Incidence of hypoglycaemia among insulin-treated patients with type 1 or type 2 diabetes mellitus: South African cohort of International Operations Hypoglycaemia Assessment Tool (IO HAT) study

Objectives: To assess the incidence and rates of hypoglycaemia in patients with type 1 diabetes mellitus (T1DM) or type 2 diabetes mellitus (T2DM) in the South African cohort of the International Operations Hypoglycaemia  Assessment Tool (IO HAT) study.Methods: Patients diagnosed with either T1DM or T2DM, aged ≥ 18 years and treated with insulin for > 12 months, completed selfassessmentquestionnaires to record demography, treatment information and  hypoglycaemia during a 6-month retrospective and 4-week prospective periods (ClinicalTrials.gov: NCT02306681).Results: In T1DM 76.2% (95% confidence interval [CI] 69.1%, 82.3%) of patients reported hypoglycaemia in the retrospective period and 98.2% (95% CI 94.7%, 99.6%) in the prospective period. The corresponding figures for patients with T2DM were 52.2% (95% CI 48.6%, 55.9%) and 90.1% (95% CI 87.7%, 92.3%), respectively. Rates of any and severe hypoglycaemia, respectively were T1DM 90.7 events per patient year (PPY) (95% CI 85.5, 96.1) and 8.8 events PPY (95% CI 7.2, 10.6) and T2DM 45.7 events PPY (95% CI 43.9, 47.5) and 8.9 events PPY (95% CI 8.1, 9.8) during the prospective period. The rates of hypoglycaemia were  independent of glycated haemoglobin levels.Conclusions: This is the first patient dataset of self-reported hypoglycaemia in South Africa; results showed that hypoglycaemia is under-reported.Keywords: diabetes, hypoglycaemia, hypoglycaemic, insulin, South Afric

Pathways to care and outcomes among hospitalised HIV-seropositive persons with cryptococcal meningitis in South Africa.

INTRODUCTION: Cryptococcus causes 15% of AIDS-related deaths and in South Africa, with its high HIV burden, is the dominant cause of adult meningitis. Cryptococcal meningitis (CM) mortality is high, partly because patients enter care with advanced HIV disease and because of failure of integrated care following CM diagnosis. We evaluated pathways to hospital care, missed opportunities for HIV testing and initiation of care. METHODS: We performed a cross-sectional study at five public-sector urban hospitals. We enrolled adults admitted with a first or recurrent episode of cryptococcal meningitis. Study nurses conducted interviews, supplemented by a prospective review of medical charts and laboratory records. RESULTS: From May to October 2015, 102 participants were enrolled; median age was 40 years (interquartile range [IQR] 33.9-46.7) and 56 (55%) were male. In the six weeks prior to admission, 2/102 participants were asymptomatic, 72/100 participants sought care at a public-sector facility, 16/100 paid for private health care. The median time from seeking care to admission was 4 days (IQR, 0-27 days). Of 94 HIV-seropositive participants, only 62 (66%) knew their status and 41/62 (66%) had ever taken antiretroviral treatment. Among 13 participants with a known previous CM episode, none were taking fluconazole maintenance therapy. In-hospital management was mostly amphotericin B; in-hospital mortality was high (28/92, 30%). Sixty-four participants were discharged, 92% (59/64) on maintenance fluconazole, 4% (3/64) not on fluconazole and 3% (2/64) unknown. Twelve weeks post-discharge, 31/64 (48%) participants were lost to follow up. By 12 weeks post discharge 7/33 (21%) had died. Interviewed patients were asked if they were still on fluconazole, 11% (2/18) were not. CONCLUSIONS: Among hospitalised participants with CM, there were many missed opportunities for HIV care and linkage to ART prior to admission. Universal reflex CrAg screening may prompt earlier diagnosis of cryptococcal meningitis but there is a wider problem of timely linkage to care for HIV-seropositive people

The Epidemiology of Meningitis among Adults in a South African Province with a High HIV Prevalence, 2009-2012.

INTRODUCTION:Meningitis is a major cause of mortality in southern Africa. We aimed to describe the aetiologies and frequencies of laboratory-confirmed fungal and bacterial meningitis among adults in a South African province with an 11% HIV prevalence, over 4 years. METHODS:We conducted a retrospective, observational study of secondary laboratory data, extracted on all cerebrospinal fluid (CSF) specimens submitted to public-sector laboratories in Gauteng province from 2009 through 2012. We calculated cause-specific incidence rates in the general and HIV-infected populations and used Poisson regression to determine if trends were significant. RESULTS:We identified 11,891 (10.7%) incident cases of meningitis from 110,885 CSF specimens. Cryptococcal meningitis, tuberculous meningitis and pneumococcal meningitis accounted for 62.3% (n = 7,406), 24.6% (n = 2,928) and 10.1% (n = 1,197) of cases over the four-year period. The overall incidence (cases per 100,000 persons) of cryptococcal meningitis declined by 23% from 24.4 in 2009 to 18.7 in 2012 (p <0.001) and decreased by 19% among HIV-infected persons from 178.2 to 144.7 (p <0.001). Tuberculous meningitis decreased by 40% from 11.3 in 2009 to 6.8 in 2012 (p <0.001) and decreased by 36% among HIV-infected persons from 54.4 to 34.9 (p <0.001). Pneumococcal meningitis decreased by 41% from 4.2 in 2009 to 2.5 in 2012 (p <0.001) and decreased by 38% among HIV-infected persons from 28.0 to 17.5 (p <0.001). Among cases of other bacterial meningitis (248/11,891, 2.1%), Neisseria meningitidis (n = 93), Escherichia coli (n = 72) and Haemophilus influenzae (n = 20) were the most common organisms identified. CONCLUSIONS:In this high HIV-prevalence province, cryptococcal meningitis was the leading cause of laboratory-confirmed meningitis among adults. Over a 4-year period, there was a significant decrease in incidence of cryptococcal, tuberculous and pneumococcal meningitis. This coincided with expansion of the national antiretroviral treatment programme, enhanced tuberculosis control programme and routine childhood immunisation with pneumococcal conjugate vaccines

Population incidence of cryptococcal, tuberculous and pneumococcal meningitis among adults in Gauteng province, South Africa, showing key treatment interventions, 2009–2012 (n = 11,531).

<p>PCV-7 = seven-valent pneumococcal conjugate vaccine introduction. PCV-13 = thirteen-valent pneumococcal conjugate vaccine introduction. GeneXpert = GeneXpert MTB/Rif assay introduction. CrAg screening = introduction of cryptococcal antigen screening and treatment intervention.</p

Demographic characteristics of patients with laboratory-confirmed fungal and bacterial meningitis in Gauteng province, South Africa, 2009 through 2012 (n = 11,891).

<p>Demographic characteristics of patients with laboratory-confirmed fungal and bacterial meningitis in Gauteng province, South Africa, 2009 through 2012 (n = 11,891).</p

Incidence of cryptococcal meningitis and pneumococcal meningitis, by age group and gender, 2012.

<p>CM = cryptococcal meningitis, PM = pneumococcal meningitis.</p

Number and percentage of major pathogenic organisms isolated from all CSF specimens tested, as recorded in the NHLS CDW, in Gauteng province, South Africa, by year 2009 through 2012 (n = 11,891).

<p>Number and percentage of major pathogenic organisms isolated from all CSF specimens tested, as recorded in the NHLS CDW, in Gauteng province, South Africa, by year 2009 through 2012 (n = 11,891).</p