Netcare Unitas Hospital

The fields of molecular and cellular medicine have, in recent years, witnessed a great deal of progress globally, particularly in understanding disease pathogenesis and through the development of advanced cellular therapy products and gene therapies. Despite the transformative potential of these new therapies, low- and middle-income countries face significant barriers to their access. Advanced cellular therapy legislation in South Africa (SA) has not kept up with this fast-advancing field, and requires a fast-tracked renewal. Furthermore, the prohibitive cost of commercial therapies, including chimeric antigen receptor (CAR) T-cell products, and the lack of infrastructure, manufacturing and research capacity, must be addressed to make equitable patient access an achievable goal in our setting. To this end, a national cell and gene therapy consortium, comprising clinicians, clinician-scientists, scientists, legal experts, postgraduate students and representatives from industry, the national blood service and the pharmaceutical industry, was initiated. The mandate of this group is to aid the progression of advanced cellular therapies in SA, and the purpose of this article is to outline the progress that has been made. We will highlight the gaps in each core field of practice within this space, and provide a proposal for making these therapies more accessible in SA.

INTRODUCTION: The demand for total hip arthroplasty is increasing in South Africa and globally. Occupational therapists provide rehabilitation to promote engagement in activities of daily living following total hip arthroplasty. This review aimed to identify evidence for occupational therapy intervention for total hip arthroplasty across care settings and ages. METHOD: Rapid review methodology was used and the Cochrane Library and MEDLINE databases were searched for articles published between 1 January 2012 and 31 March 2023. Eleven articles were selected and analysed. RESULTS: Evidence from randomised controlled trials and systematic reviews reported interventions across care settings. Pre-operative occupational therapy emphasised education and training on adaptive devices, with tele-rehabilitation identified as a promising approach for pre-operative preparation. Post-operative interventions centred on exercises, safety, activities of daily living training, and standard occupational therapy rehabilitation primarily targeting lower limb function. The review highlights the disparity between occupational therapy evidence in high versus low- to middle-income countries, emphasising the importance of contextual interpretation. CONCLUSION: While evidence largely aligns with South African occupational therapy practices, gaps exist in upper body strengthening, return to work interventions, and pain management. The need for tailored approaches and further exploration of tele-rehabilitation for optimised outcomes in resource constrained contexts are further noted. IMPLICATIONS FOR PRACTICE • Occupational therapists in South Africa need to plan total hip arthroplasty interventions based on local healthcare settings, resources, and patient priorities. • Occupational therapists should strive for a comprehensive approach to intervention for total hip arthroplasty that includes attention to upper body strengthening, return to work, driving rehabilitation, and pain management. • Pre-operative education-focused interventions by occupational therapists can enhance patient outcomes and show the use of occupational therapy communication skills in preparing patients for surgery and post-operative recovery after total hip arthroplasty. • Occupational therapists should explore the use and feasibility of tele-rehabilitation in optimising outcomes for total hip arthroplasty patients in resource constrained contexts

Abstract Purpose: Thoracic trauma causes pain and hospitalisation. Middle- and high-income countries have different trauma contexts and populations. To report patients’ clinical presentation (pain and shortness of breath) and its influence on hospital length of stay (LOS), acute care management, and discharge destinations in South Africa (SA) and Sweden. Methods: Prospective observational multicenter study by means of clinical record review. One thousand nine hundred and eighteen adults with thoracic trauma were screened. Study objectives guided information retrieved from clinical records. Statistical analysis was done with significance at p-value < 0.05. Results: Three-hundred-sixty-four participants were recruited with most being male (n = 170 (95%) SA; n = 125 (68%) Sweden). Type and mechanism of injury differed (SA penetrating (82%) versus Sweden blunt (95%); SA assaults (90%) versus Sweden falls (44%)). Unilateral haemopneumothorax was common (SA 68%, Sweden 35%) and managed with intercostal drainage. Rib cage injuries were common in the Swedish cohort with rib fixation surgery for 17%. Physiotherapy treatment frequency was mostly daily. Swedish participants reported higher pain levels during deep breathing (day 1: p = 0.053; day 2: p < 0.001; day 3: p < 0.001). Shortness of breath during activity was higher for the Swedish cohort (day 1: p = 0.023; day 2: p = 0.001; day 3: p < 0.001). LOS was shorter for SA cohort (5.4 (± 4.3) versus 6.6 (± 5.1) days; p = 0.024). Pulmonary complications (p = 0.013) and moderate-to-severe pain on day 3 (p = 0.005) influenced LOS. Discharge destination was mostly home (99% SA, 56% Sweden). Conclusion: Moderate-to-severe pain on day three suggests priority care for those with thoracic trauma to prevent pulmonary complications and prolonged hospitalisation.

Peripheral spondyloarthritis (SpA) includes psoriatic arthritis (PsA), inflammatory bowel disease (IBD)-associated arthritis, reactive arthritis and undifferentiated peripheral SpA. These South African guidelines offer information on diagnosis, assessment and therapy of peripheral SpA. Emphasis is placed on a multidisciplinary team, and a treat-to-target strategy with escalation of therapy if the target of minimal or very low disease activity is achieved. Screening for and treatment of comorbidities are paramount.

Globally, there is a rising trend in obesity, known to increase morbidity and mortality. Metabolic surgery and adequate weight loss decrease mortality but may worsen pre-existing nutrient deficiencies. Most data on pre-existing nutritional deficiencies in the population undergoing metabolic surgery is from the developed world, where an extensive micronutrient assessment is achievable. In resource-constrained environments, the cost of a comprehensive micronutrient assessment must be weighed against the prevalence of nutritional deficiencies and the potential harm if one or more nutritional deficiencies are missed. This cross-sectional study investigated the prevalence of micronutrient and vitamin deficiencies in participants scheduled to undergo metabolic surgery in Cape Town, South Africa, a low-middle income country. 157 participants were selected and 154 reported on; who underwent a baseline evaluation from 12 July 2017 to 19 July 2020. Laboratory measurements were conducted, including vitamin B12 (Vit B12), 25-hydroxy vitamin D (25(OH)D), folate, parathyroid hormone (PTH), thyroid-stimulating hormone (TSH), thyroxine (T4), ferritin, glycated haemoglobin (HbA1c), magnesium, phosphate, albumin, iron, and calcium. Participants were predominantly female, aged 45 years (37-51), with a preoperative BMI of 50.4 kg/m2 (44.6-56.5). A total of 64 individuals had Type 2 diabetes mellitus (T2D), with 28 undiagnosed cases at study entry (18% of study population). 25(OH)D deficiency was most prevalent (57%), followed by iron deficiency (44%), and folate deficiency (18%). Other deficiencies (vitamin B12, calcium, magnesium, phosphate) were rarely encountered and affected ≤1% of participants. Folate and 25(OH)D deficiency were related to obesity classification, with a higher prevalence in participants with a BMI ≥40 kg/m2 (p <0.01). A higher prevalence of some micronutrient deficiencies was noted compared with data from similar populations in the developed world. The minimum baseline/preoperative nutrient evaluation in such populations should include 25(OH)D, iron studies, and folate. Additionally, screening for T2D is recommended. Future efforts should seek to collate broader patient data on a national scale and include longitudinal surveillance after surgery. This may provide a more holistic picture of the relationship between obesity, metabolic surgery and micronutrient status inform more appropriate evidence-based care.

The minimal standard terminology (MST) was developed by the World Endoscopy Organization (WEO) to standardise endoscopic reporting. This study compared current reporting within the Durban Metropolitan complex with the MST. This observational retrospective study included 130 upper gastrointestinal endoscopy reports from five different hospitals. The data were compared to the current reporting standard in the MST. The Noorbhai Maharaj (NM) score was used to assess and grade the quality of reporting. Each of the five hospitals has different endoscopic reporting systems. One hundred and thirty patients were included in the study, of which 60 were female. The indications for upper endoscopy were stated in 77 reports (59%). The commonest indications were epigastric pain (23%), dyspepsia (10%) and heartburn (10%). Sedation information per hospital was mostly seen at Inkosi Albert Luthuli Central Hospital (IALCH) (83%), followed by Prince Mshiyeni Memorial Hospital (PMMH) (67%), Addington (ADH) (13%), King Edward VIII Hospital (KEH) (13%), and RK Khan Hospital (RKKH) (0%). Consultant endoscopies per hospital were RKKH (91%), IALCH (86%), PMMH (78%), ADH (73%) and KEH (40%). All 130 reports were graded as NM Grade C. Scores of less than 20 points were seen in 106 reports (82%) and reflected across the different hospitals as follows: RKKH (100%), ADH (97%), KEH (93%), PMMH (56%) and IALCH (55%). There is no uniform structured endoscopic reporting system within the Durban Metropolitan Hospital complex. The current reporting methods do not meet the MST. The introduction of a structured standard endoscopic reporting system could improve the quality of reporting.

BackgroundWe evaluated the prevalence of vascular complications and associated risk factors in individuals with type 2 diabetes mellitus (T2DM) initiating second-line glucose-lowering therapy from the Middle East and Africa (MEA) cohort of the 3-year prospective DISCOVER study involving 15,992 patients in 38 countries.MethodsBaseline cross-sectional data collected from healthcare settings were used to assess micro and macrovascular complications prevalence as crude and age- and sex-standardised. The multi‐variable analysis assessed factors associated with these complications.ResultsOf 3,525 enrolled patients (mean age: 54.3 ± 10.8 years), >40% had hypertension and hyperlipidaemia. Metformin monotherapy was the first-line therapy in 56.5%, followed by metformin+sulphonylurea (20.3%). Crude and standardised prevalence of microvascular complications were 17.7% and 16.9% (95% confidence interval [CI], 16.77‐16.98) and macrovascular complications were 10.7% and 8.7% (95% CI, 8.59–8.76). Factors significantly (p<0.05) associated with micro and macrovascular complications (odds ratios [95% CI]) were age (1.24 [1.12–1.39] and 1.58 [1.35–1.84]), male sex (1.33 [1.04‐1.70] and 1.71 [1.22–2.40]), hyperlipidaemia (1.33 [1.07-1.65] and 1.96 [1.46-2.63]) and hypertension (1.75 [1.40–2.19] and 2.84 [2.07-3.92]).ConclusionA substantial burden of vascular complications with prominent risk factors in the MEA cohort calls for early preventive interventions.

Background: Paroxysmal nocturnal hemoglobinuria (PNH) is characterized by hemolysis due to uncontrolled activity of the alternative pathway (AP) of complement. BCX9930 is an oral Factor D inhibitor that targets the AP rate-limiting enzyme with the potential to prevent both intravascular hemolysis and extravascular hemolysis. We previously presented safety and effectiveness data for BCX9930 at 11 weeks in subjects with an inadequate response (IR) to C5 inhibitors (C5 INH; Kulasekararaj et al. EHA 2021). Here, we report further long-term safety, tolerability, and effectiveness of BCX9930. Aims: This analysis evaluated effectiveness of BCX9930 in subjects completing at least 48 weeks of treatment at target dose of 400 mg BID or 500 mg BID. Additionally, safety data are presented for all subjects enrolled (n=16, including 10 subjects naïve to C5 INH) in an open-label, dose-ranging study (NCT04330534) and extension study (NCT04702568). Methods: Study BCX9930-101 enrolled subjects with PNH with either no history of C5 INH use or those with an IR to C5 INH (defined as having a transfusion within 3 months of screening or Hb <10 g/dL). For subjects with an IR to C5 INH treatment, BCX9930 was added to C5 INH and subjects were treated with 200 mg orally twice daily (BID) escalated to 400 mg BID, or 400 mg BID escalated to 500 mg BID. Subjects deriving clinical benefit could rollover into an extension study after 28 days, and C5 INH could be withdrawn. Safety and effectiveness outcomes were evaluated monthly. Effectiveness endpoints were change from baseline (CFB) to 48 weeks in hemoglobin (Hb), red blood cell (RBC) transfusions, lactate dehydrogenase (LDH), absolute reticulocyte count (ARC), and % PNH RBCs relative to PNH white blood cells (WBC). CFB in fatigue was assessed by Functional Assessment of Chronic Illness Therapy (FACIT) Fatigue Scale (clinically important difference ≥3-point change, higher scores indicate less fatigue). Results: Six adult subjects with an IR to C5 INH enrolled in Study BCX9930-101 and rolled over into the open-label extension study, and 4 completed 48 weeks of treatment (3 of 4 on BCX9930 monotherapy at Week 48, mean [range] duration on monotherapy 107 [85, 129] days). Mean (SD) age and time since PNH diagnosis were 31 (9.42) and 7.7 (5.80) years, mean (SD) number of RBC units transfused in 12 months prior to study entry was 5.5 (4.4), and median (range) treatment exposure at 400 mg or 500 mg BID was 413.5 (337, 420) days. Mean (SEM) Hb CFB to Week 48 was 2.69 (0.97) g/dL (8.91 [0.56] g/dL to 11.60 [1.27] g/dL). 3 of 4 subjects were transfusion-free at Week 48 versus 1 of 4 in 12 months prior to study. At Week 48, Mean (SEM) ARC CFB was –63 (17.1) 103/µL (204 [15.5] vs. 141 [19.6] 103/µL), and mean (SEM) % PNH RBC/WBC clone size increased from 59% (4.4%) to 92% (3.8%,). Clinically meaningful improvements in FACIT-Fatigue scores were observed over 48 weeks, with mean (SEM) CFB of 10.7 (6.0) points (mean score 37.3 vs. 47.9). The most common adverse events for all subjects (n=16) were headache (38%), self-limited rash (25%), and abdominal pain (19%). Summary/Conclusion: BCX9930 at doses up to 500 mg BID was generally well-tolerated. Notable improvements were observed from baseline to 48 weeks in Hb, ARC, and fatigue scores, with concomitant increases in PNH RBC clone size. Proximal AP inhibition of Factor D by BCX9930 in combination with C5 INH (with 3 of 4 subjects transitioning to monotherapy) led to sustained relief of anemia, fatigue, and reduction of transfusion burden, supporting ongoing pivotal trials of oral BCX9930 monotherapy for treatment of PNH.