Studies on aspects of autonomic neuropathy in non insulin dependent Diabetes

Autonomic neuropathy (AN) is a well-recognized complication of diabetes mellitus. It has multiple clinical features and is often associated with debilitation and an increased mortality. However, there appears to be a paucity of knowledge with regard to its effects on hormone release and its biochemical sequelae. Recent evidence has accumulated suggesting a role for the autonomic nervous system in regulating release of a number of gastrointestinal hormones. It is therefore possible that autonomic dysfunction may be associated with altered gastrointestinal hormone release and indeed various studies have revealed abnormalities in t he release of these peptides in diabetes mellitus. The prime purpose of this thesis was to provide evidence which might contribute to an understanding of t he interrel a tionship between non insulin dependent diabetes (NIDDM), gastrointestinal hormone release and the autonomic nervous system. Thus studies to evaluate basal and stimulated release of the gastrointestinal hormones gluc a gon (IRG), pancreatic polypeptide (PP), gastrin, gastric inhibitory polypeptide (GIP) and somatostatin (SRIF-LI) have been undertaken in NIDDM. Studies were also carried out to assess whether AN may be implicated in abnormal release of these five gut hormones in diabetes and to determine if one of the hormones, PP, might be used as a marker for AN. Finally the effect of dietary fibre on glucose tolerance was studied to assess whether its effect would be altered in the presence of AN in NIDDM

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

Factors associated with excessive body fat in men and women: cross-sectional data from Black South Africans living in a rural community and an urban township

Objective To determine the factors associated with excessive body fat among black African men and women living in rural and urban communities of South Africa. METHODS: This is a cross-sectional analysis of data from the Prospective Urban and Rural Epidemiology (PURE) study, Cape Town, South Africa conducted in 2009/2010. The study sample included 1220 participants (77.2% women) aged 35-70 years, for whom anthropometric measurements were obtained and risk factors documented through face-to-face interviews using validated international PURE study protocols. Sex-specific logistic regression models were used to evaluate socio-demographic, lifestyle and psychological factors associated with three excessive body fat indicators, namely body mass index (BMI), waist circumference (WC) and body fat percent (BF%). RESULTS: The prevalence of excessive body fat based on BF%, WC and BMI cut-offs were 96.0%, 86.1%, and 81.6% for women respectively, and 62.2%, 25.9%, and 36.0% for men respectively. The significant odds of excessive body fat among the currently married compared to unmarried were 4.1 (95% CI: 1.3-12.5) for BF% and 1.9 (95% CI: 1.3-2.9) for BMI among women; and 4.9 (95% CI: 2.6-9.6), 3.2 (95% CI: 1.6-6.4) and 3.6 (95% CI: 1.9-6.8) for BF%, WC and BMI respectively among men. Age ≤50 years (compared to age >50 years) was inversely associated with excessive BF% in men and women, and less-than-a-college education was inversely associated with excessive BMI and WC in men. Tobacco smoking was inversely associated with all three excessive adiposity indicators in women but not in men. Unemployment, depression, and stress did not predict excessive body fat in men or women. CONCLUSION: The sex-differences in the socio-demographic and lifestyle factors associated with the high levels of excessive body fat in urban and rural women and men should be considered in packaging interventions to reduce obesity in these communities

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

A high burden of hypertension in the urban black population of Cape Town: the cardiovascular risk in Black South Africans (CRIBSA) study

Objective To determine the prevalence, associations and management of hypertension in the 25-74-year-old urban black population of Cape Town and examine the change between 1990 and 2008/09 in 25-64-year-olds. METHODS: In 2008/09, a representative cross-sectional sample, stratified for age and sex, was randomly selected from the same townships sampled in 1990. Cardiovascular disease risk factors were determined by administered questionnaires, clinical measurements and fasting biochemical analyses. Logistic regression models evaluated the associations with hypertension. RESULTS: There were 1099 participants, 392 men and 707 women (response rate 86%) in 2008/09. Age-standardised hypertension prevalence was 38.9% (95% confidence interval (CI): 35.6-42.3) with similar rates in men and women. Among 25-64-year-olds, hypertension prevalence was significantly higher in 2008/09 (35.6%, 95% CI: 32.3-39.0) than in 1990 (21.6%, 95% CI: 18.6-24.9). In 2008/09, hypertension odds increased with older age, family history of hypertension, higher body mass index, problematic alcohol intake, physical inactivity and urbanisation. Among hypertensive participants, significantly more women than men were detected (69.5% vs. 32.7%), treated (55.7% vs. 21.9%) and controlled (32.4% vs. 10.4%) in 2008/09. There were minimal changes from 1990 except for improved control in 25-64-year-old women (1990∶14.1% vs. 2008/09∶31.5%). CONCLUSIONS: The high and rising hypertension burden in this population, its association with modifiable risk factors and the sub-optimal care provided highlight the urgent need to prioritise hypertension management. Innovative solutions with efficient and cost-effective healthcare delivery as well as population-based strategies are required

Effectiveness of a group diabetes education programme in underserved communities in South Africa: pragmatic cluster randomized control trial

BACKGROUND: Diabetes is an important contributor to the burden of disease in South Africa and prevalence rates as high as 33% have been recorded in Cape Town. Previous studies show that quality of care and health outcomes are poor. The development of an effective education programme should impact on self-care, lifestyle change and adherence to medication; and lead to better control of diabetes, fewer complications and better quality of life. METHODS: Trial design: Pragmatic cluster randomized controlled trialParticipants: Type 2 diabetic patients attending 45 public sector community health centres in Cape TownInterventions: The intervention group will receive 4 sessions of group diabetes education delivered by a health promotion officer in a guiding style. The control group will receive usual care which consists of ad hoc advice during consultations and occasional educational talks in the waiting room.Objective: To evaluate the effectiveness of the group diabetes education programmeOutcomes: Primary outcomes: diabetes self-care activities, 5% weight loss, 1% reduction in HbA1c. Secondary outcomes: self-efficacy, locus of control, mean blood pressure, mean weight loss, mean waist circumference, mean HbA1c, mean total cholesterol, quality of lifeRandomisation: Computer generated random numbersBlinding: Patients, health promoters and research assistants could not be blinded to the health centre's allocationNumbers randomized: Seventeen health centres (34 in total) will be randomly assigned to either control or intervention groups. A sample size of 1360 patients in 34 clusters of 40 patients will give a power of 80% to detect the primary outcomes with 5% precision. Altogether 720 patients were recruited in the intervention arm and 850 in the control arm giving a total of 1570.DISCUSSION:The study will inform policy makers and managers of the district health system, particularly in low to middle income countries, if this programme can be implemented more widely.TRIAL REGISTER:Pan African Clinical Trial Registry PACTR20120500038038

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

Sensory neuropathy and metabolic risk factors in human immune deficiency virus infected South Africans receiving protease inhibitors

BackgroundProtease inhibitors (PI)s have been associated with distal sensory polyneuropathy (DSP) and metabolic complications in high-income countries. No data exist in Africans where second-line antiretroviral therapy (ART) often include PIs.MethodWe performed a cross-sectional study to assess the DSP frequency and metabolic risk factors in community-based South Africans taking ritonavir-boosted lopinavir as PI. Examination findings categorized subjects as having DSP (≥1 neuropathic sign) or symptomatic DSP [DSP with symptom(s)]. Fasting-state glucose and lipid profiles were assessed. We compared the ritonavir/lopinavir-group to a nested group on first-line ART [dideoxy-nucleoside reverse transcriptase inhibitors (d-drugs)] selected from a dataset collected at the same time and matched for d-drug exposure.ResultsThe ritonavir/lopinavir-group (n=86) consisted predominantly of women (84%) with a median age of 36years (IQR 32–41). The median current CD4+ count was 489cells/μL (IQR 291–665). The median exposure time to ritonavir/lopinavir was 18months (IQR 10–26) and to d-drugs, 24months (IQR 16–38). DSP was present in 78% and symptomatic DSP in 48%; symptoms were most frequently of moderate intensity. Only age independently associated with DSP and symptomatic DSP (p=0.08 and p=0.04, respectively). None of the metabolic syndrome components showed associations with DSP or symptomatic DSP despite a trend towards hypertriglyceridemia overall. The ritonavir/lopinavir-group had less DSP compared to the d-drug only group (p=0.002) but the frequency of symptomatic DSP was similar (p=0.49).ConclusionRitonavir-boosted lopinavir did not add additional risk to developing DSP in this community-based African cohort after a median of 18months on second-line ART.Electronic supplementary materialThe online version of this article (doi:10.1186/s12981-015-0073-8) contains supplementary material, which is available to authorized users

Evaluating the use of mobile phone technology to enhance cardiovascular disease screening by community health workers

Primary prevention of cardiovascular disease (CVD),by identifying individuals at risk is a well-established, but costly strategy when based on measurements that depend on laboratory analyses. A non-laboratory, paper-based CVD risk assessment chart tool has previously been developed to make screening more affordable in developing countries. Task shifting to community health workers (CHWs) is being investigated to further scale CVD risk screening. This study aimed to develop a mobile phone CVD risk assessment application and to evaluate its impact on CHW training and the duration of screening for CVD in the community by CHWs.A feature phone application was developed using the open source online platform, CommCare(©). CHWs (n=24) were trained to use both paper-based and mobile phone CVD risk assessment tools. They were randomly allocated to using one of the risk tools to screen 10-20 community members and then crossed over to screen the same number, using the alternate risk tool. The impact on CHW training time, screening time and margin of error in calculating risk scores was recorded. A focus group discussion evaluated experiences of CHWs using the two tools.The training time was 12.3h for the paper-based chart tool and 3h for the mobile phone application. 537 people were screened. The mean screening time was 36 min (SD=12.6) using the paper-base chart tool and 21 min (SD=8.71) using the mobile phone application, p