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The association between tuberculosis and the development of insulin resistance in adults with pulmonary tuberculosis in the Western sub-district of the Cape Metropole region, South Africa: a combined cross-sectional, cohort study.

ABSTRACT: The existence of a bi-directional relationship between tuberculosis (TB) and insulin resistance (IR)/diabetes has been alluded to in literature. Although diabetes has been linked to increased tuberculosis risk, the relationship between tuberculosis as a causative factor for IR remains unclear. The study aimed to determine if an association existed between tuberculosis and IR development in adults with newly diagnosed pulmonary tuberculosis at baseline. It was additionally aimed to document changes in IR status during TB follow-up periods.This cross-sectional study evaluated ambulatory participants at baseline for IR prevalence via anthropometry, biochemistry and diagnostic IR tests [homeostasis model assessment-IR (HOMA-IR) and quantitative insulin sensitivity check index (QUICKI)]. A prospective cohort sub-section study was additionally performed on approximately half of the baseline study population, who were followed-up at two and five months whilst on tuberculosis treatment. Summary statistics, correlation co-efficients and appropriate analysis of variance were used to describe and analyse data. Participants were excluded if they presented with other forms of tuberculosis, were HIV-positive, obese or had any pre-disposing IR conditions such as diabetes or metabolic syndrome.Fifty-nine participants were included from August 2013 until December 2014 (33.95 ± 12.02 years old; 81.4% male). IR prevalence was 25.4% at baseline, determined by a calculated HOMA-IR cut-off point of 2.477. Patients with IR were younger (p = 0.04). Although the difference between IR levels in participants between baseline and follow-up was not significant, a decrease was observed over time. The majority of participants (61.0%) presented with a normal BMI at baseline. Mean baseline values of fasting glucose were within normal ranges (4.82 ± 0.80 mmol/L), whereas increased mean CRP levels (60.18 ± 50.92 mg/L) and decreased mean HDL-cholesterol levels (males: 0.94 ± 0.88 mmol/L; females: 1.14 ± 0.88 mmol/L) were found.The study found an association between tuberculosis and IR development in newly diagnosed pulmonary tuberculosis patients. Although not significant, IR levels decreased over time, which could be indicative of a clinical improvement. A high prevalence of IR amongst young tuberculosis patients therefore highlights the need for early identification in order to facilitate a reversal of IR and prevent possible IR-related complications.

SUBMITTER: Philips L

PROVIDER: S-EPMC5556352 | biostudies-other | 2017 Aug

REPOSITORIES: biostudies-other

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Project description:Background:Sub-Saharan Africa bears a disproportionate burden of mortality from trauma. District hospitals, although not trauma centres, play a critical role in the trauma care system by serving as frontline hospitals. However, the clinical characteristics of patients receiving trauma care in African district hospitals remains under-described and is a barrier to trauma care system development. We aim to describe the burden of trauma at district hospitals by analysing trauma patients at a prototypical district hospital emergency centre. Methods:An observational study was conducted in August, 2014 at Wesfleur Hospital, a district facility in the Western Cape Province of South Africa. Data were manually collected from a paper registry for all patients visiting the emergency centre. Patients with trauma were selected for further analysis. Results:Of 3299 total cases, 565 (17.1%) presented with trauma, of which 348 (61.6%) were male. Of the trauma patients, 256 (47.6%) were ages 18-34 and 298 (52.7%) presented on the weekend. Intentional injuries (assault, stab wounds, and gunshot wounds) represented 251 (44.4%) cases of trauma. There were 314 (55.6%) cases of injuries that were unintentional, including road traffic injuries. There were 144 (60%) intentionally injured patients that arrived overnight (7pm-7am). Patients with intentional injuries were three times more likely to be transferred (to higher levels of care) or admitted than patients with unintentional injuries. Conclusion:This district hospital emergency centre, with a small complement of non-EM trained physicians and no trauma surgical services, cared for a high volume of trauma with over half presenting on weekends and overnight when personnel are limited. The high volume and rate of admission/ transfer of intentional injuries suggests the need for improving prehospital trauma triage and trauma referrals. The results suggest strengthening trauma care systems at and around this resource-limited district hospital in South Africa may help alleviate the high burden of post-trauma morbidity and mortality.

Project description:BACKGROUND: We conducted a survey to estimate point prevalence of bacteriologically positive pulmonary TB (PTB) in a rural area in South India, implementing TB program DOTS strategy since 2002. METHODS: Survey was conducted among persons ≥ 15 years of age in fifteen clusters selected by simple random sampling; each consisting of 5-12 villages. Persons having symptoms suggestive of PTB or history of anti-TB treatment (ATT) were eligible for sputum examination by smear microscopy for Acid Fast Bacilli and culture for Mycobacterium tuberculosis; two sputum samples were collected from each eligible person. Persons with one or both sputum specimen positive on microscopy and/or culture were labeled suffering from PTB. Prevalence was estimated after imputing missing values to correct for bias introduced by incompleteness of data. In six clusters, registered persons were also screened by X-ray chest. Persons with any abnormal shadow on X-ray were eligible for sputum examination in addition to those with symptoms and ATT. Multiplication factor calculated as ratio of prevalence while using both screening tools to prevalence using symptoms screening alone was applied to entire study population to estimate prevalence corrected for non-screening by X-ray. RESULTS: Of 71,874 residents ≥ 15 years of age, 63,362 (88.2%) were screened for symptoms and ATT. Of them, 5120 (8.1%) - 4681 (7.4%) with symptoms and an additional 439 (0.7%) with ATT were eligible for sputum examination. Spot specimen were collected from 4850 (94.7%) and early morning sputum specimens from 4719 (92.2%). Using symptom screening alone, prevalence of smear, culture and bacteriologically positive PTB in persons ≥ 15 years of age was 83 (CI: 57-109), 152 (CI: 108-197) and 196 (CI :145-246) per 100,000 population respectively. Prevalence corrected for non-screening by X-ray was 108 (CI: 82-134), 198 (CI: 153-243) and 254 (CI: 204-301) respectively. CONCLUSION: Observed prevalence suggests further strengthening of TB control program.

Project description:BackgroundIn 2021, South Africa introduced a 6-month internship rotation in family medicine, in the second year of a 2-year internship programme for newly qualified doctors. This was a major change from the previous 3-months training in family medicine, and expanded the training platform to smaller district hospitals and primary health care (PHC) facilities, many of which had never had interns. The medical disciplines in South Africa needed to know if this change in the internship programme was worthwhile and successful. The aim of this study was to assess the new family medicine rotation for medical interns at district health facilities in the Western Cape Province.MethodsDescriptive exploratory qualitative research included six intern programmes across the province. Purposeful sampling identified a heterogeneous group with maximum variation in experience. Overall, eight interns, four managers, four supervisors and four intern curators were included. Individual semi-structured interviews were audio-recorded and the transcripts were thematically analysed using the framework method and Atlas-ti software.ResultsFour major themes emerged around the varied structure and organisational characteristics of the rotations, the orientation and arrival of interns, their learning during the rotation, and impact on health services. A programme theory was developed that defined the key inputs (i.e. infrastructure, communication, orientation, preparation, prior learning and guidelines), processes (i.e. model of the rotation, clinical training and supervision, clinical teaching), outputs (i.e. more independent decision making, approach to undifferentiated problems, approach to chronic care and continuity, development of procedural skills, approach to sequential coordination of care and referrals, working in a multidisciplinary team and inter-professional learning, integration of multiple competencies, as well as becoming more person and community orientated).ConclusionsThe new rotation in family medicine was positively experienced by most interns, supervisors and managers. It should lead to improved quality of care, better preparation for obligatory community service, and an increased likelihood of considering a career in district level health services. This study will form part of an exploratory sequential mixed methods study that incorporates the key issues into a questionnaire for a descriptive survey of all interns in a subsequent study.

Project description:Pulmonary endarterectomy (PEA) is the only definitive and potentially curative therapy for chronic thromboembolic pulmonary hypertension (CTEPH), associated with impressive improvements in symptoms and haemodynamics. However, it is only offered at a few centres in South Africa. The characteristics and outcomes of patients undergoing PEA in Cape Town have not been reported previously. To assess the difference in World Health Organization functional class (WHO-FC) before and at least 6 weeks after surgery. We interrogated the adult cardiothoracic surgery database at the University of Cape Town between December 2005 and April 2021 for patients undergoing PEA at Groote Schuur Hospital and a private hospital. A total of 32 patients underwent PEA, of whom 8 were excluded from the final analysis owing to incomplete data or a histological diagnosis other than CTEPH. The work-up of these patients for surgery was variable: all had a computed tomography pulmonary angiogram, 7 (29%) had a ventilation/perfusion scan, 5 (21%) underwent right heart catheterisation, and none had a pulmonary angiogram. The perioperative mortality was 4/24 (17%): 1 patient (4%) had a cardiac arrest on induction of anaesthesia, 2 patients (8%) died of postoperative pulmonary haemorrhage, and 1 patient (4%) died of septic complications in the intensive care unit. Among the survivors, the median (interquartile range) improvement in WHO-FC was 2 (1 - 3) classes (p=0.0004); 10/16 patients (63%) returned to a normal baseline (WHO-FC I). Even in a low-volume centre, PEA is associated with significant improvements in WHO-FC and a return to a normal baseline in survivors. What the study adds. South African patients undergoing pulmonary endarterectomy (PEA) for chronic thromboembolic pulmonary hypertension (CTEPH) have a marked improvement in functional status, with many returning to a normal functional baseline. However, the small number of patients included in this study indicates that PEA is probably underutilised. Pre- and postoperative assessment is inconsistent, despite availability of established guidelines.Implications of the findings. More patients should be referred to specialist centres for assessment for this potentially curative procedure. Use of guidelines to standardise investigations and monitoring of patients with CTEPH may improve patient selection for surgery.

Project description:Extensively drug-resistant tuberculosis (XDR-TB), defined as resistance to at least isoniazid (INH), rifampicin (RIF), a fluoroquinolone (FQ) and a second-line injectable drug (SLID), is difficult to treat and poses a major threat to TB control. The transmission dynamics and distribution of XDR Mycobacterium tuberculosis (Mtb) strains have not been thoroughly investigated. Using whole genome sequencing data on 461 XDR-Mtb strains, we aimed to investigate the geographical distribution of XDR-Mtb strains in the Western Cape Province of South Africa over a 10 year period (2006-2017) and assess the association between Mtb sub-lineage, age, gender, geographical patient location and membership or size of XDR-TB clusters. First, we identified transmission clusters by excluding drug resistance-conferring mutations and using the 5 SNP cutoff, followed by merging clusters based on their most recent common ancestor. We then consecutively included variants conferring resistance to INH, RIF, ethambutol (EMB), pyrazinamide (PZA), SLIDs and FQs in the cluster definition. Cluster sizes were classified as small (2-4 isolates), medium (5-20 isolates), large (21-100 isolates) or very large (>100 isolates) to reflect the success of individual strains. We found that most XDR-TB strains were clustered and that including variants conferring resistance to INH, RIF, EMB, PZA and SLIDs in the cluster definition did not significantly reduce the proportion of clustered isolates (85.5-82.2 %) but increased the number of patients belonging to small clusters (4.3-12.4 %, P=0.56). Inclusion of FQ resistance-conferring variants had the greatest effect, with 11 clustered isolates reclassified as unique while the number of clusters increased from 17 to 37. Lineage 2 strains (lineage 2.2.1 typical Beijing or lineage 2.2.2 atypical Beijing) showed the large clusters which were spread across all health districts of the Western Cape Province. We identified a significant association between residence in the Cape Town metropole and cluster membership (P=0.016) but no association between gender, age and cluster membership or cluster size (P=0.39). Our data suggest that the XDR-TB epidemic in South Africa probably has its origin in the endemic spread of MDR Mtb and pre-XDR Mtb strains followed by acquisition of FQ resistance, with more limited transmission of XDR Mtb strains. This only became apparent with the inclusion of drug resistance-conferring variants in the definition of a cluster. In addition to the prevention of amplification of resistance, rapid diagnosis of MDR, pre-XDR and XDR-TB and timely initiation of appropriate treatment is needed to reduce transmission of difficult-to-treat TB.

Project description:ObjectivesTo describe the characteristics, clinical management and outcomes of patients with COVID-19 at district hospitals.DesignA descriptive observational cross-sectional study.SettingDistrict hospitals (4 in metro and 4 in rural health services) in the Western Cape, South Africa. District hospitals were small (<150 beds) and led by family physicians.ParticipantsAll patients who presented to the hospitals' emergency centre and who tested positive for COVID-19 between March and June 2020.Primary and secondary outcome measuresSource of referral, presenting symptoms, demographics, comorbidities, clinical assessment and management, laboratory turnaround time, clinical outcomes, factors related to mortality, length of stay and location.Results1376 patients (73.9% metro, 26.1% rural). Mean age 46.3 years (SD 16.3), 58.5% females. The majority were self-referred (71%) and had comorbidities (67%): hypertension (41%), type 2 diabetes (25%), HIV (14%) and overweight/obesity (19%). Assessment of COVID-19 was mild (49%), moderate (18%) and severe (24%). Test turnaround time (median 3.0 days (IQR 2.0-5.0 days)) was longer than length of stay (median 2.0 day (IQR 2.0-3.0)). The most common treatment was oxygen (41%) and only 0.8% were intubated and ventilated. Overall mortality was 11%. Most were discharged home (60%) and only 9% transferred to higher levels of care. Increasing age (OR 1.06 (95% CI 1.04 to 1.07)), male (OR 2.02 (95% CI 1.37 to 2.98)), overweight/obesity (OR 1.58 (95% CI 1.02 to 2.46)), type 2 diabetes (OR 1.84 (95% CI 1.24 to 2.73)), HIV (OR 3.41 (95% CI 2.06 to 5.65)), chronic kidney disease (OR 5.16 (95% CI 2.82 to 9.43)) were significantly linked with mortality (p<0.05). Pulmonary diseases (tuberculosis (TB), asthma, chronic obstructive pulmonary disease, post-TB structural lung disease) were not associated with increased mortality.ConclusionDistrict hospitals supported primary care and shielded tertiary hospitals. Patients had high levels of comorbidities and similar clinical pictures to that reported elsewhere. Most patients were treated as people under investigation. Mortality was comparable to similar settings and risk factors identified.

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The association between tuberculosis and the development of insulin resistance in adults with pulmonary tuberculosis in the Western sub-district of the Cape Metropole region, South Africa: a combined cross-sectional, cohort study.

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