Prevalence and Psychosocial Correlates of Diabetes Mellitus in South Africa: Results from the South African National Health and Nutrition Examination Survey (SANHANES-1).

In South Africa, there are a limited number of population estimates of the prevalence of diabetes and its association with psychosocial factors. This study investigates the prevalence of diabetes and its psychosocial correlates in both the general South African population and the Black South African subpopulation using data from the SANHANES-1. Diabetes was defined as a hemoglobin A1c (HbA1c) ≥6.5% or currently on diabetes treatment. Multivariate ordinary least squares and logistic regression models were used to determine factors associated with HbA1c and diabetes, respectively. The prevalence of diabetes was significantly higher among participants who identified as Indian, followed by White and Coloured people, and lowest among Black South Africans. General population models indicated that being Indian, older aged, having a family history of diabetes, and being overweight and obese were associated with HbA1c and diabetes, and crowding was inversely associated with HbA1c and diabetes. HbA1c was inversely associated with being White, having higher education, and residing in areas with higher levels of neighborhood crime and alcohol use. Diabetes was positively associated with psychological distress. The study highlights the importance of addressing the risk factors of psychological distress, as well as traditional risk factors and social determinants of diabetes, in the prevention and control of diabetes at individual and population levels.

Comparison of Melioidosis Indirect Hemagglutination Assay between Three Testing Laboratories in Australia.

Melioidosis caused by Burkholderia pseudomallei causes significant morbidity and mortality in Southeast Asia and northern Australia. Clinical manifestations remain diverse, including localized skin infection, pneumonia, and chronic abscess formation. Culture remains the gold standard of diagnosis, with serology and antigen detection tests playing a role if culture is unfeasible. Serologic diagnosis remains challenging, with limited standardization across different assays. In areas of endemicity, high rates of seropositivity have been documented. The indirect hemagglutination assay (IHA) is one of the more widely used serologic tests in these areas. In Australia, only three centers perform the test. Annually, laboratory A, laboratory B, and laboratory C perform approximately 1,000, 4,500, and 500 tests, respectively. A comparison of a total of 132 sera was analyzed from the routine quality exchange program between these centers from 2010 until 2019. Overall, 18.9% of sera tested had an interpretative discrepancy between laboratories. IMPORTANCE This study found significant discrepant results between three Australian centers offering the melioidosis indirect hemagglutination assay (IHA), despite testing the same samples. We have highlighted that the IHA is a nonstandardized test, which had different source antigens at each of the different laboratories. Melioidosis is a global disease, is associated with significant mortality, and is perhaps under recognized. It is likely to have increasing impact with changing weather patterns. The IHA has been used frequently as an adjunct to the diagnosis of clinical disease and is the mainstay of determining seroprevalence within populations. Despite its relative ease of use, especially in low resource settings, our study highlights the significant limitations of the melioidosis IHA. It has wide ranging implications, serving as an impetus for developing better diagnostic tests. This study is of interest to practitioners and researchers working in the various geographic regions affected by melioidosis.

Family Stressors and Resources as Social Determinants of Health among Caregivers and Young Children.

Life course-informed theories of development suggest it is important to integrate information about positive and negative aspects of the social environment into studies of child and parental wellbeing, including both stressors that compromise health and resources that promote well-being. We recruited a sample of 169 pairs of caregivers and young children (birth to 5 years) from a community health clinic and administered survey questions to assess stressors and resources. We constructed inventories of stressors and resources and examined the relationships between these inventories and caregivers' depressive symptoms, anxiety symptoms, and sleep problems, and young children's medical diagnoses derived from electronic health records. Cumulative stressors and resources displayed bivariate and adjusted associations with caregivers' depressive symptoms, anxiety symptoms, and sleep problems. For depressive and anxiety symptoms, these associations were evident in models that included stressors and resources together. Caregivers with high stressors and low resources displayed the highest levels of depressive and anxiety symptoms and sleep problems. In terms of children's health outcomes, only modest trends were evident for developmental/mental health outcomes, but not other diagnostic categories. Future studies are needed to examine stressors and resources together in larger samples and in relation to prospectively assessed measures of child well-being.

Racial disparities in psychological distress in post-apartheid South Africa: results from the SANHANES-1 survey.

PURPOSE: South Africa has long endured a high prevalence of mental disorders at the national level, and its unique social and historical context could be a contributor to an increased risk of mental health problems. Our current understanding is limited regarding the relative importance of various social determinants to mental health challenges in South Africa, and how existing racial inequities may be explained by these determinants. METHODS: This study attempted to elucidate potential social determinants of mental health in South Africa using data from the nationally representative South African National Health and Nutrition Examination Survey (SANHANES-1). The main outcome of interest was psychological distress, measured with the Kessler-10 scale. Hierarchical linear regression models included covariates for demographic and socioeconomic factors, count of traumatic events, and a series of stress-related constructs. Analyses were conducted on two populations: the entire sample (n = 15,981), and the African subpopulation (n = 10,723). RESULTS: Regression models on the entire sample indicated racial disparities in psychological distress, with Africans experiencing higher distress than White and Coloured individuals. Results within the African sub-population indicated geo-spatial disparities, with Africans in formal urban settings experiencing higher psychological distress than those living in formal and informal rural locales. Across both samples, results indicated a cumulative association between count of stressors and traumatic events and distress. CONCLUSION: We found racial disparities across several mental health-related domains. Africans had greater exposure to traumatic events, social stressors, and psychological distress. This research is a necessary foundation for public health interventions and policy change to effectively reduce inequities in psychological distress.

Race, geographical location and other risk factors for hypertension: South African National Health and Nutrition Examination Survey 2011/12.

BACKGROUND: Hypertension is the leading cardiovascular disease in Africa. It is increasing in prevalence due partly to the epidemiological transition that African countries, including South Africa, are undergoing. This epidemiological transition is characterised by a nutrition transition andurbanisation; resulting in behavioural, environmental and stress changes that are subject to racial and geographic divides. The South African National Health and Nutrition Examination Survey (SANHANES) examined the association of traditional risk factors; and less traditional risk factors such as race, geographical location, social stressors and psychological distress with hypertension in a national population-based sample of South Africans. METHODS: Data were analysed on individuals ≥15 years who underwent a physical examination in the SANHANES (n = 7443). Hypertension was defined by blood pressure ≥140/90 mmHg or self-reported hypertension medication usage. Stepwise regression examined the association of demographic, socioeconomic, life stressors, and health risk factors with systolic blood pressure, diastolic blood pressure, and hypertension. Secondly, the risk factor associations and geographical location effects were investigated separately for the African race group. RESULTS: Increasing age (AOR = 1.069, p < 0.001); male gender (AOR = 1.413, p = 0.037); diabetes (AOR = 1.66, p = 0.002); family history of high blood pressure (AOR = 1.721, p < 0.001); and normal weight, overweight and obesity (relative to underweight: AOR = 1.782, p = 0.008; AOR = 2.232, p < 0.001; AOR = 3.874, p < 0.001 respectively) were associated with hypertension. Amongst African participants (n = 5315) age (AOR = 1.068, p < 0.001); male gender (AOR = 1.556, p = 0.001); diabetes (AOR = 1.717, p = 0.002); normal weight, overweight and obesity (relative to underweight: AOR = 1.958, p = 0.006; AOR = 2.118, p = 0.002; AOR = 3.931, p < 0.001); family history of high blood pressure (AOR = 1.485, p = 0.005); and household crowding (AOR = 0.745, p = 0.037) were associated with hypertension. There was a significantly lower prevalence of hypertension in rural informal compared to urban formal settings amongst African participants (AOR = 0.611, p = 0.005). Other social stressors and psychological distress were not significantly associated with hypertension. CONCLUSION: There was no significant association between social stressors or psychological distress and hypertension. However, the study provides evidence of high-risk groups for whom hypertension screening and management should be prioritised, including older ages, males, people with diabetes or with family history of hypertension, and Africans who live in urban formal localities.

Improving Birth Outcomes And Lowering Costs For Women On Medicaid: Impacts Of 'Strong Start For Mothers And Newborns'.

The federal Strong Start for Mothers and Newborns initiative supported alternative approaches to prenatal care, enhancing service delivery through the use of birth centers, group prenatal care, and maternity care homes. Using propensity score reweighting to control for medical and social risks, we evaluated the impacts of Strong Start's models on birth outcomes and costs by comparing the experiences of Strong Start enrollees to those of Medicaid-covered women who received typical prenatal care. We found that women who received prenatal care in birth centers had lower rates of preterm and low-birthweight infants, lower rates of cesarean section, and higher rates of vaginal birth after cesarean than did the women in the comparison groups. Improved outcomes were achieved at lower costs. There were few improvements in outcomes for participants who received group prenatal care, although their costs were lower in the prenatal period, and no improvements in outcomes for participants in maternity care homes.

Stepwise Approach for Parathyroid Localisation in Primary Hyperparathyroidism.

INTRODUCTION: Primary hyperparathyroidism (PHPT) is a relatively common condition in surgical practice. Availability of localisation studies has shifted the treatment from bilateral neck exploration to selective parathyroidectomy. Several imaging modalities, each with varying sensitivities, are available to detect abnormal parathyroid glands. Ultrasound is almost universally accepted as the first line radiological investigation however its sensitivity is particularly heterogeneous and operator-dependent. MATERIAL AND METHODS: We studied 250 consecutive patients with PHPT who underwent parathyroidectomy in our hospital over a period of 33 months. Pre-operative neck ultrasound, 99mTc-sestamibi and single-photon emission computed tomography (SPECT CT) were performed in 249, 237 and 198 patients respectively. Unilateral and bilateral neck exploration was performed in 190 and 60 patients, respectively. Sensitivity, positive predictive value (PPV) and accuracy were calculated comparing the results with surgical and pathology findings. RESULTS: Mean pre and postoperative PTH and adjusted calcium were, 11 ± 10.6 pmol/L, 1.9 ± 3.6, 2.81 ± 0.2 and 2.45 ± 0.2 mmol/L. There were 71 (29.95%) discordant results between US, compared to sestamibi and SPECT CT. An average of 1.9 parathyroid glands were removed with a mean weight of 0.92 g. Overall success rate based on postoperative PTH levels was 94.8%. Overall sensitivity, PPV and accuracy for US were 80.80%, 92.35%, and 75.73% respectively; for sestamibi were 71.82%, 94.61%, 69.00% and for SPECT CT were; 70.21%, 97.78%, 69.11% respectively. CONCLUSION: Ultrasound performed by an experienced specialist sonographer is highly sensitive in localising abnormal parathyroid glands. It can be used as a main and sole investigation in the majority of patients. Sestamibi, SPECT CT and other investigations should be performed in a step-wise manner and reserved for patients with negative US, failed primary procedure and recurrences.

Virtual Patient Journey: a novel learning resource.

BACKGROUND: Virtual Patient Journey (VPJ) is a novel online resource that follows a patient through their illness and integrates first-person video content with in-video decision making, allowing the student to take on the responsibility of a health care professional. The aim of our project was to compare this new VPJ format with standard teaching tutorials. METHODS: Third-year medical students selected from two Bristol hospitals were allocated to either the VPJ format or a typical tutorial-style teaching session. Both formats covered an identical level and scope of material and lasted the same length of time. Data were collected on pre- and post-test knowledge and confidence gain using self-reported questionnaires at the time of the teaching. RESULTS: The study recruited 30 students. The average knowledge gain for the VPJ group and for the tutorial group was 39% and 35%, respectively. The confidence increase was 2.4 and 1.8 on a scale of 1-10 for the VPJ and tutorial groups, respectively. Of the students who used the VPJ, 92% believed that it was a useful teaching resource and 96% enjoyed the VPJ experience and would re-watch the material at home. CONCLUSIONS: VPJ can expose students to clinical situations that they may not see on placement and can help to deliver a baseline level of clinical exposure and knowledge. Our VPJ may help overcome the rigidity of current virtual patients in teaching a range of core competencies and also allowing the students to take responsibility for a patient's care in a safe, controlled environment.

Pregnant women with opioid use disorder and their infants in three state Medicaid programs in 2013-2016.

BACKGROUND: Maternal opioid use disorder (OUD) has serious consequences for maternal and infant health. Analysis of Medicaid enrollee data is critical, since Medicaid bears a disproportionate share of costs. METHODS: This study analyzes linked maternal and infant Medicaid claims data and infant birth records in three states in the year before and after a delivery in 2014-2015 (2013-2016) examining health, health care use, treatment, and neonatal outcomes. Diagnosis and procedure codes identify OUD and other substance use disorders (SUDs). RESULTS: In the year before and after delivery, 2.2 percent of the sample had an OUD diagnosis, and 5.9 percent had a SUD diagnosis other than OUD. Of the women with OUD, 72.8% had treatment for a SUD in the year before and after delivery, but most had none in an average enrolled month, and only 8.8% received any methadone treatment in a given month. Pregnant women with OUD had delayed and lower rates of prenatal care compared to women with other substance use disorders (SUDs). Infants of mothers with OUD did not differ from infants of mothers with other SUDs in rate of preterm or low birth weight but had higher NICU admission rates and longer birth hospitalizations. Health care costs for women with an OUD were higher than those with other SUDs. CONCLUSIONS: There is an urgent need for comprehensive, evidence-based OUD treatment integrated with maternity care. To fill critical gaps in care, workforce and infrastructure innovations can facilitate delivery of preventive and treatment services coordinated across settings.

Continuous monitoring of kidney transplant perfusion with near-infrared spectroscopy.

Background: Current reliance on clinical, laboratory and Doppler ultrasound (DUS) parameters for monitoring kidney transplant perfusion in the immediate post-operative period in children risks late recognition of allograft hypoperfusion and vascular complications. Near-infrared spectroscopy (NIRS) is a real-time, non-invasive technique for monitoring tissue oxygenation percutaneously. NIRS monitoring of kidney transplant perfusion has not previously been validated to the gold standard of DUS. We examined whether NIRS tissue oxygenation indices can reliably assess blood flow in established paediatric kidney transplants. Methods: Paediatric kidney transplant recipients ages 1-18 years with stable allograft function were eligible. Participants underwent routine DUS assessment of kidney transplant perfusion, including resistive index (RI) and peak systolic velocity at the upper and lower poles. NIRS data [tissue oxygenation index (TOI%)] were recorded for a minimum of 2 min with NIRS sensors placed on the skin over upper and lower allograft poles. Results: Twenty-nine subjects with a median age of 13.3 (range 4.8-17.8) years and a median transplant vintage of 26.5 months participated. Thirteen (45%) were female and 20 (69%) were living donor kidney recipients. NIRS monitoring was well tolerated by all, with 96-100% valid measurements. Significant negative correlations were observed between NIRS TOI% and DUS RI at both the upper and lower poles (r = -0.4 and -0.6, P = 0.04 and 0.001, respectively). Systolic blood pressure but not estimated glomerular filtration rate also correlated with NIRS TOI% (P = 0.01). Conclusions: NIRS indices correlate well with DUS perfusion and haemodynamic parameters in established paediatric kidney transplant recipients. Further studies are warranted to extend NIRS use for continuous real-time monitoring of early post-transplant perfusion status.

First-person perspective video to enhance simulation.

BACKGROUND: Simulation training is increasingly being used as part of the undergraduate medical curriculum, but it remains time and faculty member intensive. To improve efficacy, videos have been used prior to the simulation of practical procedures; however, using videos prior to simulation training concerning the management of patients who are unwell has not been investigated. The aim of this project was to see whether clinical decision-making and non-technical skills can be improved if a video is used prior to simulation training, and uniquely to enhance the authenticity we filmed it using a first-person perspective. METHODOLOGY: We conducted a randomised controlled trial with 40 final-year medical students randomised into two groups. One group viewed a video filmed in first person prior to a simulation scenario, whereas the other group did not view the video. The two groups then carried out the simulation and were assessed with 'time to' investigation and treatment decisions. Further quantitative data were collected for non-technical skills using the Ottawa Crisis Resource Management (OCRM) score. Qualitative data were collected from the students as to the perceived ease of use and helpfulness of the video. Simulation training is increasingly being used as part of the undergraduate medical curriculum RESULTS: The students who watched the video appeared to perform better in clinical decision-making and non-technical skills. The students were extremely receptive to the use of a first-person perspective video, and highlighted its perceived realism and its help as a memory aid. DISCUSSION: The use of this style of video was warmly received by students and opens the possibility of further use to enhance simulation training.

Acting like a doctor: oral case presentation curriculum for medical students.

This article was migrated. The article was marked as recommended. Background Verbal communication is an important element to clinical practice and an integral part of undergraduate medical education. The oral case presentation (OCP) is often used in professional verbal communication and remains commonplace in the clinical setting. The OCP additionally has a complex role in undergraduate teaching. Methods We designed a OCP curriculum taking into account reasoning, rhetorical and linguistic mechanisms. Delivered through a content and drama workshop involving a trained theatre actor to 45 pre-clinical, undergraduate medical students at our U.K. institution. Students were assessed objectively at weekly intervals by trained faculty. A paired t-test was performed to determine if the curriculum was effective in increasing OCP scores. Students' confidence was assessed using Likert scales. Findings An overall mean score improvement (M=20.3, SD 14.6, N=45) was significantly greater than zero, t (44) =9.3, two tail p <0.05, providing evidence that the curriculum was effective. A 95% confidence interval around the mean difference in score was 15.9-24.7. Confidence scores for both non-verbal and verbal elements of the OCP improved. Conclusion This curriculum led to an improvement in OCP scores and increased our students 'confidence with this modality of communication. Consideration should be given to incorporating dedicated teaching of the OCP in undergraduate education.

The Impact of Laparoscopic Adjustable Gastric Banding on an NHS Cohort of Type 2 Diabetics: a Prospective Cohort Study.

BACKGROUND: Obesity is an independent risk factor for diabetes, which is associated with significant morbidity and premature death. This study aims to evaluate the impact of laparoscopic adjustable gastric banding (LAGB) on a cohort of morbidly obese diabetics. METHODS: Inclusion and exclusion criteria were applied to consecutive diabetic patients undergoing LAGB. Demographic and disease-specific data were collected at baseline and 6-monthly intervals corresponding to follow-up assessments. Minimum follow-up was 24 months. Normally distributed variables were assessed with one-way analysis of variance/t tests; proportions were analysed with chi-squared/Fisher's exact tests. Follow-up was ≥90 % complete at each time point. RESULTS: One hundred twenty patients with a median age of 43.3 years, mean (± standard deviation (SD)) pre-op body mass index (BMI) of 48.7 (±8) kg/m2, and HbA1c of 8.6 (±2) % were included. BMI reduced significantly, with annual post-operative means of 41.4 ± 7.8, 39.9 ± 7.7, 39.5 ± 7.8, 39.3 ± 7.1 and 36.6 ± 5.4 kg/m(2) (p < 0.001). Corresponding percentage excess body weight lost was 32.8 ± 18, 39.8 ± 21.4, 38.5 ± 21.3, 37.0 ± 22.3 and 43.1 ± 14.1 %. HbA1c was significantly lower at each time point until 30 months post-operatively (p < 0.001). Thereafter, differences were insignificant, and HbA1c was comparable to pre-operative levels by 5 years. Seventy-six (63 %) patients achieved an HbA1c <7 % at 30 months (p < 0.001). Twenty-six (23 %) patients achieved remission from diabetes. The cumulative 5-year cost saving from reductions in anti-diabetes medications was £1650/patient. There were no mortalities, and 18 device explants. CONCLUSIONS: Modest but durable weight loss associated with significant improvements in glycaemic control and anti-diabetic medication use have been demonstrated. Peak effects occur within 24-30 months and diminish thereafter, possibly reflecting progression of pathological processes due to residual obesity.

Evaluation of the BD Max Cdiff assay for the detection of toxigenic Clostridium difficile in human stool specimens.

The Becton Dickinson (BD) PCR-based GeneOhm Cdiff assay has demonstrated a high sensitivity and specificity for detecting Clostridium difficile. Recently, the BD Max platform, using the same principles as BD GeneOhm, has become available in Australia. This study aimed to investigate the sensitivity and specificity of BD Max Cdiff assay for the detection of toxigenic C. difficile in an Australian setting. Between December 2013 and January 2014, 406 stool specimens from 349 patients were analysed with the BD Max Cdiff assay. Direct and enrichment toxigenic culture were performed on bioMérieux ChromID C. difficile agar as a reference method. isolates from specimens with discrepant results were further analysed with an in-house PCR to detect the presence of toxin genes. The overall prevalence of toxigenic C. difficile was 7.2%. Concordance between the BD Max assay and enrichment culture was 98.5%. The sensitivity, specificity, positive predictive value and negative predictive value for the BD Max Cdiff assay were 95.5%, 99.0%, 87.5% and 99.7%, respectively, when compared to direct culture, and 91.7%, 99.0%, 88.0% and 99.4%, respectively, when compared to enrichment culture. The new BD Max Cdiff assay appeared to be an excellent platform for rapid and accurate detection of toxigenic C. difficile.

Obesity surgery smartphone apps: a review.

BACKGROUND: The purpose of this study are to review available smartphone applications ('apps') relating to weight loss surgery, and assess the level of medical professional involvement in their design METHODS: Smartphone apps relating to weight loss surgery were identified by searching the three app stores: Apple's App Store, Google Play (Android) and Blackberry AppWorld. A data search was undertaken using keywords and phrases relating to weight loss surgery. Apps designed for the non-surgical treatment of obesity were excluded. RESULTS: A total of 38 apps were identified (Google Play = 17, Apple App Store = 21, Blackberry World = 0). Ten of 38 apps were duplicated therefore 28 apps were reviewed. Mean app rating was 3.6/5 and mean app cost was £1.89. Twenty-six of 28 (92.9%) apps were designed for use by patients. Apps were categorised into the following categories: patient information (ten), patient support forums (six), patient record tools (six), weight loss clinic advertisements (four), a journal app (one) and a conference tool (one). Health professional involvement was evident in 12 of 28 (42.9%) apps. CONCLUSIONS: This study has identified that the majority of available apps relating to weight loss surgery do not have health professional input. The establishment of a 'quality stamp' provided by an established bariatric surgical body could improve the confidence with which patients and clinicians use these new information sources. Weight loss surgery apps offer a unique opportunity to provide accurate and reliable patient information and their use as part of the informed consent process should be explored.

Ethnic minorities have equal access to bariatric surgery in the UK and Ireland.

Under-representation of ethnic minority groups in bariatric surgery rates has been reported in the USA. Ethnic minorities form 7.9 % of the UK population, but comparable data on provision of bariatric surgery for these groups have not previously been reported in the UK. We calculated an estimate of rates of bariatric surgery amongst ethnic groups in the UK and Ireland using data from the National Bariatric Surgery Registry and census data from the UK and Ireland. The number of procedures recorded per 1,000 morbidly obese patients was 5.2 for Caucasian patients, 5.2 for Asian patients and 5.2 for Black patients. The identical rates across different ethnic groups suggest that bariatric services are provided equitably in the UK, with ethnic minority groups achieving equal access.

An analysis of driving and working hour on commercial motor vehicle driver safety using naturalistic data collection.

Current hours-of-service (HOS) regulations prescribe limits to commercial motor vehicle (CMV) drivers' operating hours. By using naturalistic-data-collection, researchers were able to assess activities performed in the 14-h workday and the relationship between safety-critical events (SCEs) and driving hours, work hours, and breaks. The data used in the analyses were collected in the Naturalistic Truck Driving Study and included 97 drivers and about 735,000 miles of continuous driving data. An assessment of the drivers' workday determined that, on average, drivers spent 66% of their shift driving, 23% in non-driving work, and 11% resting. Analyses evaluating the relationship between driving hours (i.e., driving only) and SCE risk found a time-on-task effect across hours, with no significant difference in safety outcomes between 11th driving hour and driving hours 8, 9 or 10. Analyses on work hours (i.e., driving in addition to non-driving work) found that risk of being involved in an SCE generally increased as work hours increased. This suggests that time-on-task effects may not be related to driving hours alone, but implies an interaction between driving hours and work hours: if a driver begins the day with several hours of non-driving work, followed by driving that goes deep into the 14-h workday, SCE risk was found to increase. Breaks from driving were found to be beneficial in reducing SCEs (during 1-h window after a break) and were effective in counteracting the negative effects of time-on-task.