Treating 4,000 diabetic patients in Cambodia, a high-prevalence but resource-limited setting: a 5-year study

BACKGROUND: Despite the worldwide increasing burden of diabetes, there has been no corresponding scale-up of treatment in developing countries and limited evidence of program effectiveness. In 2002, in collaboration with the Ministry of Health of Cambodia, Médecins Sans Frontières initiated an outpatient program of subsidized diabetic care in two hospital-based chronic disease clinics in rural settings. We aimed to describe the outcomes of newly and previously diagnosed diabetic patients enrolled from 2002 to 2008. METHODS: We calculated the mean and proportion of patients who met the recommended treatment targets, and the drop from baseline values for random blood glucose (RBG), hemoglobin A1c (HbA1c), blood pressure (BP), and body mass index (BMI) at regular intervals. Analysis was restricted to patients not lost to follow-up. We used the t test to compare baseline and subsequent paired values. RESULTS: Of 4404 patients enrolled, 2,872 (65%) were still in care at the time of the study, 24 (0.5%) had died, and 1,508 (34%) were lost to follow-up. Median age was 53 years, 2,905 (66%) were female and 4,350 (99%) had type 2 diabetes. Median (interquartile range (IQR)) follow-up was 20 months (5 to 39.5 months). A total of 24% (51/210) of patients had a HbA1c concentration of <7% and 35% (709/1,995) had a RBG <145 mg/dl within 1 year. There was a significant drop of 109 mg/dl (95% confidence interval (CI) 103.1 to 114.3) in mean RBG (P < 0.001) and a drop of 2.7% (95% CI 2.3 to 3.0) in mean HbA1c (P < 0.001) between baseline and month 6. In all, 45% (327/723) and 62% (373/605) of patients with systolic or diastolic hypertension at baseline, respectively, reached = 130/80 mm Hg within 1 year. There was a drop of 13.5 mm Hg (95% CI 12.1 to 14.9) in mean systolic blood pressure (SBP) (P < 0.001), and a drop of 11.7 mm Hg (95% CI 10.8 to 12.6) in mean diastolic blood pressure (DBP) (P < 0.001) between baseline and month 6. Only 22% (90/401) patients with obesity at baseline lowered their BMI <27.5 kg/m2 after 1 year. Factors associated with loss to follow-up were male sex, age >60 years, living outside the province, normal BMI on admission, high RBG on last visit, and coming late for the last consultation. CONCLUSION: Significant and clinically important improvements in glycemia and BP were observed, but a relatively low proportion of diabetic patients reached treatment targets. These results and the high loss to follow-up rate highlight the challenges of delivering diabetic care in rural, resource-limited settings

Health-related quality of life of patients after mechanical valve replacement surgery for rheumatic heart disease in a developing country

Objective: To evaluate the health-related quality of life (HRQoL) of people in Fiji (n=128) undergoing heart valve replacement (VR) surgery for rheumatic heart disease (RHD), conducted by Open Heart International. Methods: Patients who had undergone surgery from 1991 to 2009 (n=72) and patients undergoing surgery for the years 2010-2012 (n=56) were surveyed prospectively, preoperatively and/or postoperatively (the mean follow-up time 5.9 years) using the standard recall Short-Form 36, V.2 (SF-36v2) HRQoL Survey. Results: The sample had a mean age of 26.7 years and 56% (n=72) were women. Preoperative HRQoL is impaired but by early postoperative (1 year) there is significant improvement across all domains (p2 years), all HRQoL domains, except for mental health, were significantly better than preoperative (p=0.066 ). Predictors of less improved HRQoL included having an isolated mitral valve replacement (MVR) (for six of eight health domains, p<0.05), older age (three domains; role- physical, vitality and bodily pain, p<0.05) and male gender (in the role-emotional domain, p<0.05). Conclusions: This first investigation of the HRQoL of people in a developing country after VR surgery for RHD found significant improvement from surgery with this improvement generally sustained. The lack of improvement in mental health requires further exploration as does the influence of an isolated MVR, age and gender

Induction of metabolic acidosis with ammonium chloride (NH4Cl) in mice and rats-species differences and technical considerations

Ammonium chloride addition to drinking water is often used to induce metabolic acidosis (MA) in rodents but may also cause mild dehydration. Previous microarray screening of acidotic mouse kidneys showed upregulation of genes involved in renal water handling. Thus, we compared two protocols to induce metabolic acidosis in mice and rats: standard 0.28M NH(4)Cl in drinking water or an equivalent amount of NH(4)Cl in food. Both treatments induced MA in mice and rats. In rats, NH (4)Cl in water caused signs of dehydration, reduced mRNA abundance of the vasopression receptor 2 (V2R), increased protein abundance of the aquaporin water channels AQP2 and AQP3 and stimulated phosphorylation of AQP2 at residues Ser256 and Ser261. In contrast, NH(4)Cl in food induced massive diuresis, decreased mRNA levels of V2R, AQP2, and AQP3, did not affect protein abundance of AQP2 and AQP3, and stimulated phosphorylation at Ser261 but not pSer256 of AQP2. In mice, NH(4)Cl in drinking water stimulated urine concentration, increased AQP2 and V2R mRNA levels, and enhanced AQP2 and AQP3 protein expression with higher levels of AQP2 pSer256 and pSer261. Addition of NH(4)Cl to food, stimulated diuresis, had no effect on mRNA levels of AQP2, AQP3, and V2R, and enhanced only AQP3 protein abundance whereas pSer256-AQP2 and pSer261-AQP2 remained unaltered. Similarly, AQP2 staining was more intense and luminal in kidney from mice with NH(4)Cl in water but not in food. Pendrin, SNAT3 and PEPCK mRNA expression in mouse kidney were not affected by the route of N(4)Cl application. Thus, addition of NH(4)Cl to water or food causes MA but has differential effects on diuresis and expression of mRNAs and proteins related to renal water handling. Moreover, mice and rats respond differently to NH(4)Cl loading, and increased water intake and diuresis may be a compensatory mechanism during MA. It may be necessary to consider these effects in planning and interpreting experiments of NH(4)Cl supplementation to animals