Somasundram Pillay

A deadly combination - HIV and diabetes mellitus: Where are we now?

BACKGROUND The combination of HIV infection and diabetes mellitus (DM) represents a collision of two chronic conditions. Both HIV and DM increase the risk of developing tuberculosis (TB). Health resources in developing countries are already under strain as a result of the TB epidemic and poor diabetic control would further worsen this epidemic. Optimal diabetic control provides one avenue of curbing the TB epidemic in developing countries. OBJECTIVES To establish if there is a difference in blood pressure, lipid and glycaemic control and complications between HIV-infected and uninfected diabetic patients; and to compare characteristics among HIV-infected diabetic patients between those with optimal and sub- optimal glycaemic control. METHODS This was a retrospective chart review of all patients who visited the Edendale Hospital diabetic clinic, Pietermaritzburg, from 1 October 2012 to 30 September 2013. RESULTS There were statistically significant differences noted in the following parameters between HIV-infected and uninfected diabetic patients: (i) mean HbA1c% (11.08% v. 10.14%, respectively); (ii) nephropathy defined by proteinuria (25.66% v. 15.43%); (iii) neuropathy (48.68% v. 42.10%); and (iv) Kidney Disease Outcomes Quality Initiative (KDOQI) stage ≥2 chronic kidney disease (30.87% v. 41.67%). There were no significant differences noted in the percentage of patients achieving the following target parameters between the two cohorts: (i) blood pressure (42.11% v. 35.62%); (ii) total cholesterol (36.84% v. 34.67%); and (iii) triglycerides (42.76% v. 40.19%). Within the HIV-infected diabetic cohort 85.23% displayed suboptimal glycaemic control. A significant percentage of HIV-infected diabetic patients on antiretroviral (ARV) therapy (89.36%) had suboptimal glycaemic control. HIV-infected female diabetic patients showed a significant increased waist circumference when compared with their HIV-uninfected counterparts. CONCLUSION HIV-infected diabetic patients had significantly poorer blood sugar control and a higher incidence of neuropathy and nephropathy (when defined by overt proteinuria). There was a non-significant difference noted between the HIV-infected and uninfected diabetic patients with regard to blood pressure and lipid control. The majority of HIV-infected patients on ARVs failed to achieve target glycaemic control. Obesity remains a global challenge, as noted in both the HIV-infected and uninfected diabetic patients.

Diabetic patients served at a regional level hospital: what is their clinical picture?

Abstract Objectives: We describe the demographics, diabetic characteristics, diabetic control and complications in the diabetes service in Edendale Regional Hospital, Pietermaritzburg, in this study. Diabetes mellitus, together with its complications, is increasing at an alarming rate worldwide. Good glycaemic control translates into lower long-term complications and longer life expectancy. Previous studies performed in both the public and the private sectors have demonstrated that there is suboptimal diabetic control in South Africa. Design: This was a retrospective database analysis. Datasheets were designed to ensure a comprehensive and standardised assessment of patients attending Edendale Hospitals diabetic clinic. Data were stored in a designed-for-purpose database. Subjects and setting: Data from 653 first-visit diabetic patients visiting Edendale Hospitals diabetic clinic between 1 October 2012 and 30 September 2013 were collected. Outcome measures: Glycaemic control, diabetic complications and target blood pressure were the outcome measures studied. Results: A total of 653 first-visit patients were seen, of whom 77.03% were female and 83.40% were type 2 diabetes patients. Only 36.33% of the type 2, and 49.07% of the type 1, diabetes mellitus patients, achieved a target blood pressure of≤140/80 mmHg. Only 1.23% of the type 1, and 11.18% of the type 2, diabetes mellitus patients, achieved optimal glycaemic control, defined as haemoglobin (Hb)A ≤ 7%. The mean HbA in the patients with type 1 diabetes mellitus was 11.82%, and 10.52% in the type 2 diabetes mellitus patients. Conclusion: This study showed the suboptimal control of both diabetes mellitus and hypertension in the clinic, together with high rates of diabetes complications. Obesity remains a major modifiable risk factor in both type 1 and 2 diabetes patients. Blood glucose control in this resource-limited setting was similar in those patients with home blood glucose monitoring versus those without it.

The burden of diabetes mellitus in KwaZulu-Natal’s public sector: A 5-year perspective

BACKGROUND Diabetes mellitus (DM), together with its devastating complications, has a huge impact on both the patients it affects and the global economy as a whole. The economies of developing countries are already under threat from communicable diseases. More needs to be done to stem the tide of non-communicable diseases like DM. In order for us to develop new strategies to tackle this dread disease we need to obtain and analyse as many data as possible from the geographical area where we work. OBJECTIVE To describe the burden of DM in the public sector of the province of KwaZulu-Natal (KZN), South Africa (SA). METHOD Data on the number of diabetes visits, DM patients that were initiated on treatment, defaulters and DM-related amputations were accessed from the Department of Health records for the period 2010 - 2014 inclusive. RESULTS There was a decline in the number of patients initiated on treatment per 100 000 population from 2010 to 2014 inclusive (265.9 v. 197.5 v. 200.7 v. 133.4 v. 148.7). Defaulter rates for 2013 compared with 2014 were 3.31% v. 1.75%, respectively and amputation rates were 0.09% v. 0.05% for 2013 and 2014, respectively. There was a strong proportional relationship observed between the number of defaulters and number of diabetes-related amputations (r=0.801; p=0.000) (Pearson correlation). A notable percentage of DM patients ranging between 63% and 80% were commenced on pharmacological therapy at their local clinics rather than at hospitals in the province. CONCLUSION Strategies directed towards detection and treatment of DM, together with decreasing defaulter rates and thereby decreasing diabetes-related amputations, need to be addressed urgently. The majority of patients were initiated on therapy at the clinic level. This emphasises the need to strengthen our clinics in terms of resources, staffing, and nursing and clinician education, as this is where diabetes control begins. Although this study was based solely in KZN, the second most populous province in SA, it probably reflects the current situation regarding DM in other provinces of SA as well.

Improvement noted after a multifaceted approach to diabetes mellitus management

Background: Optimal control of diabetes mellitus remains elusive, especially in developing countries. A comprehensive and standardised approach, coupled with intensive patient and clinician education, may provide the solution. Methods: Comprehensive datasheets accompanied by patient education from a multidisciplinary team and clinician retraining on diabetes management was introduced into the Edendale Hospital diabetes clinic in 2012. This study compares diabetes control starting October 1, 2012 to September 30, 2013 (Y1) to October 1, 2013 to September 30, 2014 (Y2). Results: Significant changes (p-values < 0.005) were noted in the following parameters between Y2 and Y1 respectively: * Mean HbA1c% (10.41 ± 2.91 vs. 11.26 ± 2.99). * Mean HbA1c in males (9.46 vs. 10.57) and (10.38 vs. 11.19) for females. * Mean HbA1c for type 1 (11.80 vs.10.77) and type 2 patients (10.91 vs.10.10). * Percentage of patients achieving triglyceride control (64.28 vs. 52.85). * Percentage of patients making lifestyle changes and performing home glucose monitoring. * Increase in female waist circumference (97.29 vs. 85.95 cm). * Increase in BMI in males (29.65 vs. 27.92 kg/m2). Conclusion: This multifaceted approach to diabetes care in a resource-limited clinic significantly improved glycaemic and triglyceride control. Obesity remains a major challenge. This model could serve as a blueprint for other such resource-limited clinics.

Introducing a multifaceted approach to the management of diabetes mellitus in resource-limited settings

Globally diabetes mellitus (DM) and its complications are placing an enormous burden on individual patients and countries alike. South Africa is a developing country already under enormous pressure from communicable diseases such as HIV and tuberculosis. Added to this is DM, which serves to fuel the interactions between communicable and non-communicable diseases. Data from KwaZulu-Natal Province (KZN) have demonstrated that the majority of patients with DM in the public healthcare sector are diagnosed and started on treatment at their local resource-limited healthcare clinics. This article describes introduction of a multifaceted approach to the management of DM in a resource-limited clinic at Edendale Hospital, Pietermaritzburg, KZN. Strategies like this may help provide a blueprint for other resource-limited healthcare facilities in developing countries.

Effects of self-monitoring of blood glucose on diabetes control in a resource-limited diabetic clinic

Background: Diabetes mellitus places an enormous burden upon both patients and countries’ health systems. Integral to achieving control is patients assuming responsibility for their condition. Self-monitoring of blood glucose (SMBG) can serve as a powerful tool modifying lifestyle behaviour and can aid in achieving optimal control. Methods: This study assessed the effect on diabetes control in patients who received glucometers and education over 12 months. This data was analysed at baseline, 6 and 12 months. Results: Glycaemic control improved significantly between baseline, 6 and 12 months (HbA1c% 12.29 ± 3.17 vs. 11.16 ± 3.09 vs.±10.68 ± 3.10, respectively). The number of patients achieving target glycaemic control increased substantially while the number of patients achieving target total cholesterol and triglyceride levels improved at six months. Mean HDL cholesterol increased significantly between baseline and 12 months (1.20 ± 0.42 vs. 1.31 ± 0.40, respectively; p-value 0.0095). The mean BMI of male patients in the study increased between 6 and 121 months (27.59 ± 6.42 vs. 31.90 ± 8.85, respectively, p = 0.0012) and between baseline and 12 months (27.64 ± 6.13 vs. 31.90 ± 8.85, respectively, p = 0.0012). Conclusion: This study demonstrated that the introduction of SMBG and patient education, within this resource-limited clinic setting, had beneficial effects on diabetes control; however, obesity remains an obstacle to optimal control.

A retrospective analysis of electrocardiographic abnormalities found in black South African patients with diabetes attending a regional hospital in KwaZulu- Natal

Objectives: Diabetes mellitus increases the risk of coronary heart disease and myocardial infarction (MI). Silent MI occurs with greater frequency in patients with diabetes with or without autonomic neuropathy and carries a similar prognosis to overt MI. Regular electrocardiographic (ECG) assessment is integral in the chronic management of patients with diabetes. Limited data exist on the spectrum of ECG abnormalities of black South African patients with diabetes. The primary aim of this study was a description of ECG abnormalities found and the secondary aim was the determination of factors associated with left ventricular hypertrophy (LVH) and MI. Setting and participants: The study was carried out at a regional hospital diabetes clinic in Pietermaritzburg, KwaZulu-Natal. The initial ECGs performed on patients from October 1, 2012 to September 30, 2014 were analysed. The first ECGs of 637 black South African patients with diabetes were studied, representing 80.1% of all eligible patients. Results: The major ECG abnormalities detected were those suggestive of LVH (36.0%), MI (21.7%), conduction defects (17.7%), T-wave inversion (14.1%) and ventricular ectopics (6.8%). Most infarctions were silent (89.8%), and affected the inferior territory significantly more than anterior, lateral and antero-lateral territories (52.9% vs. 33.3% vs. 9.4% vs. 1. 5%, respectively). A substantial percentage of patients with MI failed to achieve target HbA1c and triglyceride levels and waist-to-height-ratios. Diet, exercise and self-monitoring of glucose were all associated with positive effects on both MI and LVH. A greater percentage of patients with LVH had evidence of MI versus those without hypertrophy (28.4% vs. 19.4%). Conclusion: This study demonstrates a high prevalence of undiagnosed MI within this cohort of South African patients with diabetes. Patients with LVH were more prone to infarction. Poor glycaemic and triglyceride control and obesity were associated with infarction. Improving glycaemic and lipid control together with lifestyle modification may help prevent macrovascular cardiac complications.

The Magnesium and Glucose (MAG) Study: the prevalence and effect of hypomagnesaemia on diabetes control in a regional hospital in KwaZulu-Natal

Background: Diabetes mellitus (DM) poses a great burden of disease worldwide. The adverse effects of hypomagnesaemia (hypoMg2+) in patients with DM have been well described, with a higher prevalence of hypoMg2+ in patients with DM than in the general population (up to 35% vs. up to 15%). No data exist for South Africa (SA). Objectives: The study aimed to determine the prevalence of hypoMg2+ in a cohort of patients visiting a specialised DM clinic and to ascertain whether there is a relationship between hypoMg2+ and glycaemic control and hypoMg2+ and renal dysfunction. Methods: Data recorded on standardised clinical sheets from patients who attended a specialised DM clinic at Edendale Hospital, Pietermaritzburg, SA, over a period of one year (July 1, 2015 to June 30, 2016) were collected. Patient demographics, diabetes type, glycaemic control, serum magnesium (Mg2+) and renal function are presented for statistical analysis. Results: A total of 744 patients were enrolled. Most patients were female (527; 70.8%) and were diagnosed with Type 2 diabetes (DM2) (633; 85.1%) with a mean age of 52.3 (SD 15.6 years). The prevalence of hypoMg2+ was found to be 8.44%. HypoMg2+ was associated with poor glycaemic control (r = –0.16, p < 0.0001). A significant relationship was observed between glycaemic control and hypoMg2+ in males (r = –0.21, p = 0.0038), but not females (r = –0.011, p = 0.81). No significant relationship was evident between hypoMg2+ and renal dysfunction (r = –0.064, p = 0.11). Conclusion: HypoMg2+ in patients with DM was associated with poorer glycaemic control in the male population, potentially increasing the risk of adverse health outcomes. However, the prevalence of hypoMg2+ was not higher than in published data, but population-specific controls are required. No association could be found between hypoMg2+and renal dysfunction. The need for routine Mg2+ testing and supplementation in our population requires further assessment.

Audit of computed tomography brain findings in HIV-infected patients with space occupying infective lesions at a regional level hospital in KwaZulu-Natal

Background: With the increased prevalence of HIV pandemic, more focus is placed on pathology involving the central nervous system secondary to HIV infection. Medical computerised tomography scans have become an integral investigation at a regional hospital level. Objective: To provide a description of central nervous system space occupying infective lesion found within this cohort of patients. Setting: Edendale Hospital, Pietermaritzburg, KwaZulu-Natal. Methods: This was a retrospective study in which the charts of all HIV-infected medical patients with findings of a space occupying infective lesion on computerised tomography brain seen for the time period 1 January 2015 up to and including 31 December 2015 were analysed. A total of 110 patient files were evaluated. Results: Most patients were in the third to fourth decade of life with mean cluster of differentiation 4 of 125 cells/mm3. A differential comprising toxoplasmosis or tuberculoma (80.9%) was the leading aetiology described. Most frequent clinical features in these patients included seizures (41.8%), confusion or altered mental state (38.2%), headaches (33.6%), hemiparesis (48.2%) and cranial nerve abnormality (22.7%). The most common central nervous system sites involved were, in order of decreasing prevalence was parietal, basal ganglia, frontal cortex (31.8% vs 31.8% vs 26.4%, respectively). Early initiation of co-trimoxazole and anti-tuberculosis treatment yielded better outcomes compared to the group who received delayed or no treatment with p-values (Pearson’s χ2) of 0.0002 and <0.0001, respectively. Conclusion: Computerised tomography scans to detect space-occupying infective lesion of the brain are invaluable for rapid diagnosis and to reduce morbidity and mortality.

Atypical chest pain : needles in a haystack : in practice - case report

A 20-year-old man presented with a 6-month history of intermittent chest pain. Initial imaging demonstrated approximately 15 sewing needles lodged in his myocardium, predominantly in the left ventricle. The patient has been referred to cardiothoracic surgery for further management. His progress will be monitored closely.