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 metropolis.

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.

Trend of selected risk factors for hepatitis B infection among the drug addicts in Bangladesh: a five year statistics

The present retrospective study was conducted by review of records of last five years from 1996 to 2000, among 1497 drug addicts, admitted in a selected drug addicts treatment centre in Dhaka, with an aim to find out the trend of occurrence of hepatitis B infection among the drug addicts, as well as the trend of the risk factors. It was found from the study that during the period of five years, among the total drug addicts, sixty-nine addicts were found to be hepatitis B positive as determined by HBsAg status. The main contributing risk factors were found to be history of exposure to the commercial sex workers (CWS), injecting drug use (IDUs) and needle sharing. It was also found that the trend of hepatitis B infection was gradually falling down among the drug addicts probably due to reduction of the risk factors, especially the injection of drugs. It can be recommended that as a considerable portion of (NUDS) have shown evidence of hepatitis B infection, especially those who were using and sharing needles with others. Therefore, for protecting them from this dreadful infection, drug addicts should be counseled to avoid the above high risk behavior.

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 metropolis.

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.

Dairy cream as a phantom material for biexponential diffusion decay

Commercially available aliquots of dairy cream are shown to have diffusion decay curves characterized by biexponential functions when studied over a wide range of b-factors. The fast and slow diffusion components responsible for the biexponential decay are attributed to water and lipid protons, respectively. The fast diffusion coefficient and relative fast and slow diffusion component fractions obtained from biexponential fits of cream phantoms over a wide range of b-factors up to 3,000 s/mm2 are similar to those obtained previously for brain. The slow diffusion coefficient from lipid protons is smaller than that found in the brain. Overall, however, the results suggest that dairy cream can serve as a widely available phantom material for testing software and hardware components designed to perform quantitative, biexponential diffusion decay studies.

Genotoxicity of nimesulide in murine bone marrow cells

The genotoxic potentiality of nimesulide was evaluated in vivo in murine bone marrow cells. The human equivalent prophylactic dose of nimesulide (5 mg/kg body wt/day) was given to animals orally, once daily for seven consecutive days. Metaphase chromosome analyses revealed the significant increase in the incidence of chromosomal aberrations with preference to structural over the numerical ones. It therefore suggested the clastogenic effect of the nimesulide. The molecular mechanism of mutagenesis is yet to be determined.

Thoracoscopic parasternal lymph node dissection for the staging of breast cancer

With the advent of advanced thoracoscopic techniques, new applications have been expanding their roles in thoracic surgery. The aim of this paper is to introduce our new thoracoscopic approach in performing parasternal lymph node dissection of advanced breast cancer for its staging. This technique does not need the removal of any costal cartilage which is usually done in the conventional classical technique after radical mastectomy. Thoracoscopic procedure, in which wide and complete parasternal lymph node dissection is done, is minimally invasive and easy to perform. Therefore, the thoracoscopic technique may be a suitable alternative to the conventional approach in the future.

Laparoscopic ovarian cystectomy using double balloon catheter: a new technical application

In the present study, a modified application of the surgical instrument with double balloon is described in the ovarian cystectomy procedure. This technique has been proved effective and safe especially in removing chocolate-like cystoma. This new instrument, which we originally designed, has two balloons at the tip of the catheter. After a cyst is punctured, the inner and outer balloons are inflated to fix the cyst well. After fixing the cyst with two balloons, the internal needle of the instrument can be removed. This catheter, named the SAND balloon catheter, is advantageous in laparoscopic ovarian cystectomy.

Intracranial adenoid cystic carcinoma of suprasellar region

Adenoid cystic carcinoma (ACC) is a relatively common head and neck tumor which grows slowly but locally aggressive and prone to recurrence. ACC most commonly arises in the major and minor salivary glands. Some rare cases of intracranial ACC with an unknown primary site have been reported. The authors present the first case of primary intracranial ACC of the suprasellar region. A 34 year-old female presented with one month's duration of visual disturbance and galactorrhea. Magnetic resonance image (MRI) showed intra- and suprasellar mass mimicking a craniopharyngioma. There was no evidence of invasion from an extracranial site. The operative findings showed the mass existed under the arachnoid membrane and seemed to originate from the pituitary stalk. Pathological diagnosis was ACC. After the first operation, local recurrence and CSF dissemination to the lower clivus occurred within two months. Recurrence repeatedly treated by Gamma knife radiosurgery 10 times and 4 times by surgery during a 3 year follow-up period. But total removal of the tumor at the first operation along with radiosurgery may control the lesion and prevent further recurrence.

Loss of irreversibility of granulocytic differentiation induced by dimethyl sulfoxide in HL-60 sublines with a homogeneously staining region

The human HL-60 acute leukemia cell line harbors double minutes (dmins) during early passages. During its continuous culture for a long term, a single marker chromosome with a homogeneously staining region (HSR) replaces the dmins. The both structures harbor amplified c-MYC sequences. Here we ask how the cellular phenotype is altered by the c-MYC integration into a HSR. Treatment with dimethyl sulfoxide induces granulocytic differentiation in the both types of cells. In contrast to HL-60/dmin cells, however, no apoptosis followed differentiation and the differentiation phenotype was reverted upon withdrawal of the drug in HL-60/HSR cells. Terminal differentiation and loss of DNase I hypersensitivity sites at c-MYC P2 promoter appeared to be unlinked in the both types of cells. By comparison with HL-60/dmin cells, we conclude that the integration into a HSR of an extrachromosomal gene(s) but not c-MYC likely leads to the loss of irreversibility of the differentiation phenotype.

Development of lumbosacral spina bifida: three-dimensional computer graphic study of human embryos at Carnegie stage twelve

There is still some controversy as to whether sacral spina bifida in humans is the result of a defect of the primary or secondary neural tube. As somites are related to the development of vertebrae and the primary neural tube is related to the development of the spinal cord in embryos, it is very important to determine the number of somites in normal human embryos at the time of closure of the primary neural tube to understand the contribution of primary neural tube defects to the development of spina bifida. However, in the literature, the number of somites in stage 12 human embryos is still controversial. The aim of this study is to find the number of somites in human embryos at Carnegie stage 12. Four human embryos at Carnegie stage 12 were selected from the laboratory of the Congenital Anomaly Research Center in Japan. The neural tube and somites were reconstructed from their slices by a three-dimensional computer graphic reconstruction technique. The reconstructed embryos were examined from multidirectional magnified images. Thirty-three pairs of somites were present in all these reconstructed embryos. As the 33rd pair of somites corresponds to the fifth sacral segment, the presence of 33 pairs of somites at Carnegie stage 12 suggests that spina bifida develops from defects of the primary neural tube.

Evaluation of pleomorphic xanthoastrocytoma by use of positron emission tomography with

We present a case of pleomorphic xanthoastrocytoma (PXA) in a patient with temporal lobe seizures. Imaging sequences included MR, and results of positron emission tomography (PET) with [18F]-fluorodeoxyglucose (FDG) and [11C]-methionine (Met) tracers revealed a hypermetabolic region equivalent or nearly equivalent to normal cerebral cortex, suggesting that the tumor might have malignant potential. Histopathologic findings indicated low-grade glioma. The mechanism for glucose hypermetabolic activity of PXA is not clear; however, the positive findings obtained from FDG-PET may not always indicate the degree of malignancy associated with PXA.

Characterization of human herpesvirus 7 U27 gene product and identification of its nuclear localization signal

A monoclonal antibody, 5H4, that recognizes human herpesvirus 7 (HHV-7) was used in Western analysis to probe HHV-7-infected SupT1 cells. This antibody recognizes a 40-kDa virus-specific polypeptide that is expressed in the absence of viral DNA synthesis. By screening a lambdagt11 HHV-7 cDNA library, the gene encoding the protein was identified as the U27 open reading frame previously reported [J. Virol. (1996) 70, 5975-5989]. Immunofluorescent studies showed a punctate nuclear localization of the protein in both HHV-7-infected cells and transfected cells. A computer program predicted two classic nuclear localization signals (NLSs) in the middle and C-terminal regions of the protein. A C-terminal deletion mutant of the protein could not enter the nucleus, whereas green fluorescent protein or maltose binding protein fused to the C-terminal region of the protein was transported into the nucleus. These findings demonstrate that the predicted C-terminal, but not middle, NLS of the protein actually function as NLS. In addition, nuclear transport of a maltose binding protein-fusion protein containing the C-terminal NLS of the U27 protein was inhibited by both wheat germ agglutinin and a Q69L Ran-GTP mutant, indicating that the U27 protein is transported into the nucleus from the cytoplasm by means of classic nuclear transport machinery. Interestingly, this NLS motif is highly conserved at the C-termini of all herpesvirus DNA polymerase processivity factors that have been examined.

Prevalence, severity and associated features of gastro-oesophageal reflux and dyspepsia: a population-based study

AIMS

To describe the prevalence and severity of dyspepsia and gastro-oesophageal reflux in the community, to investigate their association with lifestyle factors and to evaluate the consultation pattern for these conditions.

METHOD

A previously validated questionnaire was posted to 1000 adults randomly selected from the electoral rolls of the greater Wellington region. It investigated symptoms of dyspepsia, reflux, lifestyle and consultation pattern over the previous twelve months.

RESULTS

Response rate was 81.7%. Prevalence of dyspepsia was 34.2%. Prevalence of reflux was 30%. The overall prevalence of both symptom groups combined was 45.2%. Most subjects had multiple symptoms. Results indicated 63% of subjects with reflux also had symptoms of dyspepsia and 56% of subjects with dyspepsia showed symptoms of reflux. Although 69% of subjects with heartburn used over-the-counter medications, only 17% consulted medical practitioners. Current and ex-smokers had a higher prevalence of reflux. Dyspeptic symptoms were not associated with alcohol intake or aspirin use. Prevalence of dyspeptic symptoms did not change with increasing age.

CONCLUSIONS

Dyspepsia is very common in the community. Significant overlap among the subgroups of dyspepsia makes a classification, based on symptoms alone, of questionable value. Frequency and severity of symptoms should be incorporated in the definition to exclude those subjects with trivial symptoms.

Modulation of the oxygen affinity of cobalt-porphyrin by globin

We have combined two extreme effects which influence the oxygen affinity to obtain a cobalt-based oxygen carrier with an affinity similar to that of human adult hemoglobin (HbA). The goal was to obtain an oxygen transporter with a lower oxidation rate. Exchange of the heme group (Fe-protoporphyrin IX) in Hb with a cobalt-porphyrin leads to a reduction in oxygen affinity by over a factor of 10, an oxygen affinity too low for use as a blood substitute. At the other extreme, certain globin sequences are known to provide a very high oxygen affinity; for example, Hb Ascaris displays an oxygen affinity 1000 times higher than HbA. We demonstrate here that these opposing effects can be additive, yielding an oxygen affinity similar to that of HbA, but with oxygen binding to a cobalt atom. We have tested the effect of substitution of cobalt-porphyrin for heme in normal HbA, sperm whale (SW) Mb (Mb), and high affinity globins for leghemoglobin, two trematode Hbs: Paramphistomum epiclitum (Pe) and Gastrothylax crumenifer (Gc). As for HbA or SW Mb, the transition from heme to cobalt-porphyrin in the trematode Hbs leads to a large decrease in the oxygen affinity, with oxygen partial pressures for half saturation (P(50)) of 5 and 25 mm Hg at 37 degrees C for cobalt-Pe and cobalt-Gc, respectively. A critical parameter for Hb-based blood substitutes is the autoxidation rate; while both metals oxidize to an inactive state, we observed a decrease in the oxidation rate of over an order of magnitude for cobalt versus iron, for similar oxygen affinities. The time constants for autoxidation at 37 degrees C were 250 and 100 h for Pe and Gc, respectively.

Identification and analysis of the K5 gene of Kaposi's sarcoma-associated herpesvirus

Kaposi's sarcoma-associated herpesvirus (KSHV), or human herpesvirus 8 (HHV-8), belongs to the gammaherpesvirus subfamily and encodes approximately 80 open reading frames (ORFs). Among them are a few candidates for immediate-early genes (e.g., K5). We developed a monoclonal antibody (MAb), 328C7, against the K5 antigen. This MAb reacted with the K5 gene product by immunoscreening of a cDNA library from BCBL-1 cells, and this result was confirmed by transfection of the K5 ORF into Cos-7 cells. After induction of lytic infection by treatment with 12-O-tetradecanoylphorbol-13-acetate, MAb 328C7 reacted with an antigen in the cytoplasm of BCBL-1 and BC-3 cells as early as after 4 h of induction. Immunoelectron microscopy showed that the K5 antigen was situated mainly in the endoplasmic reticulum but was not present on the virion or in the nucleus. Northern blotting with a K5-specific probe revealed a single transcript of 1.2 kb, while Western blotting showed the antigen to be a 36-kDa polypeptide. The 5' and 3' ends were then determined by rapid amplification of cDNA, followed by sequencing of RACE products, and a splice was revealed upstream of the K5 ORF. K5 expression was unaffected by the respective DNA and protein synthesis inhibitors phosphonoformic acid and cycloheximide plus actinomycin D, confirming its immediate-early nature. Transient-transfection assays showed that the K5 promoter was transactivated by ORF 50 (KSHV Rta), a homolog of Epstein-Barr virus Rta, but the K5 gene product exhibited no transregulation of its own promoter or those of DNA polymerase and the human immunodeficiency virus type 1 long terminal repeat. This is the first such analysis of an immediate-early gene product; determination of its specific biological function requires further investigation.

Human herpesvirus 6 open reading frame U83 encodes a functional chemokine

Some viruses including herpesviruses have undergone evolution to benefit viral infection and propagation by pirating and modifying host genes such as chemokine genes. Human herpesvirus 6 (HHV-6), acutely or persistently infects mononuclear cells in vitro. DNA sequence analysis of HHV-6 has revealed that the putative protein encoded by an open reading frame (ORF) of the U83 gene in HHV-6 variant B resembled a human chemokine. We have cloned the U83 gene and analyzed the biological function of this gene. The U83 gene contained an ORF encoding a 113-amino-acid peptide, starting at the first methionine and containing a possible signal peptide and the typical cysteine residues characteristic of the chemokines. Reverse transcription-PCR analysis of mRNA and immunofluorescent-antibody testing of infected cells both indicated that the encoded protein was a late protein. The ORF U83 gene fused to the Fc gene was expressed as a fusion protein in COS-7 cells by transfection, and the fusion protein was purified from the supernatant of transfected cells to test its biological function. The purified protein was capable of inducing transient calcium mobilization in THP-1 cells and of chemotactically activating THP-1 cells. These findings suggested that the U83 protein might play an important role in HHV-6 propagation in vivo by activating and trafficking mononuclear cells to sites of viral replication, thus aiding the development of superbly efficient virus production mechanisms.