Ministry of Health Clinical Practice Guidelines: Anxiety Disorders

The Ministry of Health (MOH) has developed the clinical practice guidelines on Anxiety Disorders to provide doctors and patients in Singapore with evidence-based treatment for anxiety disorders. This article reproduces the introduction and executive summary (with recommendations from the guidelines) from the MOH clinical practice guidelines on anxiety disorders, for the information of SMJ readers. Chapters and page numbers mentioned in the reproduced extract refer to the full text of the guidelines, which are available from the Ministry of Health website: http://www.moh.gov.sg/content/moh_web/healthprofessionalsportal/doctors/guidelines/cpg_medical.html. The recommendations should be used with reference to the full text of the guidelines. Following this article are multiple choice questions based on the full text of the guidelines.

1.1 Background information

Anxiety disorders are known to be one of the most prevalent of psychiatric conditions, yet they often remain under-diagnosed and under-treated. Their chronic, disabling symptoms cause considerable burden not only to sufferers but also to their families, and contribute to poorer quality of life and considerable economic burden on society.In many instances, there is a delay in seeking treatment and in some cases such delay may stretch up to nearly ten years. This may result from ignorance of the condition, fear of taking medications, and the stigma of receiving a psychiatric diagnosis, and or having to accept psychiatric treatment.The anxiety disorders include panic disorder with or without agoraphobia, social anxiety disorder, specific phobia, obsessive-compulsive disorder, generalised anxiety disorder, acute stress disorder and post-traumatic stress disorder. In the clinical evaluation of anxiety disorders, it is important to ascertain the type of anxiety disorder present. This would allow treatment to be targeted at the specific type of disorder.These guidelines are developed to provide practical, evidence-based recommendations to primary care physicians and specialists in psychiatry for the diagnosis and management of the anxiety disorders.The first edition of the guidelines was published in 2003. In this edition, we present data from newer research as well as older data not previously reported in the earlier guidelines.For example, we examine the efficacy of combining medications with psychological therapy over medications alone, or psychological therapy alone. In view of the majority of anxiety sufferers being female we have made recommendations for pharmacotherapy during pregnancy and breastfeeding. As these guidelines are intended for use in the Singapore context, we have omitted treatments that are currently not available in Singapore.

1.2 Aim

These guidelines are developed to facilitate the diagnosis and assessment of the anxiety disorders, and to ensure that their management is appropriate and effective.

1.3 Scope

These guidelines will cover the management of anxiety disorders in adults and address the issues of medication use during pregnancy and breastfeeding.

1.4 Target group

The content of the guidelines will be useful for all doctors treating patients with anxiety disorders. Efforts have been made to ensure that the guidelines are particularly useful for primary care physicians and specialists in psychiatry, including all those involved in the assessment and management of patients with anxiety disorders in the community. The doctor treating the patient is ultimately responsible for clinical decisions made after reviewing the individual patient’s history, clinical presentation and treatment options available.

1.5 Development of guidelines

These guidelines have been produced by a committee of psychiatrists, a clinical psychologist, pharmacist, patient representative, and family practitioners appointed by the Ministry of Health. They were developed by revising the existing guidelines, reviewing relevant literature, including overseas clinical practice guidelines, and by expert clinical consensus of professionals with experience in treating patients in the local setting.The following principles underlie the development of these guidelines:

• Treatment recommendations are supported by scientific evidence whenever possible (randomised controlled clinical trials represent the highest level of evidence) and expert clinical consensus is used when such data are lacking.
• Treatment should maximise therapeutic benefits and minimise side effects.

1.6 What’s new in the revised guidelines

This edition of the guidelines contains updated recommendations based on latest evidence, as well as detailed discussions and recommendations on the management of anxiety disorders in adult populations.The following represent changes to the revised guidelines

• An extensive review of the literature, including new evidence. This involved the re-writing and extensive revision of the chapters.
• Length of treatment, which provides answers to a pertinent question.
• Use of medications during pregnancy and breastfeeding. Given that females are more likely to be at risk of being diagnosed with anxiety disorders, this is an important subject.

We are aware that the Diagnostic and Statistical Manual of Mental Disorders-5 (DSM-5) was released in 2013. In DSM-5, post-traumatic stress disorder and obsessive-compulsive disorder have been removed and classified separately from the rest of the anxiety disorders. If we were to adhere strictly to DSM-5, this would entail omitting discussion on post-traumatic stress disorder and obsessive-compulsive disorder. As it is our aim to provide an update on the 2003 guidelines, post-traumatic stress disorder and obsessive-compulsive disorder have been included in this edition of the guidelines.In addition, anxiety conditions in children are included in DSM-5. Since the present guidelines are meant to address only adult anxiety disorders, guidelines on children’s anxiety conditions are not included here.Hence, for purposes of these guidelines, we will continue to use classifications based on the International Classification of Diseases-10 (ICD-10) and DSM-IV-TR criteria.

1.7 Review of guidelines

Evidence-based clinical practice guidelines are only as current as the evidence that supports them. Users must keep in mind that new evidence could supersede recommendations in these guidelines. The workgroup advises that these guidelines be scheduled for review five years after publication, or when new evidence appears that requires substantive changes to the present recommendations.     

Academy of Medicine-Ministry of Health Clinical Practice Guidelines: Attention Deficit Hyperactivity Disorder

The Academy of Medicine (AMS) and the Ministry of Health (MOH) have developed the clinical practice guidelines on Attention Deficit Hyperactivity Disorder (ADHD) to provide doctors and patients in Singapore with evidence-based treatment for ADHD. This article reproduces the introduction and executive summary (with recommendations from the guidelines) from the MOH clinical practice guidelines on ADHD, for the information of SMJ readers. Chapters and page numbers mentioned in the reproduced extract refer to the full text of the guidelines, which are available from the Ministry of Health website http://www.moh.gov.sg/content/moh_web/healthprofessionalsportal/doctors/guidelines/cpg_medical.html. The recommendations should be used with reference to the full text of the guidelines. Following this article are multiple choice questions based on the full text of the guidelines.

1.1 Background information

Attention deficit hyperactivity disorder (ADHD) is a neuro-developmental disorder, characterised by the presence of early-onset persistent, pervasive and impairing hyperactive-impulsive and/or inattentive symptoms. The worldwide pooled prevalence was about 5.29%. While there has been no epidemiological study on the prevalence of this condition among children in Singapore, a local study reported the prevalence of externalising problems to be 4.9% among Singaporean primary school children. While ADHD symptoms decline with age, a meta-analysis reported that a significant proportion might have residual symptoms in adulthood. ADHD has been reported to be associated with negative outcomes, including poor academic achievement, reduced self-esteem and higher smoking rate. This condition is often picked up when the child is young, and children with ADHD are often treated by child psychiatrists and paediatricians.

1.2 Objectives and scope of guideline

These guidelines are not meant to be viewed as a protocol, but rather, to provide a framework to:

• Approach the assessment process, with the goals of arriving at a diagnosis and planning treatment.
• Inform the practitioner about the level of evidence for medication available in Singapore, to aid the decision about medication use.
• Inform about the evidence for non-pharmacological treatment approaches to help professionals plan treatment and discuss these with parents.

1.3 Target group

The target group of these guidelines are professionals who come into contact with children and adolescents below the age of 18 who have attention deficit hyperactivity disorder (ADHD). The information is intended to help professionals plan the treatment for such children and adolescents. Professionals should exercise caution when extrapolating the evidence beyond this stated age group.

1.4 Guideline development

These guidelines were produced by a multi-disciplinary workgroup appointed by the Academy of Medicine, Singapore. The workgroup comprised psychiatrists, paediatricians, educational psychologists, a medical social worker, a pharmacist, an advanced practice nurse and a parent representative.

1.5 Review of guidelines

Evidence-based clinical practice guidelines are only as current as the evidence that supports them. Users must keep in mind that new evidence could supersede recommendations in these guidelines. The workgroup advises that these guidelines be scheduled for review five years after publication, or earlier if new evidence appears that requires substantive changes to the recommendations.     

Academy of Medicine-Ministry of Health Clinical Practice Guidelines: Assessment and Management of Infertility at Primary Healthcare Level

The Academy of Medicine (AMS) and Ministry of Health (MOH) have developed the clinical practice guidelines on Assessment and Management of Infertility at Primary Healthcare Level to provide doctors and patients in Singapore with evidence-based treatment for infertility. This article reproduces the introduction and executive summary (with recommendations from the guidelines) from the AMS-MOH clinical practice guidelines on Assessment and Management of Infertility at Primary Healthcare Level, for the information of SMJ readers. Chapters and page numbers mentioned in the reproduced extract refer to the full text of the guidelines, which are available from the Ministry of Health website: http://www.moh.gov.sg/content/moh_web/healthprofessionalsportal/doctors/guidelines/cpg_ medical/2013/cpgmed_infertility.html. The recommendations should be used with reference to the full text of the guidelines. Following this article are multiple choice questions based on the full text of the guidelines.

1.1 Objectives and scope of guideline

These guidelines are intended to assist primary care physicians and other healthcare professionals in the management of infertility. This includes increasing awareness and educating about the scale of fertility problems, recognising the various causes of infertility, natural fecundity, and success rates of in vitro fertilisation (IVF) treatment in relation to female age. These guidelines also seek to establish clear referral criteria to guide primary care physicians.

1.2 Target group

The primary target group of these guidelines are primary care physicians. Nevertheless, these guidelines would also benefit all healthcare professionals involved in the management of infertility.

1.3 Guideline development

These guidelines have been produced by a committee appointed by the Ministry of Health and the Academy of Medicine, Singapore, with representation from gynaecologists, fertility specialists, urologists and family physicians. They were developed using the best available current evidence and expert opinion.

1.4 Review of guidelines

Evidence-based clinical practice guidelines are only as current as the evidence that supports them. Users must keep in mind that new evidence could supersede recommendations in these guidelines. The workgroup advises that these guidelines be scheduled for review three years after publication, or if new evidence appears that requires substantive changes to the recommendations.     

Diabetes management in Australian rural aged care facilities: A cross--sectional audit

Background

There is gap in the literature regarding the current practice of diabetes management of the elderly in Australia and its compliance with available Australian diabetes practice guidelines.

Aims

The aims of this study were to describe the pharmacological management of elderly residents with diabetes living in aged care facilities and to identify areas for improvement in the current management as recommended by the current diabetes management guidelines in Australia.

Method

Residents with diabetes from three rural aged care facilities were identified by nursing staff. A cross-sectional medical record audit was carried out to obtain data of residents diagnosed with diabetes.Thirty-four medical records were audited from three aged care facilities.Data including demographics, medical histories and medications were collected and analysed.

Results

This study had two key findings; Firstly, it showed that about a third of residents with type 2 diabetes are managed with diet only. Secondly, of the residents who are managed with medications, less than half of those audited (41%) were managed according to the current diabetes guidelines in terms of pharmacological treatment which included anti- hypertensive, lipid lowering and anti- platelet therapies. Of those patients with a history of CVD, all were receiving an antihypertensive medication, 71% were not managed for their lipids and 20% were not on any prophylactic anti- platelet therapy.

Conclusion

Management of patients with diabetes living in rural aged care facilities is inconsistent with the current management guidelines. Educational interventions targeting health professionals and patients might be beneficial to increase compliance with the current diabetes guidelines.     

Knowledge of diabetes and its associated ocular manifestations by diabetic patients: A study at Korle-Bu Teaching Hospital,Ghana

Background:

Diabetes mellitus is a significant cause of visual impairment, hence adequate knowledge on this condition and its ocular manifestations is of immense importance to diabetic patients.

Aim:

To assess the knowledge of diabetic patients on the disorder and its ocular manifestations, and their attitude towards ocular examinations.

Materials and Methods:

A cross-sectional survey involving the use of a structured interview was conducted among diabetic patients attending the Diabetic Clinic of the Korle-Bu Teaching Hospital. Using Fishers Exact Chi-square (χ²) and Odds Ratios (ORs), data obtained was analyzed.

Results:

Only 103 (26.4%) patients knew the type of diabetes mellitus they were suffering from. Knowledge on ocular effects of diabetes mellitus was low and only 15 (3.8%) knew that it could affect the ocular refraction with no patient mentioning that diabetes mellitus could cause cataract or diabetic retinopathy. Attitude to routine eye examination was poor. As much as 135 (34.6%) had never had an eye examination since being diagnosed of diabetes. Knowledge of the type of diabetes mellitus the individual had or any ocular complication of this disorder was significantly related (OR: 4.22; P < 0.001 and OR: 2.55; P < 0.001) respectively to their attitude to seeking eye care.

Conclusion:

Diabetic patients’ knowledge on diabetes mellitus and its ocular manifestations, and the attitude of diabetic patients towards eye examination were poor. Intensive health education by diabetes care givers and leaders of the Ghana Diabetic Association for diabetic patient is therefore required to improve attitude towards eye care to prevent visual impairment.     

Problem alcohol use among problem drug users: development and content of clinical guidelines for general practice

Background

Problem alcohol use is common and associated with considerable adverse outcomes among patients who attend primary care in Ireland and other European countries for opiate substitution treatment.

Aims

This paper aims to describe the development and content of clinical guidelines for the management of problem alcohol use among this population.

Methods

The guidelines were developed in three stages: (1) identification of key stakeholders, (2) development of evidence-based draft guidelines, and (3) determination of a modified ‘Delphi-facilitated’ consensus among the group members.

Results

The guidelines incorporate advice for physicians on all aspects of care, including (1) definition of problem alcohol use among problem drug users, (2) alcohol screening, (3) brief intervention, and (4) subsequent management of patients with alcohol dependence.

Conclusions

Primary care has an important role to play in the care of problem alcohol use among problem drug users, especially opiate substitution patients. Further research on strategies to inform the implementation of these guidelines is a priority.     

Using care plans to better manage multimorbidity

Background

The health care for patients having two or more long-term medical conditions is fragmented between specialists, allied health professionals, and general practitioners (GPs), each keeping separate medical records. There are separate guidelines for each disease, making it difficult for the GP to coordinate care. The TrueBlue model of collaborative care to address key problems in managing patients with multimorbidity in general practice previously reported outcomes on the management of multimorbidities. We report on the care plan for patients with depression, diabetes, and/or coronary heart disease that was embedded in the TrueBlue study.

Methods

A care plan was designed around diabetes, coronary heart disease, and depression management guidelines to prompt implementation of best practices and to provide a single document for information from multiple sources. It was used in the TrueBlue trial undertaken by 400 patients (206 intervention and 194 control) from 11 Australian general practices in regional and metropolitan areas.

Results

Practice nurses and GPs successfully used the care plan to achieve the guideline-recommended checks for almost all patients, and successfully monitored depression scores and risk factors, kept pathology results up to date, and identified patient priorities and goals. Clinical outcomes improved compared with usual care.

Conclusion

The care plan was used successfully to manage and prioritise multimorbidity. Downstream implications include improving efficiency in patient management, and better health outcomes for patients with complex multimorbidities.     

Screening for Addison's disease in patients with type 1 diabetes mellitus and recurrent hypoglycaemia

Background

Addison''s disease may present with recurrent hypoglycaemia in subjects with type 1 diabetes mellitus. There are no data, however, on the prevalence of Addison''s disease presenting with recurrent hypoglycaemia in patients with diabetes mellitus.

Methods

Three year retrospective study of diabetic patients with “unexplained” recurrent hypoglycaemia investigated with a short Synacthen test to exclude adrenocortical insufficiency.

Results

95 patients with type 1 diabetes mellitus were studied. Addison''s disease was identified as the cause of recurrent hypoglycaemia in one patient with type 1 diabetes mellitus.

Conclusion

Addison''s disease is a relatively rare but remedial cause of recurrent hypoglycaemia in patients with type 1 diabetes mellitus. A low threshold for investigating patients with type 1 diabetes mellitus and recurrent hypoglycaemia to detect Addison''s disease is therefore suggested.Addison''s disease may present as recurrent hypoglycaemia in patients with type 1 diabetes mellitus^{1,2,3,4,5,6,7} and it is recommended that diabetic patients with unexplained recurrent hypoglycaemia be screened for Addison''s disease.⁸ There are, however, no data on the prevalence of Addison''s disease presenting with recurrent hypoglycaemia in patients with diabetes. We report on the prevalence of Addison''s disease presenting with recurrent hypoglycaemia in patients with type 1 diabetes mellitus.     

Prevalence of coeliac disease in children and adolescents with type 1 diabetes mellitus in a clinic based population

Background

Although the association between type 1 diabetes mellitus (T1DM) and coeliac disease is well known, the presenting features and clinical characteristics of the two diseases when they coexist are less well documented.

Methods

All patients with T1DM attending a paediatric diabetes clinic in London, UK, were screened for coeliac disease by serological testing for coeliac antibodies (antiendomysial and either/both tissue transglutaminase and antigliadin). Antibody positive patients were reviewed and their presenting symptoms, tissue biopsy result and coexisting morbidities investigated. Glycaemic control, growth and the effect of a gluten‐free diet on these variables were also evaluated.

Results

Of the 113 patients with T1DM, 7 (6.2%) tested antibody positive. Jejunal biopsy confirmed coeliac disease in 5 of the 7 (4.4%) patients. Coeliac disease presented atypically or silently in the majority of cases with an unpredictable interval between diagnosis of diabetes and coeliac disease presentation. Coeliac disease did not appear to affect growth. Mean glycated haemoglobin (HbA1c) levels were not significantly raised in subjects (9.87%) compared with matched controls without coeliac disease (9.08%) (p = 0.249). Analyses of the effect of a gluten‐free diet on growth and HbA1c were limited. Of the seven subjects, two suffered other autoimmune diseases.

Conclusion

Coeliac disease presents atypically and unexpectedly in children and adolescents with T1DM. This, along with the strong association between the two diseases, supports the regular screening of coeliac disease among these patients. The value of a gluten‐free diet cannot be commented on from this study alone although other studies show it reduces the risk of complications.The association between type 1 diabetes mellitus (T1DM) and coeliac disease was observed as early as the late 1960s and has been noted in various studies since.^1,2,3 This is unsurprising given that both conditions are strongly linked to the HLA system, in particular the haplotypes A1, B8, DR3 and DQ2.⁴ Coeliac disease and T1DM coexist more frequently than would be expected by chance and the prevalence of coeliac disease among patients with T1DM has been estimated as being between 1–10%. A large UK based study estimated the prevalence among children and adolescents to be 4.8%.⁵Healthcare professionals face two challenges in caring for young people with coeliac disease and T1DM: firstly, the diagnosis of coeliac disease among a large number of patients who present asymptomatically or atypically; and secondly, the prevention of the long term complications of coeliac disease. Given the increased prevalence of coeliac disease among diabetics, regular and repeated screening for coeliac autoantibodies has become a widely accepted practice. Symptomatic coeliac disease is only the “tip of the iceberg” and it has been recognised that coeliac disease is “more common and more varied in its presentation than previously thought”.⁵ The classical symptoms of failure to thrive, weight loss, steatorrhoea and a change in bowel habit are less commonly seen than milder or less specific symptoms (for example, recurrent abdominal pain).⁶Coeliac disease is believed to have an adverse effect on T1DM, particularly with regards to glycaemic control. In addition, coeliac disease carries with it an increased risk of long term complications, including decreased bone density and gastrointestinal malignancies.^7,8 Adherence to a gluten‐free diet is difficult but appears to reduce the risk of malignancy.⁹ However, its effect on diabetes remains controversial.This retrospective study aims to:

• estimate the prevalence of coeliac disease among a population of children and adolescents with T1DM within a clinical setting;
• investigate how coeliac disease presents among children and adolescents with T1DM in terms of its presentation and time course of development;
• investigate the effect of coeliac disease on the growth and glycaemic control of children and adolescents with T1DM and the benefit of a gluten free diet;
• examine the association of other diseases with coeliac disease and T1DM.

     

An audit of “do not attempt resuscitation” decisions in two district general hospitals: do current guidelines need changing?

Introduction

Doctors in all specialties are involved in making “do not attempt resuscitation” (DNAR) decisions; this can be a difficult and challenging process. Guidelines exist to provide an ethical and legal framework for the process and documentation of these decisions.

Objective

To audit the documentation of resuscitation decisions in a sample of medical inpatients from two district general hospitals.

Method

A retrospective case note audit of 50 medical inpatients, in which a DNAR decision had been made (28 from hospital 1, 22 from hospital 2).

Results

Average age was 78.9 years (48% male:52% female). In both hospitals DNAR decisions were usually discussed with relatives (84%), documented in nursing notes (100%) and made by senior team members (90%). Although the decision was usually dated and clearly documented (98%), abbreviations were commonly used in hospital 2 (45.5% vs 0% in hospital 1, p<0.05). Decisions regarding other treatment were not consistently documented (78.6% and 72.7%, respectively) and there was little evidence that decisions were reviewed (14.3% and 31.8%). The decision was rarely discussed with the patient (6% of all patients), although 66% of patients were not in a position to have a discussion.

Conclusions

Specific forms for recording DNAR decisions improve the clarity of documentation. Current recommendations to discuss resuscitation with patients are controversial and not followed. However, many patients are not in a position to hold a discussion when the need arises and the guidelines should advocate early discussion during a hospital admission in patients where this is appropriate, prior discussion with family and/or wider use of advanced directives.After the introduction of cardiopulmonary resuscitation (CPR) in the 1960s its use has been widened to involve many situations where it has been shown to have little benefit. In the UK, there are joint guidelines on decisions relating to CPR from the British Medical Association, the UK Resuscitation Council and the Royal College of Nursing and these were updated in 2001, partly to incorporate the implications of the Human Rights Act 1998 (in particular, the right to life (article 2) and the right to hold opinions and receive information (article 10)).^1,2The guidelines acknowledge that it is essential to identify patients for whom CPR is inappropriate and those who competently refuse it.¹ It is appropriate to consider a do not attempt resuscitation (DNAR) order where:

• attempting CPR will not restart the patient''s heart and breathing,
• where there is no clear benefit in restarting the patient''s heart and breathing, and
• where the expected benefit is outweighed by the burdens.

     

Efficacy of insulin analogues in diabetic patients attending primary care centers

Objectives:

To measure the efficacy of new insulin analogues compared with the conventional types of insulin, and to compare their effects on patient satisfaction regarding their weight changes and the frequency of hypoglycemic episodes.

Methods:

In this retrospective cohort observational study, data was collected from the medical records of 122 eligible diabetics on insulin therapy attending government primary care centers in Jeddah, Kingdom of Saudi Arabia from June 2013 to July 2014. The data collected considered the efficacy, safety, and patient satisfaction of the types of insulin therapy used for their treatment.

Results:

After 12 weeks, there was a reduction in mean glycosylated hemoglobin (HbA1c) of -0.88% for the analogue type versus -0.19% for the conventional type, and at 24 weeks, the mean drop in HbA1c was -2.02% for the analogue type versus -1.12% for the conventional type, but the differences were not statistically significant. More patients (87% versus 38%) on analogue compared with conventional insulin treatment were satisfied with therapy.

Conclusion:

In the primary health care setting, insulin analogues showed greater efficacy improvements than conventional insulin therapy within 6 months. However, conventional insulin therapy can still be used at primary care centers with limited resources, and when patients refuse to be converted.Diabetes mellitus is a major cause of morbidity and mortality, and its global prevalence is rising rapidly.1 The estimated direct annual medical cost of diabetes care in Saudi Arabia is enormous; it constitutes an economic burden on the country.2 Since diabetes mellitus is a chronic illness that requires continuing medical care to reduce the risk of long-term complications,3 currently many diabetic patients attend the governmental primary care centers to receive this care. Studies from the United Kingdom confirmed the benefits of improved glycemic control in patients with types 1 and 2 diabetes mellitus,4,5 and they recommended tight glycemic control to maintain the glycosylated hemoglobin (HBA1c) concentrations of 7% or less. Insulin therapy is indicated to control all patients with type 1 diabetes, uncontrolled type 2 diabetics, and gestational diabetes to achieve the recommended target. There are 2 main types of insulin, the old conventional insulin that include the regular human insulin, and intermediate-acting neutral protamine Hagedorn insulin (NPH); however, these agents could not mimic the physiological pattern of endogenous insulin secretion, so insulin analogues were developed to overcome this limitation.6 Despite this theoretical superiority, the short acting insulin analogues were found to have a minor benefit to HBA1c values compared with the regular insulin in adult patients with type 1 diabetes mellitus, and no benefit in the population with type 2 or gestational diabetes.7 The 2 basal insulin analogues, insulin Glargine and Detemir, which have different chemical structures and modes of actions, were also developed to overcome the limitations of NPH insulin. Hypoglycemia and weight gain were always the main fear for patients on insulin, but studies on the analogues were conflicting, some did not observe a major clinical advantage in terms of hypoglycemia for either the rapid-acting or the long-acting insulin analogues over conventional insulins, others found that both rapid and long-acting analogues had little benefit in terms of glycemic control or reduced hypoglycemia. But insulin analogues were superior over the conventional insulins in terms of quality of life.8,9 The insulin analogues although expensive, adding to the enormous budget of the Ministry of Health in the treatment of diabetes mellitus, were introduced for free dispensing in some governmental primary health care centers in January 2014. The available analogues are the long-acting, Glargine (Sanofi, Bridgewater, NJ, USA), and the short acting Lispro (Eli Lilly & Co, Indianapolis, IN, USA) and Aspart (Novo Nordisk Inc., Plainsboro, NJ, USA), and their biphasic analogues, namely, Humalog in both concentrations 25/75 and 50/50 (Eli Lilly & Co, Indianapolis, IN, USA), and also NovoMix 30/70 (Novo Nordisk Inc., Plainsboro, NJ, USA). Though some patients are satisfied and refused to convert, efforts are in place to replace the current conventional insulin with the new insulin analogues for their proposed superiority of efficacy, safety, and quality of life. This study was carried out to help the general practitioners in choosing among the different insulin types, and in counseling their diabetic patients attending the government primary care health centers regarding their choice of insulin therapy.     

Vascular disease burden in Indian subjects with vascular dementia

Background

Vascular disease factors like hypertension, diabetes mellitus, dyslipidaemia, and ischaemic heart disease contribute to the development of vascular dementia. As comorbidity of vascular disease factors in vascular dementia is common, we investigated the vascular disease burden in subjects with vascular dementia.

Aims

To investigate the vascular disease burden due to four vascular disease factors: hypertension, diabetes mellitus, dyslipidaemia, and ischaemic heart disease in Indian subjects with vascular dementia.

Methods

In this study, 159 subjects with probable vascular dementia (as per NINDS-AIREN criteria) attending the memory clinic at a tertiary care hospital were assessed for the presence of hypertension, diabetes mellitus, dyslipidaemia, and ischaemic heart disease using standardised operational definitions and for severity of dementia on the Clinical Dementia Rating (CDR) scale. The data obtained was subjected to appropriate statistical analysis.

Results

Dyslipidaemia (79.25 per cent) was the most common vascular disease factor followed by hypertension (73.58 per cent), ischaemic heart disease (58.49 per cent), and diabetes mellitus (40.80 per cent). Most subjects (81.1 per cent) had two or more vascular disease factors. Subjects with more severe dementia had more vascular disease factors (sig 0.001).

Conclusion

People with moderate to severe dementia have a significantly higher vascular disease burden; therefore, higher vascular disease burden may be considered as a poor prognostic marker in vascular dementia. Subjects with vascular dementia and their caregivers must manage cognitive impairment and ADL alongside managing serious comorbid vascular diseases that may worsen the dementia.     

12th Annual College of Medicine Research Dissemination Meeting,November 29th, 2008

Objectives

This study was aimed at understanding cultural attitudes, beliefs and perceptions to biomedical research, community consultation and informed consent process in peri-urban and rural settings in Malawi. It attempted to provide a base for informing, reforming and improving informed consent policy and practice by describing the local cultural attitudes and perceptions to research, autonomy, informed consent process and community consultation. It also assessed the validity of the Western concepts of informed consent and autonomy in a Malawian (African) setting.

Methods

The study employed both qualitative and quantitative research methods. Data were obtained from research participants during focus groups and individual interviews. 50 FGDs were conducted with 494 research participants. Individual interviews were conducted with 319 participants drawn from 5 different clinical trials in Lilongwe and Blantyre. The data were analyzed both manually and electronically.

Results

A majority of research participants described biomedical research as activities associated with preventive health measures such as community assessment and health education. This was common among the refusers and non-participants. Most research participants could differentiate between biomedical research and standard health care; but the difference was seen in the quality of care, rather than procedures involved. Among the category of participants, the need to receive better medical treatment was said to be their motivating factor to participate in biomedical research. 94.6% (298) of clinical research participants said they understood the study objectives, but only 21.8% (65) were able to state them correctly. 92% (294) of participants understood the informed consent procedure and its meaning. 33% (97) of those who perceived benefits of participation mentioned the care provided to them in clinical research as one of the benefits. 16.6% (52) acknowledged existence of risks to their participation in the clinical research; and were able to name the risks involved While 98% (313) said they joined clinical research freely, only 92% (294) understood the informed consent procedures. 90.9% (290) informed their partners/relatives about study participation; rather than seeking permission, 64.4% (187) said they did so “to let them know what was happening.” 84.6% (270) had no problem with allowing their samples to be stored for future research.

Conclusion

People who refuse to take part in biomedical research do so with an impaired understanding of its meaning and objectives due to rumors associated with biomedical research. There is a knowledge gap between real and perceived objectives among those who participated or were participating in biomedical research. People are motivated to take part in biomedical research by the “quality of care” provided to research participants. Participants understand their voluntary participation in research and understand the informed consent procedures; with community consultation seen as customary and preceding individual consent. People accept to participate in clinical research with knowledge of the existence of risks to their participation. Preference of signing or thumb printing is contrary to the Western concepts which allude to oral consent to be sought in illiterate communities. Communities have a good attitude towards biomedical research but are put off by researchers who

• do not follow customary procedures like community consultation and
• do not give feedback of results after the research is over.

Recommendations

Researchers should state objectives in simple terms and should remind participants about the objectives throughout the study. Researchers should clearly explain why each procedure is being done or why materials are being given to participants in biomedical research. Researchers have social obligations to provide services to communities where they recruit participants. Researchers have to engage communities before initiating biomedical research in communities or health centres; community engagement would help to dispel rumors associated with clinical research and would encourage community members to participate.

• Malawi Med J. 2009 Mar; 21(1): 34–43.
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• Rotavirus gastroenteritis in children in Blantyre, Malawi

Malawi Med J. 2009 Mar; 21(1): 34–43.

Rotavirus gastroenteritis in children in Blantyre, Malawi

NA CunliffeAuthor information Copyright and License information DisclaimerDepartment of Medical Microbiology, University of Liverpool, UKCopyright © Malawi Medical Journal     

Clinical profile and outcomes of adult patients with hyperglycemic emergencies managed at a tertiary care hospital in Nigeria

Background:

To document the clinical profile and treatment outcomes of diabetic ketoacidosis (DKA) and hyperosmolar hyperglycemic state (HHS) managed in a tertiary care hospital.

Materials and Methods:

This was a retrospective review of hospital records of patients with DKA and HHS admitted to a tertiary care hospital over a 24-month period. Data on demographics, precipitating factors, clinical features, serum electrolytes, duration of hospital admission, and mortality were extracted.

Results:

Eighty-four patients were included in the study. Fifty (59.5%) were females. Ten (11.9%) persons had type 1 diabetes mellitus (T1DM) and 74 (88.1%) had type 2 diabetes mellitus (T2DM). There were 35 cases of DKA and 49 cases of HHS. Nine patients with T1DM presented in DKA and one in HHS. Forty-eight (55.2%) subjects were previously not diagnosed of diabetes mellitus (DM). The mean±SEM age, casual blood glucose, calculated serum osmolality, and duration of hospital stay of the study subjects were 50.59±1.63 years, 517.98±11.69 mg/dL, 313.59±1.62 mOsmol/L, and 18.85±1.78 days, respectively. Patients with T2DM were significantly older than those with T1DM (54.32±1.34 vs. 23.40±1.38 years, P<0.001).The precipitating factors were poor drug compliance 23 (27.4%), malaria 12 (14.3), urinary tract infection 10 (11.9%), lobar pneumonia 4 (4.8%), and unidentifiable in 29 (34.5%). Common electrolyte derangements were hyponatremia, 31 (36.9%) and hypokalemia 21 (25%). Mortality rate was 3.6%.

Conclusion:

DKA is common in patients with T2DM.Over 50% of the patients presenting with DKA or HHS have no previous diagnosis of DM. Non-compliance, malaria, and infections are important precipitants. Mortality rate is low.     

Abstracts of the 1st Annual Malawi Mental Health Research andPractice Development Conference, 7th & 8th February 2011, Blantyre,Malawi

Introduction

Contemporary mental services delivery is moving towards cost-effective community based as opposed to institutionalized care (Harrison, Alam & Mashall, 2001). Domiciliary mental health care is one example of such service that is being promoted in developed countries. Domiciliary mental health care refers to the delivery of mental health services in the home for purposes of restoring and maintaining the health of clients when they are in acute state (Campbell, 1996). This paper highlights successes and lessons learnt in the domiciliary mental health care approach that St. John of God Community Services is implementing in the northern city of Mzuzu.

Objectives of the program

The broad objective of domiciliary mental health care in Mzuzu service is to provide an alternative community based mental health care to clients with mental health problems in the city of Mzuzu and its environs through care delivery, family education, community participation and alleviation of stigma associated with psychiatric admission.

Strategies

Strategies used in the program include provision of nursing care to clients in their homes; mobile clinics and mental health education to family members and the entire community.

Successes

Some successes of this cost-effective initiative include attainment of optimum level of functioning by 275 clients since establishment in 2006; reduced recovery period when compared with those in residential unit; family/community involvement, reduced stigma associated with admission to a psychiatric hospital and the freedoms enjoyed whilst in the homes.

Challenges

The biggest challenge is that some carers do not cooperate and prefer that their client be managed in the hospital even when client is less problematic at home.

Conclusion

Domiciliary mental health care is cost-effective and feasible in Malawi provided families are given support within their communities.

• Malawi Med J. 2011 Sep; 23(3): 99–103.
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• Increasing the Capacity of Health Surveillance Assistants in Community Mental Health Care in Zomba District — Interim Findings of an Education Intervention

2011 Sep; 23(3): 99–103.

Increasing the Capacity of Health Surveillance Assistants in Community Mental Health Care in Zomba District — Interim Findings of an Education Intervention

Jerome Wright, Dr Stephanie Common, Dr Felix Kauye, and Mr Chikayiko ChiwandiraAuthor information Copyright and License information Disclaimer“Zomba Link”, Harrogate, UK and Zomba Mental Hospital, Zomba, MalawiCopyright notice     

Adherence to the American Diabetes Association standards of care among patients with type 2 diabetes in primary care in Saudi Arabia

Objectives:

To assess adherence to 11 American Diabetes Association (ADA) standards of diabetic care.

Methods:

We conducted this one-year historical prospective study between October 2010 and September 2011 on 450 adult type 2 diabetes patients in a primary care center in Saudi Arabia. We used the definitions of the 2010 ADA standards of diabetic care processes and targets.

Results:

Four-hundred and fifty medical files were valid. The adherence to ADA process standards of measurement of glycated hemoglobin (HbA1c) was 68.7%, 92.9% for blood pressure, and 80.2% for serum lipids. Screening was lowest for nephropathy (35.6%), and highest for diabetic foot (72%). Adherence to medications ranged between 82.2% for antiplatelets, and 92.4% for dyslipidemia. For outcome standards, 24.2% of the patients had an HbA1c <7%, and 32.2% had controlled blood pressure (<130/80 mm Hg); and 58.5% achieved targeted low-density lipoproteins (LDL). Only 7.2% had glycemic control in addition to controlled blood pressure and targeted LDL level. An increasing trend of patients achieving glycemic control (<7%) was shown throughout follow-up (p=0.003).

Conclusions:

We found suboptimal adherence with many ADA standards of diabetic care among patients with type 2 diabetes treated at a primary care center in Saudi Arabia. The achievement of outcome standards, either singly or combined, is lower than the adherence rates. However, the figures show improvement in adherence during the follow-up period.Diabetes mellitus is a chronic disease that can cause devastating secondary complications, reducing the quality and length of life as well as increasing medical costs for the patient and society.1-3 Saudi Arabia has one of the highest diabetes prevalence rates worldwide. The International Diabetes Federation estimates that 8.3% of the world’s adult population (20-79 years) have diabetes, with Saudi Arabia one of the top countries affected (20%).4 Additionally, a national study estimated the overall prevalence of diabetes in Saudis aged 30-70 years at 23.7% (26.7% in women, and 21.5% in men).5Diabetes care is a complex process requiring ongoing patient self-management, education, and support to prevent acute complications, and to reduce the risk of long-term complications.6 Compelling evidence from clinical trials shows that intensive glycemic control effectively delays the onset and slows the progression of diabetic complications, such as nephropathy, retinopathy, and neuropathy.7-9 Likewise, substantial evidence shows that control of associated risk factors such as hypertension and dyslipidemia is protective against undesirable outcomes in patients with diabetes.10-14 The American Diabetes Association (ADA) put together a set of diabetic care standards that are annually revised.15 However, despite the availability of convincing evidence and clear guidelines, many studies throughout the world reported suboptimal adherence to diabetic care standards.16-19 Only a few studies have examined the quality of diabetic care among Saudi patients in a primary care setting,20 outpatient clinics of internal medicine,21,22 and specialized diabetic care centers.23 These studies covered one or more of the screening, diagnostic, and therapeutic components of the ADA standards of diabetic care. However, the extent to which these standards are met at primary care settings was not comprehensively studied. Moreover, the degree to which multiple ADA processes and outcomes are simultaneously achieved was also not studied. Therefore, we aimed to assess the adherence of primary care patients to 11 ADA standards of diabetic care including glycemic control, blood pressure control, and lipid management, singly and combined.     

Determinants of exocrine pancreatic function as measured by fecal elastase-1 concentrations (FEC) in patients with diabetes mellitus

Objective

Recently it has been shown that there is not only endocrine insufficiency in diabetic patients, but a frequent co-morbidity of both, the endocrine and exocrine pancreas. The present study was performed to further analyse the determinants of exocrine pancreatic function in patients with diabetes mellitus.

Methods

The records of 1992 patients with diabetes mellitus who had been treated in our hospital during a 2-year period were re-evaluated. Defined parameters were documented in standardized data sheets. Records were further checked for the results of imaging procedures of the pancreas. In 307 patients FEC had been performed and documented. Only these patients were included in further evaluation.

Results

FEC was inversely correlated with diabetes duration and HbA1c-levels but not with age. C-peptide levels correlated positively with FEC. BMI and FEC were also significantly correlated. There was no correlation between diabetes therapy and exocrine pancreatic function as there was no correlation with any concomitant medication. The presence of diabetes-associated antibodies was not related to FEC. According to the documented data 38 were classified as type-1 diabetes (12.4%), 167 as type-2 (54.4%), and 88 patients met the diagnostic criteria of type-3 (28.7%). Fourteen patients could not be classified because of lacking information (4.6%).

Conclusions

Exocrine insufficiency might be explained as a complication of diabetes mellitus. However, it is more likely that type-3 diabetes is much more frequent than previously believed. Consequently the evaluation of exocrine function and morphology should be included into the clinical workup of any diabetic patient at least at the time of manifestation.     

Adherence reporting in clinical trials of type 2 Diabetes Metellius in the field of Traditional Chinese Medicine

OBJECTIVE

To assess the medication adherence reporting in clinical trials the field of Traditional Chinese Medicine (TCM) and the impact factors of medication adherence.