RESUMO
BACKGROUND: This study aimed to identify social characteristics associated with higher levels of morbidity from diabetes and their relationship to health care utilization. METHODS: During a 6-month period 1149/1447 (79%) subjects admitted to Port of Spain Hospital, Trinidad with diabetes responded to a structured interview. Data collection included social factors, diabetes-related morbidity and health care utilization. Analyses were adjusted for age, sex, ethnic group and self-reported diabetes duration. RESULTS: Of 12 indicators of morbidity, nine were more frequent in subjects with no schooling compared with those with secondary education. At ages 15-59 years, nine morbidity indicators were less frequent among subjects in full-time jobs compared with those not in employment. The association of educational attainment was explained by confounding with age, sex, ethnic group and diabetes duration but five morbidity indicators were associated with employment status after adjusting for confounding. The type of water supply in the home was generally not associated with morbidity. Each of the indicators of lower socioeconomic status was associated with less use of private doctors and with more use of government health centres. CONCLUSIONS: Morbidity from diabetes was greater in groups with lower socioeconomic status. While morbidity associated with lower educational attainment was mostly explained by older age; the results suggested the possibility that diabetes may contribute to unemployment of those in the labour force. Private care was less accessible to social groups with higher levels of morbidity and the availability of government funded health services was important for reducing inequalities in health care utilization.
Assuntos
Diabetes Mellitus/epidemiologia , Serviços de Saúde/estatística & dados numéricos , Classe Social , Adolescente , Adulto , África/etnologia , Idoso , Distribuição de Qui-Quadrado , Intervalos de Confiança , Fatores de Confusão Epidemiológicos , Estudos Transversais , Diabetes Mellitus/etnologia , Escolaridade , Emprego/estatística & dados numéricos , Feminino , Serviços de Saúde/normas , Humanos , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Morbidade , Razão de Chances , Trinidad e Tobago/epidemiologia , Abastecimento de ÁguaRESUMO
Many middle-income countries now have a high prevalence of diabetes and need to address the problem of providing care for people with diabetes within limited resources. This study evaluated standards of preventive care in primary settings in three Caribbean countries. We studied case records at 17 clinics in 15 government health centres and 17 private general practitioners' offices in Barbados, Trinidad and Tobago and Tortola (British Virgin Islands). A census of all attenders over a 4 to 7 week period identified 1661 attenders with diabetes mellitus, approximately two-thirds were women with a median age over 60 years. Overall 676/1342 (50%) had 'poor' blood glucose control (> or = 8 mmol l-1 fasting or > or = 10 mmol l-1 random). The proportion with BP > or = 160/95 mmHg or receiving treatment for hypertension was 943/1661 (57%), of whom 781/943 (83%) were prescribed drug treatment. Among those treated for hypertension only 181/781 (23%) had blood pressures < 140/90 mmHg. Surveillance for complications affecting the feet (11%) or eyes (2%) was not performed systematically in any setting. Only 533 (32%) had recorded dietary advice and 79 (5%) had recorded exercise advice in the last 12 months. To begin to address some of these problems at a regional level, we incorporated results from this survey into a series of workshops held in collaboration with health ministries in 10 Caribbean countries, with participants from 13 countries. At these workshops health care workers participated in the process of developing guidelines for diabetes management in primary care. The guidelines have subsequently been widely disseminated through health ministries and non-governmental organizations in the region. Further research is needed to evaluate the effectiveness of this approach, the constraints on diabetes care, and the most cost-effective means of addressing them.
Assuntos
Países em Desenvolvimento , Diabetes Mellitus/terapia , Prática Privada/normas , Saúde Pública/normas , Garantia da Qualidade dos Cuidados de Saúde , Idoso , Glicemia/metabolismo , Pressão Sanguínea/fisiologia , Região do Caribe/epidemiologia , Diabetes Mellitus/epidemiologia , Dieta , Escolaridade , Estudos de Avaliação como Assunto , Feminino , Inquéritos Epidemiológicos , Humanos , Estilo de Vida , Masculino , Pessoa de Meia-Idade , PrevalênciaRESUMO
Many middle-income countries are experiencing an increase in diabetes mellitus but patterns of morbidity and resource use from diabetes in developing countries have not been well described. We evaluated hospital admission with diabetes among different ethnic groups in Trinidad. We compiled a register of all patients with diabetes admitted to adult medical, general surgical, and ophthalmology wards at Port of Spain Hospital, Trinidad. During 26 weeks, 1447 patients with diabetes had 1722 admissions. Annual admission rates, standardized to the World Population, for the catchment population aged 30-64 years were 1031 (95% CI 928 to 1134) per 100,000 in men and 1354 (1240 to 1468) per 100,000 in women. Compared with the total population, admission rates were 33% higher in the Indian origin population and 47% lower in those of mixed ethnicity. The age-standardized rate of amputation with diabetes in the general population aged 30-64 years was 54 (37 to 71) per 100,000. The hospital admission fatality rate was 8.9% (95%CI 7.6% to 10.2%). Mortality was associated with increasing age, admission with hyperglycaemia, elevated serum creatinine, cardiac failure or stroke and with lower-limb amputation during admission. Diabetes accounted for 13.6% of hospital admissions and 23% of hospital bed occupancy. Admissions associated with disorders of blood glucose control or foot problems accounted for 52% of diabetic hospital bed occupancy. The annual cost of admissions with diabetes was conservatively estimated at TT+ 10.66 million (UK 1.24 million pounds). In this community diabetes admission rates were high and varied according to the prevalence of diabetes. Admissions, fatalities and resource use were associated with acute and chronic complications of diabetes. Investing in better quality preventive clinical care for diabetes might provide an economically advantageous policy for countries like Trinidad and Tobago.
Assuntos
Diabetes Mellitus/economia , Admissão do Paciente/economia , Adulto , África/etnologia , Fatores Etários , Idoso , Amputação Cirúrgica/economia , Glicemia/metabolismo , Causas de Morte , Custos e Análise de Custo , Diabetes Mellitus/mortalidade , Etnicidade , Feminino , Mortalidade Hospitalar , Humanos , Hiperglicemia , Índia/etnologia , Masculino , Pessoa de Meia-Idade , Fatores Sexuais , Fatores Socioeconômicos , Trinidad e TobagoRESUMO
Evaluating the effectiveness and efficiency of health services is important for all countries, especially those with limited resources. This study aimed to evaluate the volume and quality of health services research (HSR) conducted in one developing region, the English-speaking Caribbean. Data were abstracted from all 770 abstracts describing presentations at the annual scientific meetings of the Commonwealth Caribbean Medical Research Council for the decade 1984 to 1993. Of these, 341 abstracts were judged to report health services research and were from the English-speaking Caribbean. Hospital services were evaluated in 240 (70%) reports while primary health services were evaluated in only 90 (26%). Most hospital-based studies evaluated the use and outcome of medical and surgical services through the collection of case series and cohorts of cases, with a median sample size of 104 (interquartile range 38 to 320). Evaluations at primary level were more likely to evaluate need or demand for services, were more likely to report cross sectional surveys or randomized trials and included larger numbers of subjects (median 343, interquartile range 121 to 661). Patient-based measures of health status and measures of resource use were not often reported at either primary or secondary level. Estimation and hypothesis testing were infrequently employed in data analysis. A large proportion of the research presented could be classified as HSR but measures are needed to increase the motivation for research into primary care and to improve skills in HSR study design, conduct and analysis among those presently conducting research.
Assuntos
Pesquisa sobre Serviços de Saúde/métodos , Avaliação de Resultados em Cuidados de Saúde , Revisão da Utilização de Recursos de Saúde , Região do Caribe , Países em Desenvolvimento , Eficiência Organizacional , Estudos de Avaliação como Assunto , Pesquisa sobre Serviços de Saúde/normas , Idioma , Qualidade da Assistência à SaúdeRESUMO
Cimetidine may decrease concomitant medication clearance by inhibiting the oxidative system of cytochrome P-450. The authors report increased serum clozapine levels and adverse side effects during clozapine and cimetidine treatment but not during clozapine and ranitidine treatment in a patient with chronic paranoid schizophrenia.
Assuntos
Cimetidina/efeitos adversos , Clozapina/efeitos adversos , Esquizofrenia Paranoide/tratamento farmacológico , Adulto , Doença Crônica , Cimetidina/farmacologia , Clozapina/sangue , Clozapina/farmacocinética , Interações Medicamentosas , Quimioterapia Combinada , Humanos , Masculino , Ranitidina/farmacocinética , Ranitidina/uso terapêutico , Esquizofrenia Paranoide/psicologiaRESUMO
A two-pool model is described for the non-invasive measurement of urea kinetics in man. The isotope, 15N15N-urea, was given until an isotopic steady state was reached in urine and the time taken to achieve this is defined. During an isotopic steady state, a comparison was made of the effect of giving the isotope orally, intravenously and intragastrically; no differences were found between the different routes. Measurements of enrichment were made on excretion products in urine. In six normal adults with a protein intake of 200 mg N/kg/d, the urea production rate was 139 +/- 15 mg N/kg/d, 70 per cent of which was excreted in urine. Of the 34 mg N/kg/d produced by hydrolysis of urea in the gastrointestinal tract, 41 per cent was resynthesized to urea, and about 48 per cent was available for other synthetic processes.
Assuntos
Nitrogênio/metabolismo , Ureia/metabolismo , Adulto , Sistema Digestório/metabolismo , Humanos , Intubação Gastrointestinal , Cinética , Masculino , Espectrometria de Massas , Modelos Biológicos , Isótopos de Nitrogênio , Ureia/administração & dosagem , Ureia/urinaAssuntos
Peso ao Nascer , Glicemia/biossíntese , Epinefrina/deficiência , Hipoglicemia/metabolismo , Gêmeos Monozigóticos , Gêmeos , Alanina/sangue , Aminoácidos/metabolismo , Criança , Pré-Escolar , Jejum , Feminino , Gluconeogênese , Glicogênio/metabolismo , Humanos , Cinética , Masculino , Oxirredução , Gravidez , Ureia/sangueRESUMO
Satellite cells were examined qualitatively and quantitatively in muscle biopsies from children when malnourished, during nutritional rehabilitation, and after clinical recovery. The proportion of satellite cell nuclei relative to myonuclei was significantly lower in malnourished subjects than in well-nourished age-matched controls (4.5 +/- 1% vs. 8.1 +/- 1.0%). The proportion of satellite cells remained low during the early period of "catch-up growth" but was significantly increased in the recovered subjects (10.5 +/- 1.0%). Satellite cells were small and their nuclei were heterochromatic in biopsies from the malnourished subjects. The cells were often partially segregated from the parent fiber by an external lamina. In recovering and recovered subjects many of the satellite cells enlarged, and the appearance of their nuclei and cytoplasmic organelles suggested a more active state. Intervention of external lamina between the satellite cell and the myofibre was uncommon in the recovered subjects.
Assuntos
Músculos/patologia , Desnutrição Proteico-Calórica/patologia , Fatores Etários , Contagem de Células , DNA/biossíntese , Feminino , Seguimentos , Humanos , Lactente , Masculino , Microscopia Eletrônica , Músculos/metabolismo , Músculos/ultraestrutura , Desnutrição Proteico-Calórica/dietoterapia , Desnutrição Proteico-Calórica/metabolismo , RNA/metabolismoRESUMO
1. The growth of muscle fibres was analysed by light microscopy in biopsies from subjects when malnourished, during nutritional rehabilitation, and after clinical recovery. 2. Muscle fibres from malnourished subjects were extremely atrophic (cross-sectional area, 110 micrometers2). The fibres doubled in size during the early period of rehabilitation. Growth of muscle fibres during later periods of rehabilitation occurred at a slower rate. 3. The absolute rates of change in fibre sizes differed considerably between subjects, but the rates of change relative to the rate of gain of total body-weight (expressed as % recovery or % expected weight-for height (Nelson, 1975)) were similar between subjects after the initial growth spurt. The pattern of recovery appeared to differ between older and younger subjects. 4. Fibre sizes correlated with body-weight but not with age in the malnourished subjects. A significant correlation between fibre areas and either weight or age was observed during rehabilitation and after clinical recovery. 5. Fibre sizes of clinically-recovered subjects (mean age, 13.8 months; weight, 8.7 kg) were only approximately 60% of that for a well-nourished 6-month-old control subject (6.4 kg). These results suggest that a longer period of time is required for fibres to reach their expected size. Therefore, when the child has regained body-weight to that of a normal child of the same height, his muscles have not yet recovered and his body composition is abnormal.
Assuntos
Transtornos da Nutrição do Lactente/fisiopatologia , Desenvolvimento Muscular , Fatores Etários , Antropometria , Peso Corporal , Pré-Escolar , Convalescença , Feminino , Humanos , Lactente , Transtornos da Nutrição do Lactente/dietoterapia , Transtornos da Nutrição do Lactente/patologia , Jamaica , Masculino , Músculos/patologiaAssuntos
Alanina/metabolismo , Glucose/metabolismo , Distúrbios Nutricionais/metabolismo , Acetoacetatos/sangue , Aminoácidos/metabolismo , Glicemia/metabolismo , Nitrogênio da Ureia Sanguínea , Jejum , Ácidos Graxos não Esterificados/sangue , Gluconeogênese , Glicerol/metabolismo , Glicogênio/metabolismo , Humanos , Hidroxibutiratos/sangue , LactenteAssuntos
Composição Corporal , Músculos , Desnutrição Proteico-Calórica , Estatura , Água Corporal , Peso Corporal , Pré-Escolar , Creatinina/análise , Humanos , Lactente , Músculos/análiseRESUMO
1. Total body water (TBW) was measured using tritiated water in sixty-five children. The measurements were distributed throughout rehabilitation in order to define the effect of changing energy intakes. 2. Oedematous children had a high TBW which decreased to the normal range during loss of oedema providing they were not receiving more than maintenance amounts of energy during this period. 3. Marasmic children who had not received greater than maintenance amounts of energy had a normal TBW. 4. Treatment with a high-energy diet was associated with an initial increase in TBW. 5. The possible mechanisms for this phenomenon are discussed.
Assuntos
Água Corporal/metabolismo , Transtornos da Nutrição do Lactente/metabolismo , Peso Corporal , Dieta , Edema/metabolismo , Metabolismo Energético , Humanos , Lactente , Transtornos da Nutrição do Lactente/dietoterapiaRESUMO
Muscle tissue obtained by needle biopsy from the quadriceps femoris of eight malnourished and eight recovered children were examined histologically. In both groups about two-thirds of the total nuclear count was due to muscle nuclei. The remaining one-third was made up of vascular, nerve, and interstitial cells and isolated nuclei in similar proportions in the two groups. A significantly greater percentage of muscle nuclei consisted of myogenic cells in recovered children as compared to malnourished children (20.7 +/- 6.4 vs. 2.6 +/- 1.4%).
Assuntos
Núcleo Celular/ultraestrutura , Músculos/ultraestrutura , Desnutrição Proteico-Calórica/patologia , Vasos Sanguíneos/ultraestrutura , Pré-Escolar , DNA/análise , Feminino , Humanos , Lactente , Masculino , Músculos/análise , Fibras Nervosas/ultraestrutura , Desnutrição Proteico-Calórica/metabolismoRESUMO
1. Rates of total protein turnover, synthesis and breakdown were measured in five children before and after recovery from severe protein-energy malnutrition and while receiving 0.6 g of protein and 397 kJ day-1 kg-1. 2. Thes rates were calculated after giving doses of [15N]glycine every 2 h along with the feeds and measuring the rate of excretion of [15N]urea in urine. 3. Malnourished children had significantly lower rates of protein turnover, synthesis and breakdown than after they had recovered. 4. During recovery from protein-energy malnutrition, two children on a daily intake of 1.2 g of protein and 605 J/kg body weight, had rates of protein turnover, synthesis and breakdown that were twice as great as those found on admission and higher than after recovery. 5. On the study diet the malnourished children maintained their weight while the recovered children lost weight; the apparent nitrogen balance was more positive in the malnourished children. 6. In recovered children, the rate of protein synthesis was unchanged over a wide range of protein intake, whereas the rate of protein breakdown appeared to rise with a reduction in protein intake.
Assuntos
Desnutrição Proteico-Calórica/metabolismo , Proteínas/metabolismo , Peso Corporal , Glicina/metabolismo , Humanos , Lactente , Masculino , Nitrogênio/metabolismo , Biossíntese de ProteínasRESUMO
Five children with protein-energy malnutrition were were treated with a high calorie, high protein diet and the energy cost of growth in body weight and muscle mass were calculated. Energy expenditures correlated statistically with increases in muscle mass, estimated by [15N]creatine kinetics, but not with gains in body weight.