Placing the Outcome Reduction with an Initial Glargine Intervention (ORIGIN) trial in context

The results of the Outcome Reduction with an Initial Glargine Intervention (ORIGIN) trial were presented at the American Diabetes Association meeting in June 2012. The purpose of this study was to assess whether there would be any reduction in cardiovascular (CV) events if insulin glargine was started early in the course of diabetes. Therefore, the selected patients were those who were at high risk of CV events, but with impaired fasting glucose, impaired glucose tolerance or recent onset of type 2 diabetes. After 6.5 years, no differences were seen in primaryoutcomes, namely CV death, myocardial infarction, stroke,  revascularisation procedures or hospitalisation for heart failure. However, the early institution of insulin therapy using glargine was found to be an effective means of maintaining glycaemic control in this patient group. As expected, patients on glargine insulin experienced slightly increased rates of both non-severe and severe hypoglycaemia, and slight weight gain. Neither of these problems was considered to be a limiting factor in the early use of glargine insulin. A second arm of the study was designedto assess the role of omega-3 fatty acids in the prevention of CV events. The results of this arm showed no benefit and do not support the use of omega-3 fatty acids as prophylactic therapy in these patients. While the ORIGIN trial is unlikely to alter clinical practice regarding the treatment of either dysglycaemia or new-onset diabetes, it has demonstrated that glargine insulin is relatively safe when used early in diabetes and can maintain near-normal glycaemic control for over six years, without increased cancer risk and with a neutral effect on CV outcomes

Complicities

This Open Access book offers a model of the human subject as complicit in the systems that structure human society and the human psyche which draws together clinical research with theory from both psychology and the humanities to advance a more social just theory and practice. Beginning from the premise that we cannot separate ourselves from the systems that precede and formulate us as subjects, the author argues that, in reckoning with this complicity, a model of subjectivity can be created that moves beyond binaries and identity politics. In doing so, the book examines how we might develop a more socially just psychological theory and practice, which is both systems work and intra-psychological work. In bringing together ways of thinking developed in the humanities with clinical psychotherapeutic practice, this book offers one interdisciplinary take on key questions of social and emotional efficacy in action-oriented psychotherapy work

A continuous-time formulation for spatial capture-recapture models

Spatial capture-recapture (SCR) models are relatively new but have become the standard approach used to estimate animal density from capture-recapture data. It has in the past been impractical to obtain sufficient data for analysis on species that are very difficult to capture such as elusive carnivores that occur at low density and range very widely. Advances in technology have led to alternative ways to virtually "capture" individuals without having to physically hold them. Some examples of these new non-invasive sampling methods include scat or hair collection for genetic analysis, acoustic detection and camera trapping. In traditional capture-recapture (CR) and SCR studies populations are sampled at discrete points in time leading to clear and well defined occasions whereas the new detector types mentioned above sample populations continuously in time. Re- searchers with data collected continuously currently need to define an appropriate occasion and aggregate their data accordingly thereby imposing an artificial construct on their data for analytical convenience. This research develops a continuous-time (CT) framework for SCR models by treating detections as a temporal non homogeneous Poisson process (NHPP) and replacing the usual SCR detection function with a continuous detection hazard func- tion. The general CT likelihood is first developed for data from passive (also called "proximity") detectors like camera traps that do not physically hold individuals. The likelihood is then modified to produce a likelihood for single-catch traps (traps that are taken out of action by capturing an animal) that has proven difficult to develop with a discrete-occasion approach. The lack of a suitable single-catch trap likelihood has led to researchers using a discrete-time (DT) multi-catch trap estimator to analyse single-catch trap data. Previous work has found the DT multi-catch estimator to be robust despite the fact that it is known to be based on the wrong model for single-catch traps (it assumes that the traps continue operating after catching an individual). Simulation studies in this work confirm that the multi-catch estimator is robust for estimating density when density is constant or does not vary much in space. However, there are scenarios with non-constant density surfaces when the multi-catch estimator is not able to correctly identify regions of high density. Furthermore, the multi-catch estimator is known to be negatively biased for the intercept parameter of SCR detection functions and there may be interest in the detection function in its own right. On the other hand the CT single-catch estimator is unbiased or nearly so for all parameters of interest including those in the detection function and those in the model for density. When one assumes that the detection hazard is constant through time there is no impact of ignoring capture times and using only the detection frequencies. This is of course a special case and in reality detection hazards will tend to vary in time. However when one assumes that the effects of time and distance in the time-varying hazard are independent, then similarly there is no information in the capture times about density and detection function parameters. The work here uses a detection hazard that assumes independence between time and distance. Different forms for the detection hazard are explored with the most exible choice being that of a cyclic regression spline. Extensive simulation studies suggest as expected that a DT proximity estimator is unbiased for the estimation of density even when the detection hazard varies though time. However there are indirect benefits of incorporating capture times because doing so will lead to a better fitting detection component of the model, and this can prevent unexplained variation being erroneously attributed to the wrong covariate. The analysis of two real datasets supports this assertion because the models with the best fitting detection hazard have different effects to the other models. In addition, modelling the detection process in continuous-time leads to a more parsimonious approach compared to using DT models when the detection hazard varies in time. The underlying process is occurring in continuous-time and so using CT models allows inferences to be drawn about the underlying process, for example the time- varying detection hazard can be viewed as a proxy for animal activity. The CT formulation is able to model the underlying detection hazard accurately and provides a formal modelling framework to explore different hypotheses about activity patterns. There is scope to integrate the CT models developed here with models for space usage and landscape connectivity to explore these processes on a finer temporal scale. SCR models are experiencing a rapid growth in both application and method development. The data generating process occurs in CT and hence a CT modelling approach is a natural fit and opens up several opportunities that are not possible with a DT formulation. The work here makes a contribution by developing and exploring the utility of such a CT SCR formulation

Should all patients on insulin be using continuous glucose monitoring?

Continuous glucose monitoring (CGM) is being used increasingly both in patients on insulin pumps (CSII) and more recently in those on multiple injection regimens (MIR). This review lists the CGM devices available in South Africa and explores the literature supporting the use of CGM as a primary modality for monitoring blood glucose in those with diabetes on MIR. In particular, the role of CGM as a modality for improving glycaemic control and reducing hypoglycaemia is explored. The identification of appropriate patients, the possible barriers to the institution of CGM and the role of CGM in the future of diabetes care is discussed.Keywords: continuous glucose monitoring, flash monitoring, multiple injection regimens, type 1 diabete

Asymptomatic bacteriuria in diabetes mellitus

A study was undertaken to determine the frequency of asymptomatic bacteriuria among 100 ambulant diabetic patients attending a diabetic outpatient clinic. At the same time, we assessed the reliability of the Uricult dip-slide method for detecting urinary bacterial growth. Significant bacteriuria occurred in 9% of the total diabetic group, largely attributable to the high prevalence in elderly diabetic women. Important characteristics of the affected diabetic patients included infection, commonly with Escherichia coli, frequently associated pyuria, good diabetic control with normal renal function and a high recurrence rate of bacteriuria after treatment. The dipslide method compared quite favourably with the laboratory culture method, but it failed to detect 2 out of 8 cases with significant bacteriuria.S. Afr. Med. J., 48, 1306 (1974)

The Biosulin equivalence in standard therapy (BEST) study − a multicentre, open-label, non-randomised, interventional, observational study in subjects using Biosulin 30/70 for the treatment of insulin-dependent type 1 and type 2 diabetes mellitus

Introduction. The need for more cost-effective insulin therapy is critical in reducing the burden on patients and health systems. Biosimilar insulins have the potential to dramatically lower healthcare costs by delivering insulin with a similar anti-glycaemic effect and adverse reaction profile.Objectives. The purpose of this study was to confirm equivalence in glycaemic outcomes and side-effect profiles between Biosulin 30/70 and other human premixed insulin preparations on the South African market in a clinical practice setting.Methods. Subjects in this interventional, observational, multicentre, open-label, prospective study were switched from their existing human premix insulin (Actraphane, Humulin 30/70 or Insuman) to the study insulin Biosulin 30/70. The primary endpoint was the change in HbA1c from baseline to 6 months.Results. Seventy-seven adult patients with type 1(n=18) or type 2 (n=59) diabetes were enrolled. The baseline HbA1c in the overall cohort was 7.9%, 8.0% at 3 months (p=0.50) and 7.6% at 6 months (p=0.14).There was a small increase in the total daily dose of insulin used in both the type 1 and type 2 cohort, from 0.62 to 0.65 units/kg/day (p=0.0004). There was no significant difference in weight in the study subjects during the 6-month period on Biosulin 30/70 (p=0.67).Conclusion. Biosulin 30/70 achieved at least equivalent glycaemic control to existing human premix insulins, with no reported new or severe adverse events. Increased use of biosimilar insulins has the potential for significant cost savings

South African quantity surveyors: issues of gender and race in the workplace

A web-based questionnaire survey of the opinions of SA quantity surveyors was undertaken to establish gender- and race-based differences in job satisfaction. Issues explored included demographic factors, issues of gender and race in the workplace, and gender and racial harassment and discrimination at work. 'Significant' differences on the basis of gender exist on a number of issues. Women, more than men, have strong positive feelings regarding their levels of job satisfaction, feel that their career expectations have been fulfilled, would choose the same career again, and would unequivocally recommend the career to others. Females see QS practices as male-dominated, see themselves as being blocked from advancement to managerial ranks, participating less in decision-making, and remunerated at a lower level than equivalent colleagues. Issues important to women include : gender representivity in the profession, flexible working hours and maternity leave above the statutory minimum. Although both gender groups report racial harassment and discrimination at work, women experience significantly more sexual and gender harassment and religious and gender discrimination than do males. 'Significant' differences on the basis of race are evident concerning : feelings of job satisfaction and views on maternity / paternity leave above statutory minima. 'Highly significant' differences on the basis of race arise over issues of : being subjected to greater supervision because of race, not being allowed to contribute meaningfully to the decision-making process, viewing PDI status as a valid basis for promotion, seeing race representivity in the profession as important in combating discrimination at work, having personally experienced racial harassment and discrimination at work, and seeing respect for individual diversity in the workplace as important - with 'Whites' viewing these issues less 'empathically' than their 'Non-white' counterparts. The results provide valuable indicators for how the quantity surveying firms can create a more conducive work environment for professional staff, particularly females

South African quantity surveyors: issues of gender and race in the workplace

A web-based questionnaire survey of the opinions of SA quantity surveyors was undertaken to establish gender- and race-based differences in job satisfaction. Issues explored included demographic factors, issues of gender and race in the workplace, and gender and racial harassment and discrimination at work. ‘Significant’ differences on the basis of gender exist on a number of issues. Women, more than men, have strong positive feelings regarding their levels of job satisfaction, feel that their career expectations have been fulfilled, would choose the same career again, and would unequivocally recommend the career to others. Females see QS practices as male-dominated, see themselves as being blocked from advancement to managerial ranks, participating less in decision-making, and remunerated at a lower level than equivalent colleagues. Issues important to women include: gender representivity in the profession, flexible working hours and maternity leave above the statutory minimum. Although both gender groups report racial harassment and discrimination at work, women experience significantly more sexual and gender harassment and religious and gender discrimination than do males. ‘Significant’ differences on the basis of race are evident concerning: feelings of job satisfaction and views on maternity / paternity leave above statutory minima. ‘Highly significant’ differences on the basis of race arise over issues of: being subjected to greater supervision because of race, not being allowed to contribute meaningfully to the decision-making process, viewing PDI status as a valid basis for promotion, seeing race representivity in the profession as important in combating discrimination at work, having personally experienced racial harassment and discrimination at work, and seeing respect for individual diversity in the workplace as important - with ‘Whites’ viewing these issues less ‘empathically’ than their ‘Non-white’ counterparts. The results provide valuable indicators for how the quantity surveying firms can create a more conducive work environment for professional staff, particularly females.&nbsp

Allen D. Breck Award Winner: The Presence of the Past: Shakespeare in South Africa

In what ways has Shakespeare—as a collection of texts, as cultural capital, as a tool of a colonial education system as powerful as the bible and the gun—manifest in South African culture? Today I will sketch the presence of the past in a way which aims to draw out the South African in Shakespeare as much as the Shakespearean in South Africa. I do this following the post-colonial call to redress the imbalance of knowledges between the West and the Rest, and in order to break a simplistic cultural binary which posits “African,” colonized culture on one side and “European,” high culture on the other. There are ongoing debates about the details of this model of, variously, cultural hybridity, creolization, or trans- formation. Nevertheless, recognition of the synergy that occurs with the meeting of cultures, however unequally, is central to any understanding of the cultural conditions of a post-colonial world, and, ultimately, of post-apartheid South Africa