On failure, trust and our common humanity.
Authors: Professor Elmi Muller
Abstract: A few weeks ago, a patient came to see me. He had received a transplant from his sister in 2017 and the kidney failed in 2022. I had done the transplant. He told me that his graft never really functioned properly. According to him, this was most likely the result of how I did his surgery in 2017. Now he was coming for a second transplant – a kidney donated by his wife. He was meeting me to tell me that he didn’t want me to be involved in his transplant, although he was worked up for this procedure by people in my practice and in my team.
A few months ago, I transplanted a patient with a donor kidney from a friend. The day after the transplant the patient developed a very low blood pressure and a few hours later the patient died. We were not sure what had happened – if he had a myocardial infarction, had sepsis or was bleeding. Whatever it was that happened – the outcome was dismal.
Why am I telling you these stories of failure and difficulty on an evening where you want to celebrate your new qualification and success?
The answer is that failure explicates. In other words, failure makes us analyse our life events in more detail.
The increasing burden of asthma in South African children: A call to action
Authors: R Masekela, C L Gray, R J Green, A I Manjra, M Clin Pharm; F E Kritzinger, M Levin, H Zar, on behalf of the South African Childhood Asthma Working Group
Background: Asthma is a heterogeneous condition characterised by chronic inflammation and variable expiratory airflow limitation, as well as airway reversibility. The burden of asthma in children is increasing in low- and middle-income countries and remains underrecognised and poorly managed.
Objectives: To quantify the burden of asthma in the South African (SA) population and identify the risk factors associated with disease severity in the local context.
Methods: The SA Childhood Asthma Working Group (SACAWG) convened in January 2017 with task groups, each headed by a section leader, constituting the editorial committee on assessment of asthma epidemiology, diagnosis, control, treatments, novel treatments and self-management plans. The epidemiology task group reviewed the available scientific literature and assigned evidence according to the Grades of Recommendation Assessment, Development and Evaluation (GRADE) system.
Conclusions: Asthma in children remains a common condition, which has shown an increasing prevalence in urban and rural populations of SA. Of concern is that almost half of children in urban communities experience severe asthma symptoms, and many asthmatics lack a formal diagnosis and thus access to treatment. Exposure to tobacco smoke and living in highly polluted areas increase the severity of wheezing in young children.
Looking beyond the magic bullet: Novel asthma drugs or education, which works better?
Authors: R Masekela, M Levin, P M Jeena, M Annamalai, V Naidoo, A van Niekerk, D Hawarden, S Emanuel, H Zar, R J Green, F E Kritzinger, A I Manjra on behalf of the South African Childhood Asthma Working Group (SACAWG)
Abstract: Although ˂5% of children with asthma suffer from severe asthma, they account for the highest use of health resources. The field of asthma therapy is changing rapidly, with a number of new drugs and biologics being added to the treatment armamentarium, particularly for adults. This, though, is not the case for paediatric patients, in whom a number of these novel molecules and drugs have not been investigated. Even though adults have shown responses to medication in some studies, this does not necessarily imply that there will be similar results in children. In the management of severe asthma, use of specific interventions to ensure treatment adherence and goal-setting for selfmanagement is critical to ensure the best treatment outcomes. The objective of this article is to review and grade the current evidence base for use of novel asthma drugs and to make evidence-based recommendations for their administration in children with severe asthma in the South Africa context. We also review the evidence for medication-adherence strategies and self-management plans.
Asthma management and control in children, adolescents, and adults in 25 countries: a Global Asthma Network Phase I cross-sectional study
Authors: Luis García-Marcos*, Chen-Yuan Chiang*, M Innes Asher, Guy B Marks, Asma El Sony, Refiloe Masekela, Karen Bissell, Eamon Ellwood, Philippa Ellwood, Neil Pearce, David P Strachan, Kevin Mortimer†, Eva Morales†, and the Global Asthma Network Phase I Study Group‡
Background: Asthma is one of the most common non-communicable diseases globally. This study aimed to assess asthma medicine use, management plan availability, and disease control in childhood, adolescence, and adulthood across different country settings.
Methods: We used data from the Global Asthma Network Phase I cross-sectional epidemiological study (2015–20). A validated, written questionnaire was distributed via schools to three age groups (children, 6–7 years; adolescents, 13–14 years; and adults, ≥19 years). Eligible adults were the parents or guardians of children and adolescents included in the surveys. In individuals with asthma diagnosed by a doctor, we collated responses on past-year asthma medicines use (type of inhaled or oral medicine, and frequency of use). Questions on asthma symptoms and health visits were used to define past-year symptom severity and extent of asthma control. Income categories for countries based on gross national income per capita followed the 2020 World Bank classification. Proportions (and 95% CI clustered by centre) were used to describe results. Generalised structural equation multilevel models were used to assess factors associated with receiving medicines and having poorly controlled asthma in each age group.
Findings: Overall, 453 473 individuals from 63 centres in 25 countries were included, comprising 101 777 children (6445 [6·3%] with asthma diagnosed by a doctor), 157 784 adolescents (12 532 [7·9%]), and 193 912 adults (6677 [3·4%]). Use of asthma medicines varied by symptom severity and country income category. The most used medicines in the previous year were inhaled short-acting β2 agonists (SABA; range across age groups, 29·3–85·3% participants) and inhaled corticosteroids (12·6–51·9%). The proportion of individuals with severe asthma symptoms not taking inhaled corticosteroids (inhaled corticosteroids alone or with long-acting β2 agonists) was high in all age groups (934 [44·8%] of 2085 children, 2011 [60·1%] of 3345 adolescents, and 1142 [55·5%] of 2058 adults), and was significantly higher in middle-to-low-income countries. Oral SABA and theophylline were used across age groups and country income categories, contrary to current guidelines. Asthma management plans were used by 4049 (62·8%) children, 6694 (53·4%) adolescents, and 3168 (47·4%) adults; and 2840 (44·1%) children, 6942 (55·4%) adolescents, and 4081 (61·1%) adults had well controlled asthma. Independently of country income and asthma severity, having an asthma management plan was significantly associated with the use of any type of inhaled medicine (adjusted odds ratio [OR] 2·75 [95% CI 2·40–3·15] for children; 2·45 [2·25–2·67] for adolescents; and 2·75 [2·38–3·16] for adults) or any type of oral medicine (1·86 [1·63–2·12] for children; 1·53 [1·40–1·68] for adolescents; and 1·78 [1·55–2·04] for adults). Poor asthma control was associated with low country income (lower-middle-income and low-income countries vs high-income countries, adjusted OR 2·33 [95% CI 1·32–4·14] for children; 3·46 [1·83–6·54] for adolescents; and 4·86 [2·55–9·26] for adults).
Interpretation: Asthma management and control is frequently inadequate, particularly in low-resource settings. Strategies should be implemented to improve adherence to asthma treatment guidelines worldwide, with emphasis on access to affordable and quality-assured essential asthma medicines especially in low-income and middle-income countries.
Funding: International Union Against Tuberculosis and Lung Disease, Boehringer Ingelheim New Zealand, AstraZeneca, UK National Institute for Health Research, UK Medical Research Council, European Research Council, the Spanish Instituto de Salud Carlos III.