Hospitalisation of Type 2 diabetes mellitus patients with and without major depressive disorder in a private managed healthcare organisation

Background: The relationship between Type 2 diabetes mellitus (T2DM) and associated co-morbidities, particularly major depressive disorder (MDD), is poorly acknowledged in chronic disease management practices in South Africa. Managed healthcare costs and hospitalisation rates may be influenced by the discrete management of co-morbid conditions. Therefore, the relationship between T2DM and MDD in terms of co-morbidity incidence and hospitalisation resource utilisation was investigated.Method: This retrospective descriptive study analysed the data of 902 adult patients with T2DM from the health system database of a private managed healthcare organisation for 2014.Results: The mean age was 57 ± 15 years and 85% of the identified T2DM patients had at least one recorded co-morbidity. Among this population 17% presented with MDD. A higher percentage of T2DM patients with MDD were admitted to hospital (42%, p = 0.004) compared with those without MDD (30%). The number of overnight admissions was higher among the T2DM with MDD (76%, p = 0.016) compared with T2DM without MDD (66%). The T2DM with MDD group (85%, p = 0.018) had greater non-diabetes related hospital events compared with the T2DM without MDD group (73%). The T2DM patients without MDD were more likely to be hospitalised for diabetes-related events (27%, p = 0.018) at significantly higher admission cost (p = 0.001).Conclusion: Patients with T2DM and MDD present with more co-morbid conditions and had a higher number of hospitalisations than their non-MDD counterparts. However, the hospitalisation costs were significantly higher for diabetes-related admissions in the non-MDD group due to a higher number of macrovascular events. Healthcare organisations need to focus on an integrated approach in the management of chronic conditions with emphasis on active surveillance of T2DM patients, where MDD is identified and treated to lessen the risk of macrovascular complications

Spectrum of cardiac disease in maternity in a low-resource cohort in South Africa

Background: Lack of evidence-based data on the spectrum of cardiovascular disease (CVD) in pregnancy or in the postpartum period, as well as on maternal and fetal outcome, provides challenges for treating physicians, particularly in areas of low resources. The objectives of this study were to investigate the spectrum of disease, mode of presentation and maternal and fetal outcome of patients referred to a dedicated Cardiac Disease and Maternity Clinic (CDM). Methods: The prospective cohort study was conducted at a single tertiary care centre in South Africa. Two hundred and twenty-five women presenting with CVD in pregnancy, or within 6 months postpartum, were studied over a period of 2 years. Clinical assessment, echocardiography and laboratory tests were performed at baseline and follow-up visits. Prepartum, peripartum and postpartum complications were grouped into cardiac, neonatal and obstetric events. Results: Ethnicity was black African (45%), mixed ethnicity (32%), white (15%), Indian/others (8%) and 12% were HIV positive. Of the 225 consecutive women (mean age 28.8±6.4), 196 (86.7%) presented prepartum and 73 in modified WHO class I. The 152 women presenting in a higher risk group (modified WHO class II-IV) were offered close follow-up at the CDM clinic and were diagnosed with congenital heart disease (32%, 15 operated previously), valvular heart disease (26%, 15 operated previously), cardiomyopathy (27%) and other (15%). Women presenting with symptoms of CVD or heart failure postpartum (n=30) presented in a higher New York Heart Association, had higher heart rates (p42 days postpartum. Perinatal death occurred in 1/152 (0.7%) - translating to a perinatal mortality rate of 7/1000 live births. Conclusions: Disease patterns were markedly different to that seen in the developed world. However, joint obstetric-cardiac care in the low-resource cohort was associated with excellent survival outcome rates of pregnant mothers (even with complex diseases) and their offspring and was similar to that seen in the western world. Mortality typically occurred in the postpartum period, beyond the standard date of recording maternal death

Antiphospholipid antibodies in black south africans with hiv and acute coronary syndromes: prevalence and clinical correlates

<p>Abstract</p> <p>Background</p> <p>HIV infection is associated with a high prevalence of antiphospholipid antibodies (aPL) and increased thrombotic events but the aetiopathogenic link between the two is unclear.</p> <p>Findings</p> <p>Prospective single centre study from Soweto, South Africa, comparing the prevalence of aPL in highly active anti-retroviral therapy (HAART) naïve HIV positive and negative patients presenting with Acute Coronary Syndromes (ACS). Between March 2004 and February 2008, 30 consecutive black South African HIV patients with ACS were compared to 30 black HIV negative patients with ACS. The HIV patients were younger (43 ± 7 vs. 54 ± 13, p = 0.004) and besides smoking (73% vs. 33%, p = 0.002) and lower HDL levels (0.8 ± 0.3 vs. 1.1 ± 0.4, p = 0.001) had fewer risk factors than the control group. HIV patients had a higher prevalence of anticardiolipin (aCL) IgG (47% vs. 10%, p = 0.003) and anti-prothrombin (aPT) IgG antibodies (87% vs. 21%, p < 0.001) but there was no difference in the prevalence of the antiphospholipid syndrome (44% vs. 24%, p = N/S) and aPL were not predictive of clinical or angiographic outcomes.</p> <p>Conclusions</p> <p>Treatment naïve black South African HIV patients with ACS are younger with fewer traditional coronary risk factors than HIV negative patients but have a higher prevalence and different expression of aPL which is likely to be an epiphenomenon of the HIV infection rather than causally linked to thrombosis and the pathogenesis of ACS.</p

Correlation of pulse wave velocity with left ventricular mass in patients with hypertension once blood pressure has been normalized

Vascular stiffness has been proposed as a simple method to assess arterial loading conditions of the heart which induce left ventricular hypertrophy (LVH). There is some controversy as to whether the relationship of vascular stiffness to LVH is independent of blood pressure, and which measurement of arterial stiffness, augmentation index (AI) or pulse wave velocity (PWV) is best. Carotid pulse wave contor and pulse wave velocity of patients (n=20) with hypertension whose blood pressure (BP) was under control (<140/90 mmHg) with antihypertensive drug treatment medications, and without valvular heart disease, were measured. Left ventricular mass, calculated from 2D echocardiogram, was adjusted for body size using two different methods: body surface area and height. There was a significant (P<0.05) linear correlation between LV mass index and pulse wave velocity. This was not explained by BP level or lower LV mass in women, as there was no significant difference in PWV according to gender (1140.1+67.8 vs 1110.6+57.7 cm/s). In contrast to PWV, there was no significant correlation between LV mass and AI. In summary, these data suggest that aortic vascular stiffness is an indicator of LV mass even when blood pressure is controlled to less than 140/90 mmHg in hypertensive patients. The data further suggest that PWV is a better proxy or surrogate marker for LV mass than AI and the measurement of PWV may be useful as a rapid and less expensive assessment of the presence of LVH in this patient population

Relative impact of conventional blood pressure and arterial stiffness on target-organ changes

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Tranformation of a health sciences postgraduate population (2008-2017) at a higher education institution in South Africa: Has this occurred?

Despite efforts to prioritise transformation of the previously disadvantaged population, inequalities created by the Apartheid system persist in the South African higher education system. This study assessed transformation in relation to population affinity and gender of first-time enrolments of Health Sciences (HS) postgraduate students at the University of the Witwatersrand (Wits), Johannesburg. A retrospective study of the Wits HS postgraduate student database was used for this assessment. The probability of a postgraduate student being Black African increased by 7.5 per cent per year [OR: 1.075, 95% CI (1.052–1.099), p&lt;0.001] over the period 2008–2017 and of being female, increased by 5.6 per cent per year [OR: 1.056, 95% CI (1.033–1.081), p&lt;0.001]. While transformation has occurred, Black African females are still under-represented. The transformation of the postgraduate student body as observed in this study is of importance to other countries struggling with racial and gender equity in the health workforce

Personality, depressive symptoms and prior trauma exposure of new recruits at two Metropolitan Police Service academies in South Africa

Background. Police officers are predisposed to trauma exposure. The development of depression and post-traumatic stress disorder (PTSD) may be influenced by personality style, prior exposure to traumatic events and prior depression. Objectives. To describe the personality profiles of new Metropolitan Police Service (MPS) officers, and to determine the association between personality profiles, trauma exposure and depressive symptoms. Methods. We performed a cross-sectional analysis of 139 new recruits at two MPS academies in South Africa. A questionnaire elucidating traumatic life events and personality profiles was developed using the Millon Clinical Multiaxial Inventory-III (MCMI-III). Depressive symptoms were measured using the Hamilton Depression Rating Scale (HAMD). Results. Almost all subjects (99.3%) had previous trauma exposure, most commonly the unexpected death of a loved one and motor vehicle accidents. Prevalence of clinical depression was low (mean HAMD 3.57; standard deviation ±3.37). Personality characteristics revealed a high prevalence of anxiety (64.7%; 95% CI 56.8 - 72.6), depressive clinical patterns (34.5%; 95% CI 26.6 - 42.2), paranoia (33.1 %; 95% CI 26.6 - 42.2) and major depression (10.3%; 95% CI 5.1 - 15.1). There were no significant associations between any of the traumatic events and depressive symptoms, nor were there any significant associations between any of the personality variables and HAMD score (p>0.05). Conclusion. The presence of depressive symptoms among MPS officers was low, with no significant associations between traumatic events, personality variables and depressive symptoms

Efficacy of different drug classes used to initiate antihypertensive drug treatment in black subjets. Results from a randomized trial in Johannesburg, South Africa

BACKGROUND: Thiazides are recommended to initiate antihypertensive drug treatment in black subjects. OBJECTIVE: To test the efficacy of this recommendation in a South African black cohort. METHODS: Men and women (N = 409), aged 18 to 70 years, with a mean ambulatory daytime diastolic blood pressure between 90 and 114 mm Hg, were randomized to 13 months of open-label treatment starting with the nifedipine gastrointestinal therapeutic system (30 mg/d, n = 233), sustained-release verapamil hydrochloride (240 mg/d, n = 58), hydrochlorothiazide (12.5 mg/d, n = 58), or enalapril maleate (10 mg/d, n = 60). If the target of reducing daytime diastolic blood pressure below 90 mm Hg was not attained, the first-line drugs were titrated up and after 2 months other medications were added to the regimen. RESULTS: While receiving monotherapy (2 months, n = 366), the patients' systolic and diastolic decreases in daytime blood pressure averaged 22/14 mm Hg for nifedipine, 17/11 mm Hg for verapamil, 12/8 mm Hg for hydrochlorothiazide, and 5/3 mm Hg for enalapril. At 2 months the blood pressure of more patients treated with nifedipine was controlled: 133 (63.3%, P</=.03) vs 20 (39.9%) receiving verapamil, 21 (40.4%) receiving hydrochlorothiazide, and 11 (20.8%) receiving enalapril. At 13 months (n = 257), more patients (P<.001) continued receiving monotherapy with nifedipine (94/154 [61.0%]) or verapamil (22/35 [62.9%]) than hydrochlorothiazide (10/39 [25.6%]) or enalapril (1/29 [3.4%]). A sustained decrease of left ventricular mass (P<.001) with no between-group differences was achieved at 4 and 13 months. CONCLUSIONS: In contrast to current recommendations, calcium channel blockers are more effective than thiazides as initial treatment in black subjects with hypertension. If treatment is started with thiazides or converting-enzyme inhibitors, combination therapy is more likely to be required to control blood pressure and reduce left ventricular mass.status: publishe

The clinical consequences and challenges of hypertension in urban-dwelling black Africans: Insights from the Heart of Soweto Study

Background: There is a paucity of data to describe advanced forms of cardiovascular disease (CVD) in urban black Africans with hypertension (HT). Methods: Chris Hani Baragwanath Hospital services the black African community of 1.1 million people in Soweto, South Africa. We prospectively collected detailed demographic and clinical data from all de novo presentations to the hospital's Cardiology Unit in 2006. Results: Overall, 761 black African patients (56% of de novo cases) presented with a diagnosis of HT with more women (63%, aged 58.5 ± 14.9 years) than men (aged 58.0 ± 15.6 years). On presentation, 396 women (82%) versus 187 men (67%) had dizziness, palpitations and/or chest pain (OR 1.23, 95% 1.12-1.34: p < 0.0001). HT was the primary diagnosis in 266 cases (35%). In the rest (n = 495), non-ischaemic forms of heart failure were common (54% of total) while only 6.2% had coronary artery disease. Concurrent left ventricular hypertrophy, renal dysfunction and anaemia were present in 39%, 24% and 11% of cases, respectively, with a similar age-adjusted pattern of co-morbidity according to sex. However, men were more likely to present with impaired systolic function (OR 2.13, 95% CI 1.50 to 3.00; p < 0.0001). Conclusions: In the absence of effective primary and secondary prevention strategies, these unique data highlight the potentially devastating impact of advanced forms of hypertensive heart disease in urban black African communities with more women than men affected