ABSTRACT
PURPOSE OF REVIEW: To examine the evidence evaluating the association between obesity and neuropathy as well as potential interventions. RECENT FINDINGS: Although diabetes has long been associated with neuropathy, additional metabolic syndrome components, including obesity, are increasingly linked to neuropathy development, regardless of glycemic status. Preclinical rodent models as well as clinical studies are shedding light on the mechanisms of obesity-related neuropathy as well as challenges associated with slowing progression. Dietary and surgical weight loss and exercise interventions are promising, but more data is needed. SUMMARY: High-fat-diet rodent models have shown that obesity-related neuropathy is a product of excess glucose and lipid accumulation leading to inflammation and cell death. Clinical studies consistently demonstrate obesity is independently associated with neuropathy; therefore, likely a causal risk factor. Dietary weight loss improves neuropathy symptoms but not examination scores. Bariatric surgery and exercise are promising interventions, but larger, more rigorous studies are needed. Further research is also needed to determine the utility of weight loss medications and ideal timing for obesity interventions to prevent neuropathy.
Subject(s)
Obesity , Humans , Obesity/epidemiology , Obesity/complications , Animals , Peripheral Nervous System Diseases/epidemiology , Peripheral Nervous System Diseases/etiology , Peripheral Nervous System Diseases/therapy , Weight Loss/physiology , Bariatric SurgeryABSTRACT
AIMS/HYPOTHESIS: The aim of this study was to determine the effect of bariatric surgery on diabetes complications in individuals with class II/III obesity (BMI > 35 kg/m2). METHODS: We performed a prospective cohort study of participants with obesity who underwent bariatric surgery. At baseline and 2 years following surgery, participants underwent metabolic phenotyping and diabetes complication assessments. The primary outcomes for peripheral neuropathy (PN) were a change in intra-epidermal nerve fibre density (IENFD, units = fibres/mm) at the distal leg and proximal thigh, the primary outcome for cardiovascular autonomic neuropathy (CAN) was a change in the expiration/inspiration (E/I) ratio, and the primary outcome for retinopathy was a change in the mean deviation on frequency doubling technology testing. RESULTS: Among 127 baseline participants, 79 completed in-person follow-up (age 46.0 ± 11.3 years [mean ± SD], 73.4% female). Participants lost a mean of 31.0 kg (SD 18.4), and all metabolic risk factors improved except for BP and total cholesterol. Following bariatric surgery, one of the primary PN outcomes improved (IENFD proximal thigh, +3.4 ± 7.8, p<0.01), and CAN (E/I ratio -0.01 ± 0.1, p=0.89) and retinopathy (deviation -0.2 ± 3.0, p=0.52) were stable. Linear regression revealed that a greater reduction in fasting glucose was associated with improvements in retinopathy (mean deviation point estimate -0.7, 95% CI -1.3, -0.1). CONCLUSIONS/INTERPRETATION: Bariatric surgery may be an effective approach to reverse PN in individuals with obesity. The observed stability of CAN and retinopathy may be an improvement compared with the natural progression of these conditions; however, controlled trials are needed.
Subject(s)
Bariatric Surgery , Diabetes Complications , Diabetes Mellitus, Type 2 , Obesity, Morbid , Humans , Female , Adult , Middle Aged , Male , Prospective Studies , Obesity/complications , Obesity/surgery , Bariatric Surgery/adverse effects , Weight Loss , Diabetes Complications/complications , Obesity, Morbid/surgery , Diabetes Mellitus, Type 2/complications , Diabetes Mellitus, Type 2/surgeryABSTRACT
Diabetic retinopathy, neuropathy, and nephropathy occur in more than 50% of people with diabetes, contributing substantially to morbidity and mortality. Patient understanding of these microvascular complications is essential to ensure early recognition and treatment of these sequalae as well as associated symptoms, yet little is known about patient knowledge of microvascular sequalae. In this comprehensive literature review, we provide an overview of existing knowledge regarding patient knowledge of diabetes, retinopathy, neuropathy, and nephropathy. We also discuss health care provider's knowledge of these sequalae given that patients and providers must work together to achieve optimal care. We evaluated 281 articles on patient and provider knowledge of diabetic retinopathy, neuropathy, and nephropathy as well as predictors of improved knowledge and screening practices. Results demonstrated that patient and provider knowledge of microvascular sequalae varied widely between studies, which may reflect sociocultural or methodologic differences. Knowledge assessment instruments varied between studies with limited validation data and few studies controlled for confounding. Generally, improved patient knowledge was associated with greater formal education, longer diabetes duration, and higher socioeconomic status. Fewer studies examined provider knowledge of sequalae, yet these studies identified multiple misconceptions regarding appropriate screening practices for microvascular complications and the need to screen patients who are asymptomatic. Further investigations are needed that use well validated measures, control for confounding, and include diverse populations. Such studies will allow identification of patients and providers who would benefit from interventions to improve knowledge of microvascular complications and, ultimately, improve patient outcomes.
Subject(s)
Diabetes Mellitus, Type 2 , Diabetic Nephropathies , Diabetic Retinopathy , Retinal Diseases , Humans , Health PersonnelABSTRACT
Myotonic dystrophy is an autosomal dominant genetic disease of nucleotide expansion resulting in neuromuscular disease with two distinct subtypes. There are significant systemic manifestations of this condition including progressive muscular decline, neurologic abnormalities, and cardiac disease. Given the higher prevalence of cardiac dysfunction compared to the general population, there is significant interest in early diagnosis and prevention of cardiac morbidity and mortality. Cardiac dysfunction has an origin in abnormal and unstable nucleotide repeats in the DMPK and CNBP genes which have downstream effects leading to an increased propensity for arrhythmias and left ventricular systolic dysfunction. Current screening paradigms involve the use of routine screening electrocardiograms, ambulatory electrocardiographic monitors, and cardiac imaging to stratify risk and suggest further invasive evaluation. The most common cardiac abnormality is atrial arrhythmia, however there is significant mortality in this population from high-degree atrioventricular block and ventricular arrhythmia. In this review, we describe the cardiac manifestations of myotonic dystrophy with an emphasis on arrhythmia which is the second most common cause of death in this population after respiratory failure.
ABSTRACT
BACKGROUND: 'Intersectional stigma' is a concept that has emerged to characterize the convergence of multiple stigmatized identities within a person or group, and to address their joint effects on health and wellbeing. While enquiry into the intersections of race, class, and gender serves as the historical and theoretical basis for intersectional stigma, there is little consensus on how best to characterize and analyze intersectional stigma, or on how to design interventions to address this complex phenomenon. The purpose of this paper is to highlight existing intersectional stigma literature, identify gaps in our methods for studying and addressing intersectional stigma, provide examples illustrating promising analytical approaches, and elucidate priorities for future health research. DISCUSSION: Evidence from the existing scientific literature, as well as the examples presented here, suggest that people in diverse settings experience intersecting forms of stigma that influence their mental and physical health and corresponding health behaviors. As different stigmas are often correlated and interrelated, the health impact of intersectional stigma is complex, generating a broad range of vulnerabilities and risks. Qualitative, quantitative, and mixed methods approaches are required to reduce the significant knowledge gaps that remain in our understanding of intersectional stigma, shared identity, and their effects on health. CONCLUSIONS: Stigmatized identities, while often analyzed in isolation, do not exist in a vacuum. Intersecting forms of stigma are a common reality, yet they remain poorly understood. The development of instruments and methods to better characterize the mechanisms and effects of intersectional stigma in relation to various health conditions around the globe is vital. Only then will healthcare providers, public health officials, and advocates be able to design health interventions that capitalize on the positive aspects of shared identity, while reducing the burden of stigma.
Subject(s)
Social Stigma , Female , Humans , MaleABSTRACT
BACKGROUND: Stigma is associated with health conditions that drive disease burden in low- and middle-income countries (LMICs), including HIV, tuberculosis, mental health problems, epilepsy, and substance use disorders. However, the literature discussing the relationship between stigma and health outcomes is largely fragmented within disease-specific siloes, thus limiting the identification of common moderators or mechanisms through which stigma potentiates adverse health outcomes as well as the development of broadly relevant stigma mitigation interventions. METHODS: We conducted a scoping review to provide a critical overview of the breadth of research on stigma for each of the five aforementioned conditions in LMICs, including their methodological strengths and limitations. RESULTS: Across the range of diseases and disorders studied, stigma is associated with poor health outcomes, including help- and treatment-seeking behaviors. Common methodological limitations include a lack of prospective studies, non-representative samples resulting in limited generalizability, and a dearth of data on mediators and moderators of the relationship between stigma and health outcomes. CONCLUSIONS: Implementing effective stigma mitigation interventions at scale necessitates transdisciplinary longitudinal studies that examine how stigma potentiates the risk for adverse outcomes for high-burden health conditions in community-based samples in LMICs.
Subject(s)
Social Stigma , Developing Countries , Epilepsy , HIV Infections , Humans , Male , Mental Disorders , Substance-Related Disorders , TuberculosisABSTRACT
INTRODUCTION: Whether successful catheter ablation for atrial fibrillation (AF) reduces risk of cerebrovascular events (CVEs) remains controversial and whether oral anticoagulation therapy (OAT) can be safely discontinued in patients rendered free of AF recurrences remains unknown. We evaluated OAT use patterns and examined long-term rates of CVEs (stroke/TIA) and major bleeding episodes (MBEs) in patients with nonparoxysmal AF treated with catheter ablation. METHODS AND RESULTS: Four hundred patients with nonparoxysmal AF (200 persistent, 200 longstanding persistent; mean age 60.3 ± 9.7 years, 82% male) undergoing first AF ablation were followed for 3.6 ± 2.4 years. OAT discontinuation during follow-up was permitted in selected patients per physician discretion. At last follow-up, allowing for multiple ablations, 172 (43.0%) patients were free of AF recurrence. Two hundred and seven (51.8%) discontinued OAT at some point; 174 (43.5%) were off OAT at last follow-up. Patients without AF recurrence were more likely to remain off OAT (HR 0.23 [95% CI 0.17-0.33]). Patients with persistent (versus longstanding persistent) AF type prior to ablation (HR 0.6 [CI 0.44-0.83]) and those with CHA2 DS2 -VASc score <2 (HR 0.56 [0.39-0.80]) were less likely to continue OAT. Seven patients had CVEs (incidence: 0.49/100 patient years) and 14 experienced MBE during follow-up (incidence: 0.98/100 patient years). Older age (P = 0.001) and coronary artery disease (P = 0.028) were associated with CVE. CONCLUSION: Anticoagulation discontinuation in well selected, closely monitored patients following successful ablation of nonparoxysmal AF was associated with a low rate of clinical embolic CVEs. Prospective studies are required to confirm safety of OAT discontinuation after successful AF ablation.
Subject(s)
Anticoagulants/administration & dosage , Atrial Fibrillation/therapy , Catheter Ablation , Ischemic Attack, Transient/prevention & control , Stroke/prevention & control , Administration, Oral , Aged , Aged, 80 and over , Anticoagulants/adverse effects , Atrial Fibrillation/complications , Atrial Fibrillation/diagnosis , Atrial Fibrillation/physiopathology , Catheter Ablation/adverse effects , Drug Administration Schedule , Female , Hemorrhage/chemically induced , Humans , Ischemic Attack, Transient/diagnosis , Ischemic Attack, Transient/etiology , Ischemic Attack, Transient/physiopathology , Male , Middle Aged , Progression-Free Survival , Recurrence , Retrospective Studies , Risk Assessment , Risk Factors , Stroke/diagnosis , Stroke/etiology , Stroke/physiopathology , Time FactorsABSTRACT
BACKGROUND: Recurrent seizure risks in HIV-positive people with new-onset seizure are largely unknown, making it challenging to offer optimal recommendations regarding antiepileptic drug (AED) initiation. Existing outcomes data is limited, and risk factor identification requires a diagnostic assessment, which is often unavailable in regions heavily effected by HIV, like sub-Saharan Africa. METHODS: HIV-positive Zambian adults with new-onset seizure were enrolled in a prospective cohort study to determine seizure recurrence and risk factors for recurrence. Seizure etiology was evaluated, and recurrent seizures and medication usage were assessed during clinic visits. Due to unexpectedly high mortality rates, predictors of death were evaluated using proportional hazards with Gray's test to compare cumulative incidence functions for recurrent seizure across groups adjusting for the competing outcome of death. RESULTS: 95 patients were enrolled (mean age 37 years, 43% female, 83% with Karnofsky > 50) and followed for a mean of 293 days (median 241 (IQR: 29-532)). At presentation, 50 (53%) were in status epilepticus. The majority (91, 85%) had advanced HIV disease and 65 (68%) were not on combined antiretroviral therapy (cART). After extensive workup, seizure etiology remained unknown in 16 (17%). Average time to cART initiation after enrollment was 61 days. During follow up, 37 (39%) died and 23 (24%) had recurrent seizure. Most deaths (25/37, 68%) occurred in the first 60 days post-index seizure. Individuals with advanced HIV were more likely to die (HR: 19.1 [95% CI: 1.1-333.4]) as were those whose seizure etiology remained unknown (HR: 2.2 [95% CI: 1.1-4.4]). Among participants that survived from enrolment to the end of data collection on 10 May 2013 (n = 58), 20 (34%) experienced recurrent seizures. CONCLUSIONS: New-onset seizure among HIV-positive Zambian adults is associated with high mortality despite good functional status prior to presentation. Advanced HIV infection and failure to identify an underlying seizure etiology are associated with greater mortality. Recurrent seizures occur in over a third of survivors within only 2 years of follow-up. This provides evidence to support AED initiation after first seizure in HIV-positive individuals with advanced HIV disease at the time of presentation though the risks of AED-cART interactions remain a concern and warrant further study.
Subject(s)
HIV Infections/complications , Seizures/etiology , Seizures/mortality , Adult , Anticonvulsants/therapeutic use , Female , HIV Infections/mortality , Humans , Incidence , Male , Middle Aged , Prospective Studies , Recurrence , Risk Factors , Seizures/drug therapy , Young Adult , ZambiaABSTRACT
INTRODUCTION: Bipolar voltage criteria to delineate left atrial (LA) scar have been derived using point-by-point (PBP) contact electroanatomical mapping. It remains unclear how PBP-derived LA scar correlates with multielectrode fast automated mapping (ME-FAM) derived scar. We aimed to correlate scar and bipolar voltages from LA maps created using PBP versus ME-FAM. METHODS AND RESULTS: In consecutive patients undergoing repeat AF ablation, 2 separate LA maps were created using PBP and ME-FAM during sinus rhythm before ablation. Contiguous areas in the LA with a bipolar voltage cutoff of ≤0.2 mV represented dense scar; LA scar percentage was calculated for each map. Each LA shell was divided into 9 regions and each region further subdivided into 4 quadrants for additional analysis; mean voltages of all points obtained using PBP versus ME-FAM in each region were compared. Forty maps (20 PBP: mean 228.5 ± 95.6 points; 20 ME-FAM: 923.0 ± 382.6 points) were created in 20 patients. Mapping time with ME-FAM was shorter compared with PBP (13.3 ± 5.3 vs. 34.4 ± 13.1 minutes; P < 0.001). Mean LA scar percentage was higher with PBP compared with ME-FAM (15.5 ± 17.1% vs. 12.8 ± 17.6%; P = 0.04). Mean PBP voltage distribution was lower (compared with ME-FAM) in the septum (0.95 ± 0.73 vs. 1.46 ± 0.99 mV; P = 0.009), posterior wall (0.84 ± 0.42 vs. 1.40 ± 0.83 mV; P = 0.0008), roof (0.78 ± 0.80 vs. 1.39 ± 1.09 mV; P = 0.0003), and right PV-LA junction (0.34 ± 0.25 vs. 0.59 ± 0.50 mV; P = 0.01) regions, while voltages were similar in all other LA regions (all P > 0.05). CONCLUSIONS: In AF patients undergoing repeat ablation, bipolar voltage is greater in certain LA segments with ME-FAM compared with PBP mapping.
Subject(s)
Action Potentials , Atrial Fibrillation/diagnosis , Atrial Fibrillation/surgery , Catheter Ablation , Cicatrix/diagnosis , Cicatrix/surgery , Electrophysiologic Techniques, Cardiac/methods , Pulmonary Veins/surgery , Aged , Atrial Fibrillation/physiopathology , Automation , Catheter Ablation/adverse effects , Cicatrix/etiology , Cicatrix/physiopathology , Female , Heart Rate , Humans , Male , Middle Aged , Predictive Value of Tests , Prospective Studies , Pulmonary Veins/physiopathology , Recurrence , ReoperationABSTRACT
PURPOSE: Epilepsy-associated stigma is an important patient-centered outcome, yet quantification remains challenging. Jacoby's 3-item Stigma Scale is commonly used to assess felt stigma among people with epilepsy (PWE) yet has ceiling effects. The Stigma Scale of Epilepsy (SSE) is a 24-item instrument that measures felt stigma among PWE and stigmatizing attitudes among others. If cross-culturally valid, the SSE may elucidate stigma determinants and provide an outcome measure for interventions. METHODS: We assessed the properties of the SSE in 102 Zambian PWE using exploratory and confirmatory item response theories and compared the latent traits assessed by the SSE to those assessed by Jacoby's Stigma Scale. Differential item functioning based on forced disclosure of epilepsy was examined. RESULTS: The SSE yielded two latent traits--the first reflected difficulties faced by PWE; the second reflected emotions associated with epilepsy. Jacoby's Stigma Scale was associated only with the first latent trait. Forced disclosure was associated with "worry" and "pity" that were associated with the second latent trait. CONCLUSIONS: In Zambian PWE, the SSE captured two latent traits. One trait represents feelings associated with epilepsy, which is theorized as a substantial yet unmeasured part of stigma. The SSE performs well across cultures and may more comprehensively assess felt stigma than other instruments. Further validation is required to determine whether the SSE adequately assesses stigmatizing attitudes among people without epilepsy.
Subject(s)
Epilepsy/psychology , Stereotyping , Surveys and Questionnaires/standards , Adult , Emotions , Female , Humans , Male , Quality of Life , Young Adult , ZambiaABSTRACT
Muscle weakness and pain can be seen in orthopedic, rheumatologic, cardiac, and musculoskeletal conditions in addition to neurologic disorders. Myopathy, which describes a heterogenous group of hereditary and acquired disorders that affect muscle channels, structure, and metabolism, is one possible cause. This review focuses on essential information to support primary care providers as they assess patients with muscle weakness and pain for myopathy. As with most neurologic disorders, a thorough clinical history and physical examination are essential first steps. These findings will then guide diagnostic testing and facilitate appropriate management or referral for further neuromuscular care.
Subject(s)
Muscle Weakness , Muscular Diseases , Physical Examination , Humans , Muscle Weakness/diagnosis , Muscular Diseases/diagnosis , Primary Health Care , Myalgia/diagnosis , Diagnosis, Differential , Medical History TakingABSTRACT
BACKGROUND AND OBJECTIVES: Distal symmetric polyneuropathy (DSP) is a disabling, often painful condition associated with falls and reduced quality of life. Non-Hispanic Black people and people with low income are underrepresented in existing DSP studies; therefore, it is unknown whether data accurately reflect the prevalence, risk factors, and burden of disease in these populations. METHODS: Patients older than 40 years presenting to an outpatient internal medicine clinic predominantly serving Medicaid patients in Flint, Michigan, were enrolled in a cross-sectional study. Demographics, clinical characteristics, including medication use, anthropomorphic measurements, fasting lipids, and hemoglobin A1c were collected. DSP was defined using the modified Toronto Clinical Neuropathy Score (mTCNS). Multivariable logistic regression was performed to model DSP and undiagnosed DSP as a function of potential risk factors age, metabolic syndrome, and race. DSP burden was measured using Peripheral Neuropathy Quality of Life Instrument-97. RESULTS: Two hundred participants were enrolled, and 169 (85%) completed all data collection. The population was 55% female of mean age (SD) 58.2 years (10.4) and 69% non-Hispanic Black. Among the population, 50% had diabetes, 67% had metabolic syndrome, and 47% had a household income <$20,000. DSP was present in 73% of the population, of which 75% were previously undiagnosed. Neuropathic pain was documented in 57% of participants with DSP. DSP based on mTCNS criteria was associated with older age (odds ratio [OR] 1.1 [95% confidence interval (CI) 1.03-1.2]) and metabolic syndrome (OR 4.4 [1.1-18.1]). Non-Hispanic Black participants had lower odds of DSP (OR 0.1 [0.01-0.4]) than non-Hispanic White and Hispanic participants. DSP burden was high, including increased pain, health-related worry, and poorer quality of life (all p < 0.001). DISCUSSION: DSP is extremely common and often underrecognized in this predominantly non-Hispanic Black, low-income population and leads to substantial disease burden. Metabolic syndrome is a highly prevalent, modifiable risk factor in this population that should be managed to lower DSP prevalence.
Subject(s)
Black or African American , Poverty , Adult , Aged , Female , Humans , Male , Middle Aged , Cross-Sectional Studies , Michigan/epidemiology , Polyneuropathies/epidemiology , Polyneuropathies/ethnology , Prevalence , Quality of Life , Risk Factors , Hispanic or Latino , WhiteABSTRACT
BACKGROUND: Seizures are relatively common among children with HIV in low- and middle-income countries and are associated with significant morbidity and mortality. Early treatment with antiretroviral therapy (ART) may reduce this risk by decreasing rates of central nervous system infections and HIV encephalopathy. METHODS: We conducted a prospective, unmatched case-control study. We enrolled children with new-onset seizure from University Teaching Hospital in Lusaka, Zambia and 2 regional hospitals in rural Zambia. Controls were children with HIV and no history of seizures. Recruitment took place from 2016 to 2019. Early treatment was defined as initiation of ART before 12 months of age, at a CD4 percentage >15% in children aged 12-60 months or a CD4 count >350 cells/mm 3 for children aged 60 months or older. Logistic regression models were used to evaluate the association between potential risk factors and seizures. RESULTS: We identified 73 children with new-onset seizure and compared them with 254 control children with HIV but no seizures. Early treatment with ART was associated with a significant reduction in the odds of seizures [odds ratio (OR) 0.04, 95% confidence interval: 0.02 to 0.09; P < 0.001]. Having an undetectable viral load at the time of enrollment was strongly protective against seizures (OR 0.03, P < 0.001), whereas history of World Health Organization Stage 4 disease (OR 2.2, P = 0.05) or CD4 count <200 cells/mm 3 (OR 3.6, P < 0.001) increased risk of seizures. CONCLUSIONS: Early initiation of ART and successful viral suppression would likely reduce much of the excess seizure burden in children with HIV.
Subject(s)
Anti-HIV Agents , HIV Infections , Child , Humans , Infant , HIV Infections/complications , HIV Infections/drug therapy , Zambia/epidemiology , Case-Control Studies , Risk Factors , Seizures/drug therapy , Seizures/prevention & control , Seizures/complications , CD4 Lymphocyte Count , Anti-HIV Agents/therapeutic useABSTRACT
Eighty percent of people with epilepsy (PWE) reside in low-income countries where stigma contributes substantially to social and medical morbidity. Peer support groups (PSGs) are thought to be beneficial for people with stigmatized conditions, but little data exist regarding PSG effectiveness. We facilitated monthly PSG meetings for men, women, and youth from three Zambian clinics for one year. Pre- and post-intervention assessments measured internalized stigma, psychiatric morbidity, medication adherence, socioeconomic status, and community disclosure. Of 103 participants (39 men, 30 women, and 34 youth), 80 PWE (78%) attended ≥ 6 meetings. There were no significant demographic differences between PWE who attended ≥ 6 meetings and those who attended <6 meetings. Among youth attending ≥ 6 meetings, internalized stigma decreased (p<0.02). Among adults, there was a non-significant stigma decrease. No differences were detected in medication use, medication adherence, or psychiatric morbidity. Peer support groups effectively reduce stigma for youth and may offer a low-cost approach to addressing epilepsy-associated stigma in resource-poor settings.
Subject(s)
Epilepsy/psychology , Peer Group , Self-Help Groups , Social Stigma , Adaptation, Psychological , Adolescent , Adult , Age Factors , Anticonvulsants/therapeutic use , Epilepsy/drug therapy , Female , Humans , Male , Sex Factors , Statistics, Nonparametric , Surveys and Questionnaires , Young AdultABSTRACT
OBJECTIVE: This article provides an up-to-date review of the diagnosis and management of the most common neuropathies that occur in patients with diabetes. LATEST DEVELOPMENTS: The prevalence of diabetes continues to grow worldwide and, as a result, the burden of diabetic neuropathies is also increasing. Most diabetic neuropathies are caused by hyperglycemic effects on small and large fiber nerves, and glycemic control in individuals with type 1 diabetes reduces neuropathy prevalence. However, among people with type 2 diabetes, additional factors, particularly metabolic syndrome components, play a role and should be addressed. Although length-dependent distal symmetric polyneuropathy is the most common form of neuropathy, autonomic syndromes, particularly cardiovascular autonomic neuropathy, are associated with increased mortality, whereas lumbosacral radiculoplexus neuropathy and treatment-induced neuropathy cause substantial morbidity. Recent evidence-based guidelines have updated the recommended treatment options to manage pain associated with distal symmetric polyneuropathy of diabetes. ESSENTIAL POINTS: Identifying and appropriately diagnosing the neuropathies of diabetes is key to preventing progression. Until better disease-modifying therapies are identified, management remains focused on diabetes and metabolic risk factor control and pain management.
Subject(s)
Diabetes Mellitus, Type 2 , Diabetic Neuropathies , Polyneuropathies , Humans , Diabetic Neuropathies/diagnosis , Diabetic Neuropathies/therapy , Diabetes Mellitus, Type 2/complications , Risk Factors , PainABSTRACT
BACKGROUND: Uptake of lumbar puncture (LP) remains low in regions with a high prevalence of central nervous system (CNS) infections like Zambia. Efforts to improve uptake are hindered by limited understanding of factors influencing LP uptake. METHODS: Semistructured qualitative interviews were conducted with patients with suspected CNS infection, caregivers, doctors and nurses at the University Teaching Hospitals in 2016. Questions focused on LP experiences, knowledge, the consent process and health system barriers to LP among patients with an LP indication. Interviews were transcribed, translated to English and analysed using a thematic approach. RESULTS: We recruited 24 adult patients, 36 caregivers of adult patients, 63 caregivers of paediatric patients, 20 doctors and 30 nurses (173 in total). LP barriers arose from both patients/caregivers and health providers and included community apprehension about LP, proxy (family) consensus consent practices, competing clinical demands, wariness of patient/caregiver responses, limitations in consumables and time to complete the LP. This could result in consent not being obtained correctly. LP enablers included patient/caregiver perceived LP utility, provider comfort with LP and in-person counselling. CONCLUSIONS: LP uptake is a complex sociocultural process influenced by patient, healthcare and community-level factors. Interventions to improve uptake must address multiple barriers to be successful.
Subject(s)
Caregivers , Physicians , Adult , Child , Humans , Qualitative Research , Spinal Puncture , ZambiaABSTRACT
Diabetic peripheral neuropathy (DPN) occurs in up to half of individuals with type 1 or type 2 diabetes. DPN results from the distal-to-proximal loss of peripheral nerve function, leading to physical disability and sometimes pain, with the consequent lowering of quality of life. Early diagnosis improves clinical outcomes, but many patients still develop neuropathy. Hyperglycaemia is a risk factor and glycaemic control prevents DPN development in type 1 diabetes. However, glycaemic control has modest or no benefit in individuals with type 2 diabetes, probably because they usually have comorbidities. Among them, the metabolic syndrome is a major risk factor for DPN. The pathophysiology of DPN is complex, but mechanisms converge on a unifying theme of bioenergetic failure in the peripheral nerves due to their unique anatomy. Current clinical management focuses on controlling diabetes, the metabolic syndrome, and pain, but remains suboptimal for most patients. Thus, research is ongoing to improve early diagnosis and prognosis, to identify molecular mechanisms that could lead to therapeutic targets, and to investigate lifestyle interventions to improve clinical outcomes.
Subject(s)
Diabetes Mellitus, Type 2 , Diabetic Neuropathies , Metabolic Syndrome , Humans , Diabetes Mellitus, Type 2/complications , Diabetes Mellitus, Type 2/therapy , Diabetic Neuropathies/diagnosis , Diabetic Neuropathies/etiology , Diabetic Neuropathies/prevention & control , Metabolic Syndrome/complications , Pain/etiology , Quality of LifeABSTRACT
BACKGROUND: Meningitis causes significant mortality in regions with high comorbid HIV and TB. Improved outcomes are hindered by limited understanding of factors that delay adequate care. METHODS: In-depth interviews of patients admitted to the University Teaching Hospital with suspected meningitis, their caregivers, doctors and nurses were conducted. Patient/caregiver interviews explored meningitis understanding, treatment prior to admission and experiences since admission. Provider interviews addressed current and prior experiences with meningitis patients and hospital barriers to care. A conceptual framework based on the Three Delays Model identified factors that delayed care. RESULTS: Twenty-six patient/caregiver, eight doctor and eight nurse interviews occurred. Four delays were identified: in-home care; transportation to a health facility; clinic/first-level hospital care; and third-level hospital. Overcrowding and costly diagnostic testing delayed outpatient care; 23% of patients began with treatment inside the home due to prior negative experiences with biomedical care. Admission occurred after multiple clinic visits, where subsequent delays occurred during testing and treatment. CONCLUSIONS: Delays in care from home to hospital impair quality meningitis care in Zambia. Interventions to improve outcomes must address patient, community and health systems factors. Patient/caregiver education regarding signs of meningitis and indications for care-seeking are warranted to reduce treatment delays.
Subject(s)
Meningitis , Patient Acceptance of Health Care , Adult , Humans , Zambia/epidemiology , Qualitative Research , Time-to-Treatment , Meningitis/therapyABSTRACT
OBJECTIVE: This study describes clinical profiles including human immunodeficiency virus (HIV) disease history and seizure etiology among children living with HIV presenting with new-onset seizure during the era of antiretroviral therapy (ART) in Zambia. 30-day mortality and cause of death are also reported. METHODS: Children living with HIV (CLWHIV) with new-onset seizures were prospectively evaluated at one large urban teaching hospital and two non-urban healthcare facilities. Interviews with family members, review of medical records, and where needed, verbal autopsies were undertaken. Two clinicians who were not responsible for the patients' care independently reviewed all records and assigned seizure etiology and cause of death with adjudication as needed. RESULTS: From April 2016 to June 2019, 73 children (49 urban, 24 rural) were identified. Median age was 6 years (IQR 2.2-10.0) and 39 (53%) were male children. Seizures were focal in 36 (49%) and were often severe, with 37% presenting with multiple recurrent seizures in the 24 hours before admission or in status epilepticus. Although 36 (49%) were on ART at enrollment, only 7 of 36 (19%) were virally suppressed. Seizure etiologies were infectious in over half (54%), with HIV encephalitis, bacterial meningitis, and tuberculous meningitis being the most common. Metabolic causes (19%) included renal failure and hypoglycemia. Structural lesions identified on imaging accounted for 10% of etiologies and included stroke and non-accidental trauma. No etiology could be identified in 12 (16%) children, most of whom died before the completion of clinical investigations. Twenty-two (30%) children died within 30 days of the index seizure. SIGNIFICANCE: Despite widespread ART roll out in Zambia, new-onset seizure in CLWHIV occurs in the setting of advanced, active HIV disease. Seizure severity/burden is high as is early mortality. Enhanced programs to assure early ART initiation, improve adherence, and address ART failure are needed to reduce the burden of neurological injury and premature death in CLWHIV.