Individualizing Time-in-Range Goals in Management of Diabetes Mellitus and Role of Insulin: Clinical Insights From a Multinational Panel

Diabetes mellitus is a global health concern associated with significant morbidity and mortality. Inadequate control of diabetes leads to chronic complications and higher mortality rates, which emphasizes the importance of achieving glycemic targets. Although glycated hemoglobin (HbA_1c) is the gold standard for measuring glycemic control, it has several limitations. Therefore, in recent years, along with the emergence of continuous glucose monitoring (CGM) technology, glycemic control modalities have moved beyond HbA_1c. They encompass modern glucometrics, such as glycemic variability (GV) and time-in-range (TIR). The key advantage of these newer metrics over HbA_1c is that they allow personalized diabetes management with person-centric glycemic control. Basal insulin analogues, especially second-generation basal insulins with properties such as longer duration of action and low risk of hypoglycemia, have demonstrated clinical benefits by reducing GV and improving TIR. Therefore, for more effective and accurate diabetes management, the development of an integrated approach with second-generation basal insulin and glucometrics involving GV and TIR is the need of the hour. With this objective, a multinational group of endocrinologists and diabetologists reviewed the existing recommendations on TIR, provided their clinical insights into the individualization of TIR targets, and elucidated on the role of the second-generation basal insulin analogues in addressing TIR.

Tolerability and effectiveness of every-other-day atorvastatin compared to daily atorvastatin in patients with muscle symptoms: A randomized controlled clinical trial

Despite limited evidence, non-daily dosing of statins is recommended for managing muscle symptoms associated with statin therapy. We assessed the tolerability and effectiveness of every-other-day atorvastatin compared to daily atorvastatin in patients having muscle symptoms associated with atorvastatin therapy. A parallel-group, outcome-assessment-blinded, randomized controlled clinical trial was conducted at Colombo South Teaching Hospital, Sri Lanka. Patients with muscle pain, tenderness or cramps alone or in combination for ≥2 weeks while on daily atorvastatin for ≥1 month, with no alternative cause, were recruited. Patient's regular atorvastatin dose was given every-other-day to those in intervention group (IG) and daily to those in control group (CG). Primary outcomes were assessed at 24 weeks and included composite of myalgia and myositis, LDL-cholesterol level and percentage reduction of LDL-cholesterol from baseline. Number recruited was 49 to IG (women:79.6%; mean-age:60.6 ± 8.7years) and 52 to CG (women:73.1%; mean-age:61.7 ± 9.8years). Mean atorvastatin dose per day was 8.6 mg (SD = 4 mg) and 17.6 mg (SD = 8.4 mg) in IG and CG, respectively. Composite of myalgia and myositis at 24 weeks was 79.6% in IG and 69.2% in CG (OR = 1.7, 95% CI 0.7-4.3; p = 0.234). IG failed to show noninferiority for mean LDL-cholesterol (difference:0.31 mmol/L; upper limit 97.5% CI:0.61 mmol/L; p for noninferiority = 0.989) and for mean percentage reduction of LDL-cholesterol from baseline (difference:3.13%; upper limit 97.5% CI:15.5%; p for noninferiority = 0.718). At 24 weeks, mean creatine kinase and discomfort due to muscle symptoms (assessed with Visual Analogue Scale) were not different between the two groups. Findings of this study do not favor every-other-day atorvastatin as an option for managing patients with muscle symptoms associated with atorvastatin therapy.

A Practitioner's Toolkit for Insulin Motivation in Adults with Type 1 and Type 2 Diabetes Mellitus: Evidence-Based Recommendations from an International Expert Panel

AIM

To develop an evidence-based expert group opinion on the role of insulin motivation to overcome insulin distress during different stages of insulin therapy and to propose a practitioner's toolkit for insulin motivation in the management of diabetes mellitus (DM).

BACKGROUND

Insulin distress, an emotional response of the patient to the suggested use of insulin, acts as a major barrier to insulin therapy in the management of DM. Addressing patient-, physician- and drug-related factors is important to overcome insulin distress. Strengthening of communication between physicians and patients with diabetes and enhancing the patients' coping skills are prerequisites to create a sense of comfort with the use of insulin. Insulin motivation is key to achieving targeted goals in diabetes care. A group of endocrinologists came together at an international meeting held in India to develop tool kits that would aid a practitioner in implementing insulin motivation strategies at different stages of the journey through insulin therapy, including pre-initiation, initiation, titration and intensification. During the meeting, emphasis was placed on the challenges and limitations faced by both physicians and patients with diabetes during each stage of the journey through insulinization.

REVIEW RESULTS

After review of evidence and discussions, the expert group provided recommendations on strategies for improved insulin acceptance, empowering behavior change in patients with DM, approaches for motivating patients to initiate and maintain insulin therapy and best practices for insulin motivation at the pre-initiation, initiation, titration and intensification stages of insulin therapy.

CONCLUSIONS

In the management of DM, bringing in positive behavioral change by motivating the patient to improve treatment adherence helps overcome insulin distress and achieve treatment goals.

Type 2 diabetes mellitus and oral Candida colonization: Analysis of risk factors in a Sri Lankan cohort

Aims: Oral candidiasis is a major oral manifestation of uncontrolled diabetes mellitus, and a number of cofactors are associated with the pathogenesis of this infection. Here, we describe the prevalence of oral Candida in a Sri Lankan cohort of type 2 diabetes mellitus and risk factors that predispose them to this common fungal infection. Methods: A case-control study was conducted in 250 diabetics with type 2 diabetes and 81 nondiabetic controls. Clinical and demographic data were collected using an interviewer administered questionnaire, and patient records. Oral rinse samples were collected to determine the candidal carriage, and the resultant yeast growth was quantified and speciated using multiplex-PCR and phenotypic analyses. Chi-square test (χ² test) and Fisher exact test were used for the determination of the significant relationships between risk factors and oral candidiasis. Results: The oral prevalence of Candida species among both groups was similar (81%) although a significantly higher proportion of diabetics (32.8%) yielded >2000 CFU/mL of yeasts compared with only 12.3% of the healthy controls (p < .05). Significant associations were noted between oral candidal carriage amongst diabetics, and (i) denture wearing, (ii) female gender and (iii) cigarette smoking (all, p < .05). Amongst both groups, C.albicans was the most common Candida species isolated followed by C. parapsilosis, C. tropicalis and C. glabrata. Conclusions: The oral infestation of Candida in our Sri Lankan cohort of diabetics is significantly higher than their healthy counterparts, and co-carriage of multiple yeast species is a common finding in the study population. As there are no previous such reports of the latter phenomenon particularly from the Asian region it is noteworthy, mainly in view of the recent data on the emergence of drug-resistant yeast species the world over.

SAT-111 Reversal of Nonalcoholic Fatty Liver Disease with Bariatric Surgery in South Asians: Does the Type of Surgery Matter?

Nonalcoholic fatty liver disease (NAFLD) is a common complication of obesity with prevalence rates of 65 - 85% in obese individuals. It can be associated liver cell injury eventually leading to cirrhosis. Weight loss is the primary modality of treatment of NAFLD which can be difficult to achieve and maintain in a majority of patients. Bariatric surgery has been shown to reverse NAFLD but the type of bariatric surgery that is most effective, especially in South Asian patients is not clear. In this study we aimed to compare the effectiveness of laparoscopic sleeve gastrectomy (LSG) versus laparoscopic mini gastric bypass (LMGB) in reversing NAFLD in obese Sri Lankans. We did a retrospective analysis of medical records of 155 obese patients who underwent LSG and LMBG at Colombo South Teaching Hospital, Sri Lanka. Overall 114 (73.5%) and 41 (26.5%) patients underwent LSG and LMBG respectively. Among patients who underwent LSG and LMGB, there was no statistically significant difference in the baseline body weight (112.5 ± 19.5 vs 120.2 ± 29.4 kg), BMI (44.7 ± 6.1 vs 45.9 ± 8.0 kg/m²), waist circumference (WC) (female: 118.9 ± 11.2 cm vs 117.9 ± 9.0 cm, male: 125.5 ±14.7 cm vs 130.7 ±15.9 cm) and body fat percentage (BFP) (female: 45.9 ± 3.1% vs 43.1 ± 9.5%, male: 40.9 ± 6.8% vs 39.4 ± 1.6%). There was no significant difference between patients who underwent LSG and LMBG, in decrease in weight (24.7 ±7.1 kg vs 32.6 ±14.7 kg, p=0.12) and decrease in BMI (10.0 ±2.9 kg/m² vs 12.0 ±4.2 kg/m², p=0.08) at 6 months post-procedure as compared to baseline, although LMBG showed a trend towards greater benefit. There was no statistically significant difference in the decrease in WC (19.0 ±9.9 cm vs 20.8 ±5.8) and decrease in BFP (7.4% ±5.8 vs 10.8% ±5.6). Overall 88.4% of patients had NAFLD by ultrasound scan (USS) imaging criteria. Patients with LSG and LMBG did not show a significant difference in baseline AST (31.8 ±21.1 vs 26.8 ±11.6 U/L, p>0.05) and ALT (41.1 ±30.3 vs 35.8 ±25.7, p>0.05). At 6 months post procedure, AST (21.6 ±8.1 vs 25.0 ±13.9 U/L, p=0.32) and ALT (19.1 ±9.4 vs 26.9 ±11.0 U/L, p<0.05) levels were lower in patients with LSG than patients with LMBG, although only ALT values reached statistical significance. Thus LSG showed a greater degree of AST (32.1% vs 6.7%, p<0.05) and ALT (53.5% vs 24.9%, p=0.001) reduction compared to LMBG. At 6 months post-procedure, patients who underwent LSG had less patients with elevated AST (4.4% vs 11.1%) and ALT (4.4% vs 12.5%) as compared to LMBG. Overall LSG showed a higher rate of complete reversal of NAFLD (75.0% vs 44.4%) and improvement of the grade of NAFLD (91.7% vs 66.7%) on USS imaging when compared with LMBG. In conclusion, our study reveal that LSG has a more favorable effect on complete reversal and improvement of NAFLD when compared with LMBG. This effect seems to be independent of weight loss. Thus LSG should be considered ahead of LMBG when bariatric surgery is planned for obese patients with NAFLD.

SAT-116 Efficacy of Bariatric Surgery in Improving Obesity in South Asians

Obesity and its complications have become a major public health problem. Health risk conferred by obesity can be reduced by sustained weight loss but this is difficult in a majority. Bariatric surgery (BS) has proven to provide an excellent answer to this problem but there is minimal data in South Asians and especially in Sri Lankans. In this study we aimed to find the effect of BS on improving obesity in Sri Lankans. We did a retrospective analysis of medical records of 170 obese patients who underwent BS at the Colombo South Teaching Hospital, Sri Lanka. Overall 74.1% were females. Laparoscopic sleeve gastrectomy (LSG) was the commonest BS (69.5%) performed, followed by laparoscopic mini gastric bypass (LMGB) (24.1%) and laparoscopic Roux-en-Y gastric bypass (4.9%). Mean age was 38.1 ± 10.4 years. Mean pre-operative body weight and body mass index were 115.0 ± 23.0 kg and 45.1 ± 6.8 kg/m² respectively. The baseline waist circumference (WC) and body fat percentage (BFP) in females and males were 119.0 ± 11.0 cm vs 129.0 ± 14.9 cm, p<0.05 and 45.4% ± 4.8% vs 40.6% ± 6.1%, p<0.005 respectively. At 1 month, 3 months, 6 months, 9 months and 12 months after BS, patients lost 11.3 ± 5.0 kg (female: 10.0 ± 3.9 kg, male: 14.8 ± 6.0 kg, p<0.001), 19.3 ± 6.4 kg (female: 17.8 ± 4.4 kg, male: 25.5 ± 9.2 kg, p<0.01), 26.0 ± 8.8 kg (female: 24.7 ± 6.8 kg, male: 30.1 ± 13.2 kg, p=0.15), 28.7 ± 7.8 kg (female: 28.5 ± 7.8 kg, male: 29.6 ± 8.2 kg, p=0.77) and 30.1 ±8.1 kg (female: 30.0 ±8.2 kg, male: 30.8 ±8.4 kg, p=0.83) of body weight respectively. At 1 month, 3 months, 6 months, 9 months and 12 months after BS the reduction in WC from baseline were 6.1 ± 7.4 cm, 13.7 ± 8.4 cm, 19.1 ± 9.0 cm, 20.4 ± 7.8 cm and 21.1 ±8.2 cm respectively. At 1 month, 3 months, 6 months, 9 months and 12 months after BS the reduction in BFP from baseline were 1.6 ± 4.6%, 4.6 ± 6.6%, 7.5 ± 5.6%, 9.3 ± 9.9% and 9.2 ± 6.5% respectively. There was no significant difference in the reduction of WC and BFP among males and females. Patients who underwent LMGB lost more weight as compared to LSG at 3 months (22.5 ± 8.9 kg vs 18.3 ± 5.2 kg, p=0.07), 6 months (32.6 ± 14.7 kg vs 24.7 ± 7.1 kg, p=0.13) and 12 months (34.6 ± 8.4 kg vs 30.0 ± 8.4 kg, p=0.31) although this difference did not reach statistical significance. Thus BS resulted in a sustained and progressive loss of weight, WC and BFP with rapid improvement in the first 6-9 months and the effect plateauing afterwards. Males lost weight more rapidly than females in the first 6 months after BS, but at 12 months there was no difference in weight loss among the two genders. In conclusion BS provides effective, sustained and progressive weight loss in obese patients with males benefiting more in the short term but with equal efficacy among genders in the long-term. Overall LMBG shows a trend towards better efficacy in weight loss as compared to LSG, especially in the first 6 months but further studies are warranted.

SAT-104 Reversal of Nonalcoholic Fatty Liver Disease with Bariatric Surgery in South Asians: Has the Cure Been Finally Found? Real World Data From a Sri Lankan Tertiary Care Setting

Nonalcoholic fatty liver disease (NAFLD) ranges from non-progressive simple steatosis to progressive nonalcoholic steatohepatitis and can eventually progress to cirrhosis and even be complicated with hepatocellular carcinoma. The prevalence of NAFLD is alarming and is approximately 65-85% among obese individuals. In the United States, NAFLD is the commonest cause of chronic liver cell disease and it is predicted to become the most common indication for liver transplantation within the next 5 years. Unfortunately NAFLD has limited treatment options with generally suboptimal results. Although bariatric surgery has been found to have impressive rates of reversal of NAFLD in Caucasians, there is limited data on its effects among South Asians. In this study we aimed to find the effect of bariatric surgery on reversal of NAFLD among obese Sri Lankan patients. We did a retrospective analysis of medical records of 170 obese patients who underwent bariatric surgery at the Colombo South Teaching Hospital, Sri Lanka. Out of the patients 74.1% (n = 126) were females. The mean age was 38.1 ± 10.4 years. The mean pre-operative body weight and body mass index were 115.0 ± 23.0 kg and 45.1 ± 6.8 kg/m² respectively. Laparoscopic sleeve gastrectomy was the commonest type of bariatric surgery (69.5%) performed, followed by laparoscopic mini gastric bypass (24.1%) and laparoscopic Roux-en-Y gastric bypass (4.9%). One patient underwent open sleeve gastrectomy. NAFLD was detected in 88.7% pre-operatively, according to ultrasound scan (USS) imaging (grade 1 fatty liver 29.8%, grade 2 fatty liver 58.9%). On USS imaging at 6 months after the procedure, the prevalence of fatty liver reduced to 29.4% (grade 1 fatty liver 19.6%, grade 2 fatty liver 9.8%). The pre-operative mean AST and ALT values showed a significant reduction at 6 months after the procedure (30.4 ±18.6 U/L vs 22.1 ±8.9 U/L, p<0.005 and 39.1 ±28.3 U/L vs 19.8 ±9.6 U/L, p< 0.001) as compared to baseline. The percentage of patients who had AST or ALT elevation, showed significant reduction at 6 months postoperatively as compared to baseline (35.2% vs 6.9%, p<0.01). In conclusion, bariatric surgery fully reversed NAFLD in 68.1% (p<0.001) and reduced the grade of NAFLD in 87.2% (p<0.001) of patients according to USS imaging. It significantly reduced baseline AST and ALT values by 27.3% and 49.3% respectively at 6 months post procedure. Thus bariatric surgery shows impressive levels of complete reversal and downgrading of NAFLD biochemically as well as ultrasonically in Sri Lankan patients with comparable efficacy to studies done in Caucasian populations. Bariatric surgery should be considered as a potential therapeutic option in obese South Asian patients with NAFLD, especially when it is of a higher grade.

Comparison of duplex PCR and phenotypic analysis in differentiating Candida dubliniensis from Candida albicans from oral samples

Candida dubliniensis shares a wide range of phenotypic characteristics with Candida albicans including a common trait called germ tube positivity. Hence, laboratory differentiation of these two species is cumbersome. Duplex PCR analyses for C. albicans and C. dubliniensis was performed directly on DNA extracted from a total of 122 germ tube positive isolates derived from 100 concentrated oral rinse samples from a random cohort of diabetics attending a clinic in Sri Lanka. These results were confirmed by DNA sequencing of internal transcribed spacer (ITS) region of rDNA of the yeasts. Performance efficacy of duplex PCR was then compared with phenotypic identification using a standard battery of phenotypic tests. Of the 122 germ tube positive isolates three were identified by duplex PCR as C. dubliniensis and the remainder as C. albicans. On the contrary, when the standard phenotypic tests, sugar assimilation and chlamydospore formation, were used to differentiate the two species 13 germ tube positive isolates were erroneously identified as C. dubliniensis. Duplex PCR was found to be rapid, sensitive and more specific than phenotypic identification methods in discriminating C. dubliniensis from C. albicans. This is also the first report on the oral carriage of C. dubliniensis in a Sri Lankan population.

Coexistence of Primary Hyperaldosteronism and Graves' Disease, a Rare Combination of Endocrine Disorders: Is It beyond a Coincidence-A Case Report and Review of the Literature

BACKGROUND

Primary hyperaldosteronism is a known cause for secondary hypertension. In addition to its effect on blood pressure, aldosterone exhibits proinflammatory actions and plays a role in immunomodulation/development of autoimmunity. Recent researches also suggest significant thyroid dysfunction among patients with hyperaldosteronism, but exact causal relationship is not established. Autoimmune hyperthyroidism (Graves' disease) and primary hyperaldosteronism rarely coexist but underlying mechanisms associating the two are still unclear.

CASE PRESENTATION

A 32-year-old Sri Lankan female was evaluated for new onset hypertension in association with hypokalemia. She also had features of hyperthyroidism together with high TSH receptor antibodies suggestive of Graves' disease. On evaluation of persistent hypokalemia and hypertension, primary hyperaldosteronism due to right-sided adrenal adenoma was diagnosed. She was rendered euthyroid with antithyroid drugs followed by right-sided adrenalectomy. Antithyroid drugs were continued up to 12 months, after which the patient entered remission of Graves' disease.

CONCLUSION

Autoimmune hyperthyroidism and primary hyperaldosteronism rarely coexist and this case report adds to the limited number of cases documented in the literature. Underlying mechanism associating the two is still unclear but possibilities of autoimmune mechanisms and autoantibodies warrant further evaluation and research.

Novel mutation in the SLC12A3 gene in a Sri Lankan family with Gitelman syndrome & coexistent diabetes: a case report

Background

Gitelman syndrome (GS) is a rare autosomal recessively inherited salt-wasting tubulopathy associated with mutations in the SLC12A3 gene, which encodes for NaCl cotransporter (NCC) in the kidney.

Case presentation

In this report, we describe two siblings from a Sri Lankan non-consanguineous family presenting with hypokalaemia associated with renal potassium wasting, hypomagnesemia, hypocalciuria and hypereninemic hyperaldosteronism with normal blood pressure. Genetic testing showed that both were homozygotes for a novel missense mutation in exon 10 of the SLC12A3 gene [NM_000339.2, c.1276A > T; p.N426Y], which has not previously been reported in the literature in association with GS. Their mother was a heterozygous carrier for the same mutation. The father was not alive at the time of testing. This novel mutation extends the spectrum of known SLC12A3 gene mutations and further supports the allelic heterogeneity of GS. Interestingly both siblings had young onset Diabetes with strong family history.

Conclusion

These findings have implications in providing appropriate genetic counseling to the family with regard to the risk associated with inbreeding, the detection of carrier/presymptomatic relatives. It further expands the known spectrum of genotypic and phenotypic characteristics of Gitelman syndrome.

A sensitive and a rapid multiplex polymerase chain reaction for the identification of Candida species in concentrated oral rinse specimens in patients with diabetes

OBJECTIVES

Oral candidiasis is being frequently recognized in patients with diabetes, and is associated with multiple pathogens including Candida albicans, Candida parapsilosis, Candida glabrata and Candida tropicalis. The aim of this study was to evaluate a usefulness of a Multiplex Polymerase Chain Reaction as a rapid diagnostic tool for identification of four oral Candida pathogens in patients with diabetes.

MATERIALS AND METHODS

A multiplex PCR was optimized to identify four Candida species in concentrated oral rinse samples. Common reverse primer, ITS4 and four species-specific forward primers targeting ITS1 and ITS2 regions of yeast genome were used. Species-specific single amplicon were detected by agarose gel electrophoresis. Performance efficacy of multiplex PCR was compared with phenotypic identification.

RESULTS

Out of 100 oral rinse samples, 72 were culture positive and of these 43 were at risk of oral Candida infection (>600cfu/ml). Multiple Candida species including C. albicans, C. parapsilosis and C. tropicalis were identified in 22 samples which had risk of oral Candida infection. In total, 85 patients were positive for Candida by multiplex PCR and of them 49 had multiple Candida species. All 43 colonized specimens were also positive by multiplex PCR. C. albicans was the most predominant organism (75/85) followed by C. parapsilosis (47/85), C. tropicalis (17/85) and C. glabrata (6/85). In specimens with multiple species, the two most common organisms were C. albicans and C. parapsilosis. Multiplex PCR yielded a sensitivity of 10 Candida cells/ml of oral rinse sample.

CONCLUSIONS

Multiplex PCR is found to be rapid, sensitive and specific than phenotypic identification methods in discriminating multiple Candida species in oral rinse specimens.

Safe and pragmatic use of sodium-glucose co-transporter 2 inhibitors in type 2 diabetes mellitus: South Asian Federation of Endocrine Societies consensus statement

Diabetes prevalence shows a continuous increasing trend in South Asia. Although well-established treatment modalities exist for type 2 diabetes mellitus (T2DM) management, they are limited by their side effect profile. Sodium-glucose co-transporter 2 inhibitors (SGLT2i) with their novel insulin-independent renal action provide improved glycemic control, supplemented by reduction in weight and blood pressure, and cardiovascular safety. Based on the clinical outcomes with SGLT2i in patients with T2DM, treatment strategies that make a "good clinical sense" are desirable. Considering the peculiar lifestyle, body types, dietary patterns (long duration religious fasts), and the hot climate of the South Asian population, a unanimous decision was taken to design specific, customized guidelines for T2DM treatment strategies in these regions. The panel met for a discussion three times so as to get a consensus for the guidelines, and only unanimous consensus was included. After careful consideration of the quality and strength of the available evidence, the executive summary of this consensus statement was developed based on the American Association of Clinical Endocrinologists/American College of Endocrinology protocol.

Aspergillus species: An emerging pathogen in onychomycosis among diabetics

INTRODUCTION

Approximately, 33% patients with diabetes are afflicted with onychomycosis. In the past, nondermatophyte molds have been regarded as opportunistic pathogens; recently, Aspergillus species are considered as emerging pathogens of toenail infections. In Sri Lanka, the prevalence of Aspergillus species in onychomycosis among diabetics is not well documented.

OBJECTIVE

To determine the proportion of Aspergillus onychomycosis, risk factors and knowledge among diabetics.

MATERIALS AND METHODS

This was descriptive cross-sectional study. Three hundred diabetic patients were included. Clinical examinations of patients' toenails were performed by a clinical microbiologist. Laboratory identification was done, and pathogens were identified to the species level by morpho-physiological methods. All inferential statistics were tested at P < 0.05.

RESULTS

Among clinically suspected patients, 85% (255/300) were mycologically confirmed to have onychomycosis. Aspergillus species were most commonly isolated n = 180 (71%) followed by dermatophytes, yeasts, and other molds n = 75 (29%). Of the patients having Aspergillus onychomycosis, 149 (83%) were in the > age group. In men, Aspergillus onycomycosis was seen in 82%. Among patients who had Aspergillus nail infection, 114 (63%) had diabetes for a period of > years. Among patients who were engaged in agricultural activities, 77% were confirmed to have infected nails due to Aspergillus species.

CONCLUSION

Aspergillus niger was the most common pathogen isolated from toenail infection. Aspergillus species should be considered as an important pathogen in toenail onychomycosis in diabetic patients. Risk factors associated with Aspergillus onychomycosis were age, gender, duration of diabetes, length of exposure to fungi, and occupation.

Proportion of lower limb fungal foot infections in patients with type 2 diabetes at a tertiary care hospital in Sri Lanka

BACKGROUND

Superficial fungal foot infection (SFFI) in diabetic patients increases the risk of developing diabetic foot syndrome. Sixteen percent of urban population is suffering from diabetes in Sri Lanka. As the diabetes patients are more prone to get fungal foot infections, early intervention is advisable owing to the progressive nature of the infection. There is no data on the prevalence of SFFIs in diabetic patients in Sri Lanka.

OBJECTIVE

To determine the etiological agents causing SFFI in patients with type 2 diabetes.

MATERIALS AND METHODS

Three hundred eighty five diabetic patients were included. Nail clippings and swabs were collected from the infected sites using the standard protocol. Laboratory identification was done and pathogens were identified to the species level by morpho physiological methods.

RESULTS

Clinically 295 patients showed SFFI, of which 255 (86%) were mycologically confirmed for infection. Out of 236 direct microscopy (KOH) positives, 227 (96%) were culture positive. Two hundred and fifty one patients (98%) with SFFI had diabetes for more than 10 years. Of the patients with SFFIs 92% had >100 mg/dl FBS and 81% had >140 mg/dl PPBS levels and 80% had both elevated FBS and PPBS. Non-dermatophyte fungal species were the commonest pathogens followed by yeast and dermatophytes.

CONCLUSION

Aspergillus niger was the commonest pathogen followed by Candida albicans. SFFIs were seen significantly with the increasing age, gender, duration of diabetes and with less controlled glycaemic level.

Is diabetes a coronary risk equivalent? Systematic review and meta-analysis

AIMS

To determine whether patients with diabetes without prior myocardial infarction (MI) have the same risk of total coronary heart disease (CHD) events as non-diabetic patients with previous myocardial infarction.

METHODS

Using MEDLINE, EMBASE, Cochrane and MeSH in this systematic review and meta-analysis, extensive searching was carried out by cross-referencing from original articles and reviews. The study consisted of cohort or observational studies with hard clinical endpoints, including total CHD events (fatal or non-fatal myocardial infarction), stratified for patients with diabetes but no previous myocardial infarction, and patients without diabetes but with previous myocardial infarction. Studies with less than 100 subjects, follow-up of less than 4 years and/or without provisions for calculating CHD event rates were excluded. The review of articles and data extraction was performed by two independent authors, with any disagreements resolved by consensus.

RESULTS

Thirteen studies were included involving 45,108 patients. The duration of follow-up was 5-25 years (mean 13.4 years) and the age range was 25-84 years. Patients with diabetes without prior myocardial infarction have a 43% lower risk of developing total CHD events compared with patients without diabetes with previous myocardial infarction (summary odds ratio 0.56, 95% confidence interval 0.53-0.60).

CONCLUSION

This meta-analysis did not support the hypothesis that diabetes is a 'coronary heart disease equivalent'. Public health decisions to initiate cardio-protective drugs in patients with diabetes for primary CHD prevention should therefore be based on appropriate patients' CHD risk estimates rather than a 'blanket' approach of treatment.

The clinical impact of identifying metabolic syndrome in patients with diabetes: a cross-sectional study

The objectives of the study were to determine whether identifying patients with metabolic syndrome (MetS) (as defined by International Diabetes Federation [IDF] criteria) among patients with diabetes would affect the decision to prescribe statin for primary prevention of cardiovascular disease (CVD), based on currently available public health guidelines. We analysed the most recent recorded CVD risk profiles obtained from electronic patient files from 304 general practices in England and Wales. Of 60,258 patients with diabetes, 11,005 men and women aged 30-74 years fulfilled criteria for primary CVD prevention and were not on lipid-lowering drugs. Outcome data were extrapolated to an estimated national diabetes prevalence of 3.6%. Identifying MetS in this group of patients would produce an additional 29,536 (8.4%; 95% CI: 7.7, 9.0), 104,288 (29.6%; 95% CI: 28.5, 30.7) and 147, 328 (41.9%; 95% CI: 40.8, 43.0) patients nationally who would not have been eligible otherwise for primary CVD prevention strategies with statins, based on the Joint British Societies', the National Institute for Health and Clinical Excellence and the General Medical Services contract guidelines, respectively. The sensitivity and positive predictive value of these different strategies to detect metabolic syndrome were 87.5% and 69.1%; 57.3% and 76.8%; and 37.8% and 70.2%, respectively. In conclusion, among individuals with diabetes, identifying patients with MetS may further increase the use of statin therapy for primary CVD prevention.

Age threshold for vascular prophylaxis by aspirin in patients without diabetes

OBJECTIVE

To determine an appropriate age threshold at which to prescribe aspirin for primary cardiovascular disease (CVD) prevention among men and women without diabetes.

DESIGN

Cross-sectional study.

SETTING

304 general practices in England and Wales contributing to The Health Improvement Network (THIN) electronic patient files.

PARTICIPANTS

Subjects aged between 30 and 75 years without diabetes, not prescribed any lipid-lowering treatment and with no previous history of CVD. Subjects had to have been registered by their practices for the whole of the preceding 12 months to be included in the analysis.

OUTCOMES MEASURES

Relation between age and coronary heart disease (CHD) risk, and the age threshold at which subjects without diabetes develop an estimated 10-year CHD risk of >or=10%.

RESULTS

The age transition from <10% to >10%, 10-year CHD risk for men and women without diabetes occurred at ages 47.8 for men and 57.3 for women.

CONCLUSIONS

In the absence of significant bleeding risks, aspirin should routinely be considered for all men and women without diabetes above the ages of 48 and 57 years, respectively, for primary CVD prevention. For subjects below these age thresholds or for those above the age of 75 years, the decision to initiate aspirin should be based on a patient's individual cardiovascular risk profiles. These proposed age thresholds aim to take into account a patient's gender, bleeding risk and the cardioprotective benefits of low-dose aspirin treatment.

Combining population health and baseline risk strategy by determining an age cutoff for initiating statins in patients with diabetes: a population-based study

OBJECTIVE

Strategies for initiating statin use among adult patients with diabetes for primary cardiovascular disease (CVD) prevention include treating all patients (assuming diabetes is a coronary risk equivalent) or treating patients who are at risk of developing CVD. The aim of the study was to combine both strategies to derive an appropriate age cutoff for prescribing statins. By considering different strategies, we also aim to assess the effectiveness and efficiency of different strategies to reduce CVD events.

RESEARCH DESIGN AND METHODS

This was a cross-sectional primary care population study using electronic patient files from 304 general practitioner practices in England and Wales. Of 60,258 patients with diabetes, 11,005 men and women aged 30-74 years fullfilled criteria for primary CVD prevention. Model outcomes were extrapolated to an estimated national diabetes prevalence of 3.6%.

RESULTS

The age transition from a low-risk to a moderate-risk category for diabetic men and women occurred at ages 40.6 and 44.2 years, respectively, and sensitivity and specificity for fulfilling moderate CVD risk criteria were 97.9 and 61.8% for men and 92.0 and 77.0% for women. When applied to the national population, the age cutoff strategies were an effective and efficient strategy, potentially avoiding 11,094 events with a number needed to treat of 25.1.

CONCLUSIONS

A strategy to treat all men and women with diabetes aged >40 and 45 years, respectively, with statins showed good compromise between high effectiveness and high efficiency for reducing CVD events. Strategy to intervene if cholesterol was >5 mmol/l was the least effective and efficient in preventing CVD events.

Dengue fever in travellers: A challenge for European physicians

Dengue fever (DF) is one of the world's emerging infectious diseases. The steady increase in European tourists, as well as soldiers serving on peacekeeping duties, in endemic areas, coupled with the present resurgence of dengue, raises the risk of exposure for a large number of European travellers. Significant numbers of travellers have, in fact, developed DF. There is a risk of dengue haemorrhagic fever (DHF) in travellers who revisit the same place, and they have the potential not only to acquire, but also to spread, the dengue viral infection. Of concern is the potential for a dengue outbreak in a previously dengue-free country through imported cases. Another major concern is the potential area of dengue transmission, due to spread of its vectors through sizeable parts of southern Europe. In addition to the risk of haemorrhagic fever in returning tourists, the introduction of DF by returning travellers, whether they have symptoms or are unaffected by signs and symptoms of the disease, poses a threat to health systems in Europe.