Diabetes in the public healthcare sector of four South African provinces: A comparative analysis

The growing burden of diabetes has long been under the radar in developing countries such as South Africa (SA). In recent years, there has been an unprecedented and exponential increase in recorded and undiagnosed diabetes mellitus (DM) cases. Unreliable data collection, overburdened health systems and poor infrastructure have all proved to be barriers to achieving optimum disease management. The District Health Information System (DHIS) serves as the data collection tool for the SA public healthcare sector. It is used in all nine SA provinces to gather data without individual patient identifiers. Objective. To analyse and compare the DM data collected by the DHIS in the Western Cape (WC), Eastern Cape (EC), KwaZulu-Natal (KZN) and Gauteng provinces of SA. Methods. An audit of diabetes-related data from the DHIS for 2016 was conducted. The data were then analysed using Excel. Time-series and cross-sectional analyses were made possible using pivot tables. Graphics were designed using Thinkcell software. Results. Of the four provinces surveyed, Gauteng recorded the highest incidence of DM, 67% higher than the reported global DM incidence estimate, while the WC had the lowest incidence. A similar pattern was also noted regarding the incidence of DM in people aged <18 years, with Gauteng having the highest and WC the lowest prevalence results. When comparing the number of DM-related consultations conducted in each province, the metropolitan districts were highlighted as hotspots of activity for DM care. This study found a moderate inversely proportional relationship between the incidence of DM in all provinces and education deprivation (p<0.05). Among the provinces that collected data on screening (excluding EC), KZN recorded the highest number of diabetic screenings. Conclusion. Metropolitan areas were highlighted as areas to be targeted, further reinforcing the current connection observed between urbanisation and DM in SA. The presence and recording of screening efforts is an excellent step in the right direction for the SA public healthcare sector and the DHIS. With improved interprovincial co-ordination regarding standardisation of the criteria and specifications of data collection fields, and enhanced training for data officers and primary collection agents, good quality and rich data is a very close possibility.

Quantifying the relationship of HIV infection with clinicopathological spectrum and outcome among patients with colorectal cancer in a South African population

Introduction: Literature is limited on HIV and colorectal cancer (CRC) in sub-Saharan Africa despite it being the epicentre of the HIV epidemic, Purpose: To compare clinicopathological features and outcome of CRC in HIV-negative and HIV-positive patients. Methods: Retrospective analysis of a prospective CRC database. Demographic details, HIV status, anatomical site, disease stage, treatment and follow-up were documented. Results: Of 715 patients with CRC, 145 and 570 tested positive and negative respectively for HIV. Median age was 45 (IQR 36-53 and 57 (IQR 45-66) years among HIV-positive and HIV-negative patients respectively (p<0.0001). Tumour differentiation differed between the two groups (p=0.003) but staging was not different (p=0.6). Surgical resection rate was 52% for HIV-positive patients versus 59% for HIV-negative patients (p=0.07). Median follow-up was 9 (IQR 2-20.5) months for HIV-positive patients and 12 (IQR 6-29) months for HIV-negative patients (p=0.154). Recurrence rate was 14.7% among HIV positive patients and 6.8% in HIV negative patients (p=0.089). Conclusion: When compared with HIV-negative patients, HIV-positive patients with CRC presented at a younger age and tended to have lower surgical resection rates. There was no difference between the two groups with CRC in terms of anatomical sub-site distribution, disease staging and recurrence rates

Symptomatic congenital syphilis in a tertiary neonatal unit in Cape Town, South Africa: High morbidity and mortality in a preventable disease

Background. Despite preventive measures and effective treatment, congenital syphilis continues to impact significantly on neonatal morbidity and mortality. There has been no recent South African (SA) published literature reviewing congenital syphilis, particularly in the context of a tertiary neonatal setting. Objectives. To describe the clinical features of symptomatic neonates with congenital syphilis and to identify modifiable patient, clinical and health facility factors that contributed to syphilis infection. Methods. All positive serological tests for syphilis performed in neonates at Groote Schuur Hospital (GSH), Cape Town, SA, between 1 January 2011 and 31 December 2013 were obtained. Folders were reviewed, and neonates with clinical signs of congenital syphilis were included. Results. Of 50 symptomatic neonates, 19 (38%) died. Twenty-eight mothers (56%) were unbooked and therefore received no antenatal care. Most mothers (98%) were inadequately treated. Health worker-related failures included poor notification and partner tracing as well as failure to recheck syphilis serology after 32 weeks' gestation in mothers who initially tested negative. Thirty-four neonates required intensive care unit admission. Two significant predictors of mortality were 1-minute and 5-minute Apgar scores <5. Hydrops fetalis was an independent risk factor for mortality, as were moderate to severely abnormal cranial ultrasound scan findings. Conclusions. Congenital syphilis in neonates admitted to the GSH neonatal unit was associated with substantial morbidity and mortality. The modifiable factors identified represent inadequate antenatal healthcare and health system failures. These factors are longstanding, highlighting the need to establish governance and audit processes and address the continuing socioeconomic and sociocultural barriers that mothers face as a way forward in ultimately eliminating this entirely preventable disease

Relationship between magnesium and lipids in patients with diabetes mellitus

Introduction: Non-communicable diseases, especially cardiovascular diseases (CVD), have become more prevalent across the world, more so in developing countries. Novel methods in the management of CVD risks in patients with diabetes mellitus, type 2 (DM2) requires constant attention and an ever-evolving approach. The role of magnesium supplementation in the management of CVD has been described, but the relationship between serum magnesium (Mg) and the lipid subsets have had conflicting results in different population groups. Methods: A cross-sectional study was performed by collecting data on patients with DM2 from a specialised diabetes clinic at Edendale Hospital, Pietermaritzburg, KwaZulu-Natal, South Africa, between July 1, 2015 and June 30, 2016. Lipid subsets (total cholesterol [TC], high-density lipoprotein cholesterol [HDL], low-density lipoprotein cholesterol [LDL] and triglycerides [TG]), age, sex and Mg were recorded for analysis. Results: A total of 495 clinical data sheets were analysed. The majority of participants were female (73.45%) with a mean age of 56.97 years. A statistically significant, positive, linear relationship was found between Mg and TC (R= 0.11;p= 0.01) as well as Mg and LDL R= 0.14;p= 0.001), but not between Mg and HDL (R= 0.02;p= 0.66) and Mg and TG (R= 0.01;p= 0.82). Discussion: The results of this study are similar to findings by a group of researchers in China and differ when compared with studies observing Caucasian patients. It is plausible that intrinsic ethnic differences in lipid metabolism and the various ways in which magnesium requiring enzymatic processes are utilised may be responsible for the results found in the present study population versus those found in Caucasian study participants in other countries. More research is required to determine the effect of magnesium supplementation and CVD outcomes in the present study population

CRISPR: Challenges to South African biotechnology law

Genome editing using newly discovered tools such as CRISPR-Cas9 offers the potential to modify the genetic make-up of plants, non-human animals and humans in exact ways. Such genetic modification can serve the purpose of correcting gene defects, and can enhance certain characteristics. Apart from reigniting old ethical debates, genome editing also poses a particular challenge to legal practitioners, as this new technology does not always fit into existing definitional moulds, and it lacks clear legal precedent. In this article, we identify the most salient areas of concern in the South African legal context

The morphometry of the angle of mandible and its correlation with age and sex in the Ethekwini Metropolitan Region: a panoramic study / Morfometría del angulo de la mandíbula y su correlación con edad y sexo en la región metropolitana Ethekwini: un estudio panorámico

The angle of mandible is formed by the tangent line joining the posterior margin of the ramus and the base of the mandible. The angle of mandible has population-specific characteristics therefore; it is imperative to the field of forensic anthropology for age and sex determination. Literary reports regarding the use of the angle of mandible for age and sex determination vary, as some studies support it, while other studies have documented inefficiencies. Therefore, the aim of this investigation was to document the morphometry of the angle of mandible and to determine if a correlation between the angle of mandible, age and sex exists. Sixty four digital panoramic radiographs (n=128) of individuals between 16-30 years were morphometrically analysed using the Dicom Digital Imaging Software. The data was captured and analysed using the Statistical Package for Social Science (SPSS version 23.0). Despite females having a greater angle of mandible than males, no statistically significant correlation was found between the size of the angle of mandible and sex (p=0.088). The angle of mandible was observed to decrease with advancement of age, however only the 16-19 year age cohort displayed a statistically significant correlation with the size of the angle of mandible (p=0.006). Therefore, this study concluded that the angle of mandible may not be a useful indicator of sex, but may be a reliable indicator of age for individuals between 16-19 years in the eThekwini Metropolitan region.

El ángulo de la mandíbula está formado por la línea tangente que une el margen posterior de la rama y la base de la mandíbula. El ángulo de la mandíbula tiene características específicas según la población; es imperativo en el área de la antropología forense para la determinación de la edad y género. Los informes literarios sobre el uso del ángulo de la mandíbula para la determinación de edad y género varían, según algunos estudios que lo apoyan, mientras que otros estudios han documentado ineficiencias. El objetivo de esta investigación fue documentar la morfometría del ángulo de la mandíbula y determinar si existe una correlación entre el ángulo de la mandíbula, la edad y el sexo. Se analizaron 64 radiografías panorámicas digitales (n = 128) de individuos entre 16-30 años morfométricamente utilizando el software Dicom Digital Imaging. Los datos fueron capturados y analizados utilizando el Paquete Estadístico para Ciencias Sociales (SPSS versión 23.0). A pesar de que las mujeres tenían un ángulo de la mandíbula mayor que los hombres, no se encontró una correlación estadísticamente significativa entre el tamaño del ángulo de la mandíbula y el sexo (p = 0,088). Se observó que el ángulo de la mandíbula disminuyó con el avance de la edad, y solamente la cohorte de edades de 16-19 años mostró una correlación estadísticamente significativa con el tamaño del ángulo de la mandíbula (p = 0,006). Por lo tanto, este estudio concluyó que el ángulo de la mandíbula puede no ser un indicador útil de sexo, pero puede ser un indicador confiable de edad para individuos entre 16-19 años en la región metropolitana de eThekwini.

Implementation and outcome evaluation of the medical education partnership initiative biostatistical reasoning workshops for faculty and postgraduate students at the university of kwazulu-natal; durban; south africa

Background. There is a shortage of biostatistics expertise at the University of KwaZulu-Natal (UKZN); Durban; South Africa and in the African region. This constrains the ability to carry out high-quality health research in the region.Objectives. To quantitatively and qualitatively evaluate a programme designed to improve the conceptual and critical understanding of bio statistical concepts of UKZN health researchers.Methods. A 40-hour workshop in biostatistical reasoning was conducted annually between 2012 and 2015. The workshops were structured around interpretation and critical assessment of nine articles from the medical literature; with a mix of in-class sessions and small group discussions. Quantitative evaluation of the knowledge gained from the workshops was carried out using a pre- and post-workshop quiz; and qualitative evaluation of the workshop process was done using a mid-workshop questionnaire and focus group discussions.Results. For each year that the workshop was conducted; post-workshop quiz scores were significantly higher than pre-workshop scores. When quiz assessments from all 4 years of training were combined; the pretest median score was 55% (interquartile range (IQR) 40 - 62%) and the post-test median score was 68% (IQR 62 - 76%); with p0.0001 for the overall comparison of pre- v. post-scores. There was a general consensus among participants that the workshop improved their reasoning skills in biostatistics. Participants also recognised the value of the workshop in building biostatical capacity at UKZN. Conclusion. The workshops were well received and improved the critical and conceptual understanding of the participants. This education mode offers the opportunity for health researchers to advance their knowledge in settings where there are few professional biostatistician collaborators

Predictors of site choice and eventual learning experiences in a decentralised training programme designed to prepare medical students for careers in underserved areas in south Africa

Background. There is a dire need for medical schools in South Africa to train medical doctors who have the capacity and willingness to work in primary healthcare facilities; particularly in rural areas. Objectives. To assess the effect of students' gender; race; place of birth and place of high school completion on their choice of training site location and to assess the extent to which the training programme enhanced students' learning experiences relevant to primary care across training sites. Methods. A survey design involving six cohorts of 4th-year undergraduate medical students (N=187) who were part of the 2013 Family Medicine rotation at the Nelson R Mandela School of Medicine. Self-administered questionnaires were completed by students at the end of each rotation. Data analyses involved descriptive computations and inferential statistical tests; including non-parametric tests for group comparison and generalised polynomial logistic regression. Results. Students believed that their knowledge and skills relevant to primary care increased after the rotation (p0.0001). There were statistically significant differences between rural and urban sites on certain measures of perceived programme effectiveness. Male students were less likely to choose urban sites. Black students were less likely to choose rural sites compared with their white and Indian counterparts; as were students who attended rural high schools (odds ratio (OR) 9.3; p0.001). Students from a rural upbringing were also less likely to choose rural sites (OR 14; p0.001). Conclusion. Based on the findings; an objective approach for student allocation that considers students' background and individual-level characteristics is recommended to maximise learning experiences

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