Diabetes Mellitus (DM) is the new epidemic in the world with 246 million people suffering from the disease at the moment and a projected increase to 380 million in 2025 (IDF, 2007b:36). The developing countries are the most vulnerable. Statistics state that SA and Egypt have the most diabetics on the continent. Globally, each year 3,8 million deaths are attributable to DM (IDF, 2007a). The Department of Health (DOH) and the Cacadu District Municipality (Eastern Cape) are serving a population of 102 721 in the Kouga and Koukamma areas, which covers an area of 5 992 km², with health care. There are 22 clinics with 28 registered nurses for all the clinics and between 3 and 9 lay health workers (LHWs) per clinic. For the purpose of this research study, the persons suffering from DM (±3550) in this area were taken into consideration (Strydom, 2005). DM is a chronic disorder and therefore patients should be able to manage their disease pattern for the rest of their lives (Healthline, 2008, Mbanya, 2006:12). In order to achieve this, continuous and effective patient education by health care providers are necessary. This disease affects more and more people each passing day, because of the rapid westernisation of the South African population, leading to more people attending clinics in the public health sector (Bonnici, 2002:32). There are specific guidelines laid down by the Department of Health (DOH) pertaining to the control and management of DM. Guidelines include the early diagnosis, treatment and patient education regarding DM (Department of Health, 1997, [revised 2004]). Evidence from previous research studies showed that not all registered nurses are aware of these guidelines and most have not been educated regarding the utilisation of these guidelines (O’Brien, van Rooyen & Carlson, 2006:36-40). In the clinics, the health care givers are confronted with a number of difficulties, such as a lack of funds to enable them to order adequate equipment and medicine. Another problem is the migration of registered nurses out of the country thus; there is also a shortage of staff to operate these clinics (Mkhize, 2004). The organisational structure in the clinics does not function optimally and there is a lack of communication between provincial, district and clinic level. Due to the above-mentioned challenges there is also a lack of efficient auditing systems to ensure quality assurance. Furthermore, a knowledge deficit pertaining to DM and the management thereof in all the groups participating in this study, namely the registered nurses, the lay health workers (LHWs) and the diabetic patients was found. The empowerment process of the LHW is not explored fully and therefore not executed to its full potential. To be able to improve the management of DM in this region, it is important to know what the difficulties are that the health care givers as well as the patients experience in relation to this issue. This study therefore explored and described these difficulties. The research was based on a qualitative, quantitative, explorative, descriptive and contextual research design. Health care givers as well as diabetic patients attending clinics in the Cacadu region of the Eastern Cape have been requested to complete questionnaires pertaining to their knowledge of Diabetes Mellitus. The current organisational structure of the provincial department of health was explored and findings analysed using the activities of the management process (Muller, 2006:106). The SA Government is committed to combining the national human resource development strategy with the rapid upgrading of service delivery to all of the nation’s communities. Stemming from this undertaking, suitable members of the community are to be trained as LHWs. LHWs are to play an integral role in strengthening the abilities of the community to empower themselves to participate and take responsibility for their own health and wellness (Department of Health, 2001a:4). From the research, it was found that the above-mentioned national plan had been implemented, but is not functioning at optimum level due to several shortcomings/deficits. Proposed guidelines were therefore designed to address the shortcomings and fragmentation of the plan. As specific knowledge deficits in DM were identified during this research study, general educational guidelines were included for the registered nurses and the diabetic patients. The LHW was identified as an indispensable link in the chain of efficient health care and therefore, specific educational guidelines on DM were generated to prepare her for the role. With her knowledge, insight into DM and the management thereof and newly required skills in educating and supporting of the patient, she could be an asset in the road to optimum self-care for the diabetic patient.

Submitted in fulfillment of the requirements of the degree of Master in Technology, Department of Biomedical Technology and Clinical Technology, Durban University of Technology, Durban, South Africa, 2016. / Introduction In Africa, use of phytotherapy for treatment of diabetes mellitus is a common form of practice. Considering the increasing burden of non-communicable diseases in South Africa efforts are directed at simple, cost effective, non-hazardous and efficient methods to treat cancer, cardiovascular diseases and diabetes. The role of phytonanotherapy is an attractive proposition for advancing new therapies. Metal nanoparticles are a possible means for delivery of such therapies. However, this requires investigation on interactions, mechanisms and therapeutic efficacy upon co-administering ethnobotanicals with metal nanoparticles and existing drug therapy in human beings. Aim The primary aim of the study was to test the in vitro antidiabetic and antibacterial activity of Ocimum sanctum (leaf extracts and flower extracts), Ocimum basilicum (leaf extracts and flower extracts), and a combination of the leaf extracts of both, and to observe whether any antidiabetic and antibacterial activity was enhanced in due to phyto-synthesised bimetallic gold-silver (Au-Ag) nanoparticles and silver nanoparticles. Methods Aqueous and ethanol extracts of O. sanctum and O. basilicum leaf and flowers alone and combined (leaf + flower) were prepared using hot vs cold water extraction techniques and 60% and 70% ethanol as polar solvents. A simple, rapid, cost effective and reproducible green chemistry method synthesised alloyed bimetallic (Au-Ag) nanoparticles using O. basilicum leaf and flower aqueous extracts and prepared silver nanoparticles (AgNps) using O. basilicum and O. sanctum leaf aqueous extracts singly and in combination (O. sanctum + O. basilicum). The size, shape and elemental analysis of the nanoparticles was carried out using UV-Visible spectroscopy, transmission electron microscopy (TEM), scanning electron microscopy coupled with energy-dispersive X-ray (SEM-EDX), dynamic light scattering (DLS) and zeta potential. Fourier transform infrared spectroscopy (FT-IR) supported by gas chromatography mass spectroscopy (GC-MS) identified the bio-capping agents. Antidiabetic carbohydrate metabolising enzymes, α-amylase (porcine) and Bacillus stearothermophilus α-glucosidase as models tested the in vitro inhibitory potential of the aqueous and ethanol plant extracts and the phyto-synthesised (Au-Ag) bimetallic and AgNps. In addition, the study investigated the antibacterial potential for the aqueous plant preparations and their respective phyto-synthesised bimetallic and AgNps against the bacterial species Staphylococcus aureus, Escherichia coli, Bacillus subtilis, Salmonella species and Pseudomonas aeruginosa compared to gentamycin and vancomycin. Results Bimetallic nanoparticles (synthesised from leaf and flower aqueous extracts) displayed inhibitory activity that showed uncompetitive inhibition (leaf extract), and non-competitive inhibition (flower extract) of α-amylase and competitive (leaf extract) and uncompetitive inhibition (flower extract) of α-glucosidase. Bimetallic nanoparticles were higher in inhibitory activity than acarbose and the crude O. basilicum ethanol and aqueous leaf and flower extracts. In the antibacterial analysis, bimetallic nanoparticles derived from O. basilicum leaf showed inhibition against Staphylococcus aureus, Escherichia coli, Bacillus subtilis and Pseudomonas aeruginosa and were greater in activity compared to the crude aqueous leaf extract from O. basilicum. The in vitro inhibitory effect of AgNps derived from O. sanctum and AgNps derived from O. basilicum on both enzymes was higher in activity than acarbose and their respective crude extracts. However, in combination (O. sanctum + O. basilicum), the derived AgNps appeared to be a less potent inhibitor of α-amylase and α-glucosidase enzyme and was lower than acarbose. AgNps synthesised from the combination of O. sanctum and O. basilicum showed the highest percentage inhibition against Bacillus stearothermophilus α-glucosidase, and AgNps derived from O. sanctum and AgNps derived from O. basilicum displayed competitive type of inhibition. In the antibacterial analysis, AgNps derived from the various extracts showed zones of inhibition against the Gram negative and Gram positive bacterial test strains. However, AgNps synthesised from the O. sanctum leaf extract showed higher inhibition against Escherichia coli than the positive control gentamycin and higher inhibition against Staphylococcus aureus compared to vancomycin. In addition, AgNps from O. sanctum leaf extract displayed inhibition against Bacillus subtilis, Pseudomonas aeruginosa and Salmonella species, thus representing the highest antibacterial potential. Conclusion The results demonstrate the possibility of synthesis of stable silver and bimetallic nanoparticles of Ocimum sp. The synthesised silver nanoparticles and first time synthesis of bimetallic (Au-Ag) nanoparticles displayed enhanced antihyperglycaemic properties compared to their respective crude extracts and, therefore, show promising effects in lowering postprandial hyperglycaemia in diabetic patients with dual potential for antibacterial treatment. However, the antidiabetic and antibacterial effect will need to be further affirmed in a clinical context. Medicinal plants with therapeutic value may create a new platform for further research to explore the potential for herbal medicine and nanoscience as effective biomedical and industrial applications, and for improving existing drug delivery systems in diabetic patients. Investigations into the cytotoxicity of these extracts and phytosynthesised nanoparticles is recommended. / M

Background Telehealth is a communication technology that allows exchange of data between patients and health care providers. Disease management is a structured multifaceted intervention to patient care that promotes self-management skills and improves patient-doctor communication. This systematic review aims to determine the effectiveness of “telehealth diabetes management programmes” for patients with type-2 diabetes (T2DM) in improving outcomes such as glycaemic control, diabetes related mortality, hospital admissions and overall cost-effectiveness of programme. Its applicability to Hong Kong will be reviewed. Methods A literature search of electronic bibliographic databases was performed to identify relevant articles. Both randomised control trials and observational studies on patients with T2DM published up to March 2013 were included in the analysis. Results A total of 14 articles were eligible (n=9708 subjects). Eight were randomised controlled trials and six observational studies. Ten studies reported on mean change in HbA1c level, three on health care utilization and three on cost-effectiveness of telehealth management programme. No studies had diabetes related mortality as their outcome measure. Across these trials, telehealth diabetes management programme resulted in an improvement in glycaemic control, likely reduction in health service utilization and a probable cost-effective programme. Discussions The current Hong Kong’s health care system faces challenges from long wait-list for medical consultations and rising health care costs. The applicability of the results from this review to the setting in Hong Kong, and feasibility of implementation will be discussed. Conclusion Telehealth disease management programmes had clinically modest but significant improvement in HbA1c among adults with T2DM and likely to be cost-effective. The results of this review have potential important implications for policy makers in the allocation of health care resources. / published_or_final_version / Public Health / Master / Master of Public Health

In severely ill hospitalised patients with diabetes mellitus (type 1 and type 2) there is an increase in metabolic rate. Insulin requirements are increased and glycaemic control becomes more difficult to achieve. The insulin sliding-scale is a form of „top up‟ therapy used to supplement the patients existing hypoglycaemic medication. In 2002, research at Livingstone Hospital found that 14 different sliding scales were used in 38 patients (Du Plessis, 2002: 79). In 2006 the nurses and doctors working in the general medical wards at Livingstone Hospital indicated that they were willing to use a standardised insulin sliding scale protocol (Smith, 2006: 56). Thus the aim of this study was to assess whether a standardised insulin protocol can be effectively implemented. The objectives of the study were to: 1) assess insulin usage via insulin sliding scales prior to the implementation of the standardised insulin protocol; 2) implement the standardised insulin protocol; and 3) reassess insulin usage after the implementation of the standardised insulin protocol. As the study involved evaluating the use of insulin via the insulin sliding scale and the implemented insulin protocol, it occurred in four phases. The preliminary phase entailed obtaining ethical approval. The pre-intervention phase included data collection in the form of a nursing questionnaire and the auditing of patient medical records using a data collection tool. The intervention phase involved education sessions on the new insulin protocol for the nursing staff, and the implementation of a standardised insulin protocol, while the post-intervention phase comprised of post-intervention data collection, which included a nursing questionnaire, a prescribers questionnaire and the auditing of patient medical records using a data collection tool. The overall impression obtained from the comparison between the pre- and post-intervention nursing questionnaire was conflicting; in some aspects the educational intervention was successful in others not. Regardless the indication obtained was that the nursing staff require more in-service training on a more regular basis as a lack of knowledge regarding diabetes mellitus as a disease state may negatively affect patient outcomes. The overall response from the nursing staff towards the insulin protocol was positive. The prescribers‟ response to the insulin protocol was conflicted. The number of correct insulin sliding scale doses administered in the pre-intervention and post intervention phase improved by 5.25 percent. The number of incorrect insulin sliding scale doses administered during the pre- and post -intervention phase decreased by 5.25 percent. These results are positive and may be due to fewer sliding scales being prescribed in the post-intervention phase and the implemented insulin protocol. Only three (5.55%; n=54) inpatients with Type 1 diabetes mellitus were placed on the implemented protocol that is, the basal bolus regime, and rarely were dose adjustments to their insulin made rendering the effectives of the protocol undesirable. Only four (7.40%; n=54) inpatients with Type 2 diabetes mellitus were placed on the implemented protocol that is, an intermediate- to long-acting insulin (Protophane®). However all four patients experienced immediate improvements in their fasting blood glucose levels. These results indicated that by adding an intermediate- to long-acting insulin (Protophane®) to the therapy of a patient with Type 2 diabetes mellitus fasting blood glucose levels decrease. This would improve patient outcomes and decrease the risk of related diabetic complications. These limited results may indicate a clinical inertia on the part of the prescribers. Unfortunately overall the educational intervention was not successful and the implementation of the protocol was not successful and did not yield the desired results.

Pregnancy is a normal physiological process for the majority of women. These women, their families and significant others normally expect a successful period of pregnancy, labour, delivery and arrival of a normal and healthy baby. However, some of these pregnant women may develop Gestational Diabetes Mellitus (GDM) during this period and if not managed properly, the mother and the foetus in utero are affected in a negative way: there is a likelihood of the mother and baby developing Type 2 Diabetes in the future and also, other risks such as preterm labour, and foetal macrosomia. In order to prevent such occurrences, I set out to develop a best practice guideline for the nursing management of GDM in military health institutions in Ghana in order to help enhance nursing care. The design for this research was qualitative, explorative, descriptive and contextual in nature. The research is organised in three phases: Phase one deals with the data analysis and discussion of the interviews with professional nurses and midwives and women with a history of GDM. The data collected from the interviews were transcribed, analysed and extracted with Tesch’s eight steps of coding used for the coding. The services of an independent coder were employed to assist with the coding process which led to the formulation of key themes. Semi-structured individual interviews provided a means of exploring the perceptions of professional nurses and midwives on the nursing management of GDM: in addition, women with a history of GDM were interviewed so as to elicit their views on the management they had experienced from professional nurses and midwives before and after being diagnosed with GDM. The trustworthiness of the study was ensured by conforming to Lincoln and Guba’s framework of credibility, transferability, dependability, confirmability and authenticity. An independent coder assisted with the coding process. Phase two deals with the Integrative literature review of available evidence-based clinical practice guidelines for the nursing management of GDM. Evidence-based clinical practice guidelines were searched and appraised with assistance from an independent appraiser and themes were then formulated. In Phase three, the themes from Phase one and Phase two were integrated for the development of a draft best practice guideline for the nursing management of GDM in military health institutions in Ghana. The draft guideline was given to an expert panel of reviewers for their comments and recommendations. These were considered in the development of the final best practice guideline for the nursing management of GDM.