Haematogenous pyogenic bone and joint sepsis – reducing avoidable morbidity

Background and objectives. Delayed presentation of haematogenous bone and joint sepsis is common in our childhood population and leads to a large burden of avoidable morbidity extending into adult life. We set out to determine causative factors in these delays. Design. A prospective study was undertaken over a 1-year period. Setting. Ngwelezane Hospital, a regional hospital in Kwa-Zulu- Natal serving 9 rural district hospitals. Subjects. Children under 15 years with their first presentation of bone and joint sepsis, comprising 80 consecutive cases. Tuberculosis cases were excluded. Outcome measures. Children were categorised at follow-up into two groups. The first group had uncomplicated recoveries, with complete return of function and no clinical or radiological signs of unresorbed sequestra. The second group had complications, with evidence of one or more of the following: chronicity of infection, pathological fracture, deformity, growth plate disturbance, avascular necrosis or joint stiffness. Results. Delay in obtaining definitive treatment correlated strongly with initial misdiagnosis. Only 4/25 septic hips were correctly diagnosed and referred expediently; 19/50 osteomyelitis cases were initially misdiagnosed and treated as cellulitis, and a further 19/50 were misdiagnosed as trauma. Predictably, delayed treatment correlated strongly with a complicated outcome. No significant associations were found between delays and distance to nearest primary health care facility, relative levels of socio-economic deprivation within the study group, maternal educational attainment, or traditional healer consultation. Conclusion. Health care professionals at all levels should be alerted to the continued high incidence of this disease. We propose some ‘red flags' to assist primary health care workers in the diagnosis of this condition. South African Medical Journal Vol. 97 (6) 2007: pp. 456-46

Predicting outcomes in the dose adjustment for normal eating (DAFNE) trial

Background: In the UK, DAFNE training in flexible intensive insulin therapy significantly reduced the negative impact of diabetes on quality of life (QoL) and improved blood glucose (BG) control without significantly increasing severe hypoglycaemia or body mass index (BMI). Analyses were conducted to predict who would benefit most from the generally highly successful DAFNE training and who might experience undesirable effects (e.g. weight gain).Methods: Multiple regression was used to predict change in outcomes (6-months post-DAFNE) using baseline data: demographic, biomedical, ADDQoL (measure of the impact of diabetes on QoL), extended DTSQ (Diabetes Treatment Satisfaction Questionnaire), and other psychological measures including diabetes-specific well-being and locus of control.Findings: Greatest improvement in ADDQoL scores was achieved by those reporting less dietary freedom and less treatment satisfaction at baseline (R2=0.21). BG improvement was predicted by higher baseline BG, lower perceived frequency of hypoglycaemia, greater expectations of DAFNE, and greater BMI (R2=0.30). Increase in BMI was predicted by less dietary freedom, DAFNE training centre, and less &lsquo;satisfaction with insulin&rsquo; at baseline (R2=0.23).Conclusions/Discussion: DAFNE has important benefits to offer. Lifting dietary restrictions had substantial benefits for QoL. BG improvement was predicted by baseline BG but also by expectations (perhaps reflecting greater optimism or determination). Prediction of weight gain was more complex. The influence of training centre will have involved implicit messages conveyed by Educators before and during DAFNE. While DAFNE was successful overall, outcomes are likely to be maximised for individuals if their expectations and personal goals are considered by DAFNE Educators.<br /

A phenomenological inquiry into psychosocial issues in people with Type 2 diabetes in the community

Introduction Qualitative enquiry in diabetes care services and user perspectives has received relatively little attention. Explorations have been focused on Type 1 diabetes and experiences of new diagnosis. Aim To explore and identify important psychosocial (PS) issues which influence management by people with Type 2 diabetes under primary sector health care. Methods Purposive sampling with people with Type 2 diabetes cared for in the community taken from all areas within the North-west Region. Unstructured, in-depth interviews with prompts focussed on psychological parameters and social effects of illness trajectory. Analysis based on grounded theory thematic identification + personal construct analysis (PCA) used to identify a psychosocial matrix to explain PS issues. Results 23 participants interviewed, varied demography, 6 main themes: family effects, social life, adjustments, meaningful work, scarring, loss of control. When PCA applied, a complex hexagonal framework identified which illustrates the person with Type 2 diabetes PS construct, in living with chronic illness. Discussion Social issues need to be addressed as well as complex psychological factors. Using sociological analysis will illuminate ÔhiddenÕ areas of life impact and quality. The emerging PS theory could be used to underpin practice and further research