Thailand diabetes registry project: prevalence of vascular complications in long-standing type 2 diabetes.

OBJECTIVE: To explore the nature of diabetic complications in type 2 diabetic patients who had had diabetes for longer than 15 years (long-DM), compared to those with duration of less than 15 years (short-DM). MATERIAL AND METHOD: Patients studied were adult type 2 diabetic patients registered to the Diabetes Registry Project, a nationwide cross-sectional study of diabetes mellitus in Thailand. Information collected included demographic data, age at diagnosis of diabetes, blood pressure, body mass index, fasting plasma glucose, HbA(1c), serum creatinine, and major diabetic vascular complications, including diabetic retinopathy (DR), albuminuria or renal insufficiency (diabetic nephropathy; DN), myocardial infarction (MI), stroke, peripheral arterial disease (PAD), foot ulcer and amputation. RESULTS: There were 9284 patients, consisting of 2244 (24.17%) subjects with long-DM (mean +/- SD, mean duration of DM21.3 +/- 5.8 years), and 7040 subjects with short-DM (mean duration 7.0 +/- 3.9 years). The long-DM group was older than the short-DM group (65.5 +/- 10.3 vs. 58.2 +/- 12.6 year-old, p less than 0.0001), and had higher HbA(1c) (8.5 vs. 8.0%, p = 0.009). The prevalence of diabetic complications in the long-DM group was higher than that in the short-DM group (DN 49.4% vs. 33.9%, DR 54.3% vs. 22.8%; MI 9.4% vs. 3.5%, PAD 17.3% vs. 5.5%, foot ulcer 13.4% vs. 5.3%, stroke 9.4% vs. 7.0% and amputation 5.5% vs 2.0%; allp values less than 0.01). The duration of DM significantly affected the risk of diabetic complications after adjustment for age, hypertension, and levels of glycemic control. CONCLUSION: Diabetic duration was independently associated with increased risk of having diabetes-related complications without threshold. Monitoring of complications in patients having long-standing diabetes is warranted in order to provide appropriate management.

Validation of the OSTA index for discriminating between high and low probability of femoral neck and lumbar spine osteoporosis among Thai postmenopausal women.

RATIONALE: Bone mineral density (BMD) measurement of postmenopausal women is needed to diagnose osteoporosis. This is an expensive procedure and available in only a few hospitals in Thailand. The Osteoporosis Self-Assessment Tool for Asians (OSTA) index, based on age and weight, has been developed for screening of postmenopausal Asian women to identify women for whom there is little advantage in undergoing bone densitometry. This index was developed for prediction of neck of the femur osteoporosis and did not include spinal osteoporosis, which is also common. Furthermore, the index was based on data from a sample of mainly ethnic Chinese. There is evidence that the BMD of Thai women is significantly higher for the same age and weight than that of women of several other Asian ethnics, thus there is a need to validate the appropriateness of the OSTA index for both femur and spinal osteoporosis among the Thai population. OBJECTIVE: To determine the properties of the OSTA index as a screening tool among postmenopausal women in southern Thailand. PATIENTS: Three-hundred-and-eighty-eight postmenopausal women, with no history of disease or use of drugs associated with secondary osteoporosis and no history of treatment for osteoporosis, attending the postmenopausal clinic or internal medicine out-patient department of Songklanagarind Hospital, a teaching hospital in southern Thailand, between November 2000 and April 2002. METHOD: BMD t-scores of the neck of the femur and lumbar spine were collected retrospectively and a diagnosis of osteoporosis made according to WHO criteria. Sensitivity and specificity and their 95% confidence limits were calculatedfor the dichotomized OSTA index. RESULTS: Thirty-one percent of the women were detected as having osteoporosis, comprising neck of the femur (12 percent) and lumbar spine (31 percent). Twenty nine women (7.5 percent) had evidence of spinal fracture. The OSTA index at the standard cut-point of < or = -1 had a sensitivity and specificity of 0.93 (95% CI: 0.82 - 0.99) and 0.61 (95% CI: 0.56-0.66) respectively for neck of the femur but only 0.80 (95% CI: 0.72-0.87) and 0.70 (95% CI: 0.64-0.75) respectively for lumbar spine. Raising the cut-point to < or = 0 reduced the high false negative rate (0.20) in prediction of lumbar spine osteoporosis to 0.07 (95% CI: 0.03-0.13) and identified 27 percent (95% CI: 23-32 percent) of all women at low risk of osteoporosis at either site. These women may not need to undergo BMD measurement. CONCLUSION: The standard cut-point of the OSTA index could identify most Thai postmenopausal women with osteoporosis of the neck of the femur. However, to improve the sensitivity of detection of osteoporosis of the lumbar spine, the cut-point of < or = 0 may be more appropriate.

Hypovitaminosis D in long-stay hospitalized patients in Songklanagarind Hospital.

The major source of vitamin D is endogenous synthesis under sunlight exposure, thus, vitamin D deficiency is uncommon in healthy people living in a tropical area where sunshine is plentiful. However, long-stay hospitalized patients who do not get direct sunlight may become vitamin D deficient. The authors studied the prevalence of vitamin D deficiency in patients without other risk factors for vitamin D deficiency who had been admitted to Songklanagarind Hospital for longer than 27 days. The second objective was to identify predictive factors for vitamin D deficiency. Considered variables were clinical character, basic laboratory results, and intact parathyroid hormone level (iPTH). Among 60 patients studied, there were 12 patients who were vitamin D deficient and only one had a level lower than 8 ng/ml. Despite vitamin D deficiency, average serum calcium was normal. Patients in the vitamin D deficient group had lower serum corrected calcium and higher iPTH level than patients in the vitamin D sufficient group. No other clinical or laboratory data could predict a vitamin D deficiency state. In summary, the present tropical area study showed that 20 per cent of long-stay hospitalized patients who had a mild degree of vitamin D deficiency and 1.7 per cent had severe vitamin D deficit. Vitamin D supplementation is unnecessary in this group of patients.

Screening for microalbuminuria in type 2 diabetes: a reconsideration.

To study the effect of timing of urine collection in determination of microalbuminuria in type 2 diabetic patients, timed urine (night time and daytime) as well as spot urine (first morning and random morning) samples were collected from 44 type 2 diabetic patients, 21 with normoalbuminuria and 23 with microalbuminuria. The methods of spot urine albumin expression for microalbuminuria were also compared between albumin concentration (AC) and albumin to creatinine ratio (ACR). Night time albumin excretion rate (AER) was 16 per cent lower and daytime AER was 13 per cent higher than 24-h AER (p<0.001). Forty-one (93%) of both night time and daytime urine samples had results corresponding with 24-h AER. For the spot urine, expression as AC showed a slightly stronger correlation with 24-h AER than expression as ACR. The levels of albumin in random morning urine samples were 50 and 35 per cent significantly higher than those in first morning urine samples when expressed as AC and ACR, respectively. In conclusion, because of low diurnal variation of AER, either daytime or night time urine could be used for screening of microalbuminuria in type 2 diabetes. Since mean albumin levels obtained from random morning urine were higher than those obtained from first morning urine, the cut-off level should be set higher in random morning urine in order to give comparable sensitivity in predicting microalbuminuria. The spot urine, either first morning or random morning urine, had a good correlation with the 24-h AER whether expressed as AC or ACR. Given the cost of the latter, the authors suggested measuring spot urine AC instead of ACR for screening of microalbuminuria in type 2 diabetes.