vasculature by segmenting each capillary plexus. Further more OCT-A allows for a more precise visualisation of the "foveal avascular zone (FAZ) parameters and quantification of vessel density (VD) and capillary plexus perfusion density (PD) in the macula area."12
Using OCT-A, the researchers set out to review and characterise changes to the macular capillary plexus in eyes undergoing PPC and SO tamponade for RRD with macular involvement.
A total of 14 patients were included in the analysis, the mean age of whom was 62.6 years [(SD ± 7.2). The mean preoperative macular detachment duration was 8.2 days (SD ± 3.5).
In brief, their results indicated a deterioration of vascular density in SO-treated eyes, which may cause poor postoperative visual outcomes. The researchers concluded that further studies are required to determine unequivocally whether the vascular insufficiency in SO-treated eyes could be attributed to tissue hypoxic changes due to macular detachment per see, or to the effect of SO on the retina.
Links
12. Macular microcirculation changes after macula-off rhegmatogenous retinal detachment repair with silicone oil tamponade evaluated by OCT-A: preliminary results ( Therapeutic advances in Ophthalmology)
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Tech Talks Biometric Material and Heart Valves
Heart valves are difficult to repair and replace. In particular, these replacements are made that much more challenging in children, as the valves have to be replaced as the child ages, resulting in multiple surgeries and the associated increased risks.
Researchers have attempted to find a solution to this challenge for some time. Biomaterials are one such alternative which seemed to hold much promise. Until now researchers had been unable to address the fundamental problem of finding a material that was able to mimic the "..variable stiffness and flexibility of heart valves."13
Now researchers from the Technical University in Munich, Germany appear to have cracked the code. Using biomaterial created with a method called melt electrowriting, they have been able to create "..create complex and variable patterns in the fibrous scaffolds, allowing them to mimic the structure and mechanical properties of heart valves." 13
The researchers hope that the fibrous multi-layered material will support and encourage the growth of the patient's own cells, allowing them to infiltrate the biomaterial scaffold, forming a viable, alternative autologous heart valve. The implications for heart surgery are significant, particularly for children, who, in theory, would no longer need to undergo multiple valve surgery, as their healthy tissue created a new heart valve supported by the matrix. There is an excellent summary of the invention in our Source document - Medgadgets , and the original research paper published in Advanced Functional Materials has also been provided.
Link
13. Melt Electrowriting to Make Fibrous Heart Valve Scaffolds ( Medgadets)
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Ethics, Legalities and Medical Practice
Hypermedicalisation and the overtreatment of patients in healthcare systems where there is a third-party payer model are common. This week we came across an article on the NPR website entitled 'When routine medical tests trigger a cascade of costly, unnecessary care (NPR, June 14 22)14. Considering South Africa's swiftly moving push for universal care in the form of the NHI, we thought it was worth taking a closer look.
The NPR feature refers to an article by Dr Meridith Neiss, published in JAMA Internal Medicine, in which she questions the "cascade of care" that can swiftly get out of control, resulting in a tsunami of unnecessary medical tests and procedures.
The most concerning of these tests are what researchers term 'low-values ervices', defined as " a service for which there is little to no benefit in that clinical scenario, and potential for harm." 14 So says researcher Ishani Ganguli, a primary care physician and assistant professor of medicine at Harvard.
Dr Ganguli, along with other researchers and doctors, has flagged more than 600 treatments, procedures and services over the last 30 years, which are conducted on patients without any apparent benefit to those patients. An example of those procedures includes: "…MRIs done early for uncomplicated low back pain, prostate cancer screenings for men over 80 and routine vitamin D tests."14
Here's the stat we found most scary. According to a survey conducted by Ganguli, 9 out of 10 physicians said they'd seen a cascade harm a patient, for example, physically or financially. 41% of respondents to that same indicated that they had continued the care cascade, even though "they believed the next test was not important for medical reasons." 15 You can read more about those findings here
These findings are not unique to the US. In South Africa, largely resulting from our unique private funding model and lack of competition within our healthcare system, there is an acknowledged epidemic of overtreatment.
In 2019, the Competition Commission published the results of its 4-year investigation into private healthcare, and the findings were disturbing.16
Amongst other more damning findings, it observed that people who lived near hospitals and had private health care were more likely to be admitted to hospitals than people with similar health concerns in areas further away from a hospital. Startlingly the commission found that at least a third of all medical claims made by hospitals could not be explained by the patient's age or disease. The term for this phenomenon is supply-induced demand, which boils down to the more supply you have of doctors, medicines and hospital beds, the more they will be used regardless of whether such management is necessary.
It's a multi-faceted problem, one in which we all play a role – healthcare providers, healthcare funders, the government and the individuals who make use of these services.
With the NHI looming large on the horizon, it will be interesting to see how this over-medicalisation plays out in the years to come. The full commission report can be accessed here or via the link below. 16
Next week the Health Reforms Report - Perspectives and Proposals compiled by the Concentric Alliance, Section 27, Catalysts for Social Justice, is due. We'll be reviewing that for you here in our Medical Practice Feature
Links
14. When routine medical tests trigger a cascade of costly, unnecessary care (NPR)
15. Cascades of Care After Incidental Findings in a US National Survey of Physicians ( JAMA Network Open)
16. Health Market enquiry. Provisional findings and recommendation report. July 5 2018.(PDF Download) (Competition Commission of South Africa)
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Medical Trivia
This week in Medical Trivia, we're keeping it short and sweet.
Do you know how viruses get their names, and who does the naming?
Well that's down to the International Committee on Taxonomy of Viruses (ICTV) – a community of virologists and scientists from the wider scientific community According to our source article from the WHO, viruses are named based on their genetic structure to "….facilitate the development of diagnostic tests, vaccines and medicines." 17
So if you didn't know, now you do
17. World Health Organization best practices for the naming of new human infectious diseases (WHO)
And that is all for the Week in Review.
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All that's left is to say, 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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