Titrating insulin in patients with type 2 diabetes using a structured self-monitoring blood glucose regimen.

BACKGROUND: Self-monitoring of blood glucose (SMBG) can inform on the timing of hyperglycaemia, but there is currently no standardised approach to utilising these data to improve glycaemic control in patients with type 2 diabetes. OBJECTIVES: To assess the improvement in glycaemic control when an insulin titration algorithm was used in combination with SMBG in patients with poorly controlled, insulin-treated type 2 diabetes. METHODS: This 6-month prospective study recruited 39 poorly controlled (glycated haemoglobin (HbA1c) ≥8.5%; 69.4 mmol/mol) type 2 diabetes subjects using twice-daily biphasic insulin from two state hospitals in Tshwane, South Africa. Patients were asked to perform structured SMBG over 4 weeks and return monthly for consultations where physicians titrated insulin doses using an algorithm guided by the data collected. The primary endpoint was the trend in HbA1c measured at baseline and 3 and 6 months. RESULTS: Mean HbA1c decreased over the study period by 1.89% (95% confidence interval (CI) -2.46 - -1.33; p<0.001). The hypoglycaemic event rate (<4.0 mmol/L) was 33.08 events per patient year. Total daily insulin use increased by a mean of 40.12 units over the study period (standard error 7.7; p<0.001) and weight increased by an average of 3.98 kg (95% CI 2.56 - 5.41; p<0.001). CONCLUSIONS: Monthly algorithmic insulin titration guided by structured SMBG can markedly improve glycaemic control in patients with type 2 diabetes by aggressively increasing insulin doses not previously expected in this population, with moderate hypoglycaemic events and weight gain observed.

Cervical collars and immobilisation: A South African best practice recommendation.

INTRODUCTION: The consequences of spinal injury as a result of trauma can be devastating. Spinal immobilisation using hard trauma boards and rigid cervical collars has traditionally been the standard response to suspected spinal injury patients even though the risk may be extremely low. Recently, adverse events due to the method of immobilisation have challenged the need for motion restriction in all trauma patients. International guidelines have been published for protection of the spine during transport and this article brings those guidelines into the South African context. RECOMMENDATIONS: Trauma patients need to be properly assessed using both an approved list of high and low risk factors, as well as a thorough examination. They should then be managed accordingly. Internationally validated assessment strategies have been developed, and should be used as part of the patient assessment. The method of motion restriction should be selected to suit the situation. The use of a vacuum mattress is the preferable technique, with the use of a trauma board being the least desirable. CONCLUSION: The need for motion restriction in suspected spinal injury should be properly evaluated and appropriate action taken. Not all trauma patients require spinal motion restriction.

INTRODUCTION: Les conséquences des lésions de la moelle épinière suite à un traumatisme peuvent être dévastatrices. L'immobilisation de la colonne vertébrale au moyen d'une planche dorsale rigide et de minerves rigides constituait par le passé la réponse standard aux patients que l'on suspectait de souffrir de lésions de la moelle épinière, même si le risque pouvait être extrêmement faible. Récemment, des événements indésirables qui se sont produits du fait de cette méthode d'immobilisation ont remis en question la nécessité de restreindre les mouvements chez tous les patients victimes de traumatisme. Des directives internationales ont été publiées sur la protection de la colonne vertébrale au cours du transport, et cet article adapte ces directives au contexte sud-africain. RECOMMANDATIONS: Les patients victimes de traumatisme doivent être adéquatement évalués en utilisant une liste approuvée de facteurs de risques faibles et élevés, et en procédant à un examen approfondi. Ils devraient être pris en charge en conséquence. Des stratégies d'évaluation validées au niveau international ont été développées, et devraient être utilisées dans le cadre de l'évaluation du patient. La méthode de restriction des mouvements devrait être sélectionnée en fonction de la situation. L'utilisation d'un matelas immobilisateur à dépression constitue la technique privilégiée, l'utilisation d'une planche dorsale étant la moins recommandée. CONCLUSION: La nécessité de restreindre les mouvements en cas de suspicion de lésions de la moelle épinière devrait être adéquatement évaluée et des mesures appropriées doivent être prises. Il n'est pas nécessaire de restreindre les mouvements de la colonne vertébrale chez tous les patients de traumatisme.

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

OBJECTIVE: To determine if Ringer's 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 Ringer's 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 Ringer's lactate groups. The hazard ratio (Ringer's 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 Ringer's 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 Ringer's 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 Ringer's 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 Ringer's 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 Ringer's lactate solution.

Inpatient Blood Glucose Management of Diabetic Patients in a Large Secondary Hospital

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; 60.8of patients had irregular and erratic glucose monitoring; 37.2had regular (either four- or six-hourly) monitoring and only 2were 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 19.5of 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

The Mechanism of Action of the Oral Anti-Diabetic 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

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 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.

Automated detection of malaria-associated intraleucocytic haemozoin by Cell-Dyn CD4000 depolarization analysis.

Laboratory tests for malaria are only performed if there is clinical suspicion of the disease, and a missed diagnosis contributes substantially to morbidity and mortality. Malaria parasites produce haemozoin, which is able to depolarize light and this allows the automated detection of malaria during routine complete blood count analysis (CBC) with some Abbott Cell-Dyn instruments. In this study, we evaluated the Cell-Dyn CD4000 with 831 blood samples submitted for malaria investigations. Samples were categorized as malaria negative (n = 417), convalescent malaria (n = 64) or malaria positive (n = 350) by reference to thin/thick film microscopy, 'rapid test' procedures, polymerase chain reaction analysis and clinical history. With regard to CD4000 depolarization analysis, a malaria positive CD4000 pattern was ascribed to samples that showed one or more abnormal depolarizing purple events, which corresponded to monocytes containing ingested malaria pigment (haemozoin). Positive CD4000 patterns were observed in 11 of 417, 50 of 64 and 281 of 350 of malaria negative, convalescent malaria and malaria positive samples respectively. The specificity and positive predictive values for malaria (active and convalescent) were very high (97.4 and 96.8%, respectively), while sensitivity and negative predictive values were 80.0 and 83.0% respectively. Depolarization analysis was particularly effective for Plasmodium falciparum malaria but there was lower detection sensitivity for White compared with Black African patients. CD4000 90 degrees depolarization vs 0 degrees analysis revealed a proportion of samples with small nonleucocyte-associated depolarizing particles. Appearance of such events in the form of a discrete cluster was associated with P. vivax rather than P. falciparum infection.

Development and testing of a 25-item patient satisfaction scale for black South African diabetic outpatients.

Although there is general agreement that patient satisfaction is an integral component of service quality, there is a paucity of South African research on reliable and valid satisfaction measures and the effects of health status on satisfaction. A 25-item patient satisfaction scale was developed and tested for evaluating the quality of health care for black diabetic outpatients. It was hypothesised that: (1) the underlying dimensions of patient satisfaction were interpersonal and organisational; and (2) patients in poor health would be less satisfied with the quality of their care than patients in good health. The questionnaire was administered to 263 black outpatients from Pretoria Academic Hospital and Kalafong Hospital. Factor analysis was conducted on the patient satisfaction scale and three factors, accounting for 71% of the variance, were extracted. The major items on Factor I were helpfulness, communication, support and consideration, representing the interpersonal dimension. Factors II and III were mainly concerned with service logistics and technical expertise, with the emphasis on waiting time, follow-up and thoroughness of examination. The three factors had excellent reliability coefficients, ranging between 0.82 (technical), 0.85 (logistics) and 0.98 (interpersonal). Multiple analyses of co-variance showed that patients in poor general health were significantly less satisfied with the logistical (p = 0.004) and technical (p = 0.007) quality of their care than patients in good health; patients in poor mental health were significantly less satisfied with the interpersonal quality of their care (p = 0.05) than patients in good mental health. These findings provided support for both hypotheses and suggested that patients in poor health attend to different aspects of their care than patients in good health. Of more importance to clinical practice, the results endorsed the need for a multidisciplinary health team comprising nurse/social worker (Factor I: support, communication), health service managers (Factor II: service logistics) and physician (Factor III: technical expertise) to enhance treatment outcome for diabetic patients. It is recommended that: (1) further research is conducted on this patient satisfaction scale with diverse populations in different settings to complement and validate the scale for generalised use in South Africa; (2) the scale is used to collect information on patient satisfaction before and after implementing an intervention to improve the quality of health care, and (3) measurement of health status is an essential adjunct to assessment of patient satisfaction.

Thrombocytopenia in patients with malaria: automated analysis of optical platelet counts and platelet clumps with the Cell Dyn CD4000 analyser.

Platelet counts and automated detection of platelet clumps were evaluated by optical analysis with the Abbott CD4000 analyser (Abbott Diagnostics, Santa Clara, CA, USA) in this South African study of 828 samples referred for malaria investigations. Based on microscopy (Micro) and rapid tests (RT) for HRP2 protein and parasite-associated LDH, malaria negative samples (n = 417) were defined as Micro-, RT-. Convalescent cases (n = 64) were Micro-, RT+ and had a recent record of positive microscopy. Malaria positive cases were subdivided into Micro+ (n = 315) and Micro-, RT+, PCR+ (polymerase chain reaction) (n = 32) subgroups. The mean platelet count for Micro+ cases (89.7 x 10(9)/l) was significantly lower than both the malaria negative (mean 212.6 x 10(9)/l) and convalescent malaria (mean 152.8 x 10(9)/l) groups; 89% of microscopy positive cases were thrombocytopenic (< 150 x 10(9)/l) and 30% had severe thrombocytopenia (< 50 x 10(9)/l). For comparison, 32% of the 417 malaria negative samples were thrombocytopenic and 6% of these were severe. Two thirds of samples with parasitaemia above 10% had platelet counts of < 50 x 10(9)/l while the counts were largely independent of parasite numbers when the parasitaemia was below 10%. Thirty percent of samples with microscopically detectable parasites had a PltClmp flag compared to 13% of the malaria negative group but, when the actual platelet count was taken into account, it became apparent that appearance of the flag was primarily associated with thrombocytopenia per se rather than malaria status. In most samples with a PltClmp flag, the CD4000 optical platelet clump 'signature' was indicative of small platelet aggregates and giant platelets. Morphological examination confirmed the presence of varying numbers of small platelet aggregates (3-12 individual platelets), often together with increased giant platelets, in many samples with a PltClmp flag. The observations suggest that while patients with malaria may be predisposed to the development of thrombocytopenia, a reduced platelet count in some patients may also be due in part to pseudo-thrombocytopenia.

Patterns of pseudo-reticulocytosis in malaria: fluorescent analysis with the Cell-Dyn CD4000.

This study of Plasmodium falciparum malaria evaluated patterns of fluorescent reticulocyte measurements as determined with the Abbott Cell-Dyn CD4000. The parasitaemia of positive samples (n=180) ranged from 0.04% to 25.5%, with those (19/180) showing gametocytes having lower parasitaemia levels (mean 0.31%, median 0.2%) compared to those that did not (mean 2.59%, median 0.8%). There was a reasonable association (R2=0.60) between parasitaemia level and CD4000 reticulocyte percentages, although there was overall a small statistical bias towards higher parasitaemia estimates determined microscopically. Consistently high immature reticulocyte fraction (IRF) values of >0.5 were observed in cases with a parasitaemia exceeding 5%, while samples with lower parasitaemia levels showed more variable IRF values. Visual examination of CD4000 reticulocyte histograms revealed that 81/100 malaria-positive samples with an IRF above 0.5 showed the presence of a fluorescent population 'spike' consistent with the staining of intracellular malaria parasites. Only three of the 80 malaria-positive samples with an IRF below 0.5, and none of the 237 malaria-negative samples, showed this histogram pattern. These observations indicate that samples with malaria parasites give erroneously high CD4000 reticulocyte estimates that essentially comprise the sum total of true reticulocytes and parasite-infected red cells (pseudo-reticulocytes). This limitation is common to all automated reticulocyte procedures but recognizing the differences between homogenous staining parasitized red cells and heterogeneous staining reticulocytes has potential applications in monitoring parasitaemia levels both at patient presentation and during subsequent treatment.

Fertility of stallion semen frozen in 0.5-ml straws.

Semen of 2 pony stallions was frozen by 2 methods in 0.5 ml PVC straws. The fertility of the frozen-thawed semen was evaluated by inseminating 60 mares during 69 oestrous cycles. An overall single cycle pregnancy rate of 55% was achieved. Freezing method, stallion, insemination during steroid-synchronized oestrus or insemination only every 2nd day during oestrus did not significantly influence pregnancy rates. Pregnancy rates were significantly improved from a mean 44% to a mean 73% when the mean number of progressively motile spermatozoa per insemination was increased from 175 x 10(6) to 249 x 10(6). It is concluded that the simpler freezing technique will yield satisfactory pregnancy rates when semen with a post-thaw progressive motility of 30% is used for AI. Starting when ovulation is anticipated to occur within the next 48 h mares should be inseminated every 2nd day with at least 220 x 10(6) progressively motile spermatozoa per insemination until ovulation is confirmed.