Immature ovarian teratoma in a 20-year-old woman: A case report

Immature ovarian teratomas are a rare subtype of germ cell tumours characterized by the presence of embryonic elements, particularly primitive neuroepithelium, and they typically affect young women. We report the case of a 20-year-old woman who presented with a growing abdominal mass that turned out to be a grade II immature teratoma after adnexectomy. This article reviews the clinical presentation, imaging features, and some of the main problems that arise in the management of immature ovarian teratomas.

[Recurrent acute fatty liver of pregnancy: About a case and a review of the literature]

Acute fatty liver of pregnancy (AFLP) is a specific but rare hepatopathy that can usually complicate the third trimester of pregnancy. It is potentially fatal for the mother and the fetus. To our knowledge, only eight cases of recurrence have been published, we report a new case. The first episode presented by our 23-year-old patient was suspected in front of a cutaneous-mucosal jaundice with vomiting occurring on pregnancy of 35weeks of gestation (WG). Hyperleucytosis, abnormalities of the hepatic balance, as well as a hypoglycemia were biological elements supporting the diagnostic beam. On the other hand, medical imaging could not bring a clear confirmation. The evolution was favorable after deferred delivery by caesarean section for pulmonary maturation. Three years later, she presented to the obstetrical emergency room at 36weeks and six days of gestation, with a clinical and biological picture almost similar to that of the first episode. A caesarean section was then indicated for suspicion of recurrence. The evolution is favorable for the mother and her children. The interest of the communication on the risk of recurrence, the clinical and biological monitoring in particular in the third trimester of the subsequent pregnancy are imperative, in order to improve the prognosis of this pathology.

Continuing medical education in the developing world: Timely need for better structure and regulation as a quality issue

Continuing medical education (CME) generally aims to maintain, develop, or increase the knowledge, skills, and professional performance and relationships that a physician uses to provide services for patients, the public, or the profession. CME covers the body of knowledge and skills generally recognized and accepted by the profession as within the basic medical sciences, the discipline of clinical medicine, and the provision of health care to the public. CME credit hours are generally earned through events approved by the recognized CME Committees. Physicians earn credit based upon the number of learning contact hours. Most licensing bodies require a set number of these credit hours for renewal of license (maintenance of certification). In the developing world, medical registration may not be subject to an updating (revalidation) process and may simply mean having obtained a medical qualification and paid renewal fees for the “Doctor's Syndicate”. We propose that, for the sake of patients' safety and other benefits, doctors should earn a minimum number of CME hours as a prerequisite of their maintenance of medical certification. In the development phase, voluntary scheme may be adopted. To encourage provision of such programs, the accreditation process, should initially be simple and may get progressively stricter at later stages. To avoid pharmaceutical bias the accrediting body could come up with a list of clinical topics that are of high relevance and importance to the practice, and recent translational research findings. This could be done in collaboration with scientific societies and postgraduate academic institutions. We think maintaining a list of “credible providers” is more relevant than imposing a complicated application process with each event. Using “paperless” online application and accreditation processes should save time and effort.

Emirates Diabetes Society Consensus Guidelines for the Management of Type 2 Diabetes Mellitus – 2020

Rapid urbanisation and socioeconomic development in the United Arab Emirates (UAE) have led to the widespread adoption of a sedentary lifestyle and Westernised diet in the local population and consequently a high prevalence of obesity and diabetes. In 2019, International Diabetes Federation statistics reported a diabetes prevalence rate of 16.3% for the adult population in the UAE. In view of the wealth of recent literature on diabetes care and new pharmacotherapeutics, the Emirates Diabetes Society convened a panel of experts to update existing local guidelines with international management recommendations. The goal is to improve the standard of care for people with diabetes through increased awareness of these management practices among healthcare providers licensed by national health authorities. These consensus guidelines address the screening, diagnosis and management of type 2 diabetes mellitus in adults including individuals at risk of developing the disease.

Driving and diabetes mellitus in the Gulf Cooperation Council countries: Call for action

The aim of the present article is to increase awareness concerning safe driving for patients with diabetes in the Gulf Cooperation Council (GCC) countries and to provide recommendations concerning the management of these patients. The cognitive, motor, and sensory skills required for driving can be adversely affected by diabetes as well as the side effects of anti-diabetic medications, particularly hypoglycemia. The prevalence of diabetes in the GCC countries is among the highest in the world. As the number of diabetic drivers in these countries continues to increase, the number at risk of having a motor vehicle accident is also expected to increase. We reviewed the available literature concerning driving and diabetes, particularly in relation to the current situation in the GGC countries. Unfortunately, very little published information is available addressing this issue in the GCC countries. Most of the GCC countries lack legislation on driving and diabetes. We have proposed recommendations to help diabetic drivers in the GCC countries as well as to provide guidance to health care professionals managing these patients.

[Rocuronium and sugammadex use for the management of neuromuscular blockade in urgent abdominal surgery in a patient with Landouzy-Dejerine myopathy]

In patients with neuromuscular diseases, the use of rocuronium in the general anesthesia rapid sequence induction provides safety intubation conditions, but induces a deep and prolonged neuromuscular blockade. We report dose reduction to 0.8mg/kg for a 47-year-old female with Landouzy-Dejerine myopathy. Therefore, less dose of sugammadex was given to reverse the neuromuscular block.

Effect of traditional Arabic coffee consumption on the glycemic index of Khalas dates tested in healthy and diabetic subjects

The consumption of dates with coffee is common among Arabs and may affect postprandial hyperglycemia ex-cursion. The study aimed to determine the effect of coffee on the glycemic index of a common variety of dates (Khalas) tested in healthy and type 2 diabetes mellitus individuals. Study subjects were thirteen healthy volunteers (mean age: 40.2±6.7 years) and ten diabetic participants with a mean HbA1c of 6.6±(0.7%) and a mean age of 40.8±5.7 years. Each subject participated in five days of tests with 50 g of glucose and 50 g equivalent of available carbohydrates from the dates (with/without coffee). Capillary glucose was measured in the healthy subjects at 0, 15, 30, 45, 60, 90 and 120 min, and for the diabetics at 0, 30, 60, 90, 120, 150 and 180 min. Glycemic indices were determined as ratios of the incremental areas under the response curves for the interventions. Statistical analyses were performed using the independent samples and paired t-tests. Mean±SE glycemic indices of the Khalas dates for the healthy individuals were 55.1±7.7 and 52.7±6.2 without and with coffee consumption, respectively. Similar values were observed for those with diabetes (53.0±6.0 and 41.5±5.4). Differences between glycemic indices of Khalas with or without coffee were not significant (p=0.124). There were no significant differences in glycemic index between the diabetic and healthy subjects (p=0.834 and p=0.202 without and with coffee respectively). In conclusion, at least in the short term, coffee does not adversely affect capillary glucose levels following Khalas dates consumption in healthy and diabetic volunteers.

Post-menopausal endometrial tuberculosis mimicking carcinoma: An important differential diagnosis to consider

We report the case of a menopausal 74-year-old patient who presents pyorrhoea for 6months. We suspect initially a carcinoma process, but the anatomopathological examination takings obtained by biopsy curettage of the endometrial under hysteroscopy is in favor of an inflammatory infiltrate with epithelioid and giant cells of type Langhans and type Muller without caseous necrosis. The bacteriological direct examination after coloring of Gram, Ziehl-Neelsen and Sabouraud was negative. The bacteriological culture in the Löewenstein and Coletsos environment identified Mycobacterium tuberculosis. The searches for another source of the infection was negative both at the pulmonary and urinary levels. An antituberculous quadritherapy allows the fast clinical improvement. The tuberculosis remains frequent but rarely genital. It is especially the case of young women, from non industrialized countries, consulting for infertility. It is necessary to know how to evoke it front in pelvic symptoms, whatever the age is and to realize easily mycobacteriological examinations.

Guidelines for management of type 2 diabetes 2012: Common sense prevails!

Recently, guidelines on the management of hyperglycemia in type 2 diabetes were released by the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD) as their formally adopted position statement. These guidelines are different from the previously published documents. They introduced a nonalgorithmic patient-centered approach that stressed the principles of individualization of care based on several important patients' attributes. They affirmed the role of lifestyle modification as a basic requirement, metformin as the first line pharmacological therapy and individuallytailored basis for the choice of the second and third line drugs. In this paper, the authors reflect on these guidelines from the world-wide practicing physicians' view point.

Secretion and binding of insulin-like growth factor-I by a human medullary-thyroid carcinoma cell-line

The TT human medullary thyroid carcinoma cell line secretes a 7.5 kD species with insulin-like growth factor (IGF-I) immunoreactivity and HPLC mobility and expresses IGF-I mRNA. Conditioned medium also contained IGF-binding activity with a pattern of displacement of [I-125]-IGF-I characteristic of IGF binding proteins. Western ligand analysis and immunobloting with anti-IGFBP4 antiserum identified a 34 kD IGF-I binding species. Northern analysis identified a 2.1 kb IGFBP4 mRNA species. Cell surface binding of [I-125]-IGF-I identified Type I IGF receptors. TT cells constitute a useful model to study the IGF-I autocrine system in the transformed state.

Rectal taurocholate increases L cell and insulin secretion, and decreases blood glucose and food intake in obese type 2 diabetic volunteers

AIMS/HYPOTHESIS

Glucagon-like peptide-1 (GLP-1) and peptide YY (PYY) are secreted from enteroendocrine L cells in response to numerous stimuli, including bile salts. Both have multiple effects that are potentially useful in treating diabetes and obesity. L cell number and hormone content in the intestine are highest in the rectum in humans. We investigated the effects of intrarectal sodium taurocholate on plasma GLP-1, PYY, insulin and glucose concentrations, and on food intake of a subsequent meal.

METHODS

Ten obese type 2 diabetic volunteers were each studied on five separate occasions after an overnight fast and oral administration of 100 mg sitagliptin 10 h before the study. They then received an intrarectal infusion of either one of four doses of taurocholate (0.66, 2, 6.66 or 20 mmol, each in 20 ml of vehicle) or vehicle alone (1% carboxymethyl cellulose) single-blind over 1 min. Hormone and glucose measurements were made prior to, and for 1 h following, the infusion. The consumption of a previously selected favourite meal eaten to satiety was measured 75 min after the infusion.

RESULTS

Taurocholate dose-dependently increased GLP-1, PYY and insulin, with 20 mmol doses resulting in peak concentrations 7.2-, 4.2- and 2.6-fold higher, respectively, than those achieved with placebo (p < 0.0001 for each). Plasma glucose decreased by up to 3.8 mmol/l (p < 0.001). Energy intake was decreased dose-dependently by up to 47% (p < 0.0001). The ED(50) values for effects on integrated GLP-1, insulin, PYY, food intake and glucose-lowering responses were 8.1, 10.5, 18.5, 24.2 and 25.1 mmol, respectively.

CONCLUSIONS/INTERPRETATION

Therapies that increase bile salts (or their mimics) in the distal bowel may be valuable in the treatment of type 2 diabetes and obesity.

Management of common endocrine conditions other than diabetes mellitus during ramadan fasting

Patients with any endocrine condition wishing to observe the fasting during Ramadan may seek advice from their primary care or specialist physician. In healthy people, there are minimal changes in the metabolic and hormonal parameters during fasting. However, management of common endocrine conditions may need some adjustments. Aside from diabetes mellitus, endocrine and metabolic conditions commonly seen in clinical practice include hypothyroidism, hyperthyroidism, adrenal disease, pituitary diseases and obesity. Adjustments in medications are based on physiological and clinical aspects of these conditions, and on sound knowledge of the pharmacological characteristics of all prescribed medications. Thyroid hormones should be taken on an empty (or near empty) stomach and not be followed by food by 0.5-1 hour according to the patient's life style. Glucocorticoids should be taken in the same manner at either end of the fasting period, or changed to an extended release preparation taken on its own or in combination with hydrocortisone with Iftar. Management of hypogonadism is essentially the same both during and outside of Ramadan in both men and women. Growth hormone may be taken in the same manner in both children and adults. Patients with diabetes insipidus should be careful with fluid balance, and take adequate doses of desmopresin in widely spaced dosing for maximum benefit. Spontaneous hypoglycemia may present for the first time during Ramadan, and suggestive symptoms should alert the physician to this diagnosis. Ramadan- type intermittent fasting provides an opportunity for weight loss but this is often lost as evening time feasting seems to offset any benefit from daytime fasting. In conclusion, common endocrine conditions are managed along the same lines of good clinical practice, sound understanding of physiology and pharmacology, coupled with modern approaches of individualized and ethnically competent care.

Prevalence of undiagnosed diabetes and quality of care in diabetic patients followed at primary and tertiary clinics in Abu Dhabi, United Arab Emirates

AIMS

To investigate the prevalence of undiagnosed type 2 diabetes (T2D) at primary health care (PHC) clinics, and to assess the quality of care of diabetic patients followed at a tertiary hospital diabetes center in Abu Dhabi, United Arab Emirates (UAE).

METHODS

Between May 2009 and October 2010, adult patients attending two PHC clinics, and adult diabetic patients attending the diabetes center, were invited to participate in the study. After overnight fast, participants returned for interview and laboratory tests. Undiagnosed T2D was defined by FPG ≥ 7.0 mmol/l or HbA1c ≥ 6.5%. Quality of care was assessed by reported care practices and achievement of internationally recognized targets.

RESULTS

Out of 239 patients at PHC clinics without history of T2D, 14.6% had undiagnosed T2D, and 31% had increased risk of diabetes (FPG 5.6-7.0 mmol/l or HbA1c 5.7-6.5%). The independent predictors of undiagnosed T2D were age (adjusted OR per year 1.07, 95% CI 1.04-1.11, p < 0.001) and BMI ≥ 25 (adjusted OR 4.2, 95% CI 0.91-19.7, p = 0.033). Amongst all 275 diagnosed T2D patients, including those attending PHC clinics and those followed at the diabetes center, it was found that 40.1% followed dietary recommendations, 12% reported visiting a diabetes educator, 28.2% walked for exercise, and 13.5% attained recognized targets of HbA1c < 7%, blood pressure < 130/80 mmHg, and LDL cholesterol < 2.6 mmol/l.

CONCLUSIONS

Almost half of the adult patients attending PHC clinics had undiagnosed T2D, or increased diabetes risk. Care practices, and achievement of treatment targets, were suboptimal.

Carbohydrate restriction favorably alters lipoprotein metabolism in Emirati subjects classified with the metabolic syndrome

BACKGROUND AND AIMS

Carbohydrate restriction (CR) has been shown to improve dyslipidemias associated with metabolic syndrome (MetS). We evaluated the effects of CR on lipoprotein subfractions and apolipoproteins in Emirati adults classified with the MetS.

METHODS AND RESULTS

39 subjects (15 men/24 women) were randomly allocated to a CR diet [20-25% energy from carbohydrate (CHO)] for 12 wk (CRD group) or a combination treatment consisting of CRD for 6 wk followed by the American Heart Association diet (50-55% CHO, AHA group) for an additional 6 wk. All subjects reduced body weight, LDL cholesterol and triglycerides (P<0.01). At baseline all subjects had low concentrations of medium VLDL and total HDL particles associated with the very low plasma triglycerides and HDL cholesterol in this population. After 12 wk, the large VLDL subfraction was decreased over time for subjects in the CRD group (P<0.01) while these changes were not observed in those subjects who changed to the AHA diet. The number of medium and small LDL particles decreased for all subjects rendering a less atherogenic lipoprotein profile. In agreement with these results, a significant decrease in apolipoprotein (apo) B was observed (P<0.01). The medium HDL subfraction and apo A-II, which can be considered pro-atherogenic, were also decreased over time in the CRD group only.

CONCLUSIONS

These results suggest that weight loss favorably affects lipoprotein metabolism and that the CRD had a better effect on atherogenic VLDL and HDL than the low fat diet recommended by AHA.

Screening strategy for type 2 diabetes in the United Arab Emirates

The prevalence of type 2 diabetes mellitus (DM) among Emirati nationals is one of the highest in the world. The recently released United Arab Emirates National DM guidelines call for screening all adults aged 30 years and more. The authors explored the need for such a modification of current American Diabetes Association (ADA) guidelines. They also considered the prevalence rates for undiagnosed DM based on oral glucose tolerance test (OGTT) versus glycohemoglobin (HbA( 1c)) >or= 6.5% in a population-based sample of 296 adult Emirati participants. In the low-risk ADA category, defined by age <45 years and BMI <25, only 1 of 68 (1.5%) participants was diagnosed with DM. The overall rate of DM based on HbA(1c) was lower than that based on OGTT (10.1% versus 14.2%; P < .05). The authors conclude that the ADA guidelines are adequate for screening in this high-risk population. They also find high discordance between HbA(1c) and OGTT.

Metabolic syndrome prevalence, dietary intake, and cardiovascular risk profile among overweight and obese adults 18-50 years old from the United Arab Emirates

BACKGROUND

The prevalence of diabetes mellitus is among the highest worldwide, and metabolic syndrome predisposes to diabetes.

METHODS

We recruited 227 overweight/obese Emirati adults living in the city of Al-Ain, Emirati of Abu Dhabi to screen for the metabolic syndrome and to assess for the most relevant criteria for the metabolic syndrome in this population. We identified subjects as having the metabolic syndrome if they had three of the following characteristics: Waist circumference (WC) >88 cm in women and >102 cm in men; plasma glucose >5.5 mmol/L; blood pressure >130/85 mmHg, triglycerides (TG) >1.7 mmol/L, and high-density lipoprotein cholesterol (HDL-C) <1.0 mmol/L in men and <1.3 mmol/L in women. In addition to features of metabolic syndrome, lipoprotein subfractions and 24-hour dietary recalls were assessed in a random sample of participants.

RESULTS

A total of 92 subjects (40.5%) were classified as having metabolic syndrome. The most relevant clinical criteria associated with metabolic syndrome were large WC, high blood pressure, and low HDL-C. Only 7% of subjects had TG >1.7 mmol/L, whereas 95% had plasma LDL-C >2.6 mmol/L. In addition, subjects presented low concentrations of medium very-low-density lipoprotein (VLDL) and small HDL subfractions in agreement with low concentrations of HDL-C and TG. Dietary analysis revealed high-energy consumption, with diets high in total carbohydrates, fat, and simple sugars. In addition, subjects were sedentary with only 14% of the population engaged in physical activity.

CONCLUSIONS

The high prevalence of metabolic syndrome among overweight/obese Emirati adults predisposes this population to increased risk for developing diabetes and cardiovascular disease. Public health involvement targeting poor dietary habits and exercise programs among Emirati citizens is urgently needed.

Physical activity and reported barriers to activity among type 2 diabetic patients in the United arab emirates

OBJECTIVES

This study was designed to assess the physical activity practice among type 2 diabetic patients in the United Arab Emirates (UAE).

METHODS

This is a cross-sectional study of type 2 diabetic patients who participated in the outpatient clinics in Al-Ain District, during 2006. The patients completed an interviewer-administered questionnaire, and measurements of blood pressure, body mass index, body fat, abdominal circumference, glycemic control (HbA1c), and fasting lipid profile.

RESULTS

Of the 390 patients recruited, only 25% reported an increase in their physical activity levels following the diagnosis of diabetes, and only 3% reported physical activity levels that meet the recommended guidelines. More than half of the study subjects had uncontrolled hypertension (53%) and unacceptable lipid profiles; 71% had a high low-density lipoprotein (LDL), 73% had low high-density lipoprotein (HDL), and 59% had hypertriglyceridemia. Forty-four percent were obese and a further 34% were overweight. Abdominal obesity was also common (59%). Only 32% had an acceptable glycemic control.

CONCLUSIONS

The physical activity practice of type 2 diabetic patients in the UAE is largely inadequate to meet the recommended level necessary to prevent or ameliorate diabetic complications. Interventions aiming at overcoming the barriers to physical activity are urgently needed.

Gonadal dysfunction and infertility in kidney transplant patients receiving sirolimus

Sirolimus is an immunosupressor of the mammalian target of rapamycin inhibitors (mTOR-I) group. Recent studies have emphasized a potential impact of sirolimus on male gonadal function. We report our clinical experience with sirolimus-induced gonadal dysfunction and infertility in both male and female kidney transplant patients. Of the 170 kidney transplant patients, nine (5.3%) patients (six males and three females) were receiving sirolimus. Follow-up data for two male patients were not available. The one unmarried female patient developed amenorrhea post-transplantation and had resumption of her menstrual cycles after discontinuation of sirolimus. The remaining six married patients (four males and two females), who all had fathered or conceived children in the pre-transplantation period, developed gonadal dysfunction and infertility on average 5-12 months after transplantation. Sirolimus was discontinued in all four male patients with full recovery of the oligo/azospermia and restoration of fertility. Both married female patients developed amenorrhea post-transplantation. Sirolimus was discontinued in one female patient with resumption of her menstrual cycles. In this small population of patients treated with sirolimus, the prevalence rate of reversible gonadal dysfunction and infertility was significant in both males and females. Infertility secondary to sirolimus is under-diagnosed and should be studied further.

Carbohydrate restriction, as a first-line dietary intervention, effectively reduces biomarkers of metabolic syndrome in Emirati adults

The prevalence of diabetes mellitus (DM) in the United Arab Emirates is among the highest world-wide. Metabolic syndrome (MetS) predisposes individuals to DM; therefore, dietary interventions targeting MetS biomarkers are a high priority. We evaluated whether a carbohydrate-restricted diet (CRD) could effectively be used as a first-line therapy intervention in adult Emirati to improve the characteristics of MetS. A total of 39 participants (14 men, 25 women) 18-50 y, classified with MetS, followed a CRD (20-25% carbohydrate, 50-55% fat, 25-30% protein energy distribution). After 6 wk, 19 participants were randomly switched to the AHA diet (55% carbohydrate, 25-30% fat, 15-20% protein) whereas 20 participants continued with the CRD diet for an additional 6 wk. Fasting plasma lipids, 24-h dietary recalls, body composition, anthropometrics, blood pressure (BP), glucose, insulin, and plasma markers of inflammation were measured at baseline, wk 6, and wk 12. Dietary analysis indicated high compliance. At wk 6, the CRD (n = 39) resulted in decreased body weight (-13%), waist circumference (-4.5%), body fat (-10.6%), and plasma triglycerides (TG) (-38.7%) (P < 0.001). Significant decreases in LDL cholesterol, BP, glucose, insulin, and inflammatory markers and increases in adiponectin (P < 0.05) also occurred. After 12 wk, positive changes persisted for all participants, independent of diet. However, body weight and plasma TG and insulin were lower in the CRD (P < 0.05) group than in the CRD + AHA group. Results from this study suggest that a 6-wk CRD can effectively be used as a first-line diet therapy to rapidly improve features of MetS and cardiovascular risk in adult Emirati.

[Major alpha-thalassemia: antenatal diagnosis, case report and literature review]

Homozygous alpha-thalassaemia or Bart's hydrops fetalis is a genetic disease with autosomal recessive transmission. The condition is lethal for the fetus because of hypoxia and anemia. For the mother there is an increased risk of the severe forms of preeclampsia and its complications. The diagnosis can be suspected in presence of suggestive ultrasonographic anomalies, where both parents come from South-East Asia or China. Confirmation is based on the identification of the typical deletions or mutation of the alpha globin gene by molecular genetics. We report a rare clinical case of Bart's hydrops fetalis diagnosed because of fetal growth retardation, fetal cardiomegaly and increased size of placenta on the 26 weeks fetal echography. This case underscores the need to include the alpha thalassemias in medical and midwifery education in countries where they were almost inexistent a generation ago.

Assessment of dietary practice among diabetic patients in the United arab emirates

OBJECTIVES

The aim of this study was to assess dietary practices and risk profile (hypertension, obesity, lipid profile and glycemic control) among people with diabetes in Al-Ain District, United Arab Emirates (UAE).

METHODS

During 2006, we performed a cross-sectional study of diabetic patients attending diabetic outpatient clinics at Tawam Hospital and primary health care centers in Al-Ain District. Subjects completed an interviewer-administered questionnaire, blood pressure, body mass index, percentage body fat and abdominal circumference were measured and recorded and the most recent HbA1c levels and fasting lipid profile were identified.

RESULTS

A sample of 409 diabetic patients was recruited, 50% of whom were illiterate. Only 24% read food labeling. 76% reported being unable to distinguish clearly between low and high carbohydrate index food items and no one reported counting calorie intake. 46% reported that they had never been seen by dietician since their diagnosis. Their overall risk profile, notably body weight, lipid profile and blood pressure, was very unfavorable; more than half of the study sample had uncontrolled hypertension and uncontrolled lipid profile and the majority was overweight (36%) or obese (45%). Abdominal obesity was particularly common (59%). Only 31% had an HbA1c of less than 7%.

CONCLUSIONS

The dietary practices of diabetic patients in the UAE are inadequate and need improvement.

Association of TCF7L2 polymorphism with diabetes mellitus, metabolic syndrome, and markers of beta cell function and insulin resistance in a population-based sample of Emirati subjects

AIMS

The prevalence of type 2 diabetes mellitus (DM) among Emirati subjects is one of the highest in the world. This has been attributed to rising prevalence of obesity acting on genetically susceptible individuals. We analyzed the associations between TCF7L2 polymorphism and DM, metabolic syndrome, and markers of beta cell function and insulin resistance in a population-based sample of Emirati subjects.

METHODS

We genotyped the two TCF7L2 single nucleotide polymorphisms (SNPs) rs12255372 and rs7903146 in 368 adult subjects. Homeostatic model assessment (HOMA) was used to assess beta cell function (HOMA2-%B) and insulin resistance (HOMA2-IR). The SNP genotypes were analyzed against disease stage [normal glucose=0 (n=188), pre-diabetes=1 (n=85), and DM=2 (n=95)] and against clinical and biochemical measures. Age and sex were included as covariates in all association analyses. Additional adjustments were made for body mass index (BMI) and waist circumference in several analyses.

RESULTS

Diabetes disease stage was marginally significantly associated with the frequency of the T variant at rs12255372 (p=0.057; adjusted p=0.017) but not at rs7903146 (p=0.5; adjusted p=0.2). Comparison between subjects with normal glucose and the combined DM/pre-diabetes showed a significant association with rs12255372 (OR 1.47, CI 1.04-2.08; p=0.03) but not with rs7903146 (OR 1.16, CI 0.81-1.64; p=0.4). We found no association with metabolic syndrome, or with insulin and glucose levels, HOMA2-%B or HOMA2-IR. The age-standardized prevalence rate for metabolic syndrome was 43.9% in men and 42.1% in women.

CONCLUSION

These data suggest that TCF7L2 variants are associated with increased risk for DM in Emirati subjects. We also demonstrate a high prevalence of the metabolic syndrome in this population.

Uterine Inversion; A case report

The puerperal uterine inversion is a rare and severe complication occurring in the third stage of labour. The mechanisms are not completely known. However, extrinsic factors such as oxytocic arrests after a prolonged labour, umbilical cord traction or abdominal expression are pointed. Other intrinsic factors such as primiparity, uterine hypotonia, various placental localizations, fundic myoma or short umbilical cord were also reported. The diagnosis of the uterine inversion is mainly supported by clinical symptoms. It is based on three elements: haemorrhage, shock and a strong pelvic pain. The immediate treatment of the uterine inversion is required. It is based on a medical reanimation associated with firstly a manual reduction then surgical treatment using various techniques. We report an observation of a 25 years old grand multiparous patient with a subacute uterine inversion after delivery at home.

Prevalence of diabetes mellitus and its complications in a population-based sample in Al Ain, United Arab Emirates

AIMS

To determine the prevalence of diabetes mellitus (DM) and its complications in the adult population of the United Arab Emirates (UAE) and assess the degree of metabolic control in subjects with diagnosed DM.

METHODS

A random sample of houses of Emirati citizens living in Al Ain, UAE was surveyed. Fasting blood glucose was determined by glucose meter and an oral glucose tolerance test (OGTT) was conducted if blood sugar was <7 mmol/l. DM was defined according to the WHO criteria. Pre-diabetes status was based on fasting venous blood glucose concentration of 5.6-6.9 mmol/l or 2h post-OGTT venous blood glucose level of 7.8-11.0 mmol/l.

RESULTS

There were 2455 adults (>18) living in the 452 surveyed houses of which 10.2% reported having the diagnosis of DM. A total of 373 men and non-pregnant women underwent testing, and after adjustment for factors affecting participation probability the prevalence of diagnosed DM, undiagnosed DM and pre-diabetes was 10.5, 6.6 and 20.2%, respectively. Age-standardized rates for DM (diagnosed and undiagnosed) and pre-diabetes among 30-64 years old were 29.0 and 24.2%, respectively. Logistic regression analysis showed that only age and body mass index (BMI) were significantly independently related to undiagnosed DM. In patients with diagnosed DM, the prevalence rates for retinopathy, neuropathy, nephropathy, peripheral vascular disease and coronary heart disease were 54.2, 34.7, 40.8, 11.1 and 10.5%, respectively. A significant proportion of subjects with undiagnosed DM and pre-diabetes also had micro- and macro-vascular complications. The proportion of subjects with diagnosed DM who achieved internationally recognized targets for HbA1c (<7%), LDL-C (<2.6 mmol/l) and blood pressure (<130/80 mmHg) was 33.3, 30.8 and 42.1%, respectively.

CONCLUSION

This study confirms the previously reported high prevalence of DM in the UAE. Diabetic complications were highly prevalent among subjects with diagnosed and undiagnosed DM. Metabolic control was suboptimal in most subjects with diagnosed DM. Greater efforts are urgently needed to screen early and effectively treat DM in the UAE in order to prevent long-term complications.

Audit of a diabetes clinic at Tawam hospital, United Arab Emirates, 2004-2005

The aim of this audit was to determine the current management of patients with diabetes compared to international standards and to benchmark the results against current international standards. A retrospective audit of medical records of diabetic patients attending Tawam Hospital, a tertiary healthcare facility in the Al Ain region in the Emirate of Abu Dhabi, United Arab Emirates was performed. A random sample of 30 patients (5% of the target group) was selected from the total number of 600 patients who visited the diabetes clinics in August 2005. An audit form was developed based on the priority aims and measures contained in the Institute for Clinical Systems Improvement (ICSI) Guidelines for the management of type 2 diabetes mellitus. Data analysis was carried out based on measurement specifications in the ICSI Guidelines. All patients had their blood pressure checked at their most recent appointment. All except one patient had an HbA1c test and a lipid profile performed during the study period. Although 75% of patients were referred for a dilated eye examination, only 47% complied. Approximately two-thirds of all patients had evidence of self-monitoring of blood glucose. Less than half of the patients were referred to the nutritionist and only a relatively small proportion of patients had advice on diet and exercise documented in their medical record. There was also lack of documentation, particularly for smoking status, foot examination, and body mass index (BMI). All patients received aspirin (ASA) treatment. The majority had a systolic blood pressure of 130 mmHg or less; just under half of patients had HbA1c of less than 7%. In comparison to the Center for Diseases Control (CDC) targets, we exceeded targets in three areas in relation to HbA1c testing, ASA treatment, and self-report monitoring blood glucose. We did not meet the stated target of 75% for patients having a dilated eye exam due to lack of patient compliance (more than three-quarters of all patients were referred but did not attend for appointment). Documentation of a comprehensive foot examination was present for only one-quarter of all patients compared to the recommended target of three-quarters of patients. Documentation of advice on diet and exercise was present for 40%, which did not meet the CDC target of 60%. Overall, the audit highlighted that Tawam Hospital is providing a good level of care to diabetic patients and compares favorably with international targets; however, key recommended actions have been identified for implementation to improve patient care and maintain a continuous improvement process through effective monitoring with prioritization to those related to preventative care.

Quality of age data in patients from developing countries

BACKGROUND

Age misreporting is common in demographic studies but the prevalence and magnitude of age misreporting in clinical cohorts is unknown. We analysed single-year age distribution and terminal digit preference in cancer patients from developing countries.

METHOD

Age distribution was analysed by plotting a single-year age of 3874 cancer patients from 72 different countries, mainly from the Indian subcontinent and the Middle East, who resided in the UAE at the time of cancer diagnosis. Preference for age ending with digits '0' and '5' was evaluated using Whipple's index (WI), which has value 100 in cohorts without preference. Preference for all 10 terminal digits was expressed as the difference between the found and expected frequencies using Myers blended method and was graphed.

RESULTS

Age data quality was low in cancer patients from the Indian subcontinent (WI = 177) and Middle Eastern countries (WI = 113-204). Females of all nationalities supplied better quality of age data (lower WI) than males. Preference for age ending with digits '0' and '5' was found in all populations except the UAE male citizens who did not show preference for terminal digit '0'.

CONCLUSION

Age data quality in this cohort of patients from developing countries was low. Preference for age ending with numbers '0' and '5' is common. In studies conducted in developing countries, age data quality should be analysed as it may bias results and weaken the power of the study.

Conservative management of patients with intrathyroidal well-differentiated follicular thyroid carcinoma

BACKGROUND

Total or near-total thyroidectomy for the treatment of follicular thyroid carcinoma (FTC). The prognosis of patients with low-risk FTC, however, is excellent, and thus total thyroidectomy may not be justifiable in such patients.

METHODS

A retrospective review identified 61 patients diagnosed with intrathyroidal well-differentiated FTC between 1958 and 1991.

RESULTS

Median age at diagnosis was 42 years (range, 15-78 years). Most patients (90.2%) had a lobectomy or subtotal thyroidectomy. Median tumor size was 3.0 cm (range, 0.9-9.5 cm). Fifty-eight patients (95.1%) received thyroid hormone supplementation, and 5 (8.2%) received radioactive iodine ablation postoperatively. Median follow-up was 11 years (range, 3-35 years). Local recurrence, metastasis, or both developed in 3 patients (4.9%), and all subsequently died of thyroid cancer. The cumulative 10- and 15-year cancer-specific survival rate was 96.5%. Factors significantly related to worse survival were oxyphilic histology (log-rank, P =.00) and tumor size of more than 4 cm (P =.001). However, neither was found to be an independent predictor of outcome by Cox multivariate analyses (P =.7 and.9, respectively). The extent of initial operation (unilateral versus bilateral procedure) was not significantly related to survival (P =.52).

CONCLUSION

Conservative management consisting mainly of lobectomy or subtotal thyroidectomy and thyroid hormone supplementation is associated with favorable outcome of patients with intrathyroidal well-differentiated FTC.

Acanthosis nigricans, hyperinsulinaemia and risk factors for cardiovascular disease

We examined the association between acanthosis nigricans, hyperinsulinaemia and other risk factors for cardiovascular disease in patients from the United Arab Emirates. Height, weight and sitting blood pressure were recorded in 122 patients with acanthosis nigricans, and blood samples were obtained for measuring fasting cholesterol, high-density lipoprotein cholesterol, triglyceride and uric acid levels. In addition, a glucose tolerance test was performed and blood was sampled for insulin and glucose. Our results indicate that the patients with acanthosis nigricans had a high prevalence of abnormal glucose tolerance and hyperinsulinaemia. In addition, euglycaemic patients with hyperinsulinaemia had a cluster of risk factors for cardiovascular disease

Acanthosis nigricans, hyperinsulinaemia and risk factors for cardiovascular disease

We examined the association between acanthosis nigricans, hyperinsulinaemia and other risk factors for cardiovascular disease in patients from the United Arab Emirates. Height, weight and sitting blood pressure were recorded in 122 patients with acanthosis nigricans, and blood samples were obtained for measuring fasting cholesterol, high-density lipoprotein cholesterol, triglyceride and uric acid levels. In addition, a glucose tolerance test was performed and blood was sampled for insulin and glucose. Our results indicate that the patients with acanthosis nigricans had a high prevalence of abnormal glucose tolerance and hyperinsulinaemia. In addition, euglycaemic patients with hyperinsulinaemia had a cluster of risk factors for cardiovascular disease.

Practice variation in the diagnosis and treatment of osteoporosis: a case for more effective physician education in primary care

Bone mineral density (BMD) performed by dual energy x-ray absorptiometry (DEXA) has been used at our institution as a screening test for osteoporosis since 1986. Of 2789 bone densitometry tests done between 1992 and 1996 on women aged 51-75 years, 1743 (62.5%) were ordered by general internists (GIM), endocrinologists (ENDO), rheumatologists (RHEUM), and a metabolic bone disease specialist (MBDS). We compared the percentage of densitometry tests ordered by GIM, ENDO, RHEUM, and MBDS resulting in one of three possible diagnoses (normal, osteopenia, or osteoporosis). Applying the World Health Organization's (WHO) definition of normal (< 1 standard deviation [SD] below the mean for young, adult women), osteopenia (> or = 1 SD-< 2.5 SD below the mean), and osteoporosis (> or = 2.5 SD below the mean), we found that 34% of patients tested between 1992 and 1996 were osteoporotic, 42% were osteopenic, and 24% had normal bone density results. The rate of osteoporosis diagnosis was highest in the MBDS cohort (chi 2 = 9.19, p = 0.002) compared with patients in the other cohorts. To explore trends in management of this condition, a random sample of osteoporotic women aged 51-75 who had densitometry in 1996 (n = 82) was obtained. Review of medical records revealed that 73% were on some form of osteoporosis treatment (bisphosphonate, estrogen, or calcitonin, with or without calcium and vitamin D supplementation). Treatment rates differed significantly, however, by the ordering physician specialty (96% for MBDS, 63% for ENDO, 75% for RHEUM, and 53% for GIM, chi (2)3df = 11.37, p = 0.01). There were no significant differences in selected clinical or demographic characteristics between patients treated by GIM and MBDS. This variation in treatment rates suggests that an opportunity to enhance primary care physicians' recognition and treatment of osteoporosis exists. Making osteoporosis management an educational focus may help narrow differences in practice and improve the effectiveness of a larger number of physicians treating patients with this problem.

New drugs for reducing cardiovascular risk in women

Atherosclerosis is largely preventable in women. Clinicians need to appreciate the gender-associated risks of cardiovascular disease and emphasize to their women patients that life-style changes can reduce cardiovascular risk. However, newer oral agents for diabetes and the statins for hyperlipidemia are important pharmacological adjuncts.

Clinical implications of the interaction between hypothyroidism and the cardiovascular system

Hypothyroidism frequently causes cardiovascular manifestations that can complicate treatment of both the hypothyroidism and of any underlying heart disease. This review discusses mechanisms, pathophysiology, and management.