The management of diabetic ketoacidosis at a rural regional hospital in KwaZulu-Natal

Background: Diabetic ketoacidosis (DKA) is a biochemical triad of hyperglycaemia, ketoacidosis and ketonaemia and one of the potentially life-threatening acute metabolic complications of diabetes mellitus. This study aimed at describing the clinical profile of patients presenting with DKA to a busy rural regional hospital in KwaZulu-Natal. Methods: A retrospective review of clinical notes of patients presenting with DKA to the Emergency Department was performed over a 10-month period. Data included patients' demographic profile, clinical presentation, precipitating factors, comorbidities, biochemical profile, length of hospital stay and outcome.Results: One hundred and five black South African patients above the age of 12 years were included in the study. Sixty-four (60.95%) patients had type 1 diabetes mellitus (T1DM) and 41 (39.05%) patients had type 2 diabetes mellitus (T2DM). Patients with T2DM were significantly older than those with T1DM (52.1 ± 12.4 years vs. 24.4 ± 9.5 years, p < 0.0001). The acute precipitant was identified in 68 (64.76%) cases with the commonest precipitant in T1DM patients being poor adherence to treatment, whereas in T2DM, the most common precipitant was infection. Nausea and vomiting were the most common presenting symptoms with the majority of patients presenting with non-specific symptoms. Fifty-seven (54.29%) cases had pre-existing comorbidities, with higher prevalence in T2DM than T1DM patients. Glycated haemoglobin was severely elevated in the majority of patients. Patients remained hospitalised for an average of 8.9 ± 7.5 days. The mortality rate was 17.14%, and 12 of the 18 deaths occurred in patients with T2DM.Conclusion: The prevalence of DKA was higher in patients with T1DM and those with pre-existing comorbidities. The mortality rate remains alarmingly high in older patients with T2DM

Cystatin C: An Early Marker of Cardiac Complications in Diabetics.

Introduction: Cardiovascular disease is one of the common complications of Diabetes mellitus. Serum Cystatin C level has been suggested as a marker for cardiac complications in diabetes. Material and Methods: We studied serum Cystatin C level in Diabetics to fi nd if correlation exists between cardiac complications and elevated Cystatin C levels. Results: A total of 50 diabetics were studied out of whom 25 had cardiac complications and the rest did not have cardiac complications. No signifi cant diff erence was observed between Serum Cystatin C levels of diabetics with cardiac complications (mean 1∙5±0∙45) and diabetics without cardiac complications (1∙4±0∙46) although Cystatin C levels were found to be elevated in diabetic cases. Conclusion: Keeping in view the signifi cant diff erence (p=0∙000) in Cystatin C levels of healthy and diabetic patients, it is reasonable to accept the importance of Cystatin C as an indicator of diabetes and its associated complications.

Prevalence des complications medicales chez les diabetiques hospitalises a l'hopital general de reference nationale de Ndjamena

INTRODUCTION. La prevalence du diabete au Tchad est importante et se chiffre a 12;9% chez les personnes de 55 ans et plus en milieu urbain. Mais malgre cela il n'existe aucune donnee sur sa morbimortalite. Ce travail a voulu combler partiellement ce vide. Il avait pour but de decrire les complications medicales du diabete en milieu hospitalier a N'Djamena. MeTHODE. Il s'agit d'une etude retrospective couvrant une periode de 06 ans (Janvier 2007 a Decembre 2013); qui a porte sur 1481 dossiers de patients hospitalises dans les services de medecine de l'hopital general de reference nationale. Les donnees etudiees etaient la frequence des complications medicales ainsi que les pathologies frequemment associees. ReSULTATS. La frequence hospitaliere du diabete etait de 4% avec predominance du type 2 (89;6%). Le sex-ratio etait Homme /femme etait de 1;8 et l'age moyen des patients etait de 51ans. L'evolution moyenne du diabete etait de 4;4 ans. Le niveau d'equilibre etait mediocre avec une hemoglobine glyquee moyenne de 8;3%. Les principales complications etaient le suivantes : cetoacidose (35;9%); plaies diabetiques (21;9%); myocardiopathies hypertensives (12%) et retinopathies (10;5%). Les pathologies associees etaient les suivantes: anemies (36;4%); hypertension arterielle (31;9%) et l'obesite (30%). Le taux de mortalite etait de 16;4%. Les principales causes de mortalite etaient l'insuffisance renale (44%); le neuropaludisme (36%); l'accident vasculaire cerebral (30%) et les plaies diabetiques (21%). CONCLUSION. a N'djamena; le diabete est plus frequent chez les hommes et il est en regle mal equilibre. Les complications chroniques apparaissent tot et le taux de mortalite est eleve. Les causes de mortalite les plus frequentes sont l'insuffisance renale; le neuropaludisme; et les accidents vasculaires cerebraux

Smoking and Hypertension: A Study in Subjects Admitted to Hospital for Cardiovascular Diseases.

Aims: There is a general consensus in considering cigarette smoking as a major risk factor for cardiovascular diseases: a direct causal association between smoking and hypertension however is questioned. The present paper reports a study on the effect of cigarette smoking and of other clinical parameters on hypertension in a sample of subjects admitted to Hospital for Cardiovascular Diseases (CVD). Study Design: Observational study. Place and Duration of Study: Department of Cardiology Valmontone Hospital and Department of Biomedicine and Prevention, University of Rome Tor Vergata, between April 2007- December 2013. Methodology: We have studied 335 subjects admitted to the Hospital for Cardiovascular Diseases. Statistical analyses were in the study that was approved by the Ethical Committee. We have considered hypertension in relation to smoking, diabetes, age and sex. Results: Multivariate statistical analyses have shown a high significant effect of age (P<.001) and diabetes (P<.01) on hypertension and a border line effect of smoke (P=.05). No effect of sex has been detected (P=.47). The proportion of subjects with hypertension is positively correlated with the number of risk factors examined. Conclusion: Our data indicate that an independent effect of smoking on blood pressure is relatively small and suggest an additive effect of the variables considered on the risk of hypertension.

Perioperative optic neuropathy in patients undergoing off‑pump coronary artery bypass graft surgery.

Aims and Objectives: Perioperative optic neuropathy (PON) is a rare, but devastating complication following coronary artery bypass graft surgery (CABG). We performed a retrospective study of PON associated with off‑pump CABG (OPCABG) to identify possible risk factors. Materials and Methods: 1442 patients underwent OPCABG over a 10‑month period from October 2008 to August 2009; PON was identified in four (0.28%) patients. A retrospective review of the charts was done to identify the patient characteristics, pre‑operative status, intra‑operative details, and ophthalmic examination details. Friedman test was used to compare the hematocrit (Hct) and the mean arterial pressure (MAP) values across the three time periods: Pre‑, intra‑ and post‑operative periods. Results: All four patients were male, diabetic, and in the age range 51‑69 years. All patients noted unilateral or bilateral severe visual loss in the immediate post‑operative period, which was permanent. All the four patients had statistically significant decrease in the Hct (P < 0.039) and mean arterial blood pressure (P < 0.018) in the intraoperative and post‑operative period when compared to pre‑operative value. Conclusions: PON is a rare but definite possibility in patients undergoing OPCABG. Diabetes mellitus may be a risk factor. Perioperative hemodynamic abnormalities like decrease in MAP and anemia may play a role in the development of PON in OPCABG.

Cerebrovascular Diseases and Associated Risk Factors in WHO Eastern Mediterranean Countries.

Background: In the WHO Eastern Mediterranean region, nearly one million deaths are caused by cardio-vascular diseases every year. During the last decade, the number of deaths caused by stroke increased by 23%. Most cardiovascular diseases can be prevented by addressing behavioural risk factors such as tobacco use, alcohol, unhealthy diet, physical inactivity, and metabolic risk factors like obesity, high blood pressure, diabetes and raised lipids. Methods: This is a systematic review on cerebrovascular diseases and associated risk factors in WHO Eastern Mediterranean countries. Medline, Science Direct, and other sources were used to get peer reviewed papers dealing with the review theme. The search was limited to publications between 1990 and 2013 (30th June). Results and Discussion: According to the inclusion criteria, 45 papers were included in the present review. The prevalence was found greater than 50% in 38 studies for hypertension, greater than 25% in 36 studies for diabetes, greater than 15% in 26 studies for smoking and greater than 25% in 19 studies for dyslipidemia. It was also indicated that incidence of stroke increases with ageing. The majority of studies found a prevalence of stroke higher in men than in women with a ratio male: female reaching 3.55:1 in one study. Conclusion: Although at different levels of importance, all the studies reveal that hypertension, diabetes, dyslipidemia and smoking are crucial risk factors for stroke. This review also indicates a lack or scarcity of studies in many countries with an uneven contribution by country since 33% of studies are from Pakistan whereas North Africa (Egypt, Morocco, Libya, Tunisia) contributed with only 2 papers.

Foot Wear and Footcare Knowledge - An Independent Risk Factor for Diabetic Foot in Indian Diabetics.

Diabetic foot lesions are significant health and socioeconomic problems holding adverse effect on the quality of life and imposing a heavy economic burden on patient or state. In Indian diabetics poor knowledge about footwear and foot care ,social and religious customs like walking barefoot, walking on fire also have significant role in diabetic foot problems beside traditional risk factor like peripheral neuropathy, peripheral vascular disease.

Berardinelli-Seip syndrome type 1 in an Egyptian child.

Berardinelli‑Seip syndrome type 1 or Berardinelli‑Seip congenital lipodystrophy 1 (BSCL1) is a very rare genetic disorder characterized by lipoatrophy, hypertriglyceridemia, hepatomegaly and acromegaloid features. Its prevalence in Egypt is not known. Here, we report case of a 12‑year‑old Egyptian boy with the clinical, metabolic and molecular genetics manifestations of BSCL1 including overt diabetes mellitus.

Erectile dysfunction in patients with chronic hepatitis C virus infection

Hepatitis C virus [HCV] infection is a major public health problem worldwide and in Egypt. Several studies have suggested that chronic HCV infection may be associated with erectile dysfunction [ED] in men. The aim of our study was to detect the prevalence of ED among male patients with chronic HCV infection. The study included 150 male patients with chronic HCV infection [124 patients with chronic hepatitis and 26 patients with HCV-associated liver cirrhosis]. The Child-Pugh score was used to assess the severity of cirrhosis. An Arabic validated version of the five-item International Index of Erectile Function [IIEF-5] was used to detect the presence and severity of ED. The patients' age ranged from 20 to 80 years with mean age +/- standard deviation [SD; 50 +/- 17.19] years. The prevalence of ED among patients with chronic HCV infection was found to be 29.3%. The prevalence was significantly higher in cirrhotic as compared to chronic hepatitis patients [p < 0.001] and the average ED score was significantly lower in patients with liver cirrhosis than in those with chronic hepatitis. There was a highly significant relation between the severity of ED and the severity of liver disease. There was a significant negative correlation between serum bilirubin and ED score and a significant positive correlation between serum albumin and ED score in patients with liver cirrhosis. About 30% of patients with chronic HCV infection were found to have ED: so, given the high prevalence of HCV infection in Egypt, chronic HCV infection may be considered in the differential diagnosis of ED. There was a highly significant relation between the severity of ED and the severity of liver disease and the majority of patients with liver cirrhosis proved to be suffering from ED, which may be related to the associated hypoalbuminaemia

Dental management of diabetic patients: a clinical review

Diabetes describes a group of metabolic diseases resulting from impaired insulin secretion, varying degrees of insulin resistance, or both. Management of the diabetic dental patients must take into consideration the impact of dental disease and dental treatment on the management of diabetes as well as an appreciation for the comorbidities that accompany long-standing diabetes. Those comorbidities include obesity, hypertension and dyslipidemia. Management of the diabetic dental patient should focus on periodontal health and the delivery of comprehensive dental care with minimal disruption of metabolic homeostasis and recognition of diabetic comorbidities

Retrograde Venous Perfusion in Chronic Ulcers of Lower Limb.

Chronic foot ulcers are difficult to treat. These patients need prolong treatment which is costly and often associated with non-compliance. These patients are vulnerable to develop gangrene leading to amputation. Retrograde venous perfusion (RVP) is a new therapeutic approach which was recently introduced to the treatment of diabetic foot as an adjunctive line to systemic therapy and local therapy. It is based on principle of regional anesthesia. Recently, Latin American investigators, applied this approach to local therapy of pedal ischemia. Since then this approach was mainly employed for therapy of diabetic neuropathic pedal ulcers. In this work, the efficacy of this approach was explored in 5 group of chronic foot disorder – 1) Diabetic foot presenting as foot infection, 2) Dibetic neuropathic pedal ulcers, 3) Diabetic pedal ischemia and infection, 4) Nondiabetic post traumatic foot ulcers, 5) Non-diabetic ischemic ulcer and pre-gangrene or gangrene. The present study was conducted on 56 patients having non healing ulcer of lower limb. Regular dressing and debridment and retrograde venous perfusion therapy was done in all patients. Results were assessed after completion of therapy. The following conclusions are drawn from the present study. Out of all diabetic patients, 23.7% of cases presented as diabetic foot. The incidence of diabetic foot patients was 64.29% out of all studied patients with ulcer foot. Maximum number of patients, 28.57% were in 31-40 years age group. The mean age of the patients was 44.4 years. There was male predominance with male and female ratio being 1.55:1. Mean reduction of ulcer size after RVP therapy was 63.89%. Maximum improvement was found in patients with diabetic pedal ischemia and infection i.e. 70% where as patients with non diabetic post traumatic foot ulcers had minimum improvement i.e. 52.22%. Whole foot or more than 4 toe amputation was not required in any patient in therapy group. After RVP therapy gangrene or pre-gangrene was prevented in 72.73% of patients. Minimum days of stay was 11-15 days in 32.14% of patients. Average duration of hospital stay was 18 days. Patients with foot ulcer in whom RVP therapy was not done, average duration of hospital stay was 31 days. This denotes that RVP reduces the time of therapy an avoids prolonged treatment. The ratio of diabetic and non-diabetic patients with neuropathy was 2.5:1. In Doppler ultrasound study, patients with sign of ischemia, ankle-brachial pressure index was less than 0.6 in 22 patients, out of them 16 patients were diabetic. After RVP therapy 93.33% of diabetic foot patients and 80% of non-diabetic foot ulcer patients ankle-brachial ratio became more then 0.8 denoting that after RVP therapy the blood flow in lower limb was increased. The present study confirms the good result in respect to decrease in ulcer size, overcome critical complications which are threatening the foot, early healing of ulcer, increase blood flow in ischemic foot, check progression of gangrene and pre-gangrene and to conserve the foot to avoid amputation. This study entailed expansion of the application of RVP to intractable post-traumatic ulcers of the foot and lower leg, as well as, to critical pedal ischemia in diabetic and non-diabetic patients.

Mucormicosis rinocerebral asociada a agranulocitosis más diabetes mellitus: presentación de un caso / Rhinocerebral mucormycosis associated with agranulocytosis and diabetes mellitus: a case report

La mucormicosis es una infección oportunista, poco frecuente y potencialmente letal causada por hongos del orden mucorales. Pueden ser de varias formas: rinocerebral, (que es la más frecuente), pulmonar, cutánea, gastrointestinal, del sistema nervioso central y la miscelánea. Comienza habitualmente en las fosas nasales, senos paranasales o paladar.Caso clínico: paciente de 71 años de edad, de piel blanca, femenina que presentó la forma rinocerebral asociada a agranulocitosis más diabetes mellitus.Conclusiones: en la paciente se observaron lesiones localizadas en las fosas nasales, seno maxilar, etmoidal y órbita. Se demuestra que por su especificidad como método para el diagnóstico, el uso de la tomografía axial computarizada es de gran valor, lo que permite una correcta orientación terapéutica, junto a la debridación quirúrgica amplia de áreas anatómicas afectadas y el uso adecuado del anfotericina b así como el resto de los medicamentos, permitieron una evolución satisfactoria con una recuperación completa en un tiempo corto

Mucormycosis is an opportunist; rare, potentially lethal infection caused by fungi of the order of Mucolares. They may be of several forms: rhinocerebral, (which is the most common), pulmonary, cutaneous, gastrointestinal, central nervous system and miscellaneous. It usually begins in the nasal pits, paranasal sinuses, or palate.Case report: a white skin, female patient of 71 years old, who presented the rhinocerebral form associated with agranulocytosis and diabetes mellitus.Conclusions: the patient showed lesions in the nasal pits, maxillary and ethmoidal sinus, and orbit. It is demonstrated by its specificity as a diagnostic method, the great value of the computerized axial tomography, allowing a proper therapeutic orientation, with the comprehensive surgical procedure of the anatomical areas and the proper use of the amphotericin B as well as the rest of the drugs, enabled a satisfactory evolution with a total recovery in a short time

Diabetes: Part 2. Management of Diabetes Including Hypoglycaemia and Complications

N.A.

[Evaluation of chemical urine dipstick for detection of albuminuria]

Microalbuminuria is a marker for nephropathy in diabetic patients and recognition of albuminuria is an important step for early detection and evaluation of diabetes complications. To assess the reliability of urine dipstick tests for detection of albuminuria. The first morning urine samples from candidates for urinanalysis were collected and the results of dipstick tests for protein on 200 selected samples recorded. Urine albumin concentration was determined by electroimmunoassay and the level of urine creatinine determined by Jaffe method. The albumin/creatinine ratio was further calculated as an index of urine albumin excretion rate. Comparing with reference method, the sensitivity, specificity, positive predictive value [PV+], and negative predictive value [PV-] of dipstick test for detection of microalbuminuria were calculated. Based on results obtained by dipstick test, 69 urine samples were negative for presence of protein, 51 trace [ +/- ], 22 [1+], 27 [2+], and 31 [3+]. Detection limit of dipstick for urine albumin concentration ranged from 58 to 585 mg/L with a mean of 280 mg/L. When the reference method for detection of protein in urine samples was used, 35 urine specimens were negative for albuminuria, 85 with microalbuminuria, and 80 with macroalbuminuria. Dipstick test was found to produce false positive and negative results of 3 and 25%, respectively. The sensitivity, specificity, PV+, PV- of dipstick test for detection of microalbuminuria were calculated at 70, 86, 96, and 37.5%, respectively. Chemical dipstick test is of poor sensitivity for detection of microalbuminuria. However, the severity of albuminuria among considerable numbers of diabetic patients is high enough to be detectable by urine dipsticks. While the positive predictive value of chemical urine dipstick tests are more or less at acceptable limit, the negative predictive values are controversial and need to be reevaluated by more sensitive and specific methods

Electron microscopic study of the myelinated nerve fibres and the perineurial cell basement membrane in the diabetic human peripheral nerves

To study the quantitative and ultrastructural changes in myelinated nerve fibers and the basement membranes of the perineurial cells in diabetic nerves. The study was performed at the Department of Anatomy, Faculty of Medicine, King Abdul-Aziz University, Jeddah, Saudi Arabia from 2003 to 2005. Human sural nerves were obtained from 15 lower limbs and 5 diabetic nerve biopsies. The total mean and density of myelinated nerve fibers per fascicle were calculated, with density of microtubules and mitochondria in the axoplasm. The number of the perineurial cell basement membrane layers was counted, and thickness of the basement membrane was measured. Among the 15 diabetic and 5 normal human sural nerves, the average diameters, number and surface area of myelinated nerve fibers and axonal microtubules density were found to be less in diabetic nerves. Mitochondrial density was higher in diabetic axons. Thickness of the perineurial cell basement membrane had a greater mean, but the number of perineurial cell layers was less than that of the diabetic group. The inner cellular layer of the perineurium of the diabetic nerves contained large vacuoles containing electron-dense degenerated myelin. A few specimens showed degenerated myelinated nerve fibers, while others showed recovering ones. Retracted axoplasms were encountered with albumin extravasation. Diabetes caused an increase in perineurial permeability. The diabetic sural nerve showed marked decrease in the myelinated nerve fibres, increase degenerated mitochondria, and decreased microtubules

Prevalence of neuropathy in the diabetic foot

To illustrate the prevalence of different types of neuropathy in diabetic patients with diabetic foot. This is a retrospective study of 229 diabetic foot patients treated at Princess Haya Hospital Hyperbaric Department, Aqaba, Jordan from January 1997 to January 2008, who were found to have different types of neuropathy. Neuropathy diagnosis was reached through investigating the patient's history by presence of pain, and clinical neurological examination, absence of ankle reflexes, and abnormal quantitative sensory testing. We found that 203 out of 229 [89%] patients had at least one type of neuropathy. One hundred and seventy-one out of 203 [84.2%] patients had symptoms of peripheral neuropathy, 11.8% of patients showed symptoms of different autonomic neuropathy, 2.5% of patients had been diagnosed with proximal neuropathy, and 1.5% had focal neuropathy. The mean age of diabetes in complicated neuropathy was 14.32 +/- 7.17 years. A stocking sensory loss was the leading symptom of peripheral neuropathy [77%] followed by symptoms of tingling, burning, or prickling sensations in 70% of patients. Symptoms and signs of peripheral neuropathy are considered the most important factors when counseling the diabetic patient, who should be thoroughly informed on the importance of applying ample care to the feet. The physician should consider the patient's age and chronicity of diabetes, and as they increase, it becomes imperatively important to conduct clinical examinations for early diagnosis of neuropathy