Uncontrolled Type 2 Diabetes Mellitus Research Articles

HYPERAMMONEMIA IN UNCONTROLLED DIABETES MELLITUS

TOPIC: Critical Care TYPE: Fellow Case Reports INTRODUCTION: Hyperammonemia is a known cause of encephalopathy due to neurotoxic effect. While predominantly attributed to hepatic cirrhosis, other non-cirrhotic causes of hyperammonemia such as malignancy, infection with urea-producing bacteria, and metabolic disorders have also been described. 1 Uncontrolled diabetes mellitus (DM) is a lesser understood cause of sudden or substantial increase in ammonia level. 2 We present a case of a patient with diabetes ketoacidosis (DKA) and encephalopathy in the setting of hyperammonemia. CASE PRESENTATION: The patient is a 57-year-old female with a past medical history of hypertension, type 2 DM, and liver cirrhosis presenting with lethargy and two days of nausea and vomiting in the setting of insulin noncompliance. She was noted to be significantly volume depleted with depressed level of consciousness. The patient received intravenous crystalloid resuscitation, vasopressor support, and broad-spectrum antimicrobials. She developed progressive obtundation, necessitating endotracheal intubation. Laboratory workup was consistent with DKA, with glucose of 979, anion gap >24, HCO3 <10, BHB >2, and pH of 6.74. Her ALT, AST, alkaline phosphatase, and bilirubin were all within normal limits. Additional workup for encephalopathy demonstrated an ammonia level of 1181. CT head showed no evidence of cerebral edema or other intracranial pathology. CT abdomen demonstrated hepatic surface nodularity. In the setting of significantly elevated ammonia, treatment with intravenous insulin infusion and electrolyte repletion for DKA was started. On repeat 3 hours later, the ammonia level decreased to 594 and normalized on day 2. Neurological workup including EEG, MRI and repeat CT head were unremarkable. The patient remained encephalitic precluding extubating until day 9 and was discharged home shortly thereafter. DISCUSSION: Serum ammonia is the result of protein degradation primarily produced in the GI system and removed mostly by the liver and to a lesser extent by the musculature. Hyperammonemia can be caused by a variety of causes including urea cycle disorders, medications, infections, GI bleed, hepatic or renal failure. 2 Undiagnosed hyperammonemia either in acute or chronic setting, can cause irreversible neurological damage. 2 Insulin increases protein synthesis, and insulin deficiency or resistance as it happens in type I and II diabetes mellitus respectively, increases protein catabolism and ammonia production.2–5 The mainstay of treatment in such a setting is aggressive resuscitation and treatment of the DKA. 6–8 CONCLUSIONS: Hyperammonemia due to uncontrolled diabetes mellitus is an under-recognized cause of encephalopathy and should be considered in patients presenting with DKA. REFERENCE #1: Cichoz-Lach H, Michalak A. Current pathogenetic aspects of hepatic encephalopathy and noncirrhotic hyperammonemic encephalopathy. World J Gastroenterol. 2013;19(1):26-34. doi:10.3748/wjg.v19.i1.26 REFERENCE #2: K G, Dasan.S S, Sheriff D. Hyperammonemia in uncontrolled Type2 Diabetes Mellitus. IOSR Journal of Dental and Medical Sciences. 2016;15:14-19. doi:10.9790/0853-1510031419 REFERENCE #3: Nair KS, Garrow JS, Ford C, Mahler RF, Halliday D. Effect of poor diabetic control and obesity on whole body protein metabolism in man. Diabetologia. 1983;25(5):400-403. doi:10.1007/BF00282518 DISCLOSURES: No relevant relationships by Michael Bonk, source=Web Response No relevant relationships by Seyed Kamran Hejazi Kenari, source=Web Response No relevant relationships by Arman Hemmat, source=Web Response

Evaluation of the effects of glycated hemoglobin on cardiac function in patients with short-duration type 2 diabetes mellitus: A cardiovascular magnetic resonance study

AimsTo investigate the association between glycated hemoglobin (HbA1c) and myocardial dysfunction and to determine whether its association is independent of myocardial perfusion. MethodsSixty-four patients with type 2 diabetes mellitus (T2DM) were recruited. They were divided into groups according to their HbA1c level: the controlled T2DM group (HbA1c < 7%) and uncontrolled T2DM groups (HbA1c ≥ 7%). Meanwhile, 30 age-matched healthy volunteers were included. All patients with T2DM and healthy controls underwent cardiovascular magnetic resonance imaging to evaluate the myocardial mechanics and perfusion parameters. ResultsThe circumferential and longitudinal peak strain (PS) (p = 0.009 and 0.002 respectively) and global radial, circumferential, and longitudinal peak strain diastolic strain rates (PDSRs) (p = 0.002, 0.001, and 0.001 respectively) were lower in the uncontrolled T2DM group than in the controls without diabetes. In multivariable linear regression analysis, HbA1c was independently related to all directions of the PS and PDSR. The myocardial perfusion parameters were not independently associated with the PS or PDSR. ConclusionsCardiac function is impaired in Chinese T2DM patients with poor glucose control (HbA1c ≥ 7%), with preserved left ventricular (LV) ejection fraction, and disease duration <10 years. Poor blood glucose control is an independent predictor of LV myocardial dysfunction for patients with short-term T2DM.

Do Weight trajectories influence diabetes control? A prospective study in Switzerland (CoLaus study).

ObjectiveIdentify anthropometric trajectories among subjects with type 2 diabetes mellitus (T2DM), and associate them with glycaemic control.MethodsProspective study including 268 community-dwelling participants with T2DM (34% women, mean age 68.7 ± 8.9 years) followed for 10.7 years (range: 8.8–13.6 years). T2DM control was considered for 1) fasting plasma glucose (FPG) < 7.0 mmol/L, or 2) HbA1c < 7.0% (53 nmol/mol). Changes in weight or waist and weight variability were considered.ResultsOne half (FPG) and one third (HbA1c) of participants presented with uncontrolled T2DM. Half of the participants presented with obesity and 75% with abdominal obesity. During follow-up, half of the participants maintained their weight, 25% gained > 5 kg, and 25% lost < 5 kg; almost half increased their waist by > 5 cm. Using FPG as criterion, participants who lost > 5 cm waist were more likely to be controlled: multivariable-adjusted odds ratio (OR) and 95% confidence interval (CI): 3.10 (1.23–7.78). Participants with controlled T2DM also presented with a higher weight variability: multivariable adjusted mean ± standard error 4.8 ± 0.3 vs. 3.9 ± 0.3 kg, p = 0.028. Using HbA1c as criterion, participants who lost > 5 kg were less likely to be controlled: OR and (95% CI): 0.35 (0.18–0.66). Similar findings were obtained when restricting the analysis to participants who were diabetic throughout the whole study period.ConclusionIn a Swiss community-based sample of participants with T2DM, T2DM control rates could be implemented. Neither weight nor waist variability was significantly and consistently associated with T2DM control.

Efficacy and Safety of Self-Titration Algorithms of Insulin Glargine 300 units/mL in Individuals with Uncontrolled Type 2 Diabetes Mellitus (The Korean TITRATION Study): A Randomized Controlled Trial.

BackgroundTo compare the efficacy and safety of two insulin self-titration algorithms, Implementing New Strategies with Insulin Glargine for Hyperglycemia Treatment (INSIGHT) and EDITION, for insulin glargine 300 units/mL (Gla-300) in Korean individuals with uncontrolled type 2 diabetes mellitus (T2DM).MethodsIn a 12-week, randomized, open-label trial, individuals with uncontrolled T2DM requiring basal insulin were randomized to either the INSIGHT (adjusted by 1 unit/day) or EDITION (adjusted by 3 units/week) algorithm to achieve a fasting self-monitoring of blood glucose (SMBG) in the range of 4.4 to 5.6 mmol/L. The primary outcome was the proportion of individuals achieving a fasting SMBG ≤5.6 mmol/L without nocturnal hypoglycemia at week 12.ResultsOf 129 individuals (age, 64.1±9.5 years; 66 [51.2%] women), 65 and 64 were randomized to the INSIGHT and EDITION algorithms, respectively. The primary outcome of achievement was comparable between the two groups (24.6% vs. 23.4%, P=0.876). Compared with the EDITION group, the INSIGHT group had a greater reduction in 7-point SMBG but a similar decrease in fasting plasma glucose and glycosylated hemoglobin. The increment of total daily insulin dose was significantly higher in the INSIGHT group than in the EDITION group (between-group difference: 5.8±2.7 units/day, P=0.033). However, body weight was significantly increased only in the EDITION group (0.6±2.4 kg, P=0.038). There was no difference in the occurrence of hypoglycemia between the two groups. Patient satisfaction was significantly increased in the INSIGHT group (P=0.014).ConclusionThe self-titration of Gla-300 using the INSIGHT algorithm was effective and safe compared with that using the EDITION algorithm in Korean individuals with uncontrolled T2DM (ClinicalTrials.gov number: NCT03406663).

Evaluation of salusin-α and salusin-β levels in patients with type 2 diabetes mellitus and determination of the impact of severity of hyperglycemia on salusin levels.

To investigate the usefulness of salusin-α and salusin-β as biomarkers in patients with type 2 diabetes mellitus (T2DM) and to determine whether diabetes severity and obesity have an effect on the salusin levels in diabetic patients. The study included a total of 90 patients, comprising 55 diagnosed with T2DM and 35 healthy volunteers with similar demographic characteristics. Salusins were assayed by a commercially available ELISA kit. The salusin-β levels were found to be significantly higher in T2DM group compared to control group, while the salusin-α levels were lower (p < 0.05, for both). Furthermore, in patient group, Spearman analysis showed a statistically significant negative correlation between salusin-α and fasting glucose and glycated hemoglobin (HbA1c), whereas salusin-β had a statistically significant positive correlation with fasting glucose and HbA1c (p < 0.05, for both). When analyzed according to the HbA1c groups, the patients with HbA1c > 9% had significantly lower salusin-α and higher salusin-β levels levels compared to those with HbA1c < 9% (p < 0.05, for both). When examined according to body-mass-index groups, there was no significant difference in the salusin levels of the patient and control groups (p > 0.05). We demonstrated that the serum salusin-α level was decreased whereas the salusin-β level was increased in patients with T2DM compared to healthy subjects, and this was more pronounced as T2DM-deteriorated. We also showed that obesity had no effect on salusin levels among diabetics. This study may provide a basis for the availability of salusin-targeted therapies, especially in uncontrolled T2DM.

211-OR: Differential Cerebral Blood Flow in Controlled and Uncontrolled Patients with Type 2 Diabetes Mellitus

Introduction: Patients with type 2 diabetes mellitus (T2DM) show variable brain tissue changes and mood and cognitive symptoms, which may result from altered cerebral blood flow (CBF). However, the regional CBF status in controlled and uncontrolled T2DM patients remains unclear, which can be examined with arterial spin labeling (ASL) imaging. Our aim was to examine regional CBF between controlled and uncontrolled T2DM patients using ASL imaging procedures. Methods: We collected hemoglobin A1c (A1C) data and 3D pseudo-continuous ASL data from 32 T2DM patients (16 controlled [A1C &amp;lt; 7%], age, 56.5±6.5 years; BMI, 29.6±6.2 kg/m2; 8 female; 16 uncontrolled [A1C ≥ 7%], age, 57.6±7.5 years; BMI, 30.0±5.1 kg/m2; 11 female) using a 3.0-Tesla MRI. A1C was measured by point-of-care testing. Whole-brain CBF maps were calculated, normalized to a common space, smoothed, and compared between groups (controlled T2DM patients vs. uncontrolled T2DM patients) using analysis of covariance (SPM12; covariates, age and sex; p&amp;lt;0.05). Results: No significant differences in age or sex appeared between groups. Multiple brain areas showed decreased CBF values in the cingulate, caudate, putamen, insula, hippocampus, amygdala, thalamus, hypothalamus, midbrain, cerebellum, prefrontal and frontal, and temporal cortices in uncontrolled T2DM patients over controlled T2DM patients. However, few brain sites in controlled T2DM patients, including the cerebellum, pons, medulla, parahippocampal gyrus, and temporal cortices showed reduced CBF over uncontrolled T2DM patients. Conclusion: Uncontrolled T2DM patients show significant reduction in CBF compared to controlled T2DM in areas that are involved in mood and cognition regulation. The findings suggest that uncontrolled levels may contribute to reduce regional CBF leading to site-specific tissue changes resulting to mood and cognition deficits in the condition. Disclosure S. E. Choi: None. B. Roy: None. M. Freeby: Research Support; Self; Abbott Diabetes, Novo Nordisk Inc. R. Kumar: None. Funding National Institutes of Health (1R01NR017190-03, 3R01NR017190-03S1)

Factors Affecting Opposition of Insulin Initiation Among Type 2 DM Patients at Ain Shams University Hospitals

Background: One of the obstacles to diabetes management is delayed insulin initiation in uncontrolled type 2DM patients. Objectives: To measure the frequency of insulin opposition among Egyptian type 2 diabetes patients, uncontrolled, on two or more oral hypoglycemic combination therapy and to assess factors associated with insulin opposition. Methods: Cross-sectional study was conducted in outpatient clinics at Ain Shams University hospitals, on purposive sample of 103 type 2 diabetic patients, uncontrolled, on two or more oral hypoglycemic combination therapy, using a structured questionnaire. Results: Uncontrolled type 2DM patients opposed to start insulin were 55.3%. The most common negative attitudes that differ significantly between insulin opposers and acceptors were: insulin as last resort (77.2% vs 50%), perceived diabetes severity (75.4% vs 63 %), concerns about less flexibility (59.6 %vs 52.2%), time and effort with insulin injections (29.8% vs 13 %) and expected harm from insulin (28.1% vs 13 %). Opposers had significantly less agreement on positive items regarding the role of insulin in improving energy level (22.8% vs 50%), improving health (28.1% vs 60.9%), and preventing complications of diabetes (42.1% vs 67.4%). Conclusion and recommendations: high rate of insulin opposition among uncontrolled type 2DM and its associated factors among T2DM patients, therefore, the need for increasing physicians’ awareness through training sessions is important to improve the strategy for identifying and reducing insulin opposition among patients.

Insulin Management of Patients with Inadequately Controlled Type 2 Diabetes Admitted to Hospital: Titration Patterns and Frequency of Hypoglycemia as Results of a Prospective Observational Study (Hospital Study)

IntroductionDespite the continuously growing number of therapeutic options for type 2 diabetes mellitus (T2DM) including insulins, a large percentage of patients fail to achieve HbA1c targets. Several real-world studies focused on patients with T2DM receiving insulin treatment in outpatient settings were conducted, but information about real-world in-hospital insulin management is lacking. The aim of this study was to describe the management of insulin therapy with a focus on basal-bolus and premixed insulin regimens in patients with T2DM under routine in-hospital medical practice in the Czech Republic.MethodsThis non-interventional prospective study was conducted from June 2014 to December 2017 in 22 centers in the Czech Republic under routine clinical practice conditions. Adult patients admitted to hospital with metabolically uncontrolled T2DM [HbA1c ≥ 60 mmol/mol; > 7.6% Diabetes Control and Complications Trial (DCCT)] and there treated with basal-bolus and premixed insulin regimens were documented during hospitalization.ResultsOverall, 369 patients with T2DM (54.7% male, mean age 64.44 ± 13.84 years, BMI 31.10 ± 6.00 kg/m2, duration of diabetes 8.11 ± 9.93 years, HbA1c 95.90 ± 24.38 mmol/mol, length of stay was 7.94 ± 4.53 days) were included. The percentage of glucose values under 10 mmol/l at time of randomization (the group with basal-bolus insulin regimen vs. the premix insulin regimen group) was 24.2% vs. 33.5% (p = 0.053), at time of first insulin dose adjustment it was 43.1% vs. 50.0% (p = 0.330), and 1 day before hospital discharge it was 61.7% vs. 61.4% (p = 0.107). A hypoglycemic event occurred in a total of 15 patients in the basal-bolus regimen group, and no hypoglycemic event occurred in the premixed insulin regimen group.ConclusionIn-hospital insulin management regarding basal-bolus and premixed insulin regimens is safe and in concordance with current international recommendations.

One-year performance of posterior narrow diameter implants in hyperglycemic and normo-glycemic patients\u2014a pilot study

ObjectivesThe aim of the study was to compare the performance of narrow diameter implants in patients with uncontrolled diabetes mellitus type 2 (T2DM) and normo-glycemic individuals during the first 12 months after implant loading.Material and methodsIn 16 T2DM patients with HbA1C > 6.5% (test group) and 16 normo-glycemic patients (HbA1C < 6.0%; control group), one to two narrow diameter tissue level implants were placed in the posterior maxilla or mandible. After 3-month lasting integration period, implants were loaded by fixed dentures. The clinical parameters probing depth (PD), bleeding on probing (BOP), attachment loss (CAL), recession and papilla bleeding index (PBI) were assessed manually at loading and after 12 months of function. The paired digital periapical radiographs were analyzed with regard to the change in marginal bone level (MBL) from baseline to 12 months’ control. The mean values calculated for both patient groups were statistically analyzed. The technical complications were recorded.ResultsThe T2DM group accounted 13 patients due to 3 dropouts. The overall implant survival rate after 12 months was 100%. The differences in means for the clinical parameters and the MBL were statistically non-significant between the T2DM and normo-glycemic patients for the short period of loaded function reported here. No technical complications were recorded.ConclusionsThe study demonstrated an encouraging clinical outcome with narrow diameter implants in patients with uncontrolled T2DM compared to non-diabetics after 12 months post loading. For the short observation period, no biological and technical complications were reported regardless the glycemic status.Clinical relevancePatients with HbA1C > 6.5% may benefit from the treatment with narrow diameter implants by avoiding complex surgical interventions with augmentation procedures.Trial registrationClinicaltrials.gov: NCT04630691

Glucagonoma: “A Diagnostic Challenge”

Abstract Introduction: Glucagonoma is a rare pancreatic α-islet cell tumor accounting for nearly 1% of all the neuroendocrine tumors (NET), with an incidence of 1 in 20 million people. We present here a patient with glucagonoma with uncontrolled diabetes mellitus (DM) for over ten years and necrolytic migratory erythema (NME) for two years. Clinical Case: A 50-year-old Caucasian male was referred to the endocrinology team for uncontrolled DM type 2. The DM was diagnosed over 10 years prior with initial HbA1c of 10.2% and remained uncontrolled with HbA1c &amp;gt;9%, despite compliance with lifestyle modifications and treatment with multiple agents including metformin, glipizide, empagliflozin, and pioglitazone. Given poor glycemic control, the treatment was escalated to glargine and lixisenatide. Over the years, the patient presented with unintentional weight loss of 105 pounds, fatigue, normocytic normochromic anemia, and diffuse erythematous rash with plaques and scaling on the trunk, flexor surfaces of lower and upper extremities, soles of hands and feet. Punch biopsy of the lesions revealed neutrophilic infiltration. He denied diarrhea, deep venous thrombosis, pulmonary embolism, psychiatric symptoms, or family history of neuroendocrine tumor (NET) or MEN 1 syndrome. A CT chest abdomen and pelvis revealed a 5 cm mass on the pancreatic tail along with liver metastasis. The biopsy confirmed a well-differentiated NET. Serum glucagon and chromogranin-A levels were elevated at 2967 pg/mL (N: 50-150 pg/mL) and 263.8 ng/mL (N: 0-101.8 ng/mL) respectively, consistent with pancreatic glucagonoma. Octreoscan revealed diffuse uptake in the liver, omentum, and spleen. He was started on Octreotide injections monthly, followed by distal pancreatectomy, splenectomy, hepatic wedge resection, and excision of the omental implant with the plan to treat the residual liver metastasis with radioembolization. Pathology analysis showed local invasion and metastasis to local lymph nodes with immunostaining positive for AE1/3, synaptophysin, chromogranin, and Ki67 index &amp;lt;2% consistent with Grade I well-differentiated NET. Post-surgery, serum glucagon and chromogranin-A levels dropped to 400 pg/mL and 68.8 ng/mL respectively. Insulin requirements markedly dropped with an improvement in glycemic control and resolution of the rash. Conclusions: Glucagonoma is an uncommon, slow-growing pancreatic neoplasm resulting in excessive glucagon secretion and it is characterized by diabetes mellitus, NME, chronic diarrhea, and deep vein thrombosis. Nearly 50% of glucagonomas are metastatic at the time of diagnosis. Patients without metastasis have a 10-year survival rate of almost 100%, compared with 51.6% of patients with metastasis, emphasizing the importance of early diagnosis and multidisciplinary treatment approach to achieve a better therapeutic outcome.

35. PREVALENCE OF HYPERTENSIVE CRISIS AS A COMORBID AMONG PATIENTS WITH UNCONTROLLED TYPE 2 DIABETIC MELLITUS IN EMERGENCY DEPARTMENT, KARANGANYAR GENERAL HOSPITAL: A CROSS-SECTIONAL STUDY

Background: Although uncontrolled hypertension and type 2 diabetes mellitus (T2DM) has poor prognosis, these cardiometabolic diseases are still considered trivial in rural areas. Moreover, most patients with hypertensive crisis don’t recognize it when it is asymptomatic. Objective: This study aimed to explore the hypertensive crisis in T2DM and become a pilot study in rural areas of Central Java, Indonesia. Method: This was an analytic cross-sectional study conducted at the emergency department, Karanganyar General Hospital, between October to November 2019. Data were taken using data extraction forms that include history taking, physical examination, and laboratory examination. Complete blood count, random blood glucose, and creatinine serum were documented. Data were analyzed using SPSS with univariate and bivariate analysis. Result: Our study involved 171 patients with uncontrolled T2DM in the emergency ward. Around half of the patients were males (59.6%) and above 60 years old (46.8%). Patients with a history of ischemic heart disease, chronic kidney disease, stroke, and diabetic foot were 19.3%, 19.9%, 12.3%, and 21.1%. Patients who arrived with high blood pressure were 53.8%. The hypertensive crisis among uncontrolled T2DM was 10.5% (hypertensive urgency was 5.8%, and hypertensive emergency was 4.7%). There was an association between stroke and diabetic foot towards hypertensive crisis (p &lt; 0.05). Conclusion: The proportion of hypertensive crisis in T2DM patients was higher than in the non-T2DM group. Various factors due to complications from diabetes and low treatment compliance of chronic disease may affect the development of hypertensive crisis.

Echocardiographic evaluation of the effect of poor blood glucose control on left ventricular function and ascending aorta elasticity.

Type 2 diabetes mellitus (T2DM) is associated with high cardiovascular risk. Preclinical left ventricular (LV) dysfunction and subclinical arterial stiffness have been documented in patients with T2DM. The aims of this study were to investigate whether there were any differences in LV function and ascending aorta elasticity between T2DM patients with controlled [defined as glycosylated hemoglobin (HbA1c) <6.5%] and uncontrolled (HbA1c ≥6.5%) blood glucose. We studied 86 T2DM patients: 42 T2DM patients with controlled blood glucose (controlled T2DM group) and 44 T2DM patients with uncontrolled blood glucose (uncontrolled T2DM group), and 40 healthy subjects as control. They all underwent transthoracic echocardiography examination, LV systolic function was evaluated by global longitudinal strain (GLS) and LV diastolic function was defined as the ratio of the early diastolic transmitral flow velocity (E) to average mitral annular velocity (e¯). Ascending aorta inner diameters and brachial blood pressure were measured to calculate ascending aorta elastic parameters: compliance (C), distensibility (D), strain (S), stiffness index (SI), Peterson's elastic modulus (EM). Compared to control, T2DM patients had reduced GLS, increased E/e ̅ and impaired ascending aorta elasticity. Furthermore, LV function and ascending aorta elasticity were more severely damaged in uncontrolled T2DM group compared with controlled T2DM group. By Pearson correlation analysis, the level of HbA1c was independently associated with the parameters of the LV function and ascending aorta elasticity. T2DM can impair the LV myocardial function and ascending aorta elastic properties, which may be further impaired by poor blood glucose control.

Obstructive Sleep Apnea High-Risk Prevalence, Symptoms and Sleepiness among Patients with Uncontrolled Type 2 Diabetes Mellitus Seen at the Out-Patient Department of Philippine General Hospital

Objectives. We determined the prevalence of patients at risk for obstructive sleep apnea (OSA) with uncontrolled type 2 diabetes mellitus (T2DM) at the out-patient department (OPD) of the University of the Philippines-Philippine General Hospital (UP-PGH) from December 1, 2018 - February 28, 2019. We described the demographic characteristics of patients with uncontrolled T2DM and compared them with high and low OSA risk, its association, and correlation with the quality of sleep.&#x0D; Methods. This is a prospective cross-sectional study among uncontrolled T2DM. The questionnaires were Berlin Questionnaire (screen OSA-HR) and Epworth Sleepiness Score (level of sleepiness). Clinicodemographic profile and significant laboratory data were obtained. Descriptive statistics utilized. Chi-square test was used to compare categorical variables between patients with high vs low OSA risk and to determine if an association exists between OSA-HR and sleep quality.&#x0D; Results. A total of 240 participants, 88 males and 151 females, were included in the study. The overall prevalence of OSA-HR among patients with uncontrolled type 2DM is 58.33%. The majority of the OSA–HR patients (105 /140) was 46 years old and above. There is a significant association of tonsillar grade, Mallampati score, BMI, HbA1c, hypercholesterolonemia, and Epworth sleepiness on OSA High risk. There is also a substantial association with age, BMI, Mallampati score, tonsillar grade, hypertension, asthma, HbA1c, and hypercholesterelonemia on the level of sleepiness of OSA-HR.&#x0D; Conclusion. There is a high prevalence of high OSA-risk among patients with uncontrolled DM. Factors associated with high OSA-risk among uncontrolled diabetes mellitus include HbA1c, dyslipidemia, BMI, Mallampati score, tonsillar grade, and Epworth score.

Multidisciplinary Evaluation and Treatment of Necrotizing Fasciitis in a Type I Diabetic in a Community Military Hospital

A 38-year-old right-hand dominant male mechanic with uncontrolled diabetes mellitus type I presented to the emergency department (ED) complaining of worsening pain and swelling in his right hand. In the ED, a computed tomography scan confirmed the presence of soft-tissue edema in the right arm, but necrotizing fasciitis (NF) was not initially considered as a diagnosis. His Laboratory Risk Indicator for NF (LRINEC) score at the time of his hospitalization was 4, indicating a less than 50% chance of NF. Within 12 hours of admission, he developed increased violaceous, nonblanching skin of his dorsal fingers, increased swelling in his hand and forearm, bullae development in his palm and index finger, and a high fever. His LRINEC score had increased to 7, making NF up to 75% likely. He was urgently taken to the operating room (OR) for extensive debridement then admitted to the intermediate care unit for medical stabilization. He was subsequently taken back to the OR for serial debridements, and a negative pressure wound therapy device was placed once the wound was successfully debrided down to viable tissue. This is a case study of the multidisciplinary approach taken to the very ill patient at a community military hospital.

Obstructive Sleep Apnea High-Risk Prevalence, Symptoms and Sleepiness among Patients with Uncontrolled Type 2 Diabetes Mellitus Seen at the Out-Patient Department of Philippine General Hospital

Objectives. We determined the prevalence of patients at risk for obstructive sleep apnea (OSA) with uncontrolled type 2 diabetes mellitus (T2DM) at the out-patient department (OPD) of the University of the Philippines-Philippine General Hospital (UP-PGH) from December 1, 2018 - February 28, 2019. We described the demographic characteristics of patients with uncontrolled T2DM and compared them with high and low OSA risk, its association, and correlation with the quality of sleep.&#x0D; Methods. This is a prospective cross-sectional study among uncontrolled T2DM. The questionnaires were Berlin Questionnaire (screen OSA-HR) and Epworth Sleepiness Score (level of sleepiness). Clinicodemographic profile and significant laboratory data were obtained. Descriptive statistics utilized. Chi-square test was used to compare categorical variables between patients with high vs low OSA risk and to determine if an association exists between OSA-HR and sleep quality.&#x0D; Results. A total of 240 participants, 88 males and 151 females, were included in the study. The overall prevalence of OSA-HR among patients with uncontrolled type 2DM is 58.33%. The majority of the OSA–HR patients (105/140) was 46 years old and above. There is a significant association of tonsillar grade, Mallampati score, BMI, HbA1c, hypercholesterolonemia, and Epworth sleepiness on OSA High risk. There is also a substantial association with age, BMI, Mallampati score, tonsillar grade, hypertension, asthma, HbA1c, and hypercholesterelonemia on the level of sleepiness of OSA-HR.&#x0D; Conclusion. There is a high prevalence of high OSA-risk among patients with uncontrolled DM. Factors associated with high OSA-risk among uncontrolled diabetes mellitus include HbA1c, dyslipidemia, BMI, Mallampati score, tonsillar grade, and Epworth score.

Assessment of safety of Saxagliptin in patients of type 2 diabetes mellitus who were previously on metformin monotherapy with uncontrolled diabetes

Introduction: Dipeptidyl peptidase-4 are a relatively new class of oral antihyperglycemic agent that enhance insulin secretion by reducing degradation of endogenous glucagon-like peptide 1. Currently, sitagliptin, vildagliptin, saxagliptin, linagliptin and alogliptin are approved in India, USA and Europe for the use in patients with type 2 diabetes. In this study we have tried to assess the safety of saxagliptin used in patients of type 2 DM who were previously on metformin monotherapy. Materials and Methods: A total of 35 patients who were previously on metformin montherapy with uncontrolled diabetes were enrolled. Patients were started with saxagliptin (2.5 mg OD) and were followed up at 1st, 3rd and 6th months for the estimation of Liver Function Test (SGOT, SGPT, Bilirubin direct & indirect), Renal Function Test (BUN and Sr. Creatinine). During the follow up period patients were also assessed for the adverse drug reactions. Results: Male and female patients mean age SD (61.42 yrs 6.99 and 55.93 yrs 5.74 respectively). The mean significant decrease in values from baseline at 24 weeks were seen for SGOT, SGPT, Blood urea nitrogen and serum creatinine. Conclusion: The combination of saxagliptin plus metformin for the treatment of type 2 diabetes offers an oral treatment regimen that is safe and well tolerated. Keywords: Saxagliptin, Uncontrolled type 2DM safety knee arthralgia.

Effectiveness of triple therapy with dapagliflozin add-on to dual therapy over 52 weeks in patients with uncontrolled type 2 diabetes mellitus in a centre of high complexity, Cali-Colombia.

To evaluate the effectiveness of adding dapagliflozin as an intensification strategy for the treatment of patients with uncontrolled type 2 diabetes mellitus (T2DM). A historical cohort study was conducted in 123 adult patients over 18 years old who were diagnosed with uncontrolled T2DM, who received dapagliflozin add-on to their dual base treatment: metformin plus glibenclamide (n = 32), metformin plus saxagliptin (n = 29), metformin plus exenatide (n = 28), or metformin plus insulin (n = 34). The endpoints were evaluated using analysis of variance. All the patients completed a 52-week follow-up. Overall, 52.85% of patients were female, the Hispanic population represented the largest proportion of patients in all groups (60.98%), and the mean ± SD patient age and body weight were 55.05 ± 7.58 years and 83.55 ± 9.65 kg, respectively. The mean ± SD duration of T2DM, glycated hemoglobin (HbA1c), and fasting plasma glucose (FPG) were 5.93 ± 2.98 years, 8.1 ± 0.53%, and 166.03 ± 26.80 mg/dL, respectively. The grand mean changes of HbA1c, FPG, body weight and blood pressure showed a decreasing trend during the study period and it was statistically significant in all groups (p-value = <0.001). The proportion of patients achieving HbA1c target (<7%) was highest in the group that used a dapagliflozin add-on to metformin plus saxagliptin. The addition of dapagliflozin as an alternative for intensification of dual therapy consistently improved, not only FPG and HbA1c, but also body weight and blood pressure, with statistically significant results.

Validation of newly developed culturally specific diabetes self-management education and support program for Iraqi type 2 diabetes mellitus patients.

BACKGROUND:Diabetes self-management (DSM) is the cornerstone in diabetes mellitus (DM) management. Unfortunately, the practice of DSM by Iraqi type 2 DM (T2DM) patients is poor that mainly resulted from their poor knowledge about the required DSM behaviors. This lack of knowledge may be attributed to the lack of DSM education and support (DSMES) program in Iraq. Thus, this study was conducted with aim of developing and validating a culturally specific DSMES program for Iraqi T2DM patients.MATERIALS AND METHODS:The development and validation of the DSMES program was done according to the Hilda Taba model. Content validity of the program was done by a panel of 6 health-care experts in management of Iraqi DM patients. Face validity was confirmed by conducting a pilot study for six adults with uncontrolled T2DM at the National Diabetes Center, Baghdad, Iraq. Both the experts and patients were asked to evaluate the developed program in regard to its contents, design, and supporting material (booklet). The evaluation was done by filling in a questionnaire that based on a 5-point scale. Items with a score ≥4 by <70% of the experts and patients were subjected to revision and further assessment.RESULTS:No total disagreement for any item was expressed by all participants (experts and patients). Content and face validity was ensured through obtaining a positive feedback from all participants at which all items about the program had scores of ≥4 by at least 75% of participants.CONCLUSION:The developed culturally based DSMES program is highly suitable for educating Iraqi T2DM patients.

Clinical markers and some trace elements in patients with type-2 diabetic nephropathy : Impact of insulin resistance.

INTRODUCTION : Diabetic Nephropathy (DN) is the leading reason of all excess death-rate over type-2 diabetes mellitus (T2DM) patients with microalbuminuria, macroalbuminuria or end-stage renal disease. This work was aimed to estimate insulin resistance (IR) effect on some markers and trace elements (Selenium, Zinc, Magnesium) levels for early predicting of DN in T2DM patients. METHODS : We conducted a cross-sectional clinical study. Blood and urine samples were collected from 63 subjects with T2DM and 33 healthy controls to assess glucose, insulin, IR, urea, creatinine, glomerular filtration rate (GFR), creatinine clearance (CrCl), homocysteine (Hcy), fructosamine (FA), cystatin C (CysC), albumin (Alb), neutrophil gelatinase-associated lipocalin (NGAL), 8-hydroxy-2`-deoxyguanosine (8-OHdG) and trace elements levels. Data were collected using a questionnaire that was filled out by specialized doctors. RESULTS : Compared with controls, the results revealed that T2DM patients with or without DN had significant increases in glucose, insulin, IR, urea, creatinine, Hcy, FA, CysC, Alb, NGAL and 8-OHdG and significant decreases in GFR, CrCl and trace elements levels. Body mass index (BMI) had no changes. CONCLUSION : Uncontrolled T2DM was associated with BMI, IR and physical activity in which elevated Hcy, FA, CysC, Alb, NGAL and 8-OHdG levels and decreased trace elements levels may be used as early clinical markers of DN. J. Med. Invest. 68 : 76-84, February, 2021.

Relation between the Severity of Obstructive Sleep Apnea and the Severity of Type 2 Diabetes Mellitus and Hypertension

Background: Obstructive sleep apnea syndrome (OSAS) may promote hyperglycemia, insulin resistance, and hypertension (HTN). Purpose: To evaluate if there is a relationship between the severity of OSA and the severity of type 2 diabetes mellitus (T2DM) and HTN in our patients, aiming to understand and optimize the control for comorbidities. Materials and Methods: Patients referred for polysomnography (PSG) were retrospectively recruited during the period from October 2017 to August 2020. A STOP-BANG questionnaire formed eight questions was used to assess the risk of OSAS. We divided the patients into two groups; group 1, who have snoring without T2DM, and group 2, who have snoring with T2DM. PSG was completed for all subjects and data were collected for each patient including apnoea hypopnea index (AHI), mean arterial oxygen saturation (SaO2), and Nadir SaO2 recorded during PSG. Anthropometric data, medical history, and medications for T2DM (for group 2) and HTN and HbA1c were collected (for group 2). AHI was used to evaluate the severity of OSA and its relation to T2DM and HTN. Results: The study included 300 patients who met the inclusion criteria with mean age of 49.9 ± 13.6 years. The majority of subjects (56.3%) were males and the mean body mass index (BMI) was 38.0 ± 8.4 kg/m2. Forty-two percent had HTN and 32.7% had T2DM. OSA was diagnosed in 209 patients (69.7%). OSA was more detected among those with increased age, increased BMI, and those with HTN and T2DM. The severity of both HTN and T2DM was significantly higher among patients with OSA. Conclusions: There is a relation between OSA and T2DM and HTN. The risk of OSA is higher among patients with uncontrolled T2DM and HTN. OSA should be suspected in subjects with obesity, especially with uncontrolled HTN and T2DM.