Corneal confocal microscopy identifies structural small fibre abnormalities in an adolescent with type 1 diabetes and impaired awareness of hypoglycaemia / Journal of the ASEAN Federation of Endocrine Societies

@#Impaired awareness of hypoglycaemia (IAH) is present in around 25-40% of individuals with type 1 diabetes mellitus (T1DM). Herein, we present a case of an adolescent with T1DM and IAH who had worse corneal nerve parameters compared to a T1DM adolescent without IAH. Small fibre abnormalities detected by corneal confocal microscopy in an objective easy-to-perform non-invasive test might be a surrogate indicator of underlying autonomic dysfunction in T1DM and IAH.

COMPLICATIONS IN DIABETES : A REVIEW

Diabetes is a disease chronic disease which affects global population from long time. This review is an update on unknown complications, causes, treatment modalities of this disease. This article also provides a summary on disease management through various strategies. Diabetic complications are the challenges associated with diabetes in the form of micro and macro vascular complications; microvascular compications include retinopathy, nephropathy and neuropathy whereas macrovascular compications include coronary artery disease (CAD), peripheral vascular disease (PVD) and cerebrovascular events (CVA). Complications of diabetes range from acute, life-threatening conditions such as severe hypoglycemia or ketoacidosis to chronic, debilitating complications affecting multiple organ systems, such as retinopathy, nephropathy, neuropathy, and cardiovascular disease. Estimates of the prevalence of diabetic complications are challenging, in part because there are no internationally agreed upon standards for diagnosis. This review is an update on unknown complications, causes, prevention and treatment of this disease. This article also provides a summary on disease management through various strategies.

Congenital Hyperinsulinemia of Infancy: Role of Molecular Testing in Management and Genetic Counseling

Congenital hyperinsulinemia (CHI) is a genetically and clinically heterogenous disorder. In addition to the standard care of management of the proband, genetic counseling regarding the risk of recurrence in the future siblings is an important part in the management of the disorder. The counseling needs identifcation of accurate etiology and is challenging due to the complexity of the molecular mechanisms of CHI. This case highlights the importance of molecular testing which not only helped in planning the management of the proband with CHI but also helped in providing genetic counseling for which the family had consulted the medical genetics department.

A young man presenting with persistent hypoglycaemia and reduced level of consciousness: case study with review of literature / 世界急诊医学杂志（英文）

@#Iatrogenic hypoglycaemia is a common acute presentation; either because of misuse, self-harm or criminal intent. The most common culprits are insulin and oral hypoglycaemics (sulfonylurea, biguanides) although aspirin, fluoroquinolone and beta blockers can be causative agents. Common symptoms include sweating, anxiety, tremors, and palpitations. Neuroglycopenic symptoms usually arise at serum glucose concentrations of <2.8 mmol/L and include dizziness, confusion, blurred vision, somnolence and more serious symptoms can be convulsions, coma and potentially death.

You are not yourself when you are hungry: a rare case of malignant insulinoma

We present a rare case of high-grade functional neuroendocrine carcinoma of the pancreas secreting insulin. Our patient, an 80 years old woman, presented with neuropsychiatric symptoms consistent with hypoglycaemia that regressed with food intake and dextrose administration. Abdominal imaging showed a pancreatic tumour with invasion of the spleen and lymph node metastasis, highly suggestive of an insulinoma as the cause of the hypoglycaemia. The patient underwent left pancreatectomy with splenectomy and atypical gastric resection. The postoperative course of our patient was uneventful, with complete remission of the hypoglycaemic episodes, and the definitive histological examination showed three poorly differentiated large cell neuroendocrine carcinomas of the pancreas.

A rare case of recurrent hypoglycaemia

Very often clinicians are confronted with unconscious patients; the cause being hypoglycaemia. In addition to correction of hypoglycaemia promptly, a search for the cause of hypoglycaemia must be attempted at the earliest with a stepwise approach. Here, the authors present a rare case of recurrent hypoglycaemia where a stepwise approach ultimately led to a diagnosis, but there were various reports which were misleading. The diagnosis was insulinoma which was apparent from the history and presenting features. But, the initial investigations, even though having high sensitivity, were normal, thus leading to a more invasive approach. The patient was ultimately cured by enucleation.

Ambulatory glucose profile as an educational tool in the management of patients with type 2 diabetes mellitus

A 60-year-old male patient with Type 2 Diabetes Mellitus (T2DM) since the last two years was presented in the clinic with repeated falls. He was on dietary treatment and was also taking metformin 500 mg twice daily, on and off. His Fasting Plasma Glucose (FPG) was 116 mg/dL, Postprandial Glucose (PPG) was 140 mg/dL and Glycosylated Haemoglobin (HbA1c) was 6.4%. The complete glycaemic profile obtained from the first Ambulatory Glucose Profile (AGP) revealed that the patient was not having hypoglycaemia and has very minimal glucose fluctuations without any post-prandial excursions. The visual cue obtained from Continuous Glucose Monitoring (CGM) / AGP enabled physicians to better inform the patient on the effects of medication and lifestyle on diabetes, thereby allowing the patient to make informed treatment and lifestyle modifications. This case study sheds light on the need to recommend AGP in such cases to provide insights on the glucose trends, thereby improve patient’s confidence in the therapy, with lifestyle modification.

Study of glucose levels in newborn with reference to hypoglycemia

Background: Hypoglycemia is one of the common metabolic problems in neonatal medicine. Early diagnosis and treatment of neonatal' hypoglycemia is important as many studies found that, hypoglycaemic episodes in neonates lead to neurodevelopmental and physical growth deficits. In this study, blood glucose levels at different time points were assessed and the influence of maternal blood glucose, mode of delivery, gestational age on neonatal blood glucose levels were studied.Methods: Blood glucose levels were low at 0 and 6th hour and maximum at 24th hour. The blood glucose levels ranged from 27 mg/dl to 140 mg/dl. Neonates with high maternal blood glucose were hypoglycaemic, showing a negative correlation.Results: The mean blood glucose levels were low in pre-term and post term babies compared to term and the range was wide in pre-term and term babies compared to post-term. The mean blood glucose levels were high and range was wide in babies delivered vaginally at all the time points compared to the babies delivered by LSCS. 17% babies were hypoglycaemic at birth but none of them had signs. The major signs noted were jitteriness (88%), high cry (88%), lethargy (55%), tremors (55%), limpness (22%), apathy (22%), weak cry (11%) and poor feeding (11%).Conclusions: 0 and 6th hour are the vulnerable time points for hypoglycaemia. Neonates with high maternal blood glucose, pre-term, post-term and babies delivered by LSCS were more prone for hypoglycaemia requiring blood glucose monitoring. There is a wide variation in signs of hypoglycaemia and babies showing signs require monitoring.

Glycemic status in exclusively breast fed low birth weight babies In first 72 hours of life in a teriary care hospital

Background: Neonatal hypoglycaemia, a common metabolic problem, often goes unnoticed owing to lack of specific symptoms. It can lead to considerable mortality and morbidity with long term neurological sequelae. Adequate breast feeding play an important role in maintaining normal glucose levels. So, this study is done to assess the incidence of hypoglycaemia in exclusively breast fed low birth weight babies, both term and preterm neonates and evaluate the impact of early breast feeding on glycaemic status upto 72 hours of life.Methods: This study was conducted over 12 month period involving 236 AGA (Appropriate for gestational age), SGA (Small for gestational age) babies with birth weight between 1.6-2.49 kg. Blood glucose values were measured at birth, 3h, 6h, 12h, 24h, 48h and 72h of life after delivery which was independent of feeding time. Hypoglycaemia was assessed against age of onset, gestational age, sex of baby, mode of delivery and time of initiation of breast feeding.Results: Total 56 episodes of hypoglycaemia were recorded in 52 babies of which 46 (27%) were term SGA babies and 6(8%) were preterm AGA babies (p=0.00148). The incidence of hypoglycaemia was found to be 22%, highest during the first 24 hours of life (93%) and delayed breast feeding is the most commonly noted risk factor (p=0.00024).Conclusions: Low birth babies are more prone to develop hypoglycaemia especially in first 24 hours of life with delayed introduction of breast feeding being one of the common risk factors and asymptomatic hypoglycaemia can be managed with frequent breast feeding without any formula feeds.

Hypoglycaemia As A Consequence Of Pre-operative Fasting: Myth Or Reality?

Background: The fatal risk of pulmonary aspiration of gastric contents during anaesthesia had since been recognized and consequently preoperative fasting guideline is usually prescribed to prevent this. Concern about development of hypoglycaemia during prolonged fasting has often been expressed, especially in children. AIM: This study is intended to determine the fasting blood glucose in preoperative patients of different age groups who were fasted for varying duration of time, and determine whether indeed hypoglycaemia occurs during inadvertently prolonged fasting which we often encounter in our practice setting. Methodology:A prospective cohort study of fasting blood glucose (FBG) of patients presenting for elective surgery in the principal investigator’s operating rooms at the National Orthopaedic Hospital, Enugu, Nigeria was carried out. Blood glucose meter was used for estimation of glucose in capillary whole blood of the patients and the obtained data were analysed using SPSS version 16.0 statistical software. Comparison of mean values was done using the Chi-square test with statistical significance put at P < 0.05. Results: Out of one hundred and thirty three patients studied with mean age of 30.2 ± 19.60 years (range: 1-72 years), and mean dura-tion of fasting 12.73 ± 2.01 hours, (range: 8-16 hours), the mean fasting blood glucose was found to be 91.49 ± 13.36mg/dl (range: 58 -124mg/dl). No relationship was found between age and FBG (Pearson’s correlation coeffi-cient, r = 0.025). Likewise duration of fasting did not relate with FBG (Pearson’s correlation coefficient, r = 0.088). One patient (0.8%) had hypoglycaemia, with blood glucose of 58mg/dl.Conclusion: Hypoglycaemia as a conse-quence of pre-operative fasting is rare, even in non-infants fasted for considerably long hours. Neither patient’s age, gender, nor duration of fasting had any significant influence on the fasting blood glucose of the patients.

Evaluation of antidiabetic activity of Tinospora cardifolia in alloxan induced diabetes in albino wistar rats

Background: The objective was to evaluate the antidiabetic activity of Tinospora cardifolia in alloxan induced diabetes in albino rats in comparison with a currently used oral hypoglycaemic glibenclamide.Methods: there were 24 rats with FBS in the range 80-115 mg/dl were selected for the study. Four groups each containing six rats, were induced diabetes with alloxan (150mg/kg). The diabetic control group (0.5ml normal saline), Standard control group (5mg/kg glibenclimide), Test group I (200mg/kg T. cardifolia) and test II group 400mg/kg T. cardifolia). FBS was recorded on 1, 3, 7, 14, 21 and 28th day using glucometer. Data was analysed by using one way ANOVA and posthoc Tukey’s test SPSS 21Version.Results: Extract of Tinospora cardifolia showed dependent hypoglycaemic action in both low dose (200mg/kg) and high dose group (400mg/kg). Hypoglycaemic action with high dose of Tinospora cardifolia is comparable to that of standard drug glibenclamide.Conclusions: This study demonstrates the hypoglycaemic action of T. cardifolia in diabetic rats. T. cardifolia can be a therapeutic potential to treat type 2 diabetes mellitus.

Hypoglycaemia among insulin-treated patients with Diabetes: Southeast Asia Cohort of IO HAT Study / Journal of the ASEAN Federation of Endocrine Societies

Objective@#To provide real-world data on hypoglycaemia incidence in patients with type 1 (T1D) or type 2 diabetes (T2D) from the Southeast Asian cohort of the International Operations Hypoglycaemia Assessment Tool (IO HAT) study.@*Methodology@#IO HAT was a non-interventional, multicentre, 6-month retrospective and 4-week prospective study of hypoglycaemic events among insulin-treated adults with T1D or T2D, including four countries in Southeast Asia (Singapore, Philippines, Indonesia, and Bangladesh). Data were collected using a two-part self-assessment questionnaire (SAQ1 for retrospective and SAQ2 for prospective). The primary endpoint was the percentage of patients experiencing at least one hypoglycaemic event during the 4-week prospective observational period (ClinicalTrials.gov Identifier: NCT02306681).@*Results@#A total of 2594 patients completed SAQ1. Nearly all patients reported experiencing any hypoglycaemic event in the 4-week prospective period (T1D, 100%; T2D, 97.3%), with all patients reporting higher rates in the prospective versus retrospective period. Severe hypoglycaemia was also reported higher prospectively (57.2% and 76.9%) than retrospectively (33.9% and 12.2%) in both T1D and T2D, respectively. Nocturnal hypoglycaemia was reported higher retrospectively than prospectively.@*Conclusion@#Incidence of any and severe hypoglycaemia in the Southeast Asian cohort of IO HAT was higher prospectively versus retrospectively, suggesting hypoglycaemia has previously been under-reported in this region.

Síndrome de interrupción del tallo pituitario: Relaciones clínicas, bioquímicas y neurorradiológicas / Pituitary stalk interruption syndrome: Clinical, biochemical and neuroradiological relationships

El síndrome de interrupción del tallo pituitario (PSIS) se caracteriza por la demostración neurorradiológica de un tallo pituitario ausente, interrumpido o hipoplásico, adenohipófisis aplásica/hipoplásica o neurohipófisis ectópica. Este síndrome se ha relacionado con formas severas de hipopituitarismo congénito (HPC), asociado a múltiples deficiencias de hormonas pituitarias (MPHD). Evaluamos a pacientes con HPC y PSIS, analizando los signos y los síntomas neonatales al diagnóstico, relacionándolos con las deficiencias hormonales pituitarias y signos neurorradiológicos presentes. Estudiamos retrospectivamente a 80 pacientes asistidos en el Hospital de Niños de Córdoba, con diagnóstico de HPC, de los cuales 42 (52%) presentaron PSIS; 22 mujeres y 20 varones, EC: 5 días-9,5 años. El 62% presentó MPHD y el 38% insuficiencia somatotrófica aislada (IGHD). El análisis de las variables perinatales demostró antecedentes de parto natural en el 52% (11/21) de las MPHD vs. 13% (2/15) de las IGHD. Cuatro pacientes, 2 con MPHD y 2 con IGHD presentaban antecedentes obstétricos consistentes en presentación podálica y transversa respectivamente, todos ellos resueltos mediante operación cesárea. Los signos y los síntomas perinatales fueron hipo- glucemia: 61% en MPHD vs. 19% en IGHD, p: 0,0105; ictericia: 38% en MPHD vs. 25% en IGHD; micropene: 77% en MPHD y colestasis: 19% en MPHD. Convulsiones neonatales se presentaron en el 75% de los niños con MPHD e hipoglucemia. EC media de consulta: 2,1 años en MPHD (30% en el período neonatal, 70% antes de 2 años) y 3,6 años en IGHD (44% en menores de 2 años). Los pacientes con MPHD presentaban: tallo no visible 81% (n: 21/26) vs. tallo hipoplásico: 19% (n: 5/26), p: 0,0001; en IGHD 56% (n: 9/16) vs. 44% (n: 7/16), p: 0,5067, respectivamente. El 100% de los neonatos con HPC tenían tallo pituitario ausente. Concluimos que la demostración de PSIS en niños con HPC proporciona información valiosa como predictor de la severidad fenotípica, la presencia de MPHD y de la respuesta al tratamiento. La baja frecuencia de antecedentes obstétricos posicionales potencialmente distócicos, como parte de los mecanismos fisiopatogénicos responsables de PSIS, indicaría la necesidad de analizar la importancia de posibles factores genéticos y epigenéticos involucrados. El diagnóstico precoz de HPC debe sospecharse en presencia de signos y síntomas clínicos, tales como hipoglucemia, colestasis, micropene y defectos asociados en la línea media facial. La resonancia magnética cerebral debe formar parte de los estudios complementarios en pacientes con esta presunción diagnóstica, especialmente a edades tempranas. El reconocimiento tardío de esta entidad puede aumentar la morbilidad y la mortalidad con efectos potenciales deletéreos y permanentes.

Pituitary stalk interruption syndrome (PSIS) is characterised by the combination of an interrupted or thin pituitary stalk, absent or ectopic posterior pituitary, and anterior pituitary hypoplasia. It is manifested as isolated (IGHD) or combined pituitary hormone deficiencies (CPHD) of variable degrees and timing of onset, with a wide spectrum of clinical phenotypes. PSIS may be an isolated morphological abnormality or be part of a syndrome. A retrospective evaluation is presented of clinical signs and symptoms present at early life stages, as well as an analysis of their relationship with hormone laboratory tests and diagnostic imaging in children with congenital hypopituitarism (CHP), and PSIS. This study was performed in a single centre on a sample of 42 children out of a total of 80 CHP patients, with a chronological age range between 5 days and 9.5 years from a database analysed over a period of 26 years. The study included 26/42 (62%) with CPHD and 16/42 (38%) with IGHD. The analysis of perinatal variables showed a natural delivery in 52% (11/21) of CPHD vs 13% (2/15) of IGHD. Four patients, two with CPHD and two IGHD had breech and transverse presentation respectively. All of them were resolved by caesarean section. The perinatal histories showed hypoglycaemia (61% CPHD vs 19% IGHD, P=.0105), jaundice (38% CPHDvs25% IGHD), micropenis (75%CPHD), hypoglycaemic seizures (75% CPHD), and cholestasis (19% CPHD). The mean CA of consulting for CPHD patients was 2.1 years, 30% in neonatal period and 70% before 2 years. The mean chronical age (CA) was 3.6 years in IGHD patients, with 44% of them less than 2 years. MRI showed that 81% of CPHD patients had absence of pituitary stalk vs 19% with thin pituitary stalk (P=.0001); Patients with IGHD presented 56% absence of pituitary stalk vs 44% with thin pituitary stalk (P=.5067). All (100%) of the patients diagnosed in the neonatal stage had absent pituitary stalk. The characterisation of GH deficient patients by presence and type of hypothalamic-pituitary imaging abnormality provides valuable information as a predictor of phenotypic severity, treatment response, and the potential to develop additional hormonal deficiencies. We conclude that demonstrating PSIS in children with HPC provides valuable information as a predictor of phenotypic severity, presence of MPHD, and response to treatment. The low frequency of potentially dysfunctional positional obstetric history, as part of the pathophysiological mechanisms responsible for PSIS, would indicate the need to analyse the importance of possible genetic and epigenetic factors involved. Early diagnosis of HPC should be suspected in the presence of clinical signs and symptoms, such as hypoglycaemia, cholestasis, micropenis, and associated facial midline defects. MRI should be part of complementary studies in patients with this diagnostic suspicion, especially at an early age. Late recognition of this entity may increase morbidity and mortality with potential permanent deleterious effects.

Hipoglucemia en pacientes con diabetes tipo 1 y tipo 2 en tratamiento con insulina. Resultados del estudio HAT en argentina / Hypoglycaemia in patients with type 1 and type 2 diabetes mellitus on insulin therapy. Results of the global HAT study in Argentina

Describimos los resultados del estudio internacional no intervencionista HAT en una muestra de Argentina que evaluó las hipoglucemias graves y no graves en 433 pacientes con diabetes mellitus tipo 1 (DMT1) y 823 con diabetes tipo 2 (DMT2) tratados con insulina, mediante un cuestionario de autoevaluación doble (retrospectivo y prospectivo). La incidencia anual de al menos un evento de hipoglucemia fue 46 episodios/paciente-año en DMT1 y 14.2 en DMT2 (retrospectivo) y 96.5 y 24.6 eventos/paciente/año en DMT1 y DMT2, respectivamente (prospectivo). La hipoglucemia influyó en la calidad de vida (en escala 0-10 de temor a hipoglucemia: 60% en DMT1 y 37.6% en DMT2 puntuó de 5 a 10), en el desempeño cotidiano, laboral o académico (2.1% con DMT1 y el 3.2% con DMT2 no asistieron a su labor por hipoglucemia) y en el mayor consumo de recursos (en DMT1: 66.1% aumentó el monitoreo glucémico, 60.5% la ingesta, 51% las consultas y 60.5% redujo la insulina y el 20.9% el ejercicio, con 3.5% de internación, y en DMT2 aumentó un 46.2% el monitoreo glucémico, 43.8% las consultas, 38.6% la ingesta, el 24.1% redujo y el 13.9% salteó la dosis de insulina, 14.3% suspendió el ejercicio). Se registró mayor número de episodios en el período prospectivo. Es necesario contar con un instrumento para evaluar las hipoglucemias en la práctica clínica y con estrategias para reducir su riesgo. También es importante indagar sobre los episodios y reforzar la educación de pacientes y familiares sobre ajustes de tratamiento ante episodios de hipoglucemia.

We describe the results of the HAT study in 433 Argentinean patients with type 1 diabetes (T1D) and 823 with type 2 diabetes (T2D). HAT was an international non-interventional study assessing severe and non-severe hypoglycaemia in patients with T1D and T2D under insulin treatment through a two-part self-assessment questionnaire (retrospective and prospective). The annual incidence of at least one hypoglycaemic episode was 46 episode/patient/year in T1D and 14.2 in T2D (retrospective), 96.5 and 24.6 episode/patient/year in T1D and T2D, respectively (prospective). Hypoglycaemia affected quality of life (on a scale of 0-10 for fear of hypoglycaemia: 60% in T1D and 37.6% in T2D scored 5 to 10), daily life, occupational or academic performance (2.1% with T1D and 3.2% with T2D did not attend to their work after hypoglycaemia), and induced an increased use of health resources (T1D: 66.1% increased glucose monitoring, 60.5% food intake, 51% consultations, 3.5% hospital admissions; 60.5% reduced insulin and 20.9% exercises; T2D increased 46.2% glucose monitoring, 43.8% consultations, 38.6% food intake, 24.1% reduced and 13.9% skipped the insulin dose and 14.3% suspended exercises). Greater numbers of episodes were recorded in the prospective period. An instrument to assess hypoglycaemia in clinical practice and strategies to reduce their risk are required. It is also important to ask about the episodes and reinforce the education of patients and close relatives on hypoglycaemia prevention and treatment.

Embolización de metástasis hepáticas en insulinoma maligno: de la hipoglicemia a la hiperglicemia / Embolisation of liver metastasis in malignant insulinoma: from hyperglycaemia to hypoglycaemia

Resumen Se describe el caso de un paciente de 75 años sin antecedentes de relevancia, que fue diagnosticado con insulinoma maligno en estado avanzado, con metástasis hepáticas, con síntomas por hipoglucemia hiperinsulinémica refractaria al tratamiento, y con diazóxido y octreotide de acción corta. El paciente presentó una respuesta clínica poco esperada a la embolización transarterial de metástasis hepáticas, pues a pesar de que persisten las lesiones tumorales, desarrolló hiperglucemia persistente y requirió manejo con insulina. Adicionalmente, se hace una breve revisión de la literatura sobre las opciones terapéuticas disponibles para el tratamiento sintomático de la hipoglucemia hiperinsulinémica.

Abstract The case is presented of a 75 year-old man who was diagnosed with malignant insulinoma in an advanced stage with diffuse liver metastases and symptoms due to hyperinsulinaemic hypoglycaemia refractory to treatment with diazoxide and short-acting octreotide. The patient had an unexpected clinical response to trans-arterial embolisation of liver metastases, since, despite still having the tumour, he developed persistent hyperglycaemia that required insulin treatment. A brief review of the literature is also presented on the treatment options for hyperinsulinaemic hypoglycaemia.

The mechanism of drug interactions of a selected antiarrhythmic drug with metformin, in different animal models

ABSTRACT This study was carried out to understand the influence of a selected antiarrhythmic drug on the pharmacodynamics and pharmacokinetics of an antidiabetic drug in animal models. Pharmacodynamic and pharmacokinetic responses were determined by measurements of blood glucose and serum insulin and serum metformin to drug interactions between disopyramide and metformin. Single dose and multi dose studies showed that the maximum blood glucose reductions in normal and diabetic rats were at the 6th hour, and in rabbits at the 3rd hour. Glucose-insulin homeostasis was evaluated to assess the safety and effectiveness of the combination. There was a marginal increase in the pharmacokinetic parameters of metformin with multiple dose treatments of disopyramide but no significant changes in kinetic parameters between single and multiple dose studies, compared to metformine alone. There may be a possibility of disopyramide and metformin interaction at the excretion stage, or an additive pharmacodynamic action. This study validates the drug interaction in two dissimilar species, which indicates more probability of its occurrence in humans.

Comparative Study of NPH Insulin with Glargine in Patients of Type 2 Diabetes Mellitus Poorly Controlled With Oral Hypoglycaemic Agents.

Background: Type 2 Diabetes Mellitus is an emerging pandemic with number of patients increasing rapidly in both developed and developing nations. In patients with secondary failure of type 2 diabetes after oral hypoglycaemic agents (OHAs), Insulin is the treatment, which is available in various forms with respect to viable duration of action. Basal Insulins or background insulins are used commonly either alone or with short acting insulins. NPH insulin is intermediate acting insulin given once or twice daily whereas Glargine is long acting insulin given once daily. Methods: In this study, 120 patients of type 2 diabetes mellitus already on oral hypoglycaemic agents who were not optimally controlled with combination of 2 or 3 oral hypoglycaemic agents were included after excluding patients of Type 1 diabetes, gestational diabetes and those who were newly diagnosed or already on insulin therapy. Patients were divided into 2 groups of 60 patients each. Group A were put on NPH insulin and Group B on Glargine insulin for 12 weeks. Along with parameters of diabetes and side effects were compared with special reference to early morning hypoglycaemia (at 3 am).Results: Mean reduction in fasting blood glucose was 54.42 mg/dl in Group A as compared to 66.62 mg/dl in Group B, which was statistically significant with a p value < 0.0001. Regarding hypoglycaemia it was seen in 31.67% in Group A vs. 11.67% in Group B and was significant (p=0.0078). Nocturnal hypoglycaemia was also seen to be more in Group A than Group B with values of 21.67% and 5% respectively, which was significant. There was no significant difference in daily dose requirement. Conclusion: This study showed that Insulin Glargine was better than Insulin NPH in terms of glycemic control and less side effects with respect to hypoglycemic events and nocturnal hypoglycemia with no significant difference in daily dose requirements.

Practice Of Self-Monitoring Blood Glucose Among Insulin-treated Diabetic Patients In Hospital Serdang

Background: Diabetes Mellitus (DM), characterised by chronic hyperglycaemia, exposes patients to acute and chronic complications, such as hypoglycaemia and vascular complications, respectively. The latter is associated with the degree of glycaemic control. Glycated haemoglobin (HbA1c) indicates long-term glycaemic control of the preceding 2-3 months. The practice of self-monitoring blood glucose (SMBG) is essential for insulin-treated diabetic patients to achieve optimum glycaemic control and prevent hypoglycaemia. Aim: The study aimed to determine the SMBG practice and frequency and its association with HbA1c and factors in insulin-treated diabetic patients. Methods: This was a cross-sectional study of insulin-treated diabetic patients attending follow-up at the diabetic clinic of Hospital Serdang from April 2015 to August 2015. Consented eligible patients completed validated selfadministered questionnaires. Patients’ HbA1c results were obtained from the hospital information system. Results: Ninetyone of 137 (66%) patients practiced SMBG and 46 (34%) did not. Although 82% had seen diabetic nurses, 54% of patients did not alter their treatment accordingly. Neither the practice nor the frequency of SMBG was significantly associated with differences in HbA1c levels (p=0.334 and p=0.116 respectively). Ethnicity and household income significantly affected SMBG practice. The presence and frequency of hypoglycaemia significantly increased the likelihood of SMBG practice (p<0.001) and frequency (p<0.001). Conclusions: The prevalence of SMBG practice in diabetic patients on insulin was 66%. However, SMBG was not followed by proper treatment alteration in 54% of patients. There was no association between SMBG practice and frequency with good glycaemic control. Hypoglycaemia significantly affected the practice and frequency of SMBG.

Cross-Cultural Adaptation and Linguistic Validation of the Hypoglycaemia Symptom Rating Scale (HypoSRQ) among Malaysian Patients with Diabetes Mellitus

The Hypoglycaemia Symptom Rating Questionnaire (HypoSRQ) is potentially useful for local research on hypoglycaemia. However, it requires adaptation and validation in local settings. This study reports the process and results of cross-cultural adaptation and linguistic validation of HypoSRQ for Malay and English versions in our local setting. The HypoSRQ underwent forward and backward translation and adaptation with support from professional translators and a clinical psychologist. Cognitive debriefing was done among patients with Type 1 and Type 2 diabetes mellitus from varying sociodemographic backgrounds. Discussion was done together with the original developers of the HypoSRQ to decide on the best version for local use. The finalised versions were proofread and formatted with the help of Health Psychology Research. Cognitive debriefing for Malay version involved 7 patients and for the English version5 patients. Direct literal translation into Malay language was unsuitable due to technical terms which were difficult for laypersons to understand. Amendments were made based on findings from the cognitive debriefing process. Participants found the questionnaire fairly easy to understand. The HypoSRQ-My (Malay) and HypoSRQ-EMy (English) is easily understood by local participants. These tools may undergo psychometric evaluation for future use in local settings.

DiabCare 2013: A cross-sectional study of hospital based diabetes care delivery and prevention of diabetes related complications in Malaysia

Aims: The aim of the study was to re-evaluate the relationship between hospital based diabetes care delivery and prevention of complications. Methods: DiabCare is an observational, non-interventional, cross-sectional study of hospital-based outpatient diabetes care. Results: A total of 1668 patients participated in the study: mean age 57.8 ± 11.0 years, duration of diabetes 13.0 ± 8.6 years, and duration of insulin treatment 5.6 ± 5.5 years. Mean weight was 74.3 ± 16.6 kg (BMI 29.1 ± 5.8 kg/m2). The majority of patients were female (53.6%) and the largest ethnic group was Malay (51.3%), followed by Indian (21.9%) and Chinese (20.1%). The percentage of patients with HbA1c < 6.5% (< 42 mmol/mol) and < 7.0% (< 53 mmol/mol) was 12.2% and 23.8%, respectively (mean HbA1c 8.52 ± 2.01% [70 ± 22 mmol/mol]). The proportion of patients using insulin was 65% at a total daily dose of 60 ± 37 IU. One or more episodes of hypoglycaemia were reported by 39% (n=658) of patients within the previous three months. The risk of any hypoglycaemia was associated with the use of insulin (odds ratio [OR 3.26, 95% CI 2.59–4.09]), and total daily insulin dose (OR 1.04, 95% CI 1.01–1.07 per 10 IU increase). Mean HbA1c had not changed significantly between DiabCare cohorts 2008 and 2013 (p=0.08). Conclusions: Despite evidence of improving processes of diabetes care, glycaemic control and the prevalence of many diabetes related complications were unchanged.