Pediatric endocrinology transition clinic profile at the University of Santo Tomas Hospital Outpatient Department - Clinical Division (USTH OPD-CD)

OBJECTIVE: To  determine the prevalence of depression in Filipino adult patients with type 2 diabetes mellitus (DM) and the risk factors associated in its development.METHODS:This is a prospective cross-sectional  study. Adult  patients (age 19 and above) with type 2 DM being seen at the outpatient department of the Makati Medical Center from  January  to  March  2015  were included,  taking  into  account  the  following:  age,  gender,  marital  status,  body  mass index, waist circumference, blood pressure, duration of  diabetes,  presence  of  other  co-morbid  illnesses,  pill  burden,  insulin  use,  educational  attainment,  employment  status,  family  income, and glycemic status. They  were  then screened for depression using the standardized PHQ-9 questionnaire. Bivariate analyses through Chi-square Test (for categorical variables) and Analysis of Variance (for interval/ratio variables) were used to determine which among the risk factors are significant for the development of depression.Significant  risk  factors  were  treated  for  multivariate  and univariate analyses through ordinal logistic regression.RESULTS: A  total  of  110  adult  patients  with  type  2  DM  were  enrolled  in  this  study.  There  were  no  drop-outs.  Sixty-nine  percent  of  the  patients  had  none  to  minimal  depression,  24% had mild depression, and 7% had moderate depression. None  of  the  patients  had  depression  that  warranted  anti-depressants  or  psychotherapy.After step-wise analysis, increased  BMI,  elevated  diastolic  blood  pressure  and  uncontrolled blood sugar were found to be associated with higher  PHQ-9  scores  while  unemployment  was  associated  with decreased PHQ-9 score.CONCLUSION:The  prevalence  of  depression  among  Filipino  type  2  diabetic  patients  is  higher  than  in  non-diabetic patients. Being obese, having an elevated diastolic blood pressure, and the presence of uncontrolled blood sugar were significant predictors and were associated with an increased likelihood  of  developing  major  depressive  disorder.  Being unemployed appears to have the opposite effect.

Determination of nonalcoholic fatty liver disease in patients with pre-impaired glucose tolerance

INTRODUCTION: Pre-impaired  glucose  tolerance  (pre-IGT) or  compensated  hyperinsulinemia,  is  defined  as  normal glucose,  and  elevated  insulin  two  hours  after  a  75-gram oral glucose load.  It is characteristic of the early stages of diabetes  mellitus  (DM),  where  beta  cells  compensate  for  insulin resistance by increasing insulin secretion to maintain normoglycemia. With  continuing  beta  cell  failure,  insulin  secretion  eventually  fails,  leading  to  the  progression  to diabetes.    Nonalcoholic  fatty  liver  disease  (NAFLD),  a common feature of insulin resistance, is found in 50-75% and 42-55% of DM and pre-diabetes patients. We determined if NAFLD was present in patients with pre-IGT.METHOD: A study on the determination of NAFLD - diagnosed by liver ultrasound in pre-IGT patients at a university hospital.Descriptive statistics, Chi square test of independence, 2x2 Fischer  Exact  test,  Z  test  of  difference  in  proportion, were used  for  statistical  analysis  with  a  p-value  set  at  0.05?.IBMSPSS ver 21 was used as software.RESULTS:The mean age of 22 patients was 29.95 years, with average BMI of 25.73 kg/m2;77.3% were female.  Average lipid  panels  were  within  optimal  limits;  kidney  and  liver functions were normal.  The mean insulin level was 58.36 uIU/mL. NAFLD was identified in eight of the subjects. CONCLUSION: Although  pre-IGT  is  a  subclinical  phase  in  the  diabetes  spectrum,  36%  already  have  NAFLD.This prevalence  was  lower  compared  to  diabetics  and  pre-diabetics, but higher compared to the general population.There was a noticeable trend of increasing insulin levels with increasing severity of fatty liver.

Treatment outcomes with the use of a stepwise insulin combinations algorithm among type 2 diabetic patients

INTRODUCTION: In the management of type 2 diabetes, insulin is often started late, when there is failure to achieve good control on maximum oral agents. Clinical inertia to insulin initiation and intensification is widely prevalent in our local setting resulting in poor control of diabetes. This study looked into a stepwise insulin combinations treatment algorithm used in an Endocrinology referral clinic at the University of Santo Tomas Hospital (USTH). It aimed to demonstrate the clinical course of the patients , determine the degree of HbA1c reduction, and show the associated extent of hypoglycemia and weight gain. METHODS: This is a retrospective chart review of 104 patients that used the following stepwise treatment: Oral regimen; Regimen A: basal+oral; Regimen B: basal+premeal bolus TID±oral; Regimen C: premixed aspart 70/30 or lispro 75/25 TID or BID with prelunch bolus, ± oral; Regimen D: premixed 70/30 BID+premeal bolus TID ± oral; Regimen E: premixed 70/30 BI +premeal bolus TID+basal ±oral. All received automatic snacking two hours after main meals to prevent hypoglycemia. Patients were educated on proper diet and exercise. Data was analyzed using paired t-test, frequencies and percentages. RESULTS: Most ended on the intensive insulin regimens D 57(55%), and E 18 (17%). Significant HbA1c reduction was demonstrated as follows: Regimen A (n=8):1.376±0.919 (p=0.000), Regimen B (n=18):2.320±2.177 (p=0.000), Regimen D (n=57):2.197±2.158 (p=0.000), Regimen E (n=18):2.684±1.689 (p =0.000). Overall mean weight gain was 1.070 ± 11.435 kg (p=0.335). Ten, nonsevere hypoglycemia events were reported. CONCLUSION: The use of this stepwise insulin combinations treatment algorithm exerted significant HbA1c reduction, with minimal events of hypoglycemia, and statistically insignificant weight gain. Hence, this is a feasible tool that may be used as a guide for intensification of insulin treatment.

Correlation of postprandial lipemia with postprandial hyperglycemia and poor glycemic control among patients with type 2 diabetes mellitus

INTRODUCTION: Postprandial lipemia characterized by a rise in triglyceride-rich lipoproteins after eating, is associated with increased risk of cardiovascular disease. Among diabetic patients, postprandial lipemia is often overlooked once fasting lipid parameters are within target. The aim of the study is to determine the correlation of glycemic control and postprandial hyperglycemia with postprandial lipemia among patients with type 2 diabetes mellitus (DM). The result of the study may have important implications on how dyslipidemia should be completely addressed. METHODOLOGY: A clinic-based retrospective chart review of 102 patients with recorded fasting and postprandial blood measurements was performed. Subjects included adult patients with type 2 DM whose fasting lipid parameters were controlled with diet and/or medications. Plasma glucose and glycosylated hemoglobin (HbA1C) were independent variables while triglyceride, total cholesterol, low density lipoprotein (LDL) and high density lipoprotein (HDL) were dependent variables. Pearson correlation was used to determine the strength of relationships among the variables mentioned. A p-value RESULTS: Of the 102 patients, 52.9% and 47.1% were achieving their target HbA1C and twohour postprandial plasma glucose, respectively. The postprandial level of plasma glucose, mean triglyceride, total cholesterol, LDL and HDL were 196.39 mg/dL, 189.06 mg/dL, 177.07 mg/dL, 122.40 mg/dL and 34.83 mg/dL, respectively. HbA1C has strong positive correlation with postprandial lipemia (Pearson's r=0.40) while the two-hour plasma glucose has moderate positive correlation (Pearson's r=0.34) with postprandial lipemia. Both relationships were considered significant (p-value CONCLUSION: A significant correlation of glycemic control and postprandial hyperglycemia with postprandial lipemia was observed. Our data suggest that despite achievement of optimal fasting lipid parameters, poor control of diabetes is positively correlated with abnormal elevation of postprandial triglyceride. Addressing both postprandial hyperglycemia and lipemia may improve cardiovascular outcome.

A randomized double-blind comparison of fixed versus calculated radioiodine dose in the treatment of Graves' hyperthyroidism

INTRODUCTION:Radioactive iodine(I131) therapy is an established definitive treatment for Graves' hyperthyroidism.However,the optimal method of determining the radioiodine treatment dose remains controversial.OBJECTIVE: To compare the efficacy of fixed dose versus  calculated  dose  regimen  in  the  treatment  of  Graves'  hyperthyroidism  among  Filipinos  METHODOLOGY: Diagnosed   Graves'   disease   patients underwent  thyroid  ultrasound  to  estimate  thyroid  size. Patients  were  randomized  to  either  fixed  or  calculated dose  of  radioiodine  treatment.  For  fixed  dose  group,the  WHO  goiter  grading  was  utilized:  Grade   0   (5mCi),  Grade   1  (7mCi),  Grade2  (10mCi),  Grade  3  (15mCi).  For calculated  dose  group  the  following  formula  was  used:                    Dose(mCi)= 160uCi/g thyroid x thyroid gland weight in grams x 100  /  24-hour RAIU(%)Thyroid function test (TSH,FT4)  was monitored every  three  months  for  one  year.  RESULTS: Of  the  60  patients  enrolled,  45  (fixed  dose;  n= 27,  calculated  dose;  n=  18)  completed  the  six  months follow-up  study.  Analysis  was  done  by  application  of  the  intention-to-treat  principle.  The  percentage  failure  rate  at  third  month  in  the  fixed  vs.  calculated  dose  group  was:  26  v.  28%  with  a  relative  risk  (RR)  value  of  0.93.  At  six  months  post-therapy,  there  was  a  noted  reduction  in  the  failure  rates  for  both  study  groups  (11  vs.  22%,  respectively),  with   a   further   reduction   in   the   relative   risk   value (0.67),  favoring  the  fixed  dose  group.CONCLUSION: Fixed   dose   radioiodine   therapy   for Graves'   disease   is   observed   to   have   a   lower   risk   of   treatment   failure   (persistent   hyperthyroidism)   at   three  and  six  months  post-therapy  compared  to  the calculated  dose.

Clinical profile and etiology of hypopituitarism at the University of Santo Tomas hospital

OBJECTIVE: To establish data determining the etiology of hypopituitarism in the University of Santo Tomas Hospital (USTH) and to describe the clinical and biochemical profile of these patients.METHODOLOGY: A retrospective descriptive study in a tertiary hospital (USTH) involving patients diagnosed by clinical evaluation and biochemical tests to have hypopituitarism, admitted or seen at the outpatient department from January 2001 to December 2009 and whose charts were available for review. The clinical profile, manifestations and biochemical profile were defined and causes of hypopituitarism identified. Descriptive statistics were applied using percentages and frequency distribution.RESULTS: In the nine-year period (2001-2009), a total of 191 patients were recorded to have hypopituitarism but only 143 (75%) have adequate data available for review. Sixty one (43%) were males and 82 (51%) were females with mean age was 45±6 years. Hypopituitarism was found to be most prevalent in the fourth to fifth decade of life and clinical manifestations were noted with mean duration of 20±4 months. The most predominant documented pituitary hormone deficiency was gonadotrophic hormone (60%) manifesting prominently as decreased libido (82%). The most common target end organ hormone deficiency was secondary adrenal insufficiency (90%) and most prevalent etiology of hypopituitarism was pituitary tumors (40%). Sheehan's syndrome (8%) and tuberculosis (3%) were also noted as a cause of hypopituitarism.CONCLUSION: This study shows that the leading clinical manifestation and documented hormone deficiency of hypopituitarism is hypogonadism. Pituitary adenoma is the most common cause of hypopituitarism along with its treatment. Other causes not commonly seen in other countries but proved to be more prevalent here include Sheehan's syndrome and tuberculosis infection.