Diabetes management in family practice

Chronic diseases pose a particular chal-lenge to the busy general practitioner. As such diabetes is often a complex disease with multiple complications. The therapeutic choices are often challenging and the practitioner must not only aim to control blood glucose but blood pressure and blood lipids as well. There is clear evidence that diabetes will increase and become a major public health problem in both developed and developing countries. Fortunately many studies have provided evidence as to how improve outcomes is these patients. The following five topics in diabetes management are featured, namely; the emerging epidemic, optimal glucose control, insulin therapy in type 1 diabetes, dyslipidaemia and hypertension.South African Family Practice Vol. 48 (10) 2006: pp. 1

Unsuspected glucose abnormalities in patients with coronary artery disease

Objectives: To compare the ability of fasting glucose, glycosylated haemoglobin (HbA1c), the American Diabetic Association (ADA) score and measures of the metabolic syndrome (waist circumference, high-density lipoprotein (HDL), and triglycerides) in predicting an initial diagnosis of diabetes mellitus or abnormal glucose tolerance based on the World Health Organization (WHO) criteria.Design: A cross-sectional, diagnostic study was undertaken of 120 patients admitted to the cardiology wards of Pretoria Academic Hospital for elective coronary angiographic studies. Main outcome measures: All subjects underwent a modified glucose tolerance test whereby fasting and 2-hour post glucose (75 g) plasma glucose levels were measured. Using the revised WHO criteria, the overall incidence of diabetes was found to be 11.7% (95% confidence interval (CI): 6.5 - 19) and the overall incidence of abnormal glucose tolerance was 46% (CI: 37 - 55). Results: In univariate analysis for the diagnosis of diabetes, HbA1c (p < 0.05) yielded the largest area (0.76) under the receiver operating characteristic (ROC) curve, with a sensitivity of 21%, specificity of 99%, positive predictive value (PPV) of 75% and negative predictive value (NPV) of 91%. For the prediction of abnormal glucose tolerance, applying multivariate analysis using a logistic regression model, the combination of age, ethnic group, serum HDL, serum triglycerides and HbA1c yielded an area under the ROC curve of 0.79, sensitivity of 66%, specificity of 80%, PPV of 76% and a NPV of 71%. Conclusion: Most subjects with diabetes mellitus (9 of 14) would not have been detected if a 2-hour oral glucose tolerance test had not been done. Addition of either HbA1c or lipid parameters to the model of age and ethnic group were similar in predicting abnormal glucose tolerance. Journal of Endocrinology, Metabolism and Diabetes of South Africa Vol. 11(1) 2006: 24-2

The prevalence and associations of erectile dysfunction in a South African male diabetic urban population

Background: Erectile dysfunction (ED) is a common condition in patients with type 1 or type 2 diabetes mellitus. The prevalence and predictors in our patient population are unknown since minimal data exist for this condition in South Africa.Method: An observational, cross-sectional study was performed on 150 consecutive male patients aged ≥ 50 years, with either type 1 or type 2 diabetes mellitus, attending the Steve Biko Academic Hospital Diabetes Clinic. These patients were evaluated for diabetes mellitus control and medical complications, and for the presence of ED. Morning serum testosterone levels were determined.Results: Some degree of ED was reported in 95% of the patients, with 51% reporting serious dysfunction. Using multivariate logistic regression, it was determined that the significant factors associated with ED were age, body mass index, the peripheral neuropathy score and diuretic therapy. Differences in quality-of-life scores were seen in some ED subgroups.Conclusion: This study confirms the high prevalence of ED in diabetic male patients in a tertiary setting. It is suggested that universal screening should be performed for this population group. Multiple predictors of ED were identified in this study. ED negatively affected quality of life, but not in a statistically significant way.Keywords: cardiovascular disease, diabetes mellitus, diuretic therapy, erectile dysfunction, glycaemic control, peripheral neuropath

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The Prevalence and Association of Low Testosterone Levels in a South African Male, Diabetic, Urban Population

Background: According to the literature, low serum testosterone levels are associated with diabetes mellitus. No or minimal data exist for its prevalence or predictors in South Africa.Design: This was a cross-sectional study.Setting: The setting was an academic centre, i.e. the University of Pretoria and Steve Biko Academic Hospital Diabetes Clinic.Subjects: A total of 150 consecutive male patients aged 50 years and older with diabetes mellitus were selected using convenience sampling.Outcome measures: The patients were evaluated for diabetes control and complications, and for hypogonadism symptoms. Early-morning serum testosterone levels were determined.Results: The prevalence of androgen deficiency symptoms was 94.7%. Some 50% of the men had low total testosterone levels. Using multivariate logistic regression, the significant factors associated with low total testosterone were waist circumference and known cardiovascular disease. The prevalence of symptoms of androgen deficiency was very high; 94.7% of the patients reported a significant number of symptoms listed on the Androgen Deficiency in the Aging Male questionnaire.Conclusion: This study confirms the high prevalence of low testosterone levels in diabetic male patients in a tertiary setting. Universal screening remains controversial owing to uncertainty regarding the risks and benefits of testosterone therapy in this population group. Predictors of low testosterone levels were identified.Keywords: Diabetes Mellitus, Hypogonadism, Testosteron

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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

Providing clinicians with information on laboratory test costs leads to reduction in hospital expenditure

Objectives. We aimed to ascertain the efficacy of an intervention in which laboratory test costs were provided to clinicians as a pocketsized brochure, in reducing laboratory test costs over a 4-month eriod. Methods. This was a non-randomised intervention study in the Internal Medicine wards at Steve Biko Academic Hospital, Pretoria, in which the intervention was laboratory test costs provided to clinicians as a pocket-sized brochure. The intervention period was the winter months of May - August 2008 and the pre-intervention period was the same months of the preceding year. In the two 4-month periods (2007 and 2008), the number of days in hospital and the laboratory tests ordered were computed for each patient admitted. For the intervention and control groups, pre- and postintervention cost and days in hospital were estimated. Results. The mean cost per patient admitted in the intervention group decreased from R2 864.09 to R2 097.47 &ndash; a 27% reduction. The mean cost per day in the intervention group as a whole also decreased, from R442.90 to R284.14 &ndash; a 36% reduction. Conclusion. Displaying the charges for diagnostic tests on the laboratory request form may significantly reduce both the number and cost of tests ordered, and by doing so bring about considerable in-hospital cost savings

Acute, persistent quinine-induced blindness - A case report

Quinine-induced blindness arising during empirical treatment for malaria in a young man is reported. The condition was noteworthy because it was total and permanent, which is at variance with other published reports. The condition usually disappears within minutes to weeks, but persistent deficits tend to be mild and are rare. Although quinine is an essential anti-malarial agent, physicians should be fully aware of possible side-effects

Physician education programme improves quality of diabetes care

Background. Diabetes mellitus is a common chronic disease needing long-term glycaemic control to prevent complications. Guidelines are available for achievement of optimal glycaemic control, but these are seldom properly instituted.Objectives. To determine if a physician education programme and a structured consultation schedule would improve the quality of diabetes patient care in a diabetes clinic.Setting. Two tertiary care diabetes clinics at Kalafong Hospital, Pretoria.Study design. Quasi-experimental controlled before-and-after study.Methods. A baseline audit of the quality of care in two comparable diabetes clinics was performed. Three hundred patients were randomly selected for audit of their hospital records: 141 from the intervention and 159 from the control clinics. Thereafter a physician training programme and a structured consultation schedule were introduced to the intervention clinic and maintained for a 1-year period. The control clinic continued with care as usual. Process and outcome measures were determined at a post-intervention audit and compared between the two groups. Consultation time was measured for both the intervention and control groups and data were compared.Results. At baseline the intervention and control groups did not differ significantly with regard to process and outcome measures. After intervention the intervention group had significantly higher process measure scores than the control group (p &lt; 0.01). HbA1c did not significantly differ between the two groups (p = 0.60). The average number of clinic visits reduced over time for the intervention group compared with the control group (p &lt; 0.01), but the average consultation times were significantly longer (p &lt; 0.01).Conclusion. The introduction of a physician education programme and a structured consultation schedule improved the quality of care delivered at a tertiary care diabetes clinic