Optimal glucose control in type 2 diabetes mellitus – a guide for the family practitioner

Type 2 diabetes contributes to significant risk of cardiovascular and micro-vascular complications. The family practitioner plays a significant role in the management of glycaemic control and thereby reducing the related morbidity and mortality. Monitoring of blood glucose control has become an integral part of disease management that can empower patients and physicians to optimal blood glucose management. Numerous drugs are currently available to treat type 2 diabetic patients. The role of the currently available drugs is discussed as well as the use of insulin. A suggested protocol for the initiation and adjustment of treatment is provided.South African Family Practice Vol. 48 (10) 2006: pp. 22-2

The prevalence of subclinical hypothyroidism among patients with diabetes mellitus at the Kalafong Hospital Diabetes Clinic: a cross-sectional study

Objective: The purpose of this study was to determine the prevalence of subclinical hypothyroidism among patients with diabetes mellitus at the Kalafong Diabetes Clinic in Pretoria.Design: Cross-sectional study.Setting and subjects: Five hundred and sixty-five patients with diabetes mellitus (type 1, type 2 or unknown), who were following-up at the Kalafong Hospital Diabetes Clinic.Outcome measures: The thyroid stimulating hormone (TSH) levels of patients were evaluated. Patients with TSH levels > 5.66 IU/ml (upper reference limit of the Kalafong National Health Laboratory Services laboratory) subsequently underwent repeat thyroid function evaluation, including T4 level, to determine the prevalence of subclinical hypothyroidism.Results: A total of 563 patients met the inclusion criteria for this study and underwent TSH evaluation. The prevalence of subclinical hypothyroidism was found to be 0.9% in the study population, and 1.6% in a subgroup of patients with type 2 diabetes mellitus.Conclusion: The prevalence of subclinical hypothyroidism in this South African population of patients with diabetes was significantly lower than that stated in the literature. This holds true for both the general population and populations of patients with diabetes mellitus. To our knowledge, there is no data available for the prevalence of subclinical hypothyroidism in the general population in South Africa for comparison with the study group.Keywords: subclinical hypothyroidism, diabetes mellitus, South Afric

Inpatient Blood Glucose Management of Diabetic Patients in a Large Secondary Hospital

Background: Diabetes has become a major health problem worldwide, as well as in South Africa. This, coupled with the chronicity of the disease,relate to an increasing burden on health care facilities and an increasing number of hospital admissions of patients suffering from diabetes.Admissions are mostly related to diabetes itself, but the frequency of admissions for problems not related to diabetes is increasing as the prevalence of diabetes increases in the population. Proper inpatient glycaemic management is important for improving patient outcome and for reducing the risk of inpatient complications.Objectives: The objective of this study was to evaluate current practices in the care of diabetic inpatients as well as to assess the glycaemic controlthat is achieved during hospitalisation.Methods: An audit was done of clinical hospital records of adult diabetic patients admitted to Kalafong Hospital, a large secondary hospital in SouthAfrica. All patients admitted who had type 1 or type 2 diabetes before admission, or who were newly diagnosed on admission or in hospital wereincluded, irrespective of the discipline to which the patient was admitted. All patient admissions in the eight-month period preceding the initiation ofthe audit were included.Results: The hospital records of 164 diabetic patients were audited. With regard to glucose monitoring, 60.8% of patients had irregular and erraticglucose monitoring, 37.2% had regular (either four- or six-hourly) monitoring and only 2% were monitored in relation to meals. Of the 164 patients, 160 were not fasting, 27 were treated with an insulin sliding scale at some stage during their admission, and in 14 (52%) of the patients who were on sliding scales the scale was used inappropriately. Most hospital inpatients with diabetes, i.e. 48 (30.4%), were treated with oral agents only; 29 (18.4%) were treated with oral agents plus a daily dose of NPH insulin and 17 (10.8%) with mixed insulin twice daily. Only three patients (1.9%) received insulin supplemental to their regimen. The glycaemic control treatment schedule was appropriate in only 19.5% of cases.Conclusions: Based on our findings, the monitoring and management of blood glucose in patients with diabetes during hospitalisation in a largesecondary hospital in South Africa is currently inadequate. This calls for an educational intervention for doctors and nurses working with diabeticinpatients as well as the introduction of a blood glucose management protocol

Obstructive sleep apnoea in pregnancy and its association with pre-eclampsia

Background: Obstructive sleep apnoea (OSA) in pregnancy is associated with an increased morbidity and mortality to both mother and foetus. In the South African setting the proportion of pregnant females suffering from OSA has not been well studied; nor has the association with pre-eclampsia. This study aimed to determine the prevalence of OSA in females before 35 weeks gestation using the STOP-BANG questionnaire and to determine the association with pre-eclampsia in a local South African setting.Methods: A cross-sectional analytical study including 234 patients was conveniently sampled from Kalafong Hospital’s antenatal ward, clinic and labour ward. Participants were of more than 20 weeks and less than 35 weeks gestation. All participants were interviewed with a modified STOP-BANG questionnaire. Patients were consecutively enrolled without prior knowledge of the presence of pre-eclampsia. At Kalafong hospital all pregnant patients are routinely screened and investigated for pre-eclampsia according to standard criteria.Results: The median gestational age in this sample was 28 weeks; 80.3% (CI 74.62–85.2%) of pregnant females had a low risk for OSA, 15.4% (CI 11.01–20.65%) had an intermediate risk and 3% (CI 6.47–14.58%) had a high risk for OSA. A modified STOP-BANG questionnaire had a sensitivity of 62.5% and a specificity of 82.1% for pre-eclampsia when a score of 3 and more was scored. Females at high risk of OSA had an OR of 8.4 (CI 2.88–24.6) for having pre-eclampsia.Conclusions: The authors report 15.4% of the study’s pregnant population to be at intermediate risk and 3% at high risk of OSA. The association between the hypertensive disorders and OSA must be considered and screening implementation considered.Keywords: anaesthesia, obstructive sleep apnoea, pre-eclampsia, STOP-BANG questionnair

Diabetic nephropathy in a tertiary care clinic in South Africa: a cross-sectional study

Objective: The aim of this study was to determine the prevalence of micro- or macroalbuminuria in type 1 and type 2 diabetic patients, and to  examine the relationship with the diabetes control parameters such as haemoglobin (Hb)A1c, blood pressure (BP) and lipids.Design: This was an analytical cross-sectional study.Setting and subjects: The study consisted of 754 patients with either type 1 or type 2 diabetes, attending a diabetes clinic at the Kalafong Hospital in Pretoria, South Africa.Outcome measures: Micro- or macroalbuminuria and estimated glomerular filtration rate (eGFR) were the outcome measures.Results: An HbA1c > 7% was recorded in 88.9% of the patients, and  low-density lipoprotein cholesterol . 1.8 mmol/l in 81%. Overall, the prevalence of micro- or macroalbuminuria was 33.6%. Logistic regression revealed that HbA1c, the duration of diabetes, systolic BP, male sex and triglycerides were predictive of microalbuminuria.Conclusion: The prevalence of micro- or macroalbuminuria in this study fell within the ranges of what has previously been reported in Africa. HbA1c and the duration of diabetes were the strongest predictors of microalbuminuria in all of the patients, and age was the strongest predictor of a low eGFR. Diabetes was poorly controlled, making the progression to end-stage renal failure a real concern in these patients

Frequent traces of EBV infection in Hodgkin and non-Hodgkin lymphomas classified as EBV-negative by routine methods: expanding the landscape of EBV-related lymphoma

peer-reviewedThe Epstein–Barr virus (EBV) is linked to various B-cell lymphomas, including Burkitt lymphoma (BL), classical Hodgkin lymphoma (cHL) and diffuse large B-cell lymphoma (DLBCL) at frequencies ranging, by routine techniques, from 5 to 10% of cases in DLBCL to >95% in endemic BL. Using higher-sensitivity methods, we recently detected EBV traces in a few EBV-negative BL cases, possibly suggesting a “hit-and-run” mechanism. Here, we used routine and higher-sensitivity methods (qPCR and ddPCR for conserved EBV genomic regions and miRNAs on microdissected tumor cells; EBNA1 mRNA In situ detection by RNAscope) to assess EBV infection in a larger lymphoma cohort [19 BL, 34 DLBCL, 44 cHL, 50 follicular lymphomas (FL), 10 T-lymphoblastic lymphomas (T-LL), 20 hairy cell leukemias (HCL), 10 mantle cell lymphomas (MCL)], as well as in several lymphoma cell lines (9 cHL and 6 BL). qPCR, ddPCR, and RNAscope consistently documented the presence of multiple EBV nucleic acids in rare tumor cells of several cases EBV-negative by conventional methods that all belonged to lymphoma entities clearly related to EBV (BL, 6/9 cases; cHL, 16/32 cases; DLBCL, 11/30 cases), in contrast to fewer cases (3/47 cases) of FL (where the role of EBV is more elusive) and no cases (0/40) of control lymphomas unrelated to EBV (HCL, T-LL, MCL). Similarly, we revealed traces of EBV infection in 4/5 BL and 6/7 HL cell lines otherwise conventionally classified as EBV negative. Interestingly, additional EBV-positive cases (1 DLBCL, 2 cHL) relapsed as EBV-negative by routine methods while showing EBNA1 expression in rare tumor cells by RNAscope. The relapse specimens were clonally identical to their onset biopsies, indicating that the lymphoma clone can largely loose the EBV genome over time but traces of EBV infection are still detectable by high-sensitivity methods. We suggest EBV may contribute to lymphoma pathogenesis more widely than currently acknowledged

Large Scale Comparison of Innate Responses to Viral and Bacterial Pathogens in Mouse and Macaque

Viral and bacterial infections of the lower respiratory tract are major causes of morbidity and mortality worldwide. Alveolar macrophages line the alveolar spaces and are the first cells of the immune system to respond to invading pathogens. To determine the similarities and differences between the responses of mice and macaques to invading pathogens we profiled alveolar macrophages from these species following infection with two viral (PR8 and Fuj/02 influenza A) and two bacterial (Mycobacterium tuberculosis and Francisella tularensis Schu S4) pathogens. Cells were collected at 6 time points following each infection and expression profiles were compared across and between species. Our analyses identified a core set of genes, activated in both species and across all pathogens that were predominantly part of the interferon response pathway. In addition, we identified similarities across species in the way innate immune cells respond to lethal versus non-lethal pathogens. On the other hand we also found several species and pathogen specific response patterns. These results provide new insights into mechanisms by which the innate immune system responds to, and interacts with, invading pathogens

Recent advances in understanding hypertension development in sub-Saharan Africa

Consistent reports indicate that hypertension is a particularly common finding in black populations. Hypertension occurs at younger ages and is often more severe in terms of blood pressure levels and organ damage than in whites, resulting in a higher incidence of cardiovascular disease and mortality. This review provides an outline of recent advances in the pathophysiological understanding of blood pressure elevation and the consequences thereof in black populations in Africa. This is set against the backdrop of populations undergoing demanding and rapid demographic transition, where infection with the Human Immunodeficiency Virus predominates, and where under and over-nutrition coexist. Collectively, recent findings from Africa illustrate an increased lifetime risk to hypertension from foetal life onwards. From young ages black populations display early endothelial dysfunction, increased vascular tone and reactivity, microvascular structural adaptions, as well as increased aortic stiffness resulting in elevated central and brachial blood pressures during the day and night, when compared to whites. Together with knowledge on the contributions of sympathetic activation and abnormal renal sodium handling, these pathophysiological adaptations result in subclinical and clinical organ damage at younger ages. This overall enhanced understanding on the determinants of blood pressure elevation in blacks encourages (a) novel approaches to assess and manage hypertension in Africa better, (b) further scientific discovery to develop more effective prevention and treatment strategies, and (c) policymakers and health advocates to collectively contribute in creating health-promoting environments in Africa

New approaches in the diagnosis and treatment of latent tuberculosis infection

With nearly 9 million new active disease cases and 2 million deaths occurring worldwide every year, tuberculosis continues to remain a major public health problem. Exposure to Mycobacterium tuberculosis leads to active disease in only ~10% people. An effective immune response in remaining individuals stops M. tuberculosis multiplication. However, the pathogen is completely eradicated in ~10% people while others only succeed in containment of infection as some bacilli escape killing and remain in non-replicating (dormant) state (latent tuberculosis infection) in old lesions. The dormant bacilli can resuscitate and cause active disease if a disruption of immune response occurs. Nearly one-third of world population is latently infected with M. tuberculosis and 5%-10% of infected individuals will develop active disease during their life time. However, the risk of developing active disease is greatly increased (5%-15% every year and ~50% over lifetime) by human immunodeficiency virus-coinfection. While active transmission is a significant contributor of active disease cases in high tuberculosis burden countries, most active disease cases in low tuberculosis incidence countries arise from this pool of latently infected individuals. A positive tuberculin skin test or a more recent and specific interferon-gamma release assay in a person without overt signs of active disease indicates latent tuberculosis infection. Two commercial interferon-gamma release assays, QFT-G-IT and T-SPOT.TB have been developed. The standard treatment for latent tuberculosis infection is daily therapy with isoniazid for nine months. Other options include therapy with rifampicin for 4 months or isoniazid + rifampicin for 3 months or rifampicin + pyrazinamide for 2 months or isoniazid + rifapentine for 3 months. Identification of latently infected individuals and their treatment has lowered tuberculosis incidence in rich, advanced countries. Similar approaches also hold great promise for other countries with low-intermediate rates of tuberculosis incidence

ISSN exercise & sport nutrition review: research & recommendations

Sports nutrition is a constantly evolving field with hundreds of research papers published annually. For this reason, keeping up to date with the literature is often difficult. This paper is a five year update of the sports nutrition review article published as the lead paper to launch the JISSN in 2004 and presents a well-referenced overview of the current state of the science related to how to optimize training and athletic performance through nutrition. More specifically, this paper provides an overview of: 1.) The definitional category of ergogenic aids and dietary supplements; 2.) How dietary supplements are legally regulated; 3.) How to evaluate the scientific merit of nutritional supplements; 4.) General nutritional strategies to optimize performance and enhance recovery; and, 5.) An overview of our current understanding of the ergogenic value of nutrition and dietary supplementation in regards to weight gain, weight loss, and performance enhancement. Our hope is that ISSN members and individuals interested in sports nutrition find this review useful in their daily practice and consultation with their clients