Myanmar diabetes care model: Bridging the gap between urban and rural healthcare delivery / Journal of the ASEAN Federation of Endocrine Societies

@#There has been significant magnitude of problems of diabetes in Myanmar, according to the estimates of International Diabetes Federation (IDF) and the recent National Survey on the prevalence of diabetes. There has been a wide gap of equity between the urban and rural healthcare delivery for diabetes. Myanmar Diabetes Care Model (MMDCM) aims to deliver equitable diabetes care throughout the country, to stem the tide of rising burden of diabetes and also to facilitate to achieve the targets of the Global Action Plan for the Prevention and Control of NCDs (2013-2020). It is aimed to deliver standard of care for diabetes through the health system strengthening at all level. MMDCM was developed based on the available health system, resources and the country's need. Implementation for the model was also discussed.

Summary of Myanmar clinical practice guidelines on the management of Dyslipidaemia in Type 2 Diabetes Mellitus / Journal of the ASEAN Federation of Endocrine Societies

@#Cardiovascular disease is a significant cause of morbidity and mortality in patients with diabetes mellitus (DM). According to the IDF Diabetes Atlas 2013, the prevalence of diabetes in Myanmar is 5.7%.(1) Diabetes is recognized as a risk equivalent for coronary heart disease. The lipid profile in patients with type 2 DM is characterized by elevated triglycerides, low high-density lipoprotein cholesterol and raised small dense low-density lipoprotein cholesterol (LDL-C) particles. This is believed to be a key factor in promoting atherosclerosis in these patients. There is ample evidence that aggressive statin therapy reduces cardiovascular end points in patients with DM in both primary and secondary prevention studies. In all persons with DM, current treatment guidelines recommend reduction of LDLC to less than 100 mg/dL, regardless of baseline lipid levels. In very high risk patients with DM and coronary heart disease lowering of LDL-C to less than 70 mg/dL may provide even greater benefits. Treatment for hypertriglyceridaemia is recommended only if TG levels is very high (>500 mg/dL).

Knowledge, attitude, practice and behaviour among attendants of HIV/AIDS patients in Mandalay General Hospital

HIV/AIDS epidemic is a global phenomena, still highly dynamic unstable and challenging the world. Coping with this problems entirely depends on changing individual and collective human behaviour. A total of 144 attendants of hospitalized HIV/AIDS patients were interviewed in Medical Unit II, Mandalay General Hospital with questionnaire to obtain information for his KAPB study of HIV/AIDS disease. This was a one year study starting from august 1995. Most of them knew mode of transmissions were by sex and improperly sterlized syringes and needles, ie., 77.74 per cent. Regarding the major diagnostic criteria for AIDS, 55.3 per cent, 30.49 per cent and 30.48 per cent of attendants could identify weight loss, chronic diarrhoea and fever more than one months as criteria. It is surprising that only 36.17 per cent and 46.42 per cent of attendants knew that condom use and gloves can prevent the transmission of disease. About 23.88 per cent of them have never heard about HIV/AIDS. but 25.27 per cent of attendants obtained information about HIV/AIDS from TV and Video. 13.43 per cent from magazines. 20 per cent from third person and 7.46 per cent from newspapers. Most of them felt that HIV/AIDS is a stigmata disease as 72.91 per cent of people think that they will be outcasts and 72.41 per cent felt they will lose their jobs if they have such disease. It is encouraging to know that approximately 65 per cent of attendants did not reject their patients and were willing to stay in the same house with them. Some of them have risk behaviour like IVDU (1.37 per cent) at one time, 26.20 per cent have experienced with extramarital sex and 2.75 per cent never used condom in extramarital sex. It is interesting that 64.88 per cent of people have had first sexual experience before the age of 25 and 20.13 per cent have had before 18 years of age. It seems that the level of knowledge of the public regarding HIV/AIDS is still insufficient and unsatisfactory. We need to give intensive health education aimed at target groups and emphasis should be on the under 18 age group.

A case control study on the risk factors for diabetes mellitus

The development of prevention programs for non insulin dependent diabetes mellitus is greatly needed. Before such programs are implemented, proper community assessment is essential and this includes a knowledge of relevant risk factors for non insulin dependent diabetes. To determine such risk factors, a study was done on 118 cases of diabetes mellitus from Diabetic Clinic and Wards 1 & 2, Yangon General Hospital. A questionnaire of the patient's family history and drug history, smoking and alcohol history among others were noted. Statistical analysis was done by Odds ratio and 95 percent confidence interval of Odds ratio. In this study significant risk factors for diabetes were physical inactivity, family history of diabetes, especially parenteral, history of taking diuretics and dietary excesses like high carbohydrate and high fat diet. We recommend that exercise be an adjunct to proper diet and weight control for the prevention of non insulin dependent diabetes mellitus.

A clinical profile of diabetic polyneuropathy in Mandalay General Hospital

A cross-sectional study of risk factors, associated complications and nerve conduction studies on diabetic polyneuropathy was conducted on 68 diabetics with and without clinical evidence of polyneuropathy in Mandalay General Hospital over a 9-month study period. Diabetic polyneuropathy was seen in older age groups. the duration of diabetes is a significant risk fator for diabetic polyneuropathy. there was no association with fasting blood sugar levels, smoking, hypertension and hypercholestrolaemia in our study. Diabetic polyneuropathy has increased association with retinopathy, though ischaemic heart disease and nephropathy have no association in our study. On performing nerve conduction studies, diabetic polyneuropathy patients have significantly lower nerve conduction velocity than those without polyneuropathy. Subclinical polyneuropathy was detected in 15 per cent of diabetic cases, without clinical evidence of polyneuropathy. It is concluded that early detection of diabetic subclinical polyneuropathy is possible with electrophysiologic studies. Early detection of subclinical polyneuropathy and early detection and alleviation of risk factors and intensive therapy to control blood glucose may prevent irreversible nerve damage and associated complications.

A study of HbA1c in diabetics of Mandalay General Hospital

The Diabetes Control and Complications Trial (DCCT) demonstrated that in insulin dependent diabetes mellitus, the incidence of retinopathy, nephropathy and neuropathy could be reduced by intensive treatment and reduction of blood glucose concentration and glycosylated haemoglobin values to normal. the present methods of assessing diabetic control ed. urine glucose measurements or random blood glucose estimations tend to be unreliable. They only relate to blood glucose control over the preceding few hours, or minutes respectively. The newly avail-able measurement of the degree of glycosylation of haemoglobin provides an index of integrated plasma glucose levels over a longer period of time, and a completely new tool to aid clinicians. Ninety-six diabetic cases from Medical Unit II and diabetic clinic, Mandalay General Hospital were studied over a 10-month study period from October 1994. Fasting blood sugar and HbA1c levels of patients with and without diabetic complications and risk factors were compared. There is a positive correlation between fasting blood sugar and HbA1c levels in this study. However, there is no significant difference in fasting blood sugar and HbA1c levels of diabetic patients with and without complications as patients were taking regular treatment and follow-up at the diabetic clinic. The mean duration of diabetes in diabetics with and without complications was 6.58 years and 2.69 years respectively. Patients with complications had a significantly longer duration of diabetes although their fasting blood sugar and HbA1c levels are level with those of patients without diabetic complications. This supports the evidence that long-term complications of diabetes are not solely dependent on glycaemic control and duration of diabetes plays an important role. Statistical analysis was done by correlation coefficient and Student's 't' test.

Knowledge, attitudes and behaviours on HIV infection/AIDS among clinical students and house surgeons in Mandalay

Data were collected to assess the current level of knowledge, attitude towards prevention and actual practices among clinical students and house surgeons in Mandalay in 1994. It was found that there were class related differences in KAP scores of medical students. In addition, they could correctly answer the difference between AIDS and HIV infection as their education advanced (Chi=45.55, p < 0.005), but there was no difference with regard to knowledge of AIDS counselling (p > 0.1) and the use of condom (p > 0.1). Only 49.5 percent would like to take care of AIDS patients in their wards. To avoid treating AIDS patients is the main reason in 38.6 percent of them. At the same time, 23 percent of students believed that AIDS should be prevented by isolating HIV infected cases. Percentage of presence of risk behaviour are nearly the same for the three different clases. 27.2 percent of students had heterosex and among them, 51.1 percent reported always using condom while 10.2 percent reported never using condom at all. It may be due to the misperception about the transmission or inability to break down the lod socio-cultural constraints or just due to the fact that information increases knowledge but does not change behaviour. An integrated and comprehensive educational programme and periodic feedback is recommended.

A Clinical profile of HIV infection in Mandalay General Hospital (one year study from 16-9-94)

It is now recognised that HIV infection is increasing and a major cause for concern in Myanmar. There is no cure for HIV infection and the only hope of controlling the AIDS epidemic have a responsibility to understand the relevant facts about HIV and to act as educators for their patients. A prospective one year study of HIV seropositive patients admitted to medical unit two of Mandalay General Hospital was commenced on September 1994. The objectives of this study was to study the demographic data, the personal history and clinical presentations of these patients so as to enable the health professionals and health educators to understand more about HIV infection in Myanmar. A total of 62, HIV seropositive patients were included in this study. 48 patients (77.4 percent) were diagnosed as AIDS according to the Myanmar diagnostic criteria. The amle female ratio was 9.3:1, 75.8 percent were in the 21-40 years of age group, 48 percent were single, 48 percent were gave history of travel to Pharkant Town in Kachin State. 77.4 percent were from Mandalay Division. 56.4 percent wre labourers, hawkers and had no fixed work. 59.7 percent were IVDU. 51.6 percent had multiple sex partners. Of the major criteria prolonged fever was present in 82 percent, marked weight loss 74 percent and chronic diarrhoea 38.7 percent. Of the minor criteria, oral thrush was present in 66 percent, lymphadenopathy 40 percent and persistent cough 32 percent. the commonest associated diseases were Koch's lungs 17.7 percent and uncomplicated malaria 16 percent followed by cerebral malaria 9.7 percent and meningitis 8.1 percent. 3.7 percent had cryptococcal meningitis. Mortality was 41.9 percent. The mainstay of prevention continues to be health education campaigns based around the message of safer sex. It is recommended that health education programs be enhanced in Myanmar.

A comparative study of YGH index and Wayne's index in the diagnosis of thyrotoxicosis

This study was done during 1992 to 1994. the patients were in-patients of Wards 1 & 2 and those referred from the Nuclear Medicine Department of Yangon General Hospital. they all were clinically thyrotoxic patients confirmed by either high uptake of radioactive iodine or high serum T3 and T4 levels. We took proper history taking and did thorough clinical examination for all patients. Then we recorded the findings and counted the scores for each patient according to YGH index and WAYNE index for diagnosis of thyrotoxicosis. The total numberr of patients studied was 138. Mean age was 36.5 years. The sensitivity of YGHindex was 93.47 percent. The sensitivity of WAYNE index was 89.85 percent. The difference between the sensitivities of two scoring systems was not significant statistically. Therefore, both scoring systems can be applied with the nearly same sensitivity in the clinical diagnosis of thyrotoxicosis.

Association of chronic complications of diabetes mellitus and presence of risk factors

Chronic complications of diabetes are known to be associated with certain risk factors. Once complications develop, they will never regress, denoting that reduction of these factors as much as possible, is the best way to deter the complications. To determine such risk factors, a study was done on diabetic patients with a ample size of 315 from Diabetic Clinic and Ward 1 + 2, Yanton General Hospital. There were 281 NIDDM and 341 IDDM patients. The study on NIDDM patients shows that physical inactivity and age of the patients were associated with the development of retinopathy. The following factors were identified as being associated: hypertension, high serum cholesterol and age of the patient. Smoking is also associated with neruopathy. The possible risk factors for nephropathy were age of patient, hypertension, alcohol and hyper-uricaemia. Hypertension, age of the patient, male sex and pbhysical inactivity were found to be important risk factors for CVA. For IHD, contraceptive pills, physical inactivity and age of patients were possible risk factors. On the other hand, physical inactivity, hypertension, age of patient and duration of disease were important for peripheral vascular disease. Out study spotlihgted that age factor is the mainstay in the development of chronic complications in both NIDDM and IDDM. In NIDDM physical inactivity predisposes to retinopathy and atherosclerotic complications. Hypertension enhances neuropathy, nephropathy, CVA and peripheral vascular disease. However, in IDDM, the duration of diabetes and fasting blood sugar levels are significant risks in the development of retinopathy and nephropathy.