Inpatient diabetes care : evaluation and intervention

The management of patients hospitalised with diabetes mellitus is neglected in South Africa. The research on which this thesis is based assessed factors contributing to glycaemic control as well as evaluated an intervention aimed at improving of such control in diabetic inpatients. A survey of doctors and nurses measuring their perceptions, knowledge and attitudes regarding care of diabetic inpatients was done. This indicated a need for special training in inpatient diabetes care, where 90.5% of respondents realised that diabetes is a serious condition and 92.2% valued the importance of tight glycaemic control. Despite these perceptions, the knowledge of doctors and nurses caring for diabetic inpatients was suboptimal. A before and after study regarding an intervention to improve glycaemic control of diabetic inpatients consisted of a training programme and the introduction of an inpatient management protocol. The mean blood glucose on day one of admission after the intervention was significantly higher than before the intervention (p 7.32) (HR: 1.863, CI: 0.937 to 3.705, p = 0.758) was not significantly different between the two resuscitation fluid groups The time to reach a blood glucose of 14 mmol/L was significantly longer in the Ringer’s lactate group (p = 0.044) and patients needed significantly more insulin (p = 0.02). The overall conclusion of this study is that there is no significant benefit in using Ringer’s lactate solution as initial resuscitation fluid compared to the currently advised 0.9% Sodium chloride solution.Thesis (PhD)--University of Pretoria, 2012.Internal Medicineunrestricte

Evaluation of the accuracy of visual glucose estimates by healthcare providers and patients at Kalafong Hospital, City of Tshwane, South Africa

Background: A patient-centred approach with self-monitoring of blood glucose (SMBG) has emerged as the preferred approach in monitoring and managing blood glucose. The success of SMBG in diabetes treatment and management relies heavily on the accurate and reproducible measurement of blood glucose values. Aim: To evaluate whether patients and healthcare professionals can accurately estimate blood glucose using photometric strips, by visually matching them to colorimetric charts. Methods: A cross-sectional study design was used with participants enrolled from patients and healthcare providers attending and working at the Diabetes Clinic of Kalafong Provincial Tertiary Hospital (KPTH). A convenience sample of 144 patients and 10 healthcare professionals was enrolled. Results: Limits of agreement of patient and healthcare professional visual estimates were 11.1 to 10.4 mmol/l and 6.7 to 5.7 mmol/l, respectively. The mean difference for estimates by healthcare professionals was 0.8 mmol/l (95% CI 1.30–0.31 mmol/ l) while patient estimates had a mean difference of 0.4 mmol/l (95% CI 1.2−0.5 mmol/l). Conclusions: The study noted that visual colour matching was inexact and generally would overestimate blood glucose. Healthcare  professionals gave visual estimates that were more accurate in comparison with patients

Evaluation of the accuracy of visual glucose estimates by healthcare providers and patients at Kalafong Hospital, City of Tshwane, South Africa

BACKGROUND : A patient-centred approach with self-monitoring of blood glucose (SMBG) has emerged as the preferred approach in monitoring and managing blood glucose. The success of SMBG in diabetes treatment and management relies heavily on the accurate and reproducible measurement of blood glucose values. AIM : To evaluate whether patients and healthcare professionals can accurately estimate blood glucose using photometric strips, by visually matching them to colorimetric charts. METHODS : A cross-sectional study design was used with participants enrolled from patients and healthcare providers attending and working at the Diabetes Clinic of Kalafong Provincial Tertiary Hospital (KPTH). A convenience sample of 144 patients and 10 healthcare professionals was enrolled. RESULTS : Limits of agreement of patient and healthcare professional visual estimates were 11.1 to 10.4 mmol/l and 6.7 to 5.7 mmol/l, respectively. The mean difference for estimates by healthcare professionals was 0.8 mmol/l (95% CI 1.30–0.31 mmol/ l) while patient estimates had a mean difference of 0.4 mmol/l (95% CI 1.2−0.5 mmol/l). CONCLUSIONS : The study noted that visual colour matching was inexact and generally would overestimate blood glucose. Healthcare professionals gave visual estimates that were more accurate in comparison with patients.http://www.jemdsa.co.zaindex.php/JEMDSAam2020Internal Medicin

Effects of exogenous human insulin dose adjustment on body mass index in adult patients with type 1 diabetes mellitus at Kalafong Hospital, Pretoria, South Africa, 2009-2014

BACKGROUND. To maintain fasting blood glucose levels within near to the normal range in type 1 diabetes mellitus (DM), frequent insulin dose adjustments may be required with short-, intermediate- and long-acting insulin formulations. Patients on human insulin generally experience weight gain over time, regardless of the level of glycaemic control achieved. OBJECTIVES. To determine the effects of human insulin, adjusted quarterly to achieve glycaemic control, on body mass index (BMI), and establish dose regimens that achieve optimal glycaemic control without increasing BMI in patients with type 1 DM at the Kalafong Diabetes Clinic in Pretoria, South Africa. METHODS. The sample size (N=211, 48.8% male) was obtained by non-probability convenience sampling of all available records of patients with type 1 DM aged ≥18 years at baseline at the clinic. The longitudinal relationships of covariates with time-varying BMI, as well as with time-varying glycated haemoglobin (HbA1c) levels, were explored using multilevel mixed-effects linear regression modelling. RESULTS. The majority of the patients (84.8%) received the twice-daily biphasic human insulin regimen and the remainder received the basal neutral protamine Hagedorn (NPH) plus prandial regular human insulin regimen. The multivariable multilevel mixed-effects linear regression model indicated that time-varying BMI was significantly positively related to time-varying twice-daily biphasic insulin dosage (β (standard error) 0.464 (0.190), p=0.015), baseline HbA1c (0.092 (0.026), p<0.001) and baseline BMI (0.976 (0.016), p<0.001). There were significant inverse associations with the number of years spent in the study (–0.108 (0.052), p=0.038), time-varying HbA1c (–0.154 (0.031), p<0.001) and male sex (–0.783 (0.163), p<0.001). There were non-significant negative longitudinal associations of age (–0.005 (0.006), p=0.427) and current smoking status (–0.231 (0.218), p=0.290) with BMI outcomes. CONCLUSIONS. There was no evidence that optimal quarterly-prescribed daily dosage adjustments of insulin improved and maintained blood glucose control without increasing body weight. When compared with the basal NPH plus prandial insulin regimen, twice-daily biphasic insulin was associated with a statistically significant increase in subsequent BMI. Baseline HbA1c and BMI were also significantly positively associated with time-varying BMI. However, males appeared to be at a lower risk than females of an increase in BMI during insulin therapy. A question for further research is whether the analogue insulins will be associated with the same increase in BMI, as well as the same modest improvements in HbA1c, seen in this sample.http://www.samj.org.zaam2017Internal MedicineSchool of Health Systems and Public Health (SHSPH

Effects of exogenous human insulin dose adjustment on body mass index in adult patients with type 1 diabetes mellitus at Kalafong Hospital, Pretoria, South Africa, 2009 - 2014

Background. To maintain fasting blood glucose levels within near to the normal range in type 1 diabetes mellitus (DM), frequent insulin dose adjustments may be required with short-, intermediate- and long-acting insulin formulations. Patients on human insulin generally experience weight gain over time, regardless of the level of glycaemic control achieved.Objectives. To determine the effects of human insulin, adjusted quarterly to achieve glycaemic control, on body mass index (BMI), and establish dose regimens that achieve optimal glycaemic control without increasing BMI in patients with type 1 DM at the Kalafong Diabetes Clinic in Pretoria, South Africa.Methods. The sample size (N=211, 48.8% male) was obtained by non-probability convenience sampling of all available records of patients with type 1 DM aged ≥18 years at baseline at the clinic. The longitudinal relationships of covariates with time-varying BMI, as well as with time-varying glycated haemoglobin (HbA1c) levels, were explored using multilevel mixed-effects linear regression modelling.Results. The majority of the patients (84.8%) received the twice-daily biphasic human insulin regimen and the remainder received the basal neutral protamine Hagedorn (NPH) plus prandial regular human insulin regimen. The multivariable multilevel mixed-effects linear regression model indicated that time-varying BMI was significantly positively related to time-varying twice-daily biphasic insulin dosage (β (standard error) 0.464 (0.190), p=0.015), baseline HbA1c (0.092 (0.026), p&lt;0.001) and baseline BMI (0.976 (0.016), p&lt;0.001). There were significant inverse associations with the number of years spent in the study (–0.108 (0.052), p=0.038), time-varying HbA1c (–0.154 (0.031), p&lt;0.001) and male sex (–0.783 (0.163), p&lt;0.001). There were non-significant negative longitudinal associations of age (–0.005 (0.006), p=0.427) and current smoking status (–0.231 (0.218), p=0.290) with BMI outcomes.Conclusions. There was no evidence that optimal quarterly-prescribed daily dosage adjustments of insulin improved and maintained blood glucose control without increasing body weight. When compared with the basal NPH plus prandial insulin regimen, twice-daily biphasic insulin was associated with a statistically significant  increase in subsequent BMI. Baseline HbA1c and BMI were also significantly positively associated with time-varying BMI. However, males appeared to be at a lower risk than females of an increase in BMI during insulin therapy. A question for further research is whether the analogue insulins will be associated with the same increase in BMI, as well as the same modest improvements in HbA1c, seen in this sample

Fluid management in diabetic-acidosis — Ringer’s lactate versus normal saline : a randomized controlled trial

OBJECTIVE: To determine if Ringer’s lactate is superior to 0.9% sodium chloride solution for resolution of acidosis in the management of diabetic ketoacidosis (DKA). DESIGN: Parallel double blind randomized controlled trial. METHODS: Patients presenting with DKA at Kalafong and Steve Biko Academic hospitals were recruited for inclusion in this study if they were >18 years of age, had a venous pH >6.9 and 47.2, a blood glucose of >13 mmol/l and had urine ketones of 52+. All patients had to be alert enough to give informed consent and should have received <1 l of resuscitation fluid prior to enrolment. RESULTS: Fifty-seven patients were randomly allocated, 29 were allocated to receive 0.9% sodium chloride solution and 28 to receive Ringer’s lactate (of which 27 were included in the analysis in each group). An adjusted Cox proportional hazards analysis was done to compare the time to normalization of pH between the 0.9% sodium chloride solution and Ringer’s lactate groups. The hazard ratio (Ringer’s compared with 0.9% sodium chloride solution) for time to venous pH normalization (pH = 7.32) was 1.863 (95% CI 0.937–3.705, P = 0.076). The median time to reach a pH of 7.32 for the 0.9% sodium chloride solution group was 683 min (95% CI 378–988) (IQR: 435–1095 min) and for Ringer’s lactate solution 540 min (95% CI 184–896, P = 0.251). The unadjusted time to lower blood glucose to 14 mmol/l was significantly longer in the Ringer’s lactate solution group (410 min, IQR: 240–540) than the 0.9% sodium chloride solution group (300 min, IQR: 235–420, P = 0.044). No difference could be demonstrated between the Ringer’s lactate and 0.9% sodium chloride solution groups in the time to resolution of DKA (based on the ADA criteria) (unadjusted: P = 0.934, adjusted: P = 0.758) CONCLUSION: This study failed to indicate benefit from using Ringer’s lactate solution compared to 0.9% sodium chloride solution regarding time to normalization of pH in patients with DKA. The time to reach a blood glucose level of 14 mmol/l took significantly longer with the Ringer’s lactate solution.University of Pretoria, Research Development Programmehttp://qjmed.oxfordjournals.org

Diabetes care and complications in primary care in the Tshwane district of South Africa

AIMS : To describe the diabetic population receiving primary care from the Tshwane district public health services and to assess the quality of care of members of this population, their level of disease control and the extent of their complications. METHODS : A cluster-randomised trial was conducted in 12 primary care clinics in Tshwane district. A total of 599 diabetic patients attending these clinics for review were consecutively interviewed and clinically examined. Data on the care received was also obtained from their clinical records for the previous 12 months. Patients randomised to the active arm of the study were screened for complications. RESULTS : The mean age was 58 years and 80.5% had a body mass index (BMI) ≥ 25kg/m2. Sixty-eight percent of patients were female. Acceptable glycaemic control and LDL-cholesterol were found for only 27% and 33% of patients respectively (HbA1c<7%; LDL <2.5 mmol/l). Despite more than 79% of patients reporting to be hypertensive, 68% of patients had a systolic blood pressure above 130 mmHg and 64% had a diastolic blood pressure above 80 mmHg. Evaluating patient records of the preceding year, screening for eye complications was only reported in 8.2%, feet complications in 6.5%, kidney complications in 21.4% and cardiovascular complications in 7.8%. The screening prevalences found were 29% for retinopathy, 22% for maculopathy, 5% for neuropathy (neurothesiometer), 7% for nephropathy (eGFR stage3-5), 17% for possible infarction (Rose questionnaire) and 36% for severe erectile dysfunction (SHIM questionnaire). CONCLUSION : Diabetes care and screening for complications at primary care level in the Tshwane district were found to be sub-optimal. Measures should be taken to address this.Society for Endocrinology, Metabolism and Diabetes of South Africa (SEMDSA), the African Population & Health Research Centre (APHRC) and the University of Pretoria.http://www.elsevier.com/locate/pcd2016-04-30hb201

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.http://www.jemdsa.co.zaindex.php/JEMDSAhb201

Comparison of the VersaTREK blood culture system against the Bactec9240 system in patients with suspected bloodstream infections

BACKGROUND: To evaluate the VersaTREK (TREK Diagnostic Systems, Cleveland, Ohio) blood culture system against the Bactec9240 (BD Microbiology, Cockeysville, MD), for the recovery of bloodstream pathogens. METHODS: Venous blood from patients with suspected bacterial sepsis was evenly distributed into bottles of each system. Positive signals were recorded and bottles processed onto standard media for organism recovery. False positive signals were regarded if no organisms were seen on Gram stain and no growth was observed. RESULTS: 177 bottles were available for analysis; the Bactec9240 system yielded 43 positive, 134 negative results and no false positive signals. The VersaTREK system had 58 positive signals with 14 being false positives. CONCLUSIONS: In our setting with high background burden of immuno-compromised patients, the VersaTREK system compared favourably with the Bactec9240 in recovering blood stream aerobic and facultative anaerobic pathogens from patients with suspected bacterial sepsis. A concern is the high false positivity rate. Due to its versatility to accommodate small and large workloads as well as using smaller volumes of blood, this system may establish itself as a useful alternative for the recovery of bloodstream pathogens