Introduction of a national program for HbA1c testing in Guyana South America and initial results

Diabetes is an increasing challenge for low- and middle-income countries (LMIC) and access to HbA1c testing is limited. HbA1c, a measure of glycaemic control averaged over 3 months, provides both clinicians and policymakers with a tool to identify the risk of long-term diabetes comorbidity. We describe the steps used to implement standardised testing in Guyana South America and the initial results according to a locally developed protocol as part of a country-wide project to improve the care of people with all forms of diabetes The steps identified include: a standardised method traceable to a recognized international reference standard, participation in a quality control cycle with an international reference laboratory, a clinical pathway for testing to reduce inappropriate use and minimize resource wastage, training of technicians in operation and maintenance of equipment, identification of a suitable space with constant power supply, a reliable procurement system, education of healthcare professionals on interpretation and follow-up of results and feedback of programme results to improve clinical practice. Some steps for implementation of the national HbA1c testing program were initiated better than others. Initial unreliability of the service undermined confidence in the system. Failure to follow the testing protocol led to some patients being tested too soon and others too late. Cost of reagents was about 5.60 USD/test. We trained 340 people in diabetes care and knowledge was improved but were unable to assess whether it was appropriately applied. Over one third of people tested in the 30-70 age group had an HbA1c over 9% (75 mmol/mol) and this did not improve over the 5 years of testing. Despite the difficulties we think our unique experience of implementation of a nationwide HbA1c testing programme has important lessons for other LMICs.

Cognitive effects of adjuvant endocrine therapy in older women treated for early-stage breast cancer: a 1-year longitudinal study

PURPOSE

Evidence suggests endocrine therapy (ET) for breast cancer (BC) has adverse cognitive effects, but its specific effects on older women are unknown. This is despite the fact that older women are at increased risk of both breast cancer (BC) and cognitive decline relative to younger women. This study prospectively examined the cognitive effects of ET in a cohort of older BC patients. Our primary outcome measure was change in verbal memory, the cognitive domain most consistently affected by estrogen deprivation.

METHODS

Forty-two chemotherapy-naïve women age 60+, without dementia and recently diagnosed with hormone receptor-positive BC, completed neuropsychological tests at the time of ET initiation and after 1 year of treatment. Change in age-standardized verbal memory performance was examined using paired t tests. To assess a broader range of potential cognitive effects, we also examined changes in visual memory, processing speed, frontal executive function, and perceptual reasoning.

RESULTS

Participants exhibited significant decline from baseline to 1 year in verbal memory (p = 0.01). This decline was small to moderate in effect size (d = - 0.40). Performance on other domains did not change significantly over the year (all p > 0.05).

CONCLUSIONS

Our findings suggest potentially detrimental effects of ET on verbal memory in older women after just 1 year of treatment. Given that ET is prescribed for courses of 5 to 10 years, additional studies examining longer-term effects of treatment in older women are critical.

The Relationship between Milk Fat Content, Vitamin D and Adiposity in Early Childhood

BACKGROUND: Fortified cow’s milk is the main dietary source of vitamin D and an important source of dietary fat for North American children. Current guidelines recommend reduced milk fat consumption to reduce childhood obesity, yet the relationship between lower milk fat, vitamin D stores and adiposity is unclear.

OBJECTIVES: The objective of this study was to determine the association between percent fat content of milk and both zBMI and 25-hydroxyvi-tamin D; secondly, to explore if volume of milk consumed modified this relationship.

DESIGN/METHODS: A cross-sectional study of healthy urban children 12-72 months of age was conducted. Bivariate multiple linear regression was used to test the association between percent milk fat content and child 25-hydroxyvitamin D and zBMI concurrently. The interaction between volume of milk consumed and percent milk fat content was examined to explore how milk volume might modify these relationships.

RESULTS: 2745 children were included in the analysis. Percent fat content of milk was positively associated with 25-hydroxyvitamin D (p=0.006), and negatively associated with zBMI (p<0.0001). Children who drank homogenized milk (3.25% fat) had 6.6 nmol/L (95% CI 5.49 to 7.71) higher median 25(OH)D concentration and 0.72 lower (95% CI 0.68 to 0.76) zBMI score than children who drank skim milk (0.1% fat). Volume of milk consumed potentiated the effect of percent fat content of milk on 25-hydroxyvitamin D (p=0.003) but not on zBMI (p=0.77). Children who drank 1 cup of homogenized milk each day had a similar 25-hydroxyvita-min D as children who drank 2.85 cups (95% CI 2.71 to 2.99) of skim milk, but had zBMI score 0.78 (95% CI 0.63, 0.93) units lower.

CONCLUSION: Homogenized milk may be more appropriate than reduced fat milk in maximizing serum 25-hydroxyvitamin D and minimizing adiposity in early childhood. Current guidelines for reduced milk fat consumption in childhood may require further study to achieve desired outcomes.