Assessing compliance with national guidelines in diabetes care: A study leveraging data from south Africa's National Health Laboratory Service (NHLS).

Diabetes is a major global health issue. We evaluated compliance to laboratory-based management guidelines for diabetes (type 1 and 2), essential for effective treatment and reducing diabetes-related morbidity and mortality. Our study utilized South Africa's National Health Laboratory Services (NHLS) data, focusing on patients from birth to age 80 years who underwent initial diabetes laboratory testing between January 1, 2012-January 1, 2016. Patients were categorized into type 1 (<30 years) or type 2 (≥30-80 years) diabetes based on age at first diabetes test. National diabetes guidelines recommend blood glucose to be checked every three-six months post laboratory-diagnosis. We employed a sharp regression discontinuity design to estimate the effect of a laboratory-diagnosis of diabetes on the likelihood of having a follow-up laboratory test 24 months post-diagnosis. Among patients with type 2 diabetes, the probability of a diabetes follow-up laboratory test within 24 months was 52.4% for patients presenting above the diabetes diagnosis threshold vs 31.1% for those presenting below. Although the likelihood of repeat testing rose with higher HbA1c and glucose levels, at the diagnostic threshold there was no clinically meaningful difference (risk difference: -2.2%, 95% CI: -3.3%, -1.2%). These results were consistent among patients with type 1 diabetes, those living with and without HIV, and healthcare setting. In a national laboratory cohort, diabetes laboratory-diagnosis did not lead to increased monitoring as recommended in national guidelines. Strategies to improve patient education, healthcare provider communication, and healthcare system support are essential to enhance guideline compliance and overall diabetes management.

Determination of the ursolic and oleanolic acids content with the antioxidant capacity in apple peel extract of various cultivars.

Apples are rich sources of ursolic acid (UA) and oleanolic acid (OA) which are the major and most prominent triterpenes in the peel of an apple. Pentacyclic triterpenes are ideal nutraceuticals due to their ability to reduce the risk of many life-threatening diseases such as cancer, cardiovascular and diabetes. This study was to determine the content of UA and OA in the apple peel extract from different cultivars grown in South Africa as well as the correlation of their content level with antioxidant capacity. Quantitative analysis of UA and OA in apple peels from three cultivars; red delicious (RD), royal gala (RG) and granny smith (GS) apples was carried out using HPLC and their antioxidant capacity was analyzed using the DPPH assay. The RD showed the highest content of UA and OA (248.02 ± 0.08 µg/ml and 110.00 ± 0.08 µg/ml respectively) in the apple peel extract and also displayed a significantly high level of antioxidant capacity (97.3 ± 0.40%; p < 0.0001) compared to the RG and GS cultivars. A strong positive correlation was noted between the UA, OA and antioxidant capacities of all the cultivars. Only the RD cultivar showed a significant correlation though; UA (r = 0.9570; p = 0.0027) and OA (r = 0.8503; p = 0.0319). This study demonstrated that the RD and RG apple peels possess the highest UA and OA content which invariably increases their antioxidant activities compared to GS apple. Thus, both apple cultivars would be useful and recommended for food consumption and nutraceuticals values to improve human health.

Estimating the burden of disease attributable to ambient air pollution (ambient PM2.5 and ambient ozone) in South Africa for 2000, 2006 and 2012.

Background: Globally, a growing body of research has shown that ambient air pollution is one of the most critical environmental issues, especially in relation to human health. Exposure to ambient air pollution leads to serious health conditions such as lower respiratory infections, cancers, diabetes mellitus type 2, ischaemic heart disease, stroke and chronic obstructive pulmonary disease. Objectives: To estimate the burden of disease attributable to ambient air pollution in South Africa (SA) for the years 2000, 2006 and 2012. Methods: Comparative risk assessment method was used to determine the burden of disease due to two pollutants (particulate matter (PM2.5) and ambient ozone). Regionally optimised fully coupled climate chemistry models and surface air pollution observations were used to generate concentrations of PM2.5 and ozone for each SA Census Small Area Level, for the year 2012. For 2000 and 2006, population-weighted PM2.5and ozone were estimated, based on the 2012 results. Following the identification of disease outcomes associated with particulate matter with aerodynamic diameter <2.5 µm (PM2.5) and ozone exposure, the attributable burden of disease was estimated for 2000, 2006 and 2012. Furthermore, for the year 2012, the burden of disease attributable to ambient air pollution exposure was computed at provincial levels. Results: In 2012, approximately 97.6% of people in SA were exposed to PM2.5 at levels above the 2005 World Health Organization guideline: 10 µg/m3 annual mean. From 2000 to 2012, population-weighted annual average PM2.5 increased from 26.6 µg/m3 to 29.7 µg/m3, and ozone 6-month high 8-hour daily maximum increased from 64.4 parts per billion (ppb) to 72.1 ppb. At a national scale, in the year 2000, 15 619 (95% uncertainty interval (UI) 8 958 - 21 849) deaths were attributed to PM2.5 exposure, while 1 326 (95% UI 534 - 1 885) deaths were attributed to ozone. In 2006, an estimated 19 672 deaths (95% UI 11 526 - 27 086) were attributed to PM2.5, and a further 1 591 deaths (95% UI 651 - 2 236) to ozone exposure. In 2012, deaths attributed to PM2.5 were 19 507 (95% UI 11 318 - 27 111), and to ozone 1 734 (95% UI 727 - 2 399). Additionally, population-weighted provincial scale analysis showed that Gauteng Province had the highest number of attributable deaths due to both PM2.5 and ozone in 2012. Conclusion: The study showed that ambient air pollution exposure is an important health risk in SA, requiring both short- and long-term intervention. In the short term, the SA Ambient Air Quality Standards and industrial minimum emissions standards need to be enforced. In the longer term, to reduce air pollution and the associated disease burden, the combustion of fossil fuels as a source of energy for power generation and transportation, as well as industrial and domestic uses, needs to be replaced with clean renewable energy sources. In addition to local measures, when the southern African prevalent anticyclonic air dynamics that transport regionally emitted pollutants into SA (especially from biomass burning) are considered, it is also advisable to establish long-term regional co-operation in reducing air pollution.

Sentinel seroprevalence of SARS-CoV-2 in Gauteng Province, South Africa, August - October 2020.

BACKGROUND: Estimates of prevalence of anti-SARS-CoV-2 antibody positivity (seroprevalence) for tracking the COVID-19 epidemic are lacking for most African countries. OBJECTIVES: To determine the prevalence of antibodies against SARS-CoV-2 in a sentinel cohort of patient samples received for routine testing at tertiary laboratories in Johannesburg, South Africa. METHODS: This sentinel study was conducted using remnant serum samples received at three National Health Laboratory Service laboratories in the City of Johannesburg (CoJ) district. Collection was from 1 August to 31 October 2020. We extracted accompanying laboratory results for glycated haemoglobin (HbA1c), creatinine, HIV, viral load and CD4 T-cell count. An anti-SARS-CoV-2 targeting the nucleocapsid (N) protein of the coronavirus with higher affinity for IgM and IgG antibodies was used. We reported crude as well as population-weighted and test-adjusted seroprevalence. Multivariate logistic regression analysis was used to determine whether age, sex, HIV and diabetic status were associated with increased risk for seropositivity. RESULTS: A total of 6 477 samples were analysed, the majority (n=5 290) from the CoJ region. After excluding samples with no age or sex stated, the model population-weighted and test-adjusted seroprevalence for the CoJ (n=4 393) was 27.0% (95% confidence interval (CI) 25.4 - 28.6). Seroprevalence was highest in those aged 45 - 49 years (29.8%; 95% CI 25.5 - 35.0) and in those from the most densely populated areas of the CoJ. Risk for seropositivity was highest in those aged 18 - 49 years (adjusted odds ratio (aOR) 1.52; 95% CI 1.13 - 2.13; p=0.0005) and in samples from diabetics (aOR 1.36; 95% CI 1.13 - 1.63; p=0.001). CONCLUSIONS: Our study conducted between the first and second waves of the pandemic shows high levels of current infection among patients attending public health facilities in Gauteng Province.

The role of serological testing in the SARS-CoV-2 outbreak.

Antibody tests for the novel coronavirus, SARS-CoV2, have been developed both as rapid diagnostic assays and for high-throughput formal serology platforms. Although these tests may be a useful adjunct to a diagnostic strategy, they have a number of limitations. Because of the antibody and viral dynamics of the coronavirus, their sensitivity can be variable, especially at early time points after symptom onset. Additional data are required on the performance of the tests in the South African population, especially with regard to development and persistence of antibody responses and whether antibodies are protective against reinfection. These tests may, however, be useful in guiding the public health response, providing data for research (including seroprevalence surveys and vaccine initiatives) and development of therapeutic strategies.

Type 2 diabetes remission rates 1-year post-Roux-en-Y gastric bypass and validation of the DiaRem score: the Ontario Bariatric Network experience.

Roux-en-Y gastric bypass (RYGB) is associated with the remission of type 2 diabetes mellitus (DM). There are a number of scoring systems available that help predict type 2 diabetes remission rates after bariatric surgery; however, relatively few have been validated externally. The DiaRem score, comprised of four preoperative variables (age, haemoglobin A1c [HbA1c], sulfonylurea and insulin-sensitizing agent use and insulin use), allows for the identification of patients who are most likely to have DM remission following RYGB. Our primary objective was to determine the variables predictive of DM remission 1 year post-RYGB, determine how well the DiaRem score predicts DM remission 1 year post-RYGB and identify the optimal cut-off DiaRem score. The study is based on results of RYGB performed across multiple centres in Ontario, Canada, overseen by the Centre for Surgical Invention and Innovation in Hamilton, with direction from the Ontario Bariatric Network. Regression analysis was used to determine the predictive value of demographic and clinical variables and that of the DiaRem score. The optimal DiaRem cut-off score was determined using sensitivity and specificity analysis. Of 3874 patients in the Ontario Bariatric Registry between January 2010 and February 2015, 915 had complete 1-year follow-up data. Among these, 15 were not classified as having DM at baseline and were excluded. Of the remaining 900 patients with type 2 diabetes and who underwent RYGB surgery, 333 (37.0%) had DM remission at 1-year follow-up. Three of four DiaRem variables (age, HbA1c, insulin use), in addition to use of any hypoglycaemic agent, were associated with DM remission. DiaRem score had moderate predictive value. A DiaRem score cut-off of <5 had a sensitivity of 71.8% and specificity of 71.3%. This study provides guidance to clinicians in using the DiaRem score to inform the selection and prioritization of patients to ensure timely access to bariatric surgery for those who are likely to benefit the most.

Effects of isosorbide dinitrate on pulmonary hypertension in chronic obstructive pulmonary disease.

Eighteen patients with chronic obstructive pulmonary disease with pulmonary hypertension were studied to assess the hemodynamic response to acute oxygen administration and to oral isosorbide dinitrate (ISDN). All 18 patients had baseline hemodynamic measurements and hemodynamic measurements during low-flow nasal oxygen. Following a second baseline measurement, patients received either oral ISDN (11 patients) or placebo (7 patients) in a randomized, double-blind protocol. Heart rate decreased with oxygen administration but there were no other significant hemodynamic changes. With oral ISDN, there was a significant fall in pulmonary artery and brachial artery pressure. Cardiac output, right atrial pressure, pulmonary wedge pressure, and pulmonary vascular resistance all fell but not significantly. We conclude that oral ISDN is effective in reducing pulmonary hypertension in patients with chronic obstructive pulmonary disease.

Improved exercise tolerance of the polycythemic lung patient following phlebotomy.

The present study evaluated the effects of therapeutic phlebotomy on the exercise tolerance and the maximal carbon dioxide output of polycythemic patients with chronic obstructive pulmonary disease. Fifteen maximal exercise studies were performed before and after phlebotomy in patients with moderate to severe chronic obstructive pulmonary disease (mean forced expiratory volume in one second [FEV1]= 970 ml). After phlebotomy there were no significant differences in pulmonary function, blood gases, oxygen consumption, or carbon dioxide production at rest. However, after phlebotomy there was a significant increase in the exercise tolerance of the patients. The mean workload, the duration of exercise, the maximal oxygen consumption, the maximal carbon dioxide production, and the ventilation at maximal exercise all increased significantly. The improved exercise tolerance after phlebotomy appeared due to an increased cardiac output generated mainly through an increased stroke volume. We hypothesize that the increased stroke volume was due to a higher ejection fraction of the right ventricle secondary to a lower pulmonary artery pressure. This study provides further evidence that patients with chronic obstructive pulmonary disease who have polycythemia benefit by therapeutic interventions that maintain their hematocrits below 55 percent.

Comparison of the effects of labetalol and hydrochlorothiazide on the ventilatory function of hypertensive patients with mild chronic obstructive pulmonary disease.

Labetalol is a new adrenergic antagonist with both alpha- and beta-blocking effects. The effects of labetalol and hydrochlorothiazide on the hypertension and ventilatory function of patients with both hypertension and mild reversible chronic pulmonary disease were compared. In this double-blind study, 20 patients were randomly allocated to receive increasing doses of labetalol (100 to 400 mg three times a day) or hydrochlorothiazide (25 to 50 mg three times a day) over a four-week treatment period. Patients returned at weekly intervals for spirometry baseline, two hours after receiving the medication for the following week, and five minutes after an exercise test. Each treatment reduced the blood pressure significantly and to a comparable degree. There was no significant decrease in ventilatory function two hours after administration of the drug at any visit for either drug. Ventilatory function did not deteriorate significantly following exercise with either drug. With labetalol there was a progressive statistically significant decline in baseline forced expiratory volume in one second from 1,860 +/- 190 ml to 1,685 +/- 190 ml during the four-week study period, although no patient became symptomatic from shortness of breath. We conclude that labetalol is an effective antihypertensive agent that does not adversely effect ventilatory function immediately, but that may lead to a decline in ventilatory function when administered long-term.

Suspected superior vena cava syndrome: the role of the Swan-Ganz catheter.

The use of the Swan-Ganz flow-directed catheter in establishing the diagnosis of the superior vena cava syndrome in two patients (one with Hodgkin's disease and the other with carcinoma of the lung) is described. A pressure tracing showing elevated pressure above the obstruction without respiratory or cardiac fluctuations is characteristic of obstruction of the superior vena cava.

Drug-induced pulmonary edema in a patient infected with human immunodeficiency virus.

Adverse reactions to drugs are common in patients infected with the human immunodeficiency virus (HIV). In these patients pulmonary reactions to drugs may be difficult to differentiate from opportunistic pulmonary infections. We report a HIV-infected patient who on two occasions developed acute pulmonary edema related to the administration of ibuprofen.

Conversion of COPD patients from multiple to single dose theophylline. Serum levels and symptom comparison.

The objective of the present study was to determine if patients with COPD who were taking Theo-Dur bid or tid (total dose 400 to 900 mg per day) could be safely switched to Uni-Dur, 800 mg given qd at bedtime. Twenty-eight patients were enrolled in the study, and 23 completed the study. The mean daily dose of theophylline prior to the study was 828 mg, while the mean dose after three weeks of Uni-Dur therapy was 783 mg. The mean serum theophylline level 10.5 +/- 3.6h after the last Theo-Dur dose was 10.5 mg/L. After three weeks of Uni-Dur therapy, the mean theophylline level at 8:00 AM was 14.6 mg/L, while the mean theophylline level at 8:00 PM was 9.9 mg/L. This latter level did not differ significantly from that obtained at the start of the study 10.5 +/- 3.6 h after the last dose of Theo-Dur. After three weeks of Uni-Dur therapy, the peak expiratory flow rate, the FEV1, and the FVC were not significantly changed from those at the initial evaluation. Twenty-one of the 23 patients ended up receiving 800 mg Uni-Dur qd. From this study, we conclude that once daily theophylline dosing with Uni-Dur compared with bid or tid dosing with Theo-Dur produces similar theophylline levels and pulmonary function, and most COPD patients who are taking 400 to 900 mg Theo-Dur daily can be managed with 800 mg Uni-Dur once daily at bedtime.

Acquired laryngomalacia as a cause of obstructive sleep apnea.

We describe a patient who, 4 years after a radical neck dissection and radiotherapy, presented with obstructive sleep apnea; upon bronchoscopy, he was found to have acquired laryngomalacia. Inspiration induced upper airway obstruction due to a large flaccid epiglottis, large aryepiglottic folds, and edema of the supraglottic area. We suggest that acquired laryngomalacia can lead to obstructive sleep apnea. Patients with obstructive sleep apnea after radical neck dissection need to be evaluated for laryngomalacia with fiberoptic laryngobronchoscopy. Examination of the upper airway is useful to determine the nature and extent of any upper airway collapse.

Exercise performance of polycythemic chronic obstructive pulmonary disease patients. Effect of phlebotomies.

The purpose of this study was to determine the effects of phlebotomy on the exercise tolerance and right and left ventricular ejection fraction of polycythemic patients with chronic obstructive pulmonary disease. Ten patients with COPD (mean FEV1 = 1.32 +/- 0.55 L) and polycythemia (mean Hct = 62 +/- 3 percent) were studied before and after their hematocrits had been reduced to approximately 50 percent. Post-phlebotomy the maximal oxygen consumption increased from 1.09 +/- 0.34 L/min to 1.26 +/- 0.43 L/min (p less than 0.05) and the maximum workload increased from 56.5 +/- 32.6 watts to 74.5 +/- 23.4 watts (p less than 0.05). The increase in the exercise tolerance appeared to be primarily due to an increased cardiac output at Emax. There was no relationship between the increases in the upright exercise capacity and changes in the supine ejection fractions of the right or left ventricular either at rest or during exercise.

Chronic respiratory failure due to bilateral vocal cord paralysis managed with nocturnal nasal positive pressure ventilation.

A patient with bilateral vocal cord paralysis developed chronic respiratory failure. Treatment with nocturnal inspiratory positive airway pressure via nasal mask improved symptoms and reduced hypercapnia.

Refractory hypoxemia due to intrapulmonary shunting associated with bronchioloalveolar carcinoma.

Bronchioloalveolar carcinoma caused severe refractory hypoxemia due to intrapulmonary shunting in a patient. Preoperative evaluation by occlusion of the pulmonary lobar artery supplying the tumor showed normalization of the arterial oxygen saturation. Resection of the involved lobe corrected the intrapulmonary shunting, and the patient required no further supplemental oxygen. However, with recurrence of the tumor over the next 6 months the patient became progressively more hypoxemic and died.

Effect of radiation therapy on bronchial obstruction due to bronchogenic carcinoma.

We evaluated the effect of radiation therapy in 57 patients with obstruction of a large bronchus with NSCC. Response with aeration of the atelectatic lung was seen in 12 patients (21 percent). Three patients (5 percent) showed partial response with persistent partial atelectasis, and nine patients (16 percent) showed good response with complete aeration of the atelectatic lung. In these patients the response appeared to be related to the dose of radiation. All of the patients who responded received more than 50 Gy. The difference in the response rate related to the dose of radiation was statistically significant (p less than 0.05). The rates were similar with all histologic types of NSCC. Regardless of the clinical response observed, bronchoscopy performed two to four months after completion of radiation therapy in 14 patients revealed persistent endobronchial tumor. There was no significant relationship between the persistence of endobronchial tumor, the dose of radiation therapy, and the tumor's histologic type. Of the 12 patients with radiographic improvement in atelectasis, fibrotic changes developed in four (33 percent) patients and pneumonitis in two (17 percent). Progression of disease with distant metastases occurred in 58 percent (seven) of the 12 patients who showed a clinical response of their bronchial obstruction. The median time to survival was nearly identical in responders and nonresponders.

Hemoptysis due to migration of a fractured Kirschner wire.

We report a rare complication related to the insertion of Kirschner wires for stabilization of an acromioclavicular separation. Five years after placement of the Kirschner wires, the patient presented with hemoptysis. On review of chest radiographs, a fractured wire was found to have migrated from the acromioclavicular joint, through the hemithorax and into the trachea.

Comparison of the effects of labetalol and hydrochlorothiazide on the ventilatory function of hypertensive patients with asthma and propranolol sensitivity.

Previous studies have shown that labetalol, a new alpha- and beta-adrenergic antagonist, is relatively safe for the treatment of hypertension in patients with chronic obstructive pulmonary disease (COPD). This multicenter study was designed to evaluate its effects in hypertensive patients with asthma and propranolol sensitivity. Hypertension was successfully controlled in 18 of 21 patients who received labetalol in increasing doses, up to 1,200 mg/day. The decrease in mean FEV1 (1.5 percent) two hours after the highest dose of labetalol was not statistically significant, although there was a gradual decline in mean baseline FEV1 during the four-week treatment period. Antihypertensive agents other than adrenergic antagonists should be considered for the management of hypertension in patients with asthma, especially those with marked reversibility of airflow. If treatment with beta-adrenergic antagonists is indicated, labetalol is recommended over other currently available agents.

Resolution of recurrent atelectasis in spinal cord injury patients with administration of recombinant human DNase.

Atelectasis occurs frequently in patients with spinal cord injury (SCI). Impaired cough leads to ineffective clearance of secretions. If the secretions cannot be cleared and become thick and purulent, atelectasis may occur. Recombinant human DNase (rhDNase) has been shown to decrease purulent sputum viscosity in vitro. We report two SCI patients with respiratory failure due to recurrent atelectasis from purulent secretions in whom conventional treatment methods had failed. Administration of rhDNase resulted in successful resolution of atelectasis. These results suggest the need for a controlled clinical trial.