Recurrent venous thrombosis - an unusual first presentation of autoimmune polyendocrinopathy syndrome type 3B

A 45-year-old female presented with unprovoked recurrent venous thromboembolism (VTE), in unusual sites, and pancytopenia, posing a complex diagnostic challenge. Work-up for inherited thrombophilia, antiphospholipid syndrome (APLS) and paroxysmal nocturnal haemoglobinuria were unremarkable. Investigations revealed autoimmune thyroid disease, and a mixed iron/vitamin B12 deficiency due to pernicious anaemia and resultant atrophic gastritis. Hyperhomocysteinaemia due to vitamin B12 deficiency was identified as a potential contributor to her recurrent VTE. This case highlights the unusual initial presentation of autoimmune polyendocrinopathy syndrome type 3B (APS-3B) with recurrent thromboembolism, and emphasises the importance of considering hyperhomocysteinaemia in unprovoked and atypical VTE cases.

The impact of diabetes during pregnancy on neonatal outcomes among the Aboriginal population in Western Australia: a whole-population study

BACKGROUND

Aboriginal and Torres Strait Islander (hereafter Aboriginal) women have a high prevalence of diabetes in pregnancy (DIP), which includes pre-gestational diabetes mellitus (PGDM) and gestational diabetes mellitus (GDM). We aimed to characterize the impact of DIP in babies born to Aboriginal mothers.

METHODS

A retrospective cohort study, using routinely collected linked health data that included all singleton births (N = 510 761) in Western Australia between 1998 and 2015. Stratified by Aboriginal status, generalized linear mixed models quantified the impact of DIP on neonatal outcomes, estimating relative risks (RRs) with 95% CIs. Ratio of RRs (RRRs) examined whether RRs differed between Aboriginal and non-Aboriginal populations.

RESULTS

Exposure to DIP increased the risk of adverse outcomes to a greater extent in Aboriginal babies. PGDM heightened the risk of large for gestational age (LGA) (RR: 4.10, 95% CI: 3.56-4.72; RRR: 1.25, 95% CI: 1.09-1.43), macrosomia (RR: 2.03, 95% CI: 1.67-2.48; RRR: 1.39, 95% CI: 1.14-1.69), shoulder dystocia (RR: 4.51, 95% CI: 3.14-6.49; RRR: 2.19, 95% CI: 1.44-3.33) and major congenital anomalies (RR: 2.14, 95% CI: 1.68-2.74; RRR: 1.62, 95% CI: 1.24-2.10). GDM increased the risk of LGA (RR: 2.63, 95% CI: 2.36-2.94; RRR: 2.00, 95% CI: 1.80-2.22), macrosomia (RR: 1.95, 95% CI: 1.72-2.21; RRR: 2.27, 95% CI: 2.01-2.56) and shoulder dystocia (RR: 2.78, 95% CI: 2.12-3.63; RRR: 2.11, 95% CI: 1.61-2.77). Birthweight mediated about half of the DIP effect on shoulder dystocia only in the Aboriginal babies.

CONCLUSIONS

DIP differentially increased the risks of fetal overgrowth, shoulder dystocia and congenital anomalies in Aboriginal babies. Improving care for Aboriginal women with diabetes and further research on preventing shoulder dystocia among these women can reduce the disparities.

COVID-19 severity and in-hospital mortality in an area with high HIV prevalence

Background

HIV infection causes immune dysregulation affecting T-cell and monocyte function, which may alter coronavirus disease 2019 (COVID-19) pathophysiology.

Objectives

We investigated the associations among clinical phenotypes, laboratory biomarkers, and hospitalisation outcomes in a cohort of people hospitalised with COVID-19 in a high HIV prevalence area.

Method

We conducted a prospective observational cohort study in Tshwane, South Africa. Respiratory disease severity was quantified using the respiratory oxygenation score. Analysed biomarkers included inflammatory and coagulation biomarkers, CD4 T-cell counts, and HIV-1 viral loads (HIVVL).

Results

The analysis included 558 patients, of whom 21.7% died during admission. The mean age was 54 years. A total of 82 participants were HIV-positive. People living with HIV (PLWH) were younger (mean age 46 years) than HIV-negative people; most were on antiretroviral treatment with a suppressed HIVVL (72%) and the median CD4 count was 159 (interquartile range: 66-397) cells/µL. After adjusting for age, HIV was not associated with increased risk of mortality during hospitalisation (age-adjusted hazard ratio = 1.1, 95% confidence interval: 0.6-2.0). Inflammatory biomarker levels were similar in PLWH and HIV-negative patients. Detectable HIVVL was associated with less severe respiratory disease. In PLWH, mortality was associated with higher levels of inflammatory biomarkers. Opportunistic infections, and other risk factors for severe COVID-19, were common in PLWH who died.

Conclusion

PLWH were not at increased risk of mortality and those with detectable HIVVL had less severe respiratory disease than those with suppressed HIVVL.

What this study adds

This study advances our understanding of severe COVID-19 in PLWH.

Assessing barriers to insulin therapy among people with type 2 diabetes in South Africa using the Insulin Treatment Appraisal Scale: A cross-sectional survey

AIMS

To assess barriers to insulin therapy among people with type 2 diabetes after adapting the Insulin Treatment Appraisal Scale (ITAS) to the South African context.

METHODS

A panel of experts reviewed the original ITAS for clarity and relevance to the South African context. The ITAS was administered to 253 adults with type 2 diabetes attending diabetes outpatient clinics in the Tshwane Metropolitan Municipality. Internal consistency (Cronbach's alpha) was tested and construct validity was examined using exploratory factor analysis (EFA). PIR was appraised in insulin users and non-users.

RESULTS

The EFA revealed that the adapted ITAS had a two-factor structure, similar to the original scale, with acceptable internal consistency (α = 0.85). Insulin-using participants had significantly less negative attitudes to insulin therapy than non-users (40.7 ± 7.1 vs. 51.5 ± 11.2, p < 0.001). Compared to participants who used insulin, participants who did not use insulin were afraid of injecting themselves with a needle (71% vs. 11%, p < 0.001) and saw insulin treatment as a sign of worsening diabetes (63% vs. 29%, p < 0.001).

CONCLUSIONS

Consistent with previous studies, participants who were not using insulin had more negative beliefs and attitudes towards insulin treatment than those who were already using insulin. South African clinicians should use the ITAS to assess positive and negative perceptions regarding insulin therapy in both insulin-naïve and insulin-treated people, to evaluate interventions to reduce PIR and improve treatment outcomes.

Factors affecting the implementation of a complex health intervention to improve insulin management in primary care: A SWOT analysis

Background

In South Africa, initiating and managing insulin in primary care for people living with type 2 diabetes (PLWD) is a major challenge. To address these challenges, a multidisciplinary team from the University of Pretoria (South Africa) developed the Tshwane Insulin project (TIP) intervention.

Aim

To determine internal and external factors, either facilitators or barriers, that could influence the implementation of the TIP intervention and propose strategies to ensure sustainability.

Setting

Tshwane District, Gauteng province, South Africa.

Methods

We used the SWOT framework to qualitatively analyse the strengths, weaknesses, opportunities, and threats influencing the implementation of the TIP intervention. Four field researchers and three managers from the TIP team participated in an online group discussion. We also conducted semi-structured interviews with healthcare providers (HCPs) (seven nurses, five doctors) and patients with type 2 diabetes (n = 13).

Results

Regardless of the identified weaknesses, the TIP intervention was accepted by PLWD and HCPs. Participants identified strengths including app-enabled insulin initiation and titration, pro-active patient follow-up, patient empowerment and provision of glucose monitoring devices. Participants viewed insulin resistance and the attitudes of HCPs as potential threats. Participants suggested that weaknesses and threats could be mitigated by translating education material into local languages and using the lived experiences of insulin-treated patients to address insulin resistance. The procurement of glucose monitoring devices by national authorities would promote the sustainability of the intervention.

Conclusion

Our findings may help decision-makers and health researchers to improve insulin management for PLWD in resource-constrained settings by using telehealth interventions.

Decreased severity of disease during the first global omicron variant covid-19 outbreak in a large hospital in tshwane, south africa

INTRODUCTION

The coronavirus disease 2019 (COVID-19) first reported in Wuhan China in December 2019 is a global pandemic that is threatening the health and wellbeing of people worldwide. To date there have been more than 274 million reported cases and 5.3 million deaths. The Omicron variant first documented in the City of Tshwane, Gauteng Province, South Africa on 9 November 2021 led to exponential increases in cases and a sharp rise in hospital admissions. The clinical profile of patients admitted at a large hospital in Tshwane is compared with previous waves.

METHODS

The methods should describe what study design you employed for the study and what your sample size was, as it is this is mainly results. 466 hospital COVID-19 admissions since 14 November 2021 were compared to 3976 prior admissions since 4 May 2020. Ninety-eight patient records at peak bed occupancy during the outbreak were reviewed for primary indication for admission, clinical severity, oxygen supplementation level, vaccination and prior COVID-19 infection. Provincial and city-wide daily cases and reported deaths hospitalizations and excess deaths data were sourced from the NICD, the National Department of Health and the South African Medical Research Council.

RESULTS

Deaths and ICU admissions were 4.5% vs 21.3% (p<0.00001), and 1% vs 4.3% (p<0.00001); length of stay was 4.0 days vs 8.8 days; and mean age was 39 years vs 49 years for the Omicron and previous waves respectively. Admissions peaked and declined rapidly with peak bed occupancy at 51% of highest previous peak. Sixty two (63%) patients in COVID-19 wards had incidental COVID-19 following a positive SARS-CoV-2 PCR test . Only one third (36) had COVID-19 pneumonia, of which 72% had mild to moderate disease. The remaining 38% required high care or ICU admission. Fewer than half (45%) of patients in COVID-19 wards compared to 99.5% in the first wave required oxygen supplementation. City and provincial rates show decoupling of cases, hospitalisations and deaths compared to previous waves, corroborating the clinical findings of milder omicron disease in the hospital.

CONCLUSION

There was decreased severity of disease in the Omicron driven fourth wave in the City of Tshwane, its first global epicentre.

Attitudes and beliefs of South African primary healthcare practitioners on initiating insulin in people with type 2 diabetes: Findings from the Tshwane Insulin Project (TIP)

AIMS

To investigate the attitudes and beliefs of primary healthcare practitioners (HCPs) towards initiating insulin therapy for people with type 2 diabetes (T2D) in South Africa.

METHODS

A cross-sectional survey was conducted amongst HCPs from 23 clinics. The nurses' questionnaire was administered by research nurses while doctors completed an online version about their attitudes, beliefs and perceived barriers to initiating insulin.

RESULTS

Of the 73 HCPs surveyed, 68% were nurses and 84% were women. Only 24% of HCPs believed that most patients would eventually need to initiate insulin regardless of their adherence to treatment regimens and 86% preferred to delay insulin therapy. Doctors were reluctant to initiate insulin, citing patient-related reasons such as low socio-economic level (41%), inability to refrigerate insulin (77%) and inability to self-monitor blood glucose (55%). Doctors mentioned that patient behaviour including not adhering to treatment regimen and appointments (91%) and reluctance to start insulin therapy (82%) influenced their prescription practices. Doctors mentioned that health system factors, including the pressure to see patients quickly (68%) and lack of continuity of care (64%) were barriers to initiating insulin.

CONCLUSIONS

Optimising insulin therapy in primary care requires health system changes including promoting person-centred care and continuing training for HCPs.

Risk factors for COVID-19-related in-hospital mortality in a high HIV and tuberculosis prevalence setting in South Africa: a cohort study

Background

The interaction between COVID-19, non-communicable diseases, and chronic infectious diseases such as HIV and tuberculosis is unclear, particularly in low-income and middle-income countries in Africa. South Africa has a national HIV prevalence of 19% among people aged 15–49 years and a tuberculosis prevalence of 0·7% in people of all ages. Using a nationally representative hospital surveillance system in South Africa, we aimed to investigate the factors associated with in-hospital mortality among patients with COVID-19.

Methods

In this cohort study, we used data submitted to DATCOV, a national active hospital surveillance system for COVID-19 hospital admissions, for patients admitted to hospital with laboratory-confirmed SARS-CoV-2 infection between March 5, 2020, and March 27, 2021. Age, sex, race or ethnicity, and comorbidities (hypertension, diabetes, chronic cardiac disease, chronic pulmonary disease and asthma, chronic renal disease, malignancy in the past 5 years, HIV, and past and current tuberculosis) were considered as risk factors for COVID-19-related in-hospital mortality. COVID-19 in-hospital mortality, the main outcome, was defined as a death related to COVID-19 that occurred during the hospital stay and excluded deaths that occurred because of other causes or after discharge from hospital; therefore, only patients with a known in-hospital outcome (died or discharged alive) were included. Chained equation multiple imputation was used to account for missing data and random-effects multivariable logistic regression models were used to assess the role of HIV status and underlying comorbidities on COVID-19 in-hospital mortality.

Findings

Among the 219 265 individuals admitted to hospital with laboratory-confirmed SARS-CoV-2 infection and known in-hospital outcome data, 51 037 (23·3%) died. Most commonly observed comorbidities among individuals with available data were hypertension in 61 098 (37·4%) of 163 350, diabetes in 43 885 (27·4%) of 159 932, and HIV in 13 793 (9·1%) of 151 779. Tuberculosis was reported in 5282 (3·6%) of 146 381 individuals. Increasing age was the strongest predictor of COVID-19 in-hospital mortality. Other factors associated were HIV infection (adjusted odds ratio 1·34, 95% CI 1·27–1·43), past tuberculosis (1·26, 1·15–1·38), current tuberculosis (1·42, 1·22–1·64), and both past and current tuberculosis (1·48, 1·32–1·67) compared with never tuberculosis, as well as other described risk factors for COVID-19, such as male sex; non-White race; underlying hypertension, diabetes, chronic cardiac disease, chronic renal disease, and malignancy in the past 5 years; and treatment in the public health sector. After adjusting for other factors, people with HIV not on antiretroviral therapy (ART; adjusted odds ratio 1·45, 95% CI 1·22–1·72) were more likely to die in hospital than were people with HIV on ART. Among people with HIV, the prevalence of other comorbidities was 29·2% compared with 30·8% among HIV-uninfected individuals. Increasing number of comorbidities was associated with increased COVID-19 in-hospital mortality risk in both people with HIV and HIV-uninfected individuals.

Interpretation

Individuals identified as being at high risk of COVID-19 in-hospital mortality (older individuals and those with chronic comorbidities and people with HIV, particularly those not on ART) would benefit from COVID-19 prevention programmes such as vaccine prioritisation as well as early referral and treatment.

Funding

South African National Government.

Effectiveness of an adapted diabetes nutrition education program on clinical status, dietary behaviors and behavior mediators in adults with type 2 diabetes: a randomized controlled trial

PURPOSE

This study evaluated the effectiveness of an adapted social-cognitive theory underpinned diabetes nutrition education program (NEP) on: clinical (HbA1c, BMI, blood lipids, blood pressure) and selected dietary behaviors (starchy foods and energy intake, vegetables and fruit intake) and behavior mediators (knowledge and diabetes management self-efficacy) in patients with type 2 diabetes mellitus (T2DM).

METHODS

A tertiary hospital outpatient adults (40-70 years) with poorly controlled (HbA1c ≥ 8 %) T2DM were randomized to either intervention group (n = 39: NEP, 7-monthly group education sessions, bi-monthly follow-up sessions, 15-minute individual session, workbook + education materials) or control group (n = 38: education materials only). NEP aimed to improve clinical status through improved dietary behaviors and behavior mediators. Outcomes and changes in diabetes medication were assessed at six and 12 months. Intention-to-treat analysis was conducted. ANCOVA compared the groups (baseline values, age, sex adjustments).

RESULTS

Forty-eight (62.3 %) participants completed the study. Intervention group compared to the control group had lower (-0.53 %), clinically meaningful HbA1c (primary outcome) at 6 months, albeit not sustained at 12 months. Compared to the control group, the intervention group had significantly lower: (i) systolic blood pressure at six and 12 months (ii) diastolic pressure at 12 months, (iii) energy intake at six-months, (iv) up-titration of insulin at six and 12 months and higher diabetes knowledge scores at six months.

CONCLUSIONS

NEP had limited effects on HbA1c, targeted dietary behaviors and behavior mediators but showed positive effects on blood pressure. The NEP health cost savings potential supports the need for improving program participation.

TRIAL REGISTRATION

ClinicalTrials.gov. number NCT03334773; 7 November 2017 retrospectively registered.

Suboptimal control for patients with type 2 diabetes in the Central Chronic Medicine Dispensing programme in South Africa

BACKGROUND

In South Africa, the Central Chronic Medicine Dispensing and Distribution (CCMDD) programme allows stable patients with non-communicable diseases, including type 2 diabetes mellitus (T2DM), to collect their medication from a pick-up location near their home, thus avoiding long waiting times and travel expenses. The CCMDD programme aims at improving patient retention and adherence through better access to medicines, resulting in better health outcomes.

AIM

We assessed whether patients with T2DM enrolled in CCMDD achieved the recommended targets for glycaemic, blood pressure (BP) and lipid control.

SETTING

City of Tshwane, South Africa.

METHODS

We reviewed the records of 198 T2DM patients enrolled in CCMDD and assessed their control of haemoglobin A1c (HbA1c), BP and lipids.

RESULTS

Most of the records reviewed belonged to women (64.7%), African (89.9%), hypertensive (82.7%) and to patients exclusively on oral antidiabetic agents (98.5%). Patients were, on average, 57.7 (s.d. = 12.1) years old and had participated in the CCMDD programme for, on average, 2 years. The mean HbA1c was 8% (s.d. = 2). Glycaemic control was achieved by only 29.2% of patients, and 49% of patients had HbA1c between 7% and 9%. Ninety-three patients (66%) had achieved the total cholesterol target, 57.4% achieved BP targets and 6.9% had achieved the low-density lipoprotein cholesterol target.

CONCLUSION

A small group of patients achieved the targets for glycaemic, BP and lipid control. Despite improved accessibility to medication, the CCMDD is not synonymous of improved clinical outcomes. Future research should ascertain the factors associated with suboptimal control for these patients.

No Association Between ADIPOQ or MTHFR Polymorphisms and Gestational Diabetes Mellitus in South African Women

PURPOSE

Gestational diabetes mellitus (GDM) is a growing public health concern. GDM affects approximately 14% of pregnancies globally, and without effective treatment, is associated with short- and long-term complications in mother and child. Lower serum adiponectin (ADIPOQ) concentrations and aberrant DNA methylation have been reported during GDM. The aim of this study was to investigate the association between the ADIPOQ -11377C>G and -11391G>A, and methylenetetrahydrofolate reductase (MTHFR) 677C>T polymorphisms and GDM in a population of black South African women.

MATERIALS AND METHODS

DNA was isolated from the peripheral blood of 447 pregnant women with (n=116) or without (n=331) GDM, where after ADIPOQ (rs266729 and rs17300539) and MTHFR (rs1801133) polymorphisms were genotyped using TaqMan Quantitative Real-Time PCR analysis.

RESULTS

Women with GDM had a higher body mass index (p=0.012), were more insulin resistant (p<0.001) and had lower adiponectin levels (p=0.013) compared to pregnant women with normoglycemia. Genotypic, dominant and recessive genetic models showed no association between ADIPOQ rs266729 and rs17300539 and MTHFR rs1801133 polymorphisms and GDM. Intriguingly, the risk G allele of ADIPOQ rs266729 was associated with higher fasting glucose and insulin concentrations, while the T allele in MTHFR rs1801133 was associated with higher fasting insulin concentrations only.

CONCLUSION

ADIPOQ rs266729 and rs17300539 and MTHFR rs1801133 polymorphisms are not associated with GDM in a population of black South African women. These findings suggest that these single nucleotide polymorphisms (SNPs) do not individually increase GDM risk in the African population. However, the role of these SNPs in possible gene-gene or gene-environment interactions remain to be established.

Designing an integrated, nurse-driven and home-based digital intervention to improve insulin management in under-resourced settings

BACKGROUND

In South Africa, initiating insulin for people with type 2 diabetes and subsequent titration is a major challenge for the resource-constrained healthcare system. Inadequate support systems in primary care, including not being able to access blood glucose monitors and test strips for self-monitoring of blood glucose, results in patients with type 2 diabetes being referred to higher levels of care. In primary care, initiation of insulin may be delayed due to a shortage of healthcare workers. The delayed initiation of insulin is also exacerbated by the reported resistance of both healthcare providers and people with type 2 diabetes to start insulin. In South Africa, telehealth provides an opportunity to overcome these challenges and manage insulin therapy in primary care.

METHODS

We describe the development of a digital health intervention including the framework used, the theoretical approach and subsequent implementation strategies.

RESULTS

This intervention is an innovative, nurse-driven and app-enabled intervention called 'the Tshwane Insulin Project intervention'. The Tshwane Insulin Project intervention was designed and evaluated using the framework recommended by the Medical Research Council for complex interventions. The Tshwane Insulin Project intervention was developed in four sequential phases: planning, design, implementation and evaluation. The Tshwane Insulin Project intervention followed the Integrated Chronic Disease Management framework to facilitate implementation and acceptability. The Tshwane Insulin Project comprises a facility-level intervention, where nurses evaluate patients and initiate insulin, an individual-level intervention where community healthcare workers visit patients at their homes to follow-up and provide educational information, while using telehealth to enable physician-directed insulin titration if needed, and a community-level intervention aimed at empowering community healthcare workers to support people living with diabetes and raise awareness of diabetes.

CONCLUSION

The technological advancements in digital health and telemedicine present an opportunity to improve diabetes care in resource-limited countries. This work can inform those intending to develop and implement complex interventions in primary healthcare in developing countries.

Identification of a subgroup of black South Africans with type 1 diabetes who are older at diagnosis but have lower levels of glutamic acid decarboxylase and islet antigen 2 autoantibodies

AIMS

To compare the age at diagnosis and prevalence of islet autoantibody [glutamic acid decarboxylase (65 kDa) 65 and islet antigen 2] positivity in black and white participants with type 1 diabetes in South Africa, and to analyse the relationship between age at diagnosis and the presence of autoantibodies.

METHODS

Participants were recruited from diabetes outpatient departments and autoantibodies to glutamic acid decarboxylase (65 kDa) and islet antigen 2 were measured by enzyme-linked immunosorbent assay.

RESULTS

We recruited 472 (353 black and 119 white) participants with type 1 diabetes. Age at diagnosis of diabetes was later in black (19.7 ± 10.5) than in white participants (12.7 ± 10.8 years; P < 0.001) with a median (interquartile range) disease duration of 5.0 (2.0-10.0) and 8.5 (4.0-20.0) years (P < 0.001), respectively. An older age at diagnosis (≥ 21 years) was more frequent in black (152 of 340, 45%) than in white participants (24 of 116, 21%; P < 0.001). The prevalence of islet antigen 2 autoantibodies was 19% (66/352) in black and 41% in white participants (48/118; P < 0.001). There was no significant difference in glutamic acid decarboxylase (65 kDa) autoantibody positivity between black (212/353, 60%) and white participants (77/117, 66%; P = 0.269). In black, but not white, participants the prevalence of both glutamic acid decarboxylase (65 kDa) and islet antigen 2 autoantibody positivity was significantly lower in participants diagnosed at age ≥ 21 years (P < 0.001 for both comparisons).

CONCLUSIONS

The older age at diagnosis, lower prevalence of islet antigen 2 autoantibodies and a distinct subgroup of participants with type 1 diabetes with age at diagnosis of > 20 years in the black compared to white population suggest a difference in the immunological aetiology of type 1 diabetes in these two population groups.

Willingness of people with Type 2 diabetes to start insulin therapy: Evidence from the South African Tshwane Insulin Project (TIP)

AIMS

To determine factors associated with 'hypothetical willingness' to start insulin among people with Type 2 diabetes (T2DM).

METHODS

A quantitative cross-sectional study with insulin-naïve T2DM patients at 23 primary care facilities in the Tshwane Metropolitan Municipality. Data collected included demographic and clinical data, willingness to start insulin, attitudes and barriers to insulin therapy. Factors associated with unwillingness to start insulin therapy were explored using a multivariable logistic regression model.

RESULTS

Of 468 T2DM study patients (mean age 57.2, SD = 11.3 years), more than half (51.9%) expressed unwillingness to starting insulin therapy. Unwillingness was associated with negative attitudes (OR = 1.32, 95% CI = 1.12-1.55, p = 0.001) and reluctance (OR = 1.41, 95% CI = 1.27-1.57, p < 0.001) rather than age, sex, education or diabetes duration. The strongest reasons for patient unwillingness were injection anxieties, fear of needles, insufficient knowledge of insulin, feeling unable to cope with insulin and concerns about out-of-pocket costs.

CONCLUSIONS

The prospect of insulin therapy disturbs patients' sense of self and their psychological wellbeing. The high prevalence of psychological insulin resistance among these T2DM patients needs to be addressed for effective diabetes management.

P300 Event-Related Potentials in Normal-Hearing Adults With Type 2 Diabetes Mellitus

Background P300 event-related potentials can be used to measure auditory processing speed, working memory, and attention. Purpose The purpose of the study was to compare P300 event-related potentials in normal-hearing adults with those of adults with Type II diabetes mellitus. Research Design A two-group (with diabetes and controls) comparative study (age- and sex-matched) with a nonprobability sampling method was used. Study Sample Sixty-four adult participants (32 with diabetes, 32 without diabetes) between the ages of 23 and 60 years participated. Data Collection and Analysis Pure-tone audiometry was performed to ensure participants had pure-tone averages of ≤ 25 dB HL. Folstein Mini-Mental State Examinations were conducted, which ensured absence of cognitive impairment. Blood glucose levels were measured immediately prior to P300 testing, after which amplitude and latency results were captured. Descriptive analysis was used to calculate mean, standard deviation, median, and 25th and 75th percentiles. To study differences between adults with and without diabetes as well as the effect of glucose, linear mixed-model regression analyses were performed when left and right ears were combined, and simple linear regression analyses were performed when left and right ears were analyzed separately. Results For P300 latency results, a significant statistical difference (p < .001) was observed between participants with and without diabetes (352.46 ms, SD = 36.36; 314.09 ms, SD = 32.08), respectively. A significant statistical difference (p < .001) in amplitude was observed between participants with and without diabetes, respectively (12.10 μV, SD = 3.70; 15.08 μV, SD = 2.82). Glucose was a key moderator of only amplitude after adjusting for diabetes status. Glucose had no effect on amplitude and latency for adults without Type II diabetes mellitus (DM). Conclusions Type II DM decreases amplitude and increases latency; in addition, adults with Type II DM, attention, and working memory, as denoted by P300 amplitude, may deteriorate with increased glucose levels on the day of testing.

MicroRNA Profiling in HIV-Infected South African Women with Gestational Diabetes Mellitus

BACKGROUND

Recently, we reported that the microRNAs (miRNAs) miR-20a-5p and-to a lesser extent-miR-222-3p hold potential as biomarkers for gestational diabetes mellitus (GDM) in human immunodeficiency virus (HIV)-negative South African women.

METHODS

In this preliminary study, we measured the expression of these miRNAs in HIV-positive women (GDM 15, non-GDM 52; median 26.0 weeks; range 16-30).

RESULTS

Although the same trend of decreased expression of miR-20a-5p (1.5-fold decrease) and miR-222-3p (1.4-fold decrease) was observed in sera of women with and without GDM, these differences were not statistically significant. Stratification according to antiretroviral treatment (ART) confirmed decreased expression of miR-20a-5p and miR-222-3p in ART-naïve and ART-treated women with GDM, although again this was not statistically significant.

CONCLUSION

Our results demonstrate that HIV infection modifies the expression of miR-20a-5p and miR-222-3p in women with GDM. Importantly, this study highlights the complexities of miRNA profiling and the need for GDM biomarker discovery in both HIV-infected and uninfected individuals, particularly in South Africa, where approximately 30% of pregnancies are complicated by HIV. Further studies to elucidate the mechanisms that underlie these miRNA differences are needed.

The ability of primary healthcare clinics to provide quality diabetes care: An audit

Background

In South Africa, much of diabetes care takes place at primary healthcare (PHC) facilities where screening for diabetic complications is often low. Clinics require access to equipment, resources and a functional health system to do effective screening, but what is unknown is whether these components are in place.

Aim

The aim of this study was to assess the capacity of primary care clinics in one district to provide quality diabetes care.

Setting

This study was conducted at the Tshwane district in South Africa.

Methods

An audit was done in 12 PHC clinics. A self-developed audit tool based on national and clinical guidelines was developed and completed using observation and interviewing the clinic manager and pharmacist or pharmacy assistant.

Results

Scales, height rods, glucometers and blood pressure machines were available. Monofilaments were unknown and calibration of equipment was rare. The Essential Drug List was the only guideline consistently available. All sites reported consistent access to medication, glucose strips and urine dipsticks. All sites made use of the chronic disease register, and only 25% used an appointment system. No diabetes-specific structured care form was in use. All facilities had registered and enrolled nurses and access to doctors. Availability of educational material was generally poor.

Conclusion

The capacity to deliver quality care is compromised by the poor availability of guidelines, educational material and the absence of monofilaments. These are modifiable risk factors that could be resolved by the clinic managers and staff development educators. However, patient records and health information systems need attention at policy level.

Global DNA methylation profiling in peripheral blood cells of South African women with gestational diabetes mellitus

Background/Objective: Recently, several studies have reported that DNA methylation changes in tissue are reflected in blood, sparking interest in the potential use of global DNA methylation as a biomarker for gestational diabetes mellitus (GDM). This study investigated whether global DNA methylation is associated with GDM in South African women. Methods: Global DNA methylation was quantified in peripheral blood cells of women with (n = 63) or without (n = 138) GDM using the MDQ1 Imprint® DNA Quantification Kit. Results: Global DNA methylation levels were not different between women with or without GDM and were not associated with fasting glucose or insulin concentrations. However, levels were 18% (p = 0.012) higher in obese compared to non-obese pregnant women and inversely correlated with serum adiponectin concentrations (p = 0.005). Discussion: Contrary to our hypothesis, global DNA methylation was not associated with GDM in our population. These preliminary findings suggest that despite being a robust marker of overall genomic methylation that offers opportunities as a biomarker, global DNA methylation profiling may not offer the resolution required to detect methylation differences in the peripheral blood cells of women with GDM. Moreover, global DNA methylation in peripheral blood cells may not reflect changes in placental tissue. Further studies in a larger sample are required to explore the candidacy of a more targeted approach using gene-specific methylation as a biomarker for GDM in our population.

The South African Rea Phela Health Study: A randomized controlled trial of communication retention strategies

Epidemiological transitions are occurring throughout Africa. To inform public health programs and policies, longitudinal cohorts investigating non-communicable diseases are needed. However, loss-to-follow up is a major problem. In preparation for a longitudinal study, we conducted a randomized controlled trial to test communication-based retention strategies (message content and delivery methods) among a pilot cohort of South African healthcare workers (n = 1536; median age = 36; women = 1270). Two messaging formats across three delivery modes were tested. Response rates were analyzed by intervention, survey return date and method using chi-square tests and univariate logistic regression. Sixty-seven of 238 (17.4%) control group participants and 238 of 1152 (24.6%) intervention group participants were retained (OR 1.54: CI 1.15–2.07; P = 0.004). Odds of being retained were 1.68 times greater for participants who received regular contact and themed messages compared to control (CI 1.22–2.32; P = 0.001). Neither health status nor clinical condition affected response rates (P>0.05). Time-to-first contact did not impact response rates (P>0.05). Message content and delivery method influenced response rates compared to the control, however no difference was found between intervention groups. Although greater retention is required for valid cohort studies, these findings are the first to quantitatively assess retention factors in Africa.

Detection, referral and control of diabetes and hypertension in the rural Eastern Cape Province of South Africa by community health outreach workers in the rural primary healthcare project: Health in Every Hut

BACKGROUND

 Non-communicable diseases, mainly cardiovascular diseases, diabetes, cancer and chronic respiratory diseases, are responsible for approximately 63% of all deaths occurring worldwide in any given year. The majority of these deaths have occurred in low- and middle-income countries (LMICs). The latest World Health Organization (WHO) report shows that the increase in diabetes is also most pronounced in the LMICs. The South African Labour and Development Research Unit estimated a 9% prevalence within the adult population in 2016. In the Eastern Cape Province, hypertensive heart disease has become the second most common cause of death, followed by diabetes, the third most common cause of death.Aim and setting: The aim of this study was to report on the follow-up of patients in the community with known hypertension or diabetes or who were deemed at-risk (as identified during a prior community-wide survey).

METHODS

 Data were collected via a household primary health screening, monitoring and follow-up process, which included taking anthropometric measurements, blood pressure (BP) and blood glucose and referring to clinics for further testing and treatment where necessary.

RESULTS

 Of the 1885 participants followed up by the community health outreach workers, 1702 were known to be hypertensive and 183 were deemed at-risk [of these, only 24 (13.2%) had normal or high normal systolic BP readings]. There were 341 participants with diabetes and 34 at-risk of diabetes [of these, 28 (82%) had levels of 11 mmol/l or higher at follow-up]. There was a significant improvement in BP and glucose control over repeated visits.

CONCLUSION

 In this rural area of the Eastern Cape, South Africa, the follow-up of patients with hypertension or diabetes as well as those individuals at-risk adds value to hypertension and glucose control.

Evaluating the utility of a point-of-care glucometer for the diagnosis of gestational diabetes

OBJECTIVE

To investigate the performance of the Roche Accuchek Active glucometer in diagnosing gestational diabetes mellitus (GDM) versus the gold-standard laboratory test.

METHODS

In a prospective cohort observational study at a primary healthcare clinic in Johannesburg, South Africa, pregnant women, excluding known diabetics, were recruited between 2013 and 2016. A 75-g 2-hour oral glucose tolerance test (OGTT) was scheduled at 24-28 gestational weeks. Glucose was measured in venous blood (laboratory) and capillary blood (glucometer). GDM was diagnosed via FIGO criteria. Diagnostic accuracy was evaluated by calculating the sensitivity, specificity, and coefficient of variance (CV) of the glucometer test, and by Bland-Altman plots.

RESULTS

Data from 529 women were analyzed. Of these, 141 (26.7%) and 79 (14.9%) were diagnosed with GDM by laboratory and glucometer measurements, respectively. The CV of the glucometer ranged from 15% to 17%. Bland-Altman plots showed a positive bias of the glucometer results at 0 hours, but a negative bias at 1 and 2 hours of the OGTT. The sensitivity and specificity of the glucometer for the diagnosis of GDM were 27.0% and 89.4%, respectively.

CONCLUSION

Use of the Roche Accuchek Active glucometer for the diagnosis of GDM cannot be recommended.

The effect of glycaemic control on fibrin network structure of type 2 diabetic subjects

Diabetic subjects have been shown to have altered fibrin network structures. One possible cause may be fibrinogen glycation resulting in altered structure/function properties. We investigated the effect of glucose control on fibrinogen glycation and fibrin network structure in type 2 diabetes. Blood samples were taken from twenty uncontrolled diabetic subjects at baseline to determine the levels of fibrinogen glycation and fibrin network structures. The subjects were then treated with insulin until blood glucose control was achieved before end blood samples were taken. Twenty age- and BMI-matched non-diabetic subjects were included as a reference group. The diabetic subjects had significantly higher mean fibrinogen glycation at baseline than the non-diabetic subjects (7.84 vs. 3.89 mol glucose / mol fibrinogen;p < 0.001).This was significantly reduced during the intervention (7.84 to 5.24 mol glucose / mol fibrinogen; p< 0.0002) in the diabetic group. Both groups had high mean fibrinogen concentrations (4.25 and 4.02 g/l, diabetic and non-diabetic subjects respectively). There was no difference in fibrinogen concentration, porosity, compaction and kinetics of clot formation between the diabetic subjects and non-diabetic subjects at baseline, nor were there any changes during the intervention despite the reduced fibrinogen glycation. Fibrin network characteristics correlated well with fibrinogen but not with any markers of glycaemic control. Improved glycaemic control resulted in decreased fibrinogen glycation but not fibrinogen concentration. It seems as though porosity, compaction and kinetics of clot formation are more related to fibrinogen concentration than fibrinogen glycation in this model.

A cluster-randomized trial to estimate the effect of mobile screening and treatment feedback on HbA1c and diabetes-related complications in Tshwane primary health care clinics, South Africa

AIM AND OBJECTIVES

Our study had two primary objectives. The first was to evaluate the effect of an expert review with an individualised patient management plan on change in HbA1c. The second was to determine whether a mobile screening unit would increase the proportion of patients screened for glycaemic and lipid control, as well as diabetic complications as compared to the standard guideline-driven clinic care.

METHODS

We conducted a cluster-randomised trial and enrolled 599 diabetic patients from twelve primary health care clinics in the Tshwane district of South Africa. The study was carried out in three phases: Phase 1 was a historical twelve-month record review to determine baseline characteristics; Phase 2 was the provision of the intervention (active screening for metabolic control and diabetes-related complications and health education targeting health care workers and diabetic patients) compared to the control group (routine care with similar education given to health care workers and diabetic patients) with a follow-up which included a clinical assessment. Phase 3 was a repeat of the record review to assess post-intervention changes following the proposed individualised patient management plan in the intervention clinics, and self-initiated by the health care professionals in the control clinics, based on training and results-sharing.

RESULTS

No significant changes in the HbA1c between the intervention and control clinics after one year were observed. The mean Hba1c changed from 8.68 to 8.53% (intervention) and from 8.95 to 8.76% (control) (p=0.92). Significant differences were observed in screening for diabetic complications when active screening was done by a dedicated team. The increase observed was more than 60% in all indicators monitored. Significant changes were also seen in the control clinics for two measured outcome variables (HbA1c test ordered from 15% to 25% (p=0.02) and serum-creatinine test ordered increased from 11% to 19% (p<0.001)). There was no significant difference in the proportion of actions taken, or not taken, between the control and interventions arms (p=0.83). The proposed changed patient management plans by the expert review team were implemented in only 29% of patients in the intervention arm.

CONCLUSIONS

A comprehensive programme that integrates clinical evaluations, active screening and an individualised patient management plan did not lead to significant improvement in the HbA1c levels. However, screening for glycaemic and lipid control, as well as diabetic complications, improved dramatically with a dedicated team. The lower than expected rate of uptake of the specialists-proposed patient management, with the resulting non-significant change in glycaemic control, needs further investigation.

The noncommunicable disease outcomes of primary healthcare screening in two rural subdistricts of the Eastern Cape Province, South Africa

Background

Middle and lower income countries are challenged with a double burden of disease: while still coping with the onslaught of Human Immunodeficiency Virus (HIV) and increasing levels of tuberculosis (TB), there is a considerable increase in the level of noncommunicable diseases (NCDs). The poor are especially disadvantaged and are at an increased risk for NCDs. Adequate healthcare resources for this environment can only be allocated once the extent and exact nature of the problem is determined.

Aim and setting

The aim of this study was to collect demographic and NCD-related data in the poorest community of the poorest province of South Africa in order to determine the extent of the problem and advise on allocation of resources accordingly.

Methods

Data were collected via a household primary health screening process, which included taking anthropometric measurements, blood pressure and blood glucose and referring to clinics for further testing and treatment where necessary.

Results

It was found that the population screened was generally older, consisted of women, and had a high incidence of obesity and hypertension. Of note was the fact that in those without known hypertension, close to 40% of individuals had possible newly diagnosed hypertension. This increased with increase in age and body mass index (BMI). The total prevalence of diabetes was close to 5%, but possible new diabetes was considerably lower at approximately 1%.

Conclusion

In this rural area of the Eastern Cape, South Africa, undiagnosed hypertension is a major concern and renewed efforts at detection and control are warranted.

Selective Screening Strategies for Gestational Diabetes: A Prospective Cohort Observational Study

AIM

We aimed to develop a prediction model for the diagnosis of gestational diabetes and to evaluate the performance of published prediction tools on our population.

METHODS

We conducted a cohort study on nondiabetic women < 26 weeks gestation at a level 1 clinic in Johannesburg, South Africa. At recruitment, participants completed a questionnaire and random basal glucose and HbA1c were evaluated. A 75 g 2-hour OGTT was scheduled between 24-28 weeks gestation, as per FIGO guidelines. A score was derived using multivariate logistic regression. Published scoring systems were tested by deriving ROC curves.

RESULTS

In 554 women, RBG, BMI, and previous baby ≥ 4000 g were significant risk factors included for GDM, which were used to derive a nomogram-based score. The logistic regression model for prediction of GDM had R2 0.143, Somer's Dxy rank correlation 0.407, and Harrell's c-score 0.703. HbA1c did not improve predictive value of the nomogram at any threshold (e.g,. at probability > 10%, 25.6% of cases were detected without the HbA1c, and 25.8% of cases would have been detected with the HbA1c). The 9 published scoring systems performed poorly.

CONCLUSION

We propose a nomogram-based score that can be used at first antenatal visit to identify women at high risk of GDM.

Barriers to and expectations of performing physical activity in female subjects with Type 2 Diabetes

The aims of the study were to establish in a cohort of female patients with Type Diabetes the knowledge and perceptions of exercise, personal and environmental barriers to doing exercise and the outcome expectations of performing physical activity. The sample consisted of 28 patients between the ages of 48 and 70 (mean =60.2, SD = 6.6) years and 11 ethnic groups, attending the Mamelodi Hospital Diabetic Outpatient Clinic. The duration of the disease ranged from I to 22 years and 82% of the patients were using oral hypoglycaemic agents. Demographic and qualitative data were captured by means of focus group interviews. Demographic data were summarized with descriptive statistics. Qualitative data were analysed by means of well described principles of qualitative data analyses. A percent agreement was performed and data were re-coded until the inter-rater reliability was 85%. All 28 subjects reported that they saw doing household chores and walking as ways of exercising. Sixty one percent of the subjects indicated relief from arthritis as a benefit of exercise. The main environmental barrier was the absence of a convenient venue (61%). Tiredness (36%) and arthritis (36%) were the main personal barriers to doing exercise. All subjects indicated a better quality of life and improvement of functional capabilities as outcome expectations of taking part in an exercise program. Subjects had positive attitudes towards exercise, wanted to have control in the program and also expressed the need for social support.

Point-of-care testing improves diabetes management in a primary care clinic in South Africa

INTRODUCTION

Diabetes is a major health problem in South Africa. DiabCare Africa found just 47% of diabetes patients had a hemoglobin A1c (HbA1c) test for their management in the previous year.

METHODS

Patients attending an urban diabetes clinic near Johannesburg, run by Project HOPE, accessed HbA1c (and urine albumin:creatinine ratio) point-of-care testing (POCT) as part of a quality-assured international program called ACE (Analytical and Clinical Excellence). Patients who had two or more HbA1c POC tests from 2012 to 2014 were assessed to determine their change in glycaemic control.

RESULTS

The mean (±SD) HbA1c in this group of diabetes patients (n=131) fell significantly from 9.7%±2.4 (83mmol/mol) at their first POCT measurement to 8.4%±2.4 (68mmol/mmol/mol) at their most recent POCT measurement (paired t-test p<0.01). The average time between first and most recent HbA1c test was 15 months. The number of diabetes patients achieving optimal glycaemic control (HbA1c≤6.5-7.5% [48-58mmol/mol) increased by 125%, while the number with very poor glycaemic control (HbA1c>10% [86mmol/mol]) halved. An association was observed between degree of glycaemic control and increasing albuminuria in this cohort.

DISCUSSION

POCT has promoted change in clinical practice by facilitating greater accessibility to HbA1c testing.

Perspectives on Peripheral Neuropathy as a Consequence of Metformin-Induced Vitamin B12 Deficiency in T2DM

Peripheral neuropathy (PN) is a primary complication of type 2 diabetes mellitus (T2DM) and a direct manifestation of vitamin B12 deficiency. Examining the effects of metformin use on PN status became imperative following clinical studies that showed the vitamin B12-lowering effect of the medication. The complexity of the topic and the inconsistency of the results warrant consideration of topic-specific perspectives for better understanding of the available evidence and more appropriate design of future studies.

Diabetes and hypertension screening in Zandspruit, Johannesburg 2012–2014

Background: Hypertension (HT) and diabetes mellitus (DM) affect millions of individuals in South Africa and are among the leading causes of morbidity and mortality. Given the substantial public health and socio-economic burden South Africa faces due to the rising rates of chronic diseases, prevention strategies with community engagement may play a vital role in controlling these diseases and their associated sequelae.Objectives and methods: Project HOPE, an implementing partner of the Lilly Non Communicable Disease (NCD) Partnership programme in South Africa, conducted screening days and home visits as part of a non-communicable disease awareness campaign in the Zandspruit suburb of western Johannesburg (lower income, informal settlement). Standardised assessment tools were used, which included glucose and blood pressure measurement.Results: Of 7607 participants screened, 2773/7470 (37.1%) of those with blood pressure values could be classified as hypertensive with systolic blood pressure (BP) ≥ 140 mmHg or diastolic BP ≥ 90 mmHg. Of the 7607 glucose screened individuals, 630 (8.3%) had referable random capillary glucose levels ≥ 7.8 mmol/l. There was a clear gradient of increased prevalence over age and body mass index (BMI) categories.Conclusions: In this urban low-income suburb hypertension was common with hyperglycaemia less so. The number of participants returning to the clinic for confirmation of diagnoses was less than optimal and highlights the problem of community- based screening.

Vitamin B12 deficiency in metformin-treated type-2 diabetes patients, prevalence and association with peripheral neuropathy

Background

The association between long-term metformin use and low vitamin B12 levels has been proven. However, the prevalence estimates of metformin-induced vitamin B12 deficiency showed considerable variation among the studies. The potential of the deficiency to cause or worsen peripheral neuropathy in type-2 diabetes mellitus (T2DM) patients has been investigated with conflicting results. The aim of the study was to investigate: 1) the prevalence of vitamin B12 deficiency in T2DM patients on metformin; 2) the association between vitamin B12 and peripheral neuropathy; 3) and the risk factors for vitamin B12 deficiency in these patients.

Methods

In this cross-sectional study, consecutive metformin-treated T2DM patients attending diabetes clinics of two public hospitals in South Africa were approached for participation. Participation included measuring vitamin B12 levels and assessing peripheral neuropathy using Neuropathy Total Symptom Score-6 (NTSS-6) questionnaire. The prevalence of vitamin B12 deficiency (defined by concentrations <150 pmol/L) was determined. Those with NTSS-6 scores >6 were considered to have peripheral neuropathy. The relationship between vitamin B12 and peripheral neuropathy was investigated when the two variables were in the binary and continuous forms. Multiple logistic regression was used to determine risk factors for vitamin B12 deficiency.

Results

Among 121 participants, the prevalence of vitamin B12 deficiency was 28.1 %. There was no difference in presence of neuropathy between those with normal and deficient vitamin levels (36.8 % vs. 32.3 %, P = 0.209). Vitamin B12 levels and NTSS-6 scores were not correlated (Spearman’s rho =0.056, P = 0.54). HbA1c (mmol/mol) (OR = 0.97, 95 % CI: 0.95 to 0.99, P = 0.003) and black race (OR = 0.34, 95 % CI: 0.13 to 0.92, P = 0.033) were risk factors significantly associated with vitamin B12 deficiency. Metformin daily dose (gram) showed borderline significance (OR = 1.96, 95 % CI: 0.99 to 3.88, P = 0.053).

Conclusions

Close to third of metformin-treated T2DM patients had vitamin B12 deficiency. The deficiency was not associated with peripheral neuropathy. Black race was a protective factor for vitamin B12 deficiency.

Screening in Primary Care for Diabetic Retinopathy, Maculopathy and Visual Loss in South Africa

OBJECTIVE

The aim of the study was to determine the prevalence of diabetic retinopathy, maculopathy and visual loss in primary care patients and to identify associated risk factors.

RESEARCH DESIGN AND METHODS

We conducted a cluster randomised trial at primary care clinics in the Tshwane district in South Africa. Grades of retinopathy and maculopathy (with fundus camera) and visual acuity (Snellen chart) were assessed and, using mobile screening and teleophthalmology, clinical and biochemical testing was conducted to obtain information about glycaemic control and microvascular complications.

RESULTS

The prevalence rates for any retinopathy, preproliferative retinopathy and proliferative retinopathy were 24.9, 19.5 and 5.5%, respectively. The prevalence rates of diabetic maculopathy, observable maculopathy and referable maculopathy were 20.8, 11.8 and 9.0%, respectively. The presence of retinopathy was associated with high body mass index, systolic blood pressure, being on insulin treatment, high HbA1c and the presence of neuropathy. High systolic blood pressure, being on insulin treatment, high HbA1c level and high low-density lipoprotein cholesterol level as well as the presence of albuminuria were significant in predicting any diabetic maculopathy. Laser photocoagulation was given to 8.3% of patients from the mobile unit and 12% of patients were referred to the nearest hospital with an outpatient eye clinic for follow-up treatment of various other eye conditions. Using the WHO categories, the study found that 78.1% of diabetes patients had normal vision, 19.3% were visually impaired and 2.2% were severely impaired or blind.

CONCLUSION

High prevalence rates for diabetic retinopathy, maculopathy and visual loss were found and associations were identified.

Diabetes care and complications in primary care in the Tshwane district of South Africa

AIMS

To describe the diabetic population receiving primary care from the Tshwane district public health services and to assess the quality of care of members of this population, their level of disease control and the extent of their complications.

METHODS

A cluster-randomised trial was conducted in 12 primary care clinics in Tshwane district. A total of 599 diabetic patients attending these clinics for review were consecutively interviewed and clinically examined. Data on the care received was also obtained from their clinical records for the previous 12 months. Patients randomised to the active arm of the study were screened for complications.

RESULTS

The mean age was 58 years and 80.5% had a body mass index (BMI) ≥25 kg/m(2). Sixty-eight percent of patients were female. Acceptable glycaemic control and LDL-cholesterol were found for only 27% and 33% of patients, respectively (HbA1c<7%; LDL<2.5 mmol/l). Despite more than 79% of patients reporting to be hypertensive, 68% of patients had a systolic blood pressure above 130 mmHg and 64% had a diastolic blood pressure above 80 mmHg. Evaluating patient records of the preceding year, screening for eye complications was only reported in 8.2%, feet complications in 6.5%, kidney complications in 21.4% and cardiovascular complications in 7.8%. The screening prevalences found were 29% for retinopathy, 22% for maculopathy, 5% for neuropathy (neurothesiometer), 7% for nephropathy (eGFR stages 3-5), 17% for possible infarction (Rose questionnaire) and 36% for severe erectile dysfunction (SHIM questionnaire).

CONCLUSION

Diabetes care and screening for complications at primary care level in the Tshwane district were found to be sub-optimal. Measures should be taken to address this.

Screening for dietary fat intake of grade six children: self-assessment vs. maternal assessment

As part of justifiable nutrition promotion, this study aimed to determine internal consistency of a dietary fat screener and to compare self-assessment to maternal assessment of fat intake of grade six (about 12 years old) learners in a South African public primary school. The children completed in school a pictorial, quantitative food frequency-type screener consisting of 10 high-fat food categories; mothers individually completed a text version. Internal consistency was measured with item-total correlations, Cronbach's alpha and the split-half method. Child-mother comparison was based on kappa (κ) statistics, McNemar's tests, Wilcoxon signed-rank test and the Bland-Altman method. In total, 101 (93.5%) children and 78 (72.2%) mothers responded. The screener was internally consistent, regardless of data source and statistical technique. For portion sizes and frequency of intake, children consistently reported higher intake than mothers. This resulted in systematic error, also evidenced by a significant difference from zero for the difference between child's and mother's final test scores for the whole group, and for boys and girls separately (always P < 0.001). In 76% of the pairs, classification into high fat or prudent intake was identical, yet the chance-corrected agreement was poor (κ = 0.16) and non-agreement was non-symmetrical (P = 0.001). Children and mothers reported high fat intakes (93% and 75%, respectively). It was concluded that the dietary fat screener was internally consistent, yet children and mothers did not agree in their assessment. The high fat intakes reported by children and mothers warrant measurement refinement and implementation of primary prevention programmes.

The effect of visual scanning exercises integrated into physiotherapy in patients with unilateral spatial neglect poststroke: a matched-pair randomized control trial

BACKGROUND

Unilateral spatial neglect (USN) is a visual-perceptual disorder that entails the inability to perceive and integrate stimuli on one side of the body, resulting in the neglect of one side of the body. Stroke patients with USN present with extensive functional disability and duration of therapy input.

OBJECTIVE

To determine the effect of saccadic eye movement training with visual scanning exercises (VSEs) integrated with task-specific activities on USN poststroke.

METHODS

A matched-pair randomized control trial was conducted. Subjects were matched according to their functional activity level and allocated to either a control (n = 12) or an experimental group (n = 12). All patients received task-specific activities for a 4-week intervention period. The experimental group received saccadic eye movement training with VSE integrated with task specific activities as an "add on" intervention. Assessments were conducted weekly over the intervention period.

RESULTS

Statistical significant difference was noted on the King-Devick Test (P = .021), Star Cancellation Test (P = .016), and Barthel Index (P = .004).

CONCLUSION

Intensive saccadic eye movement training with VSE integrated with task-specific activities has a significant effect on USN in patients poststroke. Results of this study are supported by findings from previously reviewed literature in the sense that the effect of saccadic eye movement training with VSE as an intervention approach has a significant effect on the visual perceptual processing of participants with USN poststroke. The significant improved visual perceptual processing translate to significantly better visual function and ability to perform activities of daily living following the stroke.