The DiabCare Asia 2008 study – Outcomes on control and complications of type 2 diabetic patients in Indonesia.

Aim: To collect information on diabetes management, diabetes complications, and awareness of self-control in diabetic population of the country. This study also evaluated the physician perspectives, psychological aspects, and quality of life of diabetic patients. Methods: This was a non-interventional, cross-sectional study, which recruited 1832 patients from secondary and tertiary medical centers across Indonesia. Data on demography, medical history, risk factors and clinical examination reports including laboratory assessments were collected from medical records of patients. Blood samples of all patients were collected for centralized HbA1c measurements. Results: Among 1832 patients, 1785 individuals were eligible for analysis. The mean age of the patients was 58.9+9.6 years. The mean duration of diabetes was 8.5+7.0 years. Majority (97.5%) of the patients had type 2 diabetes. 67.9% had poor control of diabetes (A1c:8.1 ± 2.0%). 47.2% had FPG>130 mg/dL (161.6±14.6 mg/dL). Dyslipidemia was reported in 60% (834/1390) and 74% (617/834) of those received lipid lowering treatment. Neuropathy was most common complication (63.5%); other complications were: Diabetic retinopathy 42%, nephropathy 7.3%, severe late complications 16.9%, macrovascular complications 16%, microvascular complications 27.6%. About 81.3% of patients were on OADs (± insulin), 37.7% were on insulin (±OADs). Majority used biguanides followed by sulfonylureas. Human insulin was used by 73.2%, premix regimen 58.5%, analogues usage was 24.9%. Majority of the WHO-5 well being index responses fell in positive territory. Conclusion: Poor glycaemic control in majority of patients is a concern. There is a need for a large proportion of patients to be adjusted to more intensive pharmacotherapy and a multi-disciplinary approach for management should be adopted. The study fi ndings should be communicated to policymakers and physicians to help them provide proper healthcare and its facilities in Indonesia.

Prevalence and risk factors for microalbuminuria in a cross-sectional study of type-2 diabetic patients in Indonesia : a subset of DEMAND study.

Aims Microalbuminuria (MA) is a strong predictor of diabetic nephropathy and cardiovascular morbidity and mortality in patients with type-2 DM. The present study aimed to gather information on the prevalence and risk factors for MA in Indonesian patients with type-2 DM. Methods The DEMAND study was an international open cross-sectional 1-day survey on microalbuminuria prevalence and its risk factors in type-2 diabetic patients. This study reports the results of the Indonesian survey which was performed in primary care practice in Indonesia from June to December 2003. Normotensive or hypertensive adult patients of both genders with type-2 DM without known proteinuria and/or kidney disease were recruited into the study. Patients with known pregnancy, having menstruation or acute fever were excluded. A single urinary albumin/creatinine test was carried out in all patients. Results A total of 770 patients were eligible for analysis. Approximately 80% of the patients had micro-/ macroalbuminuria, while renal insufficiency was detected in about 36% of the 433 patients with available data. Target HbA1c (< 7%) was reached by only 40% of the 118 patients who had HbA1c values. Most antidiabetic treatment prescribed was oral (82%), while insulin was used by only 14% of patients. Goal BP (< 130/80 mm Hg) was achieved in only 9% of patients. The frequency of patients receiving antihypertensives was 52%, statins 18%, and aspirin 26%. The most frequently used antihypertensives were RAS blockers (45%), while diuretics were used in 7 % of the patients. The family history of DM was found in 43% of patients, the history of retinopathy in 16%, diabetic foot 9%, and history of smoking in 20% of patients. Conclusion These data reveal that Indonesia has one of the highest frequencies of silent diabetic kidney disease seen in any national group in the global DEMAND Study. Early detection, monitoring of vascular complications, and more aggressive multifactorial treatment aiming at renal and vascular protection are urgently needed for Indonesian patients with type-2 diabetes.

The role of SOCS-3 protein in leptin resistance and obesity.

Obesity is one of the risk factors in various chronic diseases and malignancy. It may result from excess accumulation of body fat. This condition may be caused by dysfunction of appetite-regulating pathways and energy balance due to leptin resistance. Leptin, a 16 kDa hormone, is the most important regulator of appetite and energy balance in the body. Most individuals with obesity have leptin resistance characterized by increased leptin blood levels. Some possibilities of mechanism involved in leptin resistance have been proposed by researchers despite the fact that it is still being studied hitherto. One of the mechanisms considered to have a role in leptin resistance is disruption in signal transduction process through Janus-activating kinase2-signal transducer and activator of transcription 3 (JAK2-STAT3) pathway on leptin receptors by suppressor of cytokine signaling-3 (SOCS-3). SOCS-3 is a protein that inhibits the signal transduction process of various cytokines in the body, including leptin. SOCS-3 expression is induced by leptin and SOCS-3 activation will inhibit STAT3 phosphorylation which is important in signal transmission on leptin receptors. Such inhibition will consequently cause leptin resistance characterized by dysfunction of leptin biological function.

Correlation between CD4 count and intensity of Candida colonization in the oropharynx of HIV-infected/ AIDS patient.

AIM: To know the correlation between CD4 count and intensity of Candida colonizations in the oropharynx of HIV-infected/AIDS patients, to get the prevalence of oropharyngeal candidiasis (OPC), and to know what kind of Candida species that causes oropharynx candidiasis of HIV-infected/AIDS patients. METHODS: A cross-sectional study was conducted in HIV-infected/AIDS patients who came as outpatients and inpatients in Cipto Mangunkusumo Hospital. The patients were interviewed, physically examined, their CD4 counts were checked, and their mouth rinse samples were taken to be cultured. Candida species was identified in CHROMagar media, and data were processed. RESULTS: From September 2004 until January 2005, 60 HIV-infected/AIDS patients were included in this study. There were 86.7% males and 13.3% females. Majority of the patients were from 20-30 years age group (85%). The most frequent transmission was among drug users (75%) followed by sexual contact (18.3%). The median of CD4 counts was 100 cells/il, ranged from 2 to 842 cells/il. Proportion of the OPC was 63.3% (CI 95% = 51.1 - 75.5). From 59 Candida isolates in this study, 74.58% were C. albicans. Candida non C. albicans species that were found in this trial were C. krusei, C. parapsilosis and C. tropicalis. There was significant correlation between low CD4 counts and high intensity of Candida colonization on the oropharynx of the subjects (r = -0.756). CONCLUSION: There was strong negative correlation (r = -0.756) between CD4 count and intensity of Candida colonization in the oropharynx of HIV-infected/AIDS patients. Proportion of OPC in this study was 63.3%. The most frequent species found in the oropharynx of the subjects was C. albicans.

The correlation between insulin resistance and left ventricular systolic function in obese women.

AIM: To determine the correlation between insulin resistance and left ventricular systolic function in obese women. METHODS: 44 obese (BMI > or =25 kg/m2) and 45 normal weight women were studied. They had no other pathological conditions. Echocardiograms were undertaken in our echocardiographic laboratory following standard methods. The homeostasis model was used to assess insulin resistance (HOMA IR). RESULTS: Ejection fraction (p =0.22) and fractional shortening (p= 0.58) were not difference between obese women and the normal group. There was no correlation between insulin resistance and left ventricular systolic function. CONCLUSION: There was no correlation between insulin resistance and left ventricular ejection fraction.

Left ventricular diastolic dysfunction in obese women.

AIM: To determine the direct effect of obesity on echocardiographic indices of diastolic left ventricular function METHODS: 44 obese (BMI > or =25 kg/m2) and 45 normal weight women were studied. They had no other pathological conditions. Echocardiographic indices of diastolic function were obtained, and dysfunction was assumed when at least two values differed by > or =2 SD from the normal weight group. RESULTS: In obese subjects, the values of maximum velocity of active mitral filling (A) were increased and pulmonary diastolic velocity was decreased significantly (p< 0,01); all other diastolic variables were unchanged. Subclinical diastolic dysfunction tend to be more prevalent among obese subjects but it was not significantly different from non obese (p= 0.11), being present in nine obese (20.5%) and 4 normal (8.9%) subjects. CONCLUSION: Subclinical left ventricular diastolic dysfunction is present in obese women.

The correlation between hs C-reactive protein and left ventricular mass in obese women.

Plasma C-reactive protein (CRP) concentrations are increased in obese individuals. In this study, we examined the correlation between hsCRP and left ventricular mass (LV mass). Fourty five healthy obese women and fourty five healthy non obese women as the controls group were studied by echocardiography and hsCRP. There was no significant correlation between hsCRP and left ventricular mass in obese women (r = 0.29, p 0.06). There was a significant correlation between hs CRP and body mass index (r = 0.46, p 0,002), and also hsCRP and visceral fat (r= 0.33, p 0.03).

The diagnostic value of combined risk factor analysis and radiological imaging in determining osteoporosis in post-menopausal women.

AIM: To determine the diagnostic value of risk factor analysis (age, duration of menopause, body mass index and physical activities) and radiological imaging (Singh index and cortical index of the femoral neck) in diagnosing osteoporosis in post-menopausal women. METHODS: The study was cross sectional on 64 post-menopausal women without secondary risk factor for osteoporosis. They were classified proportionally using the Singh index. Bone density was measured using DEXA (dual x-ray absorptiometry) on the femoral neck and lumbal 2-4 spine areas. The Singh index and cortical index of the femoral neck were evaluated using femoral neck antero-posterior x-ray. Physical activities were measured using a Historical leisure activity questionnaire. Bivariat statistical analysis was conducted using the t-test and chi-square, whereas multivariate analysis was conducted using multinomial logistic regression. RESULTS: There was a significant association (p<0.05) between bone density and age, body weight, height, body mass index, duration of menopause and Singh index. With multinomial logistic regression analysis, it was demonstrated that only Singh index, the duration of menopause and body mass index had the highest sensitivity and specificity. The score system algorithm could be utilized in two steps, the first was to diagnose osteoporosis and the second was to distinguish between osteopenia and normal bone. This score system had a sensitivity of 91.4% and a specificity of 89.6%, a positive prediction value of 91.4% in determining osteoporosis, and a sensitivity of 66.7%, a specificity of 89.1% and a positive prediction value of 70.6% in determining osteopenia, whereas the negative prediction value was 75%. CONCLUSION: The score system algorithm is the best method for determining osteoporosis in post-menopausal women. If there is osteopenia, evaluation using DEXA is then required. The score system algorithm cannot be used to follow up the therapy.

The efficacy of repaglinide monotherapy and in combination with metformin in Indonesian type 2 diabetes mellitus patients.

AIM: To investigate the efficacy and safety of repaglinide alone and in combination with metformin therapy. METHODS: Seventy-two type 2 diabetes patients who were oral anti-diabetic drugs (OAD)-naive or currently on OAD for </=36 months with HbA1c </=9% and fasting plasma glucose (FPG) pound 13 mmol/L were recruited. Patients were titrated for 6 weeks to a dose level which maintained fasting blood glucose at 4.4-7.0 mmol/L and continued treatment for 8 weeks. Dose regimen started with 0.5 mg repaglinide each main meal, progressing to 1.0 mg repaglinide, 1.0 mg repaglinide + metformin 500 mg b.i.d. and 1.0 mg repaglinide + metformin 500 mg t.i.d., depending on patients' glycaemic status. Patients' glycaemic control (HbA(1c) and FPG), body weight and other safety parameters were evaluated. RESULTS: Thirty-seven patients completed the trial. Patients were overweight (mean BMI 25.5 +/- 4.1 kg/m(2)) with mean age 52.5 +/- 8.8 years and mean diabetes duration of 2.4 +/- 3.8 years. Mean HbA1c (2.26 +/- 0.22%, [p <0.05]) and FPG (3.31 +/- 0.47 mmol/L, [p <0.05]) decreased significantly from baseline. Body weight did not change significantly (0.85 +/-0.45 kg, p=0.068). Of the 33 patients who had baseline FPG >7.0 mmol/L, it appeared that repaglinide alone at doses 0.5 or 1.0 mg achieved FBG <7.0 mmol/L in 67% of patients. The majority of the treatment emergent adverse events were mild and unlikely related to trial product. Episodes of symptomatic hypoglycaemia were low (9.3%) in frequency. The changes in haematology, clinical biochemistry and urinalysis were mostly minor or remained unchanged. Vital signs and the results of physical examination also remained unchanged. Three of the four withdrawals were due to adverse events but were unlikely related to trial product. CONCLUSION: treatment with repaglinide alone and in combination with metformin was efficacious in glycaemic control in OAD-naive or previous users. Most of the patients appeared to achieve good control with repaglinide alone. The treatment regimens were safe (317 words).