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- Volume 19, Issue 2, 2014
Journal of Endocrinology, Metabolism and Diabetes in South Africa - Volume 19, Issue 2, 2014
Volume 19, Issue 2, 2014
Author Willie MollentzeSource: Journal of Endocrinology, Metabolism and Diabetes in South Africa 19 (2014)More Less
Most clinicians are familiar with acanthosis nigricans, a dermatosis, characterised by brownish-black velvety, papilomatous hyperkeratotic plaques, usually occurring in the neck, axillae and other intertriginous surfaces. Acanthosis nigricans is most frequently associated with insulin-resistant states, such as type 2 diabetes, polycystic ovarian disease and a variety of endocrine disorders. Less commonly, acanthosis nigricans is also associated with internal malignancies, such as carcinoma of the colon, and in the setting of niacin use, in the management of dyslipidaemia. Acanthosis nigricans is detectable in more than 50% of children with type 2 diabetes mellitus, and is recognised more frequently in darker-skinned obese individuals. In this issue of JEMDSA, Venkatswami reports that the severity of acanthosis nigricans correlated with the degree of insulin resistance in a large group of Indian patients attending a dermatology clinic, and also with the texture of the lesions. Lesions that were rough to the touch or visibly coarse also correlated with the degree of insulin resistance, determined with homeostasis model assessment. Thus, acanthosis nigricans may be a useful sign when attempting to detect individuals at high risk of developing type 2 diabetes. It may be worthwhile investigating this finding in the South African context, especially in overweight and obese children and adolescents.
Source: Journal of Endocrinology, Metabolism and Diabetes in South Africa 19, pp 56 –61 (2014)More Less
Hypertension is common among patients presenting for surgery, and is frequently untreated or inadequately treated. While the approach to the patient with hypertension presenting for anaesthesia is controversial, and the evidence base for appropriate clinical decisions is weak, this is a problem that practising clinical anaesthetists face on a regular basis. This article seeks to present a unified approach to the problem of a hypertensive patient presenting for surgery, and offers suggestions as to the appropriate management options. As far as possible, the recommendations contained in this article have been based on the best available evidence.
The authors suggest that moderate degrees of hypertension (up to 180/120 mmHg), without obvious target organ disease, should never be grounds for postponing surgery. Even with greater degrees of hypertension, the relative risk of postponing surgery should always be considered. There is little evidence that, in patients without target organ disease, delaying surgery in order to establish antihypertensive therapy is beneficial. For very severe hypertension, the benefits of delaying surgery to establish adequate hypertensive control must be weighed against the risk of delayed surgery. Where a surgical delay is considered, adequate time to establish appropriate blood pressure control must be allowed, and there is no place for sudden "cosmetic" correction of blood pressure immediately prior to anaesthesia. Previously undiagnosed hypertension, presenting for the first time at surgery, requires a basic investigation of target organ disease prior to anaesthesia, and appropriate subsequent follow-up referral for further management.
Source: Journal of Endocrinology, Metabolism and Diabetes in South Africa 19, pp 63 –66 (2014)More Less
There has been a dramatic interest in the importance of vitamin D, "the sunshine vitamin", in the past few years with regard to its impact on various aspects of health and disease. Research into well-known skeletal effects, as well as extraskeletal effects, has been overwhelming. At times it has been difficult to make informed clinical decisions regarding replacement, if needed at all. This article aims to provide the physician with a summary of the most important clinical effects of vitamin D, as well as give guidelines on testing for possible deficiency and consideration of replacement thereof.
Source: Journal of Endocrinology, Metabolism and Diabetes in South Africa 19, pp 68 –74 (2014)More Less
Objectives : Acanthosis nigricans refers to the velvety, black hyperpigmentation seen in the flexures. It is a cutaneous marker for insulin resistance (IR), some metabolic disorders and rarely malignancy. When secondary to IR, it is asymptomatic, except for the hyperpigmentation. The neck is the most accessible and easiest to grade. Our aim was to identify the predictive value of the grades of acanthosis nigricans in identifying IR, the predictive value of the textures of acanthosis nigricans in identifying IR, and the diagnostic utility of acanthosis nigricans grading in comparison to the laboratory tests.
Settings and subjects : The institutional ethics committee of Sri Ramachandra University approved this study. Three hundred, consecutively presenting adults (50 males) with acanthosis nigricans on the neck were enrolled.
Design : History, physical parameters and acanthosis nigricans grades, location and textures were noted. An oral glucose tolerance test (OGTT), fasting serum insulin and homeostasis model assessment of IR (HOMA IR) were carried out. The acanthosis nigricans grades were correlated to establish any association. Thirty obese controls without acanthosis nigricans were included.
Outcome measures : OGTT, fasting serum insulin and HOMA IR were the outcome measures studied.
Results : This cross-sectional study revealed that 94 subjects with acanthosis nigricans (31.34%) had IR. Grades III and IV, and textures II and III, were more predictive of IR. Acanthosis nigricans grading was insignificant in the non-insulin-resistant group. Acne (p-value 0.379), hirsutism (p-value 0.12) and acrochorda (p-value 0.415) were not significantly associated with IR.
Conclusion : Severe grades and higher textures of acanthosis nigricans are reliable clinical diagnostic tools for IR. The absence of acanthosis nigricans was not associated with IR. Acanthosis nigricans grading is an inexpensive and non-invasive way of identifying pre-diabetes.
Factors influencing adherence to dietary guidelines : a qualitative study on the experiences of patients with type 2 diabetes attending a clinic in Cape Town : original researchSource: Journal of Endocrinology, Metabolism and Diabetes in South Africa 19, pp 76 –84 (2014)More Less
Objective : The purpose of this study was to explore the experiences of patients with type 2 diabetes mellitus attending the Groote Schuur Hospital Diabetes Clinic in relation to contextual factors that promote or impede adherence to nutrition care guidelines.
Subjects and setting : Eight diabetic patients (four males and four females) attending the Groote Schuur Hospital Diabetes Clinic who were between 40-70 years old.
Outcome measures : Qualitative analysis of factors influencing adherence to dietary guidelines.
Method : An explorative study, using a qualitative approach with eight semi-structured interviews, was used. Patients were interviewed at the diabetes outpatient clinic in Cape Town. Semi-structured interviews were recorded and transcribed, and thereafter analysed using ATLAS/ti®.
Results : Various themes as to what influences adherence to dietary guidelines emerged. An ecological analysis is offered to understand the different levels of influence on participants' dietary behaviour. The main identified factors at individual level were motivation, individual knowledge, perceptions of moderation, self-responsibility, taste concept or cravings, and temptations. At small group (family and friends) level, family relations with the patients were identified as the main support system used to manage the diabetes. At the organisational or health systems level, long waiting times and the theme of seeing different doctors emerged as problematic factors, but overall, patients were satisfied with the clinic service. At community and policy level, culture and the cost of food were identified as key influential factors with regard to adherence to nutrition care guidelines.
Conclusion : This study shows the usefulness of adopting an ecological model in identifying factors that influenced adherence to dietary guidelines by patients with type 2 diabetes. Some factors acted as enablers and others as barriers. These had an impact on patient adherence to nutrition care guidelines. These factors should be considered by diabetes educators, including dietitians and nurses and doctors, when planning treatment modalities for patients with type 2 diabetes mellitus.
Primary congenital hypothyroidism complicated by persistent severe anaemia in early infancy : a case report with a literature review : case studySource: Journal of Endocrinology, Metabolism and Diabetes in South Africa 19, pp 85 –88 (2014)More Less
Although anaemia is a common finding in adults with hypothyroidism, there is a general paucity of studies on anaemia in infants with congenital hypothyroidism. The degree of anaemia is usually mild to moderate, with a haemoglobin concentration that is rarely less than 8-9 g/dl. The associated anaemia in hypothyroidism is generally normochromic and normocytic, and occasionally mildly macrocytic. This heterogeneity has been attributed to coexisting deficiencies of iron, vitamin B12 and folic acid, largely due to impaired absorption. Anaemia in hypothyroidism has been linked to impaired haemoglobin synthesis due to a deficiency of thyroxine (T4). There is evidence of a direct effect of the thyroid hormone on erythropoiesis. The pathogenesis of anaemia in hypothyroidism has been linked to either a lack of erythropoietin production, or a physiological adaptation to the decreased tissue oxygen requirements resulting from a decrease in the basal metabolic rate. The red cell life span is normal and the results of ferrokinetic studies are compatible with hypoproliferative erythropoiesis in hypothyroidism.