Hyperthyroidism: What the generalist should know

Thyrotoxicosis is one of the more common endocrine disorders and most cases result from hyperactivity of the thyroid gland (hyperthyroidism) (Table I). Younger patients with thyrotoxicosis of any cause may present with palpitations, anxiety, easy fatigability, psychomotor activity, diarrhoea, excessive sweating, heat intolerance, preference for cold, amenorrhoea, and marked weight loss without appetite loss

High prevalence of cardiovascular risk factors and insulin resistance 6 years after hyperglycemia first detected in pregnancy in Cape Town, South Africa

Objective To investigate the prevalence and associated cardiovascular risk factors 6 years after hyperglycemia first detected in pregnancy (HFDP) in Cape Town, South Africa. Research design and methods Data were collected during the index pregnancy from all women diagnosed with HFDP at a major referral hospital in Cape Town. Participants were evaluated 6 years later using a cross-sectional study. At follow-up participants had a 75 g oral glucose tolerance test, fasting lipogram, blood pressure and anthropometric measurements, and a fieldworker administered the questionnaire. We used the Adult Treatment Panel III criteria for the diagnosis of metabolic syndrome and individual risk factors. Insulin resistance was assessed using the homeostatic model of insulin resistance. Results At follow-up 220 women were reviewed. Their mean age at follow-up was 37.2 (SD 6.0) years. The prevalence of cardiovascular disease (CVD) risk factors was 60.9% (95% CI 54.3 to 67.2) for metabolic syndrome, 75% (95% CI 65.9 to 82.3) for insulin resistance, 62.3% (95% CI 55.6 to 68.5) for dysglycemia, 41.4% (95% CI 35.0 to 48.0) for raised blood pressure, and 74.6% (95% CI 683 to 79.9) for dyslipidemia. Women with diabetes in pregnancy compared with those with gestational diabetes during the index pregnancy had a higher prevalence of metabolic syndrome (74.3% vs 54.7%, p=0.010) and dysglycemia (88.6% vs 50.0%, p<0.001) at follow-up. Lower school education attainment, having a subsequent pregnancy, waist circumference at follow-up, and fasting blood glucose at HFDP diagnosis were associated with metabolic syndrome. Conclusion We found a high prevalence of CVD risk factors in South African women within 6 years of HFDP, which highlights the need to develop and evaluate interventions optimizing the cardiometabolic health of this vulnerable group. The main limitations of our research are the lack of a comparative group of women without HFDP and that we did not assess for CVD risk factors before HFDP. - Author(s) (or their employer(s)) 2019. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.Funding This research was funded by the Chronic Disease Initiative for Africa. We acknowledge funding from the International Development Research Centre (IDRC) (fund number: 411592) for TC (under the IINDIAGO project).Scopu

The roles of community health workers in management of non-communicable diseases in an urban township

BACKGROUND: Community health workers (CHWs) are increasingly being recognised as a crucial part of the health workforce in South Africa and other parts of the world. CHWs have taken on a variety of roles, including community empowerment, provision of services and linking communities with health facilities. Their roles are better understood in the areas of maternal and child health and infectious diseases (HIV infection, malaria and tuberculosis). AIM: This study seeks to explore the current roles of CHWs working with non-communicable diseases (NCDs). Setting: The study was conducted in an urban township in Cape Town, South Africa. Method: A qualitative naturalistic research design utilising observations and in-depth interviews with CHWs and their supervisors working in Khayelitsha was used. Results: CHWs have multiple roles in the care of NCDs. They act as health educators, advisors, rehabilitation workers and support group facilitators. They further screen for complications of illness and assist community members to navigate the health system. These roles are shaped both by expectations of the health system and in response to community needs. CONCLUSION: This study indicates the complexities of the roles of CHWs working with NCDs. Understanding the actual roles of CHWs provides insights into not only the competencies required to enable them to fulfil their daily functions, but also the type of training required to fill the present gaps. Introduction Community health workers (CHWs) are increasingly being recognised as a crucial part of the health workforce.1 In South Africa and worldwide, CHWs have provided health care to communities for many decades and have assumed a variety of roles, including communityWeb of Scienc

Contribution of growth hormone-releasing hormone and somatostatin to decreased growth hormone secretion in elderly men

Objective. The pathophysiology of the decline in circulating growth hormone (GH) concentrations that may occur with ageing remains elusive. We have investigated the potential contributions of decreased endogenous GH-releasing hormone (GHRH) and increased somatostatin secretion to this phenomenon.Design and methods. The strategy used was to stimulate GH secretion in 8 young (20 - 24 years old, body mass index (BMI) 22.8 ± 2.8 kg/m2) and 8 elderly (68- 82 years old, BMI 23.4 ± 1.6 kg/m2) male subjects on separate occasions by means of: (i) intravenous bolus 0.5 ).lg/kg D-Ala2 GHRH(1-29)-NH alone; (ii) 0.5 μg/kg GHRH after pretreatment with two oral doses of 50 mg atenolol (to inhibit somatostatin secretion); (iii) 1.25 mg oral bromocriptine alone (to increase endogenous GHRH and/or inhibit somatostatin); (iv) 50 mg oral atenolol plus 1.25 mg oral bromocriptine; and (v) 0.5 μg/kg GHRH after pre-treatment with 1.25 mg oral bromocriptine.Results. The elderly men had a significantly lower peak and area under curve (AUC) GH response to intravenous GHRH when compared with 8 young men (peak 3.1 ± 1.0 ng/ml v. 21.6 ± 5.0 ng/ ml, AUC 205 ±56 ng/ ml/min v.1 315 ± 295 ng/ ml/ min, P &lt; 0.05). Pre-treatment with atenolol before GHRH administration produced no significant increase in peak and AUC GH response in both groups, whlch remained lower in the elderly men than in their young counterparts (peak 5.5 ±1.8 ng/ ml v. 29.3 ± 7.0 ng/ml, AUC 327 ± 90 ng/ml/min v. 2 017 ± 590 ng/ ml/min, P &lt; 0.05). Bromocriptine alone did not cause a significant rise in GH concentration in either elderly or young subjects (peak 3.1 ± 1.1 v. 8.8 ± 3.2 ng/ ml, P &gt; 0.05). When atenolol was administered before bromocriptine, both groups responded but the elderly subjects had a significantly greater peak and AUC response (peak 3.6 ± 0.7 v. 10:7 ± 2.1 ng/ ml; AUC 191 ± 39 v. 533 ± 125 ng/ ml/ min, P &lt; 0.05). Bromocriptine given before GHRH failed to potentiate GHRH action on GH release in either group. Of 5 elderly men who tmderwent further evaluation of GH secretory ability, 2 subjects had GH levels &gt; 10 ng/ rnl, either basally or after intravenous GHRH. The remaining 3 had an initially impaired GH response to bolus intravenous GHRH. After 100 μg GHRH subcutaneously twice daily for up to 2 weeks the GH responses to intravenous bolus GHRH (0.5μg /kg) were reassessed. One exhibited a normal response (&gt; 10 ng/ rnl) after 1 week of daily GHRH treatment, another had a nearnormal response after 2 weeks (9.7 ng/ rnl), while the third still had an impaired response by the end of the 2-week treatment period (3.2 ng/ ml).Conclusions. The restoration of endogenous GH secretion in these elderly subjects by means of GHRH priming, and the failure of manipulation of somatostatinergic tone to restore a normal GH response to GHRH suggests that somatotroph atrophy due to a reduction in endogenous GHRH secretion is the principal cause of the diminished GH secretion with ageing

Excessive weight gain following therapy for hyperthyroidism - a major problem

One of the most characteristic presenting features of hyperthyroidism is weight loss, despite an increased appetite. This phenomenon is easily understandable, as hyperthyroidism is accompanied by a rise in metabolic rate, energy expenditure and thermogenesis which is clearly not matched by an increased appetite and caloric intake in the vast majority of patients. Consequently a decrease in adipose tissue and muscle results. (Curiously a small proportion of hyperthyroid patients, fewer than 10%, present with weight gain owing to an increased appetite that exceeds the rise in metabolic rate

Challenges facing successful scaling up of effective screening for cardiovascular disease by community health workers in Mexico and South Africa: Policy implications

The integration of community health workers (CHWs) into primary and secondary prevention functions in health programs and services delivery in Mexico and South Africa has been demonstrated to be effective. Task-sharing related to adherence and treatment, from nurses to CHWs, has also been effectively demonstrated in these areas. HIV/AIDS and TB programs in South Africa have seen similar successes in task-sharing with CHWs in the areas of screening for risk and adherence to treatment. In the area of non-communicable diseases (NCDs), there is a policy commitment to integrating CHWs into primary health care programs at public health facilities in both Mexico and South Africa in the areas of reproductive health and infant health. Yet current programs utilizing CHWs are not integrated into existing primary health care services in a comprehensive manner for primary and secondary prevention of NCDs. In a recently completed study, CHWs were trained to perform the basic diagnostic function of primary screening to assess the risk of suffering a CVD-related event in the community using a non-laboratory risk assessment tool and referring persons at moderate to high risk to local government clinics, for further assessment and management by a nurse or physician. In this paper we compare the experience with this CVD screening study to successful programs in vaccination, reproductive health, HIV/AIDS, and TB specifically to identify the barriers we identified as limitations to replicating these programs in the area of CVD diagnosis and management. We review barriers impacting the effective translation of policy into practice, including scale up issues; training and certification issues; integrating CHW to existing primary care teams and health system; funding and resource gaps. Finally, we suggest policy recommendations to replicate the demonstrated success of programs utilizing task-sharing with CHWs in infectious diseases and reproductive health, to integrated programs in NCD

The epidemic of obesity in South Africa: a study in a disadvantaged community.

Objective: The objective of this study was: 1) to determine the anthropometric profile of adults In Mamre, a small town In South Africa, which has a population of mixed ancestry ("colored" people of Afro-Euro-Malay-Khoisan ancestry); and 2) to determine the change In this profile between 1989 and 1996. Design: Cross-sectional surveys conducted In random samples of adults In 1989 and 1996. Participants: The subjects were 684 women and 529 men In 1989, and 546 women and 430 men In 1996, aged 15 and older. Main Outcome Measures; The following measurements were recorded: height, weight, and circumference of waist, hips, and mid-upper arm. Results: Based on data from the 1996 survey, 32% of women are obese (body mass index [BMI] ;;: 30) at ages 25-44 years, rising to 49% at ages 45-64 years. A much lower prevalence of obesity is seen in men: 14"10 at ages 35-64 years. Obesity levels significantly increased in women between the two surveys (P=.015): up from 44% in 1989 to 49% in 1996 at ages 45-64 years. There was an Increase In the prevalence of overweight (BMI 25-29.9) in men, though not in obesity. Mean 8MI increased by about 3% In women and 2% in men between 1989 and 1996. Conclusions; This study conducted among people of mixed ancestry living In a disadvantaged community In South Africa shows that half of middle-aged women are obese. A rising trend In 8MI was seen in adults of both sexes between 1989 and 1996. This trend may be explained by factors associated with rural-urban transition, Including electrification, reduced physical activity, and Increasing availability of energy-dense food

Barriers to initiating insulin therapy in patients with type 2 diabetes mellitus in public-sector primary health care centres in Cape Town

Background: The majority of patients with type 2 diabetes mellitus in Cape Town who attend primary care community health centres (CHCs) have unsatisfactory glycaemic control. Insulin is rarely prescribed despite its being indicated for type 2 diabetic patients with inadequate metabolic control on maximum oral glucose-lowering agent (OGLA) therapy. Objective: The study examined barriers to initiating insulin therapy in poorly controlled type 2 diabetes patients on maximum OGLAs in CHCs in the Cape Town metropole. Methods: Five focus group discussions and 10 in-depth semistructured individual interviews were conducted with 46 medical officers working at the CHCs. The discussions and interviews were transcribed and common themes were identified and categorised. Results: Doctor, patient, and system barriers to initiating insulin therapy were identified. Doctors\' barriers include lack of knowledge, lack of experience with and use of guidelines related to insulin therapy, language barriers between doctor and patients, and fear of hypoglycaemia. Patient barriers were mistaken beliefs about insulin, non-compliance, lack of understanding of diabetes, use of traditional herbs, fear of injections, and poor socioeconomic conditions. System barriers were inadequate time, lack of continuity of care and financial constraints.Conclusion: Suggestions for overcoming barriers include further education of doctors on insulin initiation and the use of standardised guidelines. In addition, a patient-centred approach with better communication between doctors and patients, which may be achieved by reorganising aspects of the health system, may improve patient knowledge, address mistaken beliefs, improve compliance and help overcome barriers. Further research is needed to investigate these recommendations and assess patients\' and nurses\' perceptions on initiating insulin therapy. South African Medical Journal Vol. 95(10) 2005: 798-80