Dg Van Zyl

Fluid management in diabetic-acidosis--Ringer's lactate versus normal saline: a randomized controlled trial.

OBJECTIVE To determine if Ringers lactate is superior to 0.9% sodium chloride solution for resolution of acidosis in the management of diabetic ketoacidosis (DKA). DESIGN Parallel double blind randomized controlled trial. METHODS Patients presenting with DKA at Kalafong and Steve Biko Academic hospitals were recruited for inclusion in this study if they were >18 years of age, had a venous pH >6.9 and ≤7.2, a blood glucose of >13 mmol/l and had urine ketones of ≥2+. All patients had to be alert enough to give informed consent and should have received <1 l of resuscitation fluid prior to enrolment. RESULTS Fifty-seven patients were randomly allocated, 29 were allocated to receive 0.9% sodium chloride solution and 28 to receive Ringers lactate (of which 27 were included in the analysis in each group). An adjusted Cox proportional hazards analysis was done to compare the time to normalization of pH between the 0.9% sodium chloride solution and Ringers lactate groups. The hazard ratio (Ringers compared with 0.9% sodium chloride solution) for time to venous pH normalization (pH = 7.32) was 1.863 (95% CI 0.937-3.705, P = 0.076). The median time to reach a pH of 7.32 for the 0.9% sodium chloride solution group was 683 min (95% CI 378-988) (IQR: 435-1095 min) and for Ringers lactate solution 540 min (95% CI 184-896, P = 0.251). The unadjusted time to lower blood glucose to 14 mmol/l was significantly longer in the Ringers lactate solution group (410 min, IQR: 240-540) than the 0.9% sodium chloride solution group (300 min, IQR: 235-420, P = 0.044). No difference could be demonstrated between the Ringers lactate and 0.9% sodium chloride solution groups in the time to resolution of DKA (based on the ADA criteria) (unadjusted: P = 0.934, adjusted: P = 0.758) CONCLUSION This study failed to indicate benefit from using Ringers lactate solution compared to 0.9% sodium chloride solution regarding time to normalization of pH in patients with DKA. The time to reach a blood glucose level of 14 mmol/l took significantly longer with the Ringers lactate solution.

The mechanism of action of oral antidiabetic drugs : a review of recent literature

Type 2 diabetes mellitus (DM) is a disorder that is placing an increasing burden on health service delivery worldwide. Consequently, it has become increasingly important that physicians who treat such patients have a good knowledge of antidiabetic drugs that are currently available or will come onto the market. This article presents an overview of all the major drug classes as well as some information on pharmacokinetics, pharmacodynamics, side-effect profiles and indications for use.Type 2 diabetes mellitus (DM) is a disorder that is placing an increasing burden on health service delivery worldwide. Consequently, it has become increasingly important that physicians who treat such patients have a good knowledge of antidiabetic drugs that are currently available or will come onto the market. This article presents an overview of all the major drug classes as well as some information on pharmacokinetics, pharmacodynamics, side-effect profiles and indications for use.

Physician education programme improves quality of diabetes care

Background. Diabetes mellitus is a common chronic disease needing long-term glycaemic control to prevent complications. Guidelines are available for achievement of optimal glycaemic control, but these are seldom properly instituted. Objectives. To determine if a physician education programme and a structured consultation schedule would improve the quality of diabetes patient care in a diabetes clinic. Setting. Two tertiary care diabetes clinics at Kalafong Hospital, Pretoria. Study design. Quasi-experimental controlled before-and after study. Methods. A baseline audit of the quality of care in two comparable diabetes clinics was performed. Three hundred patients were randomly selected for an audit of their hospital records: 141 from the intervention and 159 from the control clinics. Thereafter a physician training programme and a structured consultation schedule were introduced to the intervention clinic and maintained for a 1-year period. The control clinic continued with care as usual. Process and outcome measures were determined at a post-intervention audit and compared between the two groups. Consultation time was measured for both the intervention and control groups and data were compared. Results. At baseline the intervention and control groups did not differ significantly with regard to process and outcome measures. After intervention the intervention group had significantly higher process measure scores than the control group (p < 0.01). HbA1c did not significantly differ between the two groups (p = 0.60). The average number of clinic visits reduced over time for the intervention group compared with the control group (p < 0.01), but the average consultation times were significantly longer (p < 0.01). Conclusion. The introduction of a physician education programme and a structured consultation schedule improved the quality of care delivered at a tertiary care diabetes clinic.

Factors Influencing Non-Attendance of Clinic Appointments in Diabetic Patients at a Gauteng Hospital in 2007/2008

Abstract Objective: To determine the factors influencing non-attendance with clinic appointments in diabetic patients at a Gauteng Hospital in 2007/2008. Setting: Two diabetes clinics situated at a secondary-level hospital, that offer more specialised outpatient care to adult patients with type 1 and 2 diabetes. Design: Between 21 November 2007 and 12 March 2008, a convenience sample of consecutive non-attending diabetic patients (n = 76) was prospectively recruited for the study. A survey of the non-attending patients was conducted, using two data collection methods, namely face-to-face interviews and telephone interviews. Patient demographics, reasons for non-attendance, perceived severity of diabetes, and perceived encouragement from others to attend were investigated. The characteristics of the non-attending patients and the reasons for non-attendance were explored. Results: Of the 520 patients who were booked during the study period, 35% were not compliant with their clinic visit. The mean age of the patients was 51 years (range 18–85). All patients perceived diabetes to be a serious disease. Of the interviewed patients, 83% perceived their health to be either good or excellent, and 95% claimed that a clinic visit assisted them in managing their diabetes. Only 20% of the patients diarised their appointment dates, while the rest simply used the appointment card given by the clinic. Patients had various reasons for not complying with their clinic appointments, with forgetting being the most frequently dominant response (22%). Conclusion: Forgetfulness, which was found to be the major cause of non-attendance, can easily be addressed in ensuring the attendance of scheduled clinic visits.

Diagnosis and Treatment of Diabetic Ketoacidosis

Diabetic ketoacidosis (DKA) is the most frequent hyperglycaemic acute diabetic complication. Furthermore it carries a significant risk of death, which can be prevented by early and effective management. All physicians, irrespective of the discipline they are working in and whether in primary, secondary or tertiary care institutions, should be able to recognise DKA early and initiate management immediately.Abstract Diabetic ketoacidosis (DKA) is the most frequent hyperglycaemic acute diabetic complication. Furthermore it carries a significant risk of death, which can be prevented by early and effective management. All physicians, irrespective of the discipline they are working in and whether in primary, secondary or tertiary care institutions, should be able to recognise DKA early and initiate management immediately.

Optimal glucose control in type 2 diabetes mellitus – a guide for the family practitioner

Type 2 diabetes contributes to significant risk of cardiovascular and microvascular complications. The pharmacist can play a significant role in the management of glycaemic control and thereby reducing the related morbidity and mortality. Monitoring of blood glucose control has become an integral part of disease management that can empower patients and primary health care workers to optimise blood glucose management. Numerous drugs are currently available to treat type 2 diabetic patients. The role of the currently available drugs is discussed as well as the use of insulin. A suggested protocol for the initiation and adjustment of treatment is provided.Abstract Type 2 diabetes contributes to significant risk of cardiovascular and micro-vascular complications. The family practitioner plays a significant role in the management of glycaemic control and thereby reducing the related morbidity and mortality. Monitoring of blood glucose control has become an integral part of disease management that can empower patients and physicians to optimal blood glucose management. Numerous drugs are currently available to treat type 2 diabetic patients. The role of the currently available drugs is discussed as well as the use of insulin. A suggested protocol for the initiation and adjustment of treatment is provided.

Obstructive sleep apnoea in pregnancy and its association with pre-eclampsia

Background: Obstructive sleep apnoea (OSA) in pregnancy is associated with an increased morbidity and mortality to both mother and foetus. In the South African setting the proportion of pregnant females suffering from OSA has not been well studied; nor has the association with pre-eclampsia. This study aimed to determine the prevalence of OSA in females before 35 weeks gestation using the STOP-BANG questionnaire and to determine the association with pre-eclampsia in a local South African setting. Methods: A cross-sectional analytical study including 234 patients was conveniently sampled from Kalafong Hospital’s antenatal ward, clinic and labour ward. Participants were of more than 20 weeks and less than 35 weeks gestation. All participants were interviewed with a modified STOP-BANG questionnaire. Patients were consecutively enrolled without prior knowledge of the presence of pre-eclampsia. At Kalafong hospital all pregnant patients are routinely screened and investigated for pre-eclampsia according to standard criteria. Results: The median gestational age in this sample was 28 weeks; 80.3% (CI 74.62–85.2%) of pregnant females had a low risk for OSA, 15.4% (CI 11.01–20.65%) had an intermediate risk and 3% (CI 6.47–14.58%) had a high risk for OSA. A modified STOP-BANG questionnaire had a sensitivity of 62.5% and a specificity of 82.1% for pre-eclampsia when a score of 3 and more was scored. Females at high risk of OSA had an OR of 8.4 (CI 2.88–24.6) for having pre-eclampsia. Conclusions: The authors report 15.4% of the study’s pregnant population to be at intermediate risk and 3% at high risk of OSA. The association between the hypertensive disorders and OSA must be considered and screening implementation considered.

Diabetic nephropathy in a tertiary care clinic in South Africa: a cross-sectional study

Abstract Objective: The aim of this study was to determine the prevalence of micro- or macroalbuminuria in type 1 and type 2 diabetic patients, and to examine the relationship with the diabetes control parameters such as haemoglobin (Hb)A1c, blood pressure (BP) and lipids. Design: This was an analytical cross-sectional study. Setting and subjects: The study consisted of 754 patients with either type 1 or type 2 diabetes, attending a diabetes clinic at the Kalafong Hospital in Pretoria, South Africa. Outcome measures: Micro- or macroalbuminuria and estimated glomerular filtration rate (eGFR) were the outcome measures. Results: An HbA1c > 7% was recorded in 88.9% of the patients, and low-density lipoprotein cholesterol ≥ 1.8 mmol/l in 81%. Overall, the prevalence of micro- or macroalbuminuria was 33.6%. Logistic regression revealed that HbA1c, the duration of diabetes, systolic BP, male sex and triglycerides were predictive of microalbuminuria. Conclusion: The prevalence of micro- or macroalbuminuria in this study fell within the ranges of what has previously been reported in Africa. HbA1c and the duration of diabetes were the strongest predictors of microalbuminuria in all of the patients, and age was the strongest predictor of a low eGFR. Diabetes was poorly controlled, making the progression to end-stage renal failure a real concern in these patients.

Inpatient blood glucose management of diabetic patients in a large secondary hospital

Abstract Background: Diabetes has become a major health problem worldwide, as well as in South Africa. This, coupled with the chronicity of the disease, relate to an increasing burden on health care facilities and an increasing number of hospital admissions of patients suffering from diabetes. Admissions are mostly related to diabetes itself, but the frequency of admissions for problems not related to diabetes is increasing as the prevalence of diabetes increases in the population. Proper inpatient glycaemic management is important for improving patient outcome and for reducing the risk of inpatient complications. Objectives: The objective of this study was to evaluate current practices in the care of diabetic inpatients as well as to assess the glycaemic control that is achieved during hospitalisation. Methods: An audit was done of clinical hospital records of adult diabetic patients admitted to Kalafong Hospital, a large secondary hospital in South Africa. All patients admitted who had type 1 or type 2 diabetes before admission, or who were newly diagnosed on admission or in hospital were included, irrespective of the discipline to which the patient was admitted. All patient admissions in the eight-month period preceding the initiation of the audit were included. Results: The hospital records of 164 diabetic patients were audited. With regard to glucose monitoring, 60.8% of patients had irregular and erratic glucose monitoring, 37.2% had regular (either four- or six-hourly) monitoring and only 2% were monitored in relation to meals. Of the 164 patients, 160 were not fasting, 27 were treated with an insulin sliding scale at some stage during their admission, and in 14 (52%) of the patients who were on sliding scales the scale was used inappropriately. Most hospital inpatients with diabetes, i.e. 48 (30.4%), were treated with oral agents only; 29 (18.4%) were treated with oral agents plus a daily dose of NPH insulin and 17 (10.8%) with mixed insulin twice daily. Only three patients (1.9%) received insulin supplemental to their regimen. The glycaemic control treatment schedule was appropriate in only 19.5% of cases. Conclusions: Based on our findings, the monitoring and management of blood glucose in patients with diabetes during hospitalisation in a large secondary hospital in South Africa is currently inadequate. This calls for an educational intervention for doctors and nurses working with diabetic inpatients as well as the introduction of a blood glucose management protocol.