Patient Characteristics, Disease Burden, Treatment Patterns and Outcomes in Patients with Acromegaly: Real-World Evidence from the Malaysian Acromegaly Registry.

Objective: This study aims to report the demographic features of patients with acromegaly, the disease burden, and the corresponding treatment patterns and outcomes in Malaysia. Methodology: This is a retrospective study that included patients from the Malaysian Acromegaly registry who were diagnosed with acromegaly from 1970 onwards. Data collected included patient demographics, clinical manifestations of acromegaly, biochemical results and imaging findings. Information regarding treatment modalities and their outcomes was also obtained. Results: Registry data was collected from 2013 to 2016 and included 140 patients with acromegaly from 12 participating hospitals. Median disease duration was 5.5 years (range 1.0 - 41.0 years). Most patients had macroadenoma (67%), while 15% were diagnosed with microadenoma. Hypertension (49.3%), diabetes (37.1%) and hypopituitarism (27.9%) were the most common co-morbidities for patients with acromegaly. Majority of patients had surgical intervention as primary treatment (65.9%) while 20.7% were treated medically, mainly with dopamine agonists (18.5%). Most patients had inadequate disease control after first-line treatment regardless of treatment modality (79.4%). Conclusion: This registry study provides epidemiological data on patients with acromegaly in Malaysia and serves as an initial step for further population-based studies.

Growth management and prevalence of underweight of indigenous children (Orang Asli) in Peninsular Malaysia: a clinical audit.

BACKGROUND: Most indigenous people (Orang Asli in Peninsular Malaysia) live in poverty, and their children are at risk of growth problems due to nutrition deficiency. Routine health and growth assessments are essential to identify these children. This clinical audit aimed to determine the growth management of indigenous children and the prevalence of underweight among these children in Perak state, Malaysia. METHODS: A clinical audit was conducted in 2016 after obtaining consensus from stakeholders for audit criteria, forms, and procedures. All weight-for-age growth charts of Orang Asli children aged 2 and below were sampled for retrospective audit. This audit excluded children who required special needs. Growth charts were examined against audit criteria: (i) quality of growth chart plotting (charts were not plotted, incompletely plotted, or incorrectly plotted), (ii) presence of underweight, and (iii) appropriateness of action taken (appropriate or inappropriate action) according to local standard operating policies. Eligible auditors were first trained using simulated growth charts. RESULTS: Out of 1329 growth charts audited, 797 (60%) growth charts were correctly plotted, 527 (39.7%) were incompletely or incorrectly plotted, and five (0.3%) were not plotted. Overall, 40.0% of the growth chart was plotted incorrectly or completely not plotted. 550 (41.4%) children were found to be underweight, and 71.5% of them received inappropriate care management. Where growth charts were correctly plotted, 283 children were identified with underweight problems, and 194 (68.6%) of them received inappropriate care. For growth charts that were plotted incompletely or incorrectly, 267 children were identified as having underweight problems, and 199 (74.5%) received inappropriate care. The growth status of 265 (19.9%) children was unable to be determined due to incomplete plotting. CONCLUSION: Approximately 40% of indigenous Orang Asli children aged 2 years and under were underweight, and most of them received inappropriate care.

Statins-related peripheral neuropathy among diabetic patients.

BACKGROUND: Peripheral neuropathy (PN) is a complaint with often unidentified reasons. Some medicines, including statins therapy, are anticipated to be amongst the reasons for PN. AIMS: This study intended to assess the association of peripheral neuropathy with statins therapy amongst Type 2 diabetic patients. METHODS: At Penang General Hospital, 757 cases were categorized into two groups (564 with statins therapy and 193 without statins therapy). The diagnosis of PN was investigated retrospectively for a period of 10 years (2006-2016). Confounding risk factors as age, diabetes period, hypertension, glycemic control, other co-morbidity, and prescriptions were matched. RESULTS: About 129 (22.9%) cases from 564 statins users had PN. Only 30 (15.5%) subjects had PN from 193 statins non-users. Chi-square test showed a significant variance among statins treatment cohort and statin-free cohort in the occurrence of PN (P-value: 0.001). Spearman's investigation presented a positive correlation (r: 0.078, p-value: 0.031) among statins use and PN prevalence. Binary logistic regression was statistically significant for statins therapy as a predictor of peripheral neuropathy incidence (r2: 0.006, p-value: 0.027) amid diabetic patients. The relative risk of peripheral neuropathy connected with statins therapy is (RR: 1.47, 95% CI: 1.02-2.11). The excess relative risk is 47.1%. While the absolute risk (AR) is 7.3% and the number needed to harm (NNH) is 14. CONCLUSIONS: The study indicated a positive association between peripheral neuropathy and statins utilization. Peripheral neuropathy was higher amongst statins users than the statins-free group.

Evaluation of statins impacts on cognitive function among diabetic patients.

AIMS: The study was intended to evaluate the association of cognitive impairment with statins therapy among diabetic outpatients. METHODS: Mini-Addenbrooke's Cognitive Examination (M-ACE) was conducted for 280 cases in a cross-sectional study at Hospital Pulau Pinang. M-ACE score is 30, and the cut-off score for mild cognitive impairment is ≤ 21 and ≤ 16 for dementia. RESULTS: The cognitive impairment was distributed among 59 (55.1%) patients with mild cognitive impairment and 48 (44.9%) patients with dementia. From 177 patients using statins, about 80 (45.2%) cases had cognitive impairment. While from 103 statins non-users, only 27 (26.2%) had cognitive impairment. The relative risk of cognitive impairment associated with statins use in diabetic patients is (RR: 1.72, 95% CI: 1.2-2.48) and the excess relative risk is 72.4%. The absolute risk is 19%, and the number needed to harm is 6. Spearman's test indicated a positive association between statins usage and cognitive impairment incidence (r: 0.188, p-value: 0.002). However, Spearman's test showed a non-significant correlation amongst statins and dementia incidence (P-value: 0.587, RR: 1.16, 95% CI: 0.67-2.02). CONCLUSIONS: Statins therapy has a higher association with cognitive impairment risk than statins-free treatment; however, there is no association between statin use and dementia incidence among diabetic patients.

Prescribing statins among patients with type 2 diabetes: The clinical gap between the guidelines and practice.

BACKGROUND: Statins are recommended for cardiovascular protection for people with diabetes (high-risk groups). This study aimed to evaluate the gap between the guidelines of statin utilization and clinical practice among outpatients with type 2 diabetes regarding the patient's age and gender, to assess if this preventive drug is being satisfactorily utilized or not. MATERIALS AND METHODS: In this cross-sectional study, patients aged <40 or >75 years, pregnant patients, and patients with type 1 diabetes, human immunodeficiency virus, or liver cirrhosis were excluded. Demographics, laboratory parameters, and prevalence of exposure to statin therapy were evaluated. This study was guided by the 2013 American College of Cardiology/American Heart Association cholesterol guidelines. IBM SPSS software was used for data management. RESULTS: The study cohort involved 576 patients, with age being 58.3 ± 8.9 years. There were 50.5% of females and 49.5% of males. Overall 81.1% of patients aged 58.8 ± 8.8 years were statin users and 18.9% of patients aged 56.2 ± 9 years were statin nonusers. About 83.2% of females and 78.9% of males were prescribed statins. Statin medications included simvastatin 79.2%, atorvastatin 11.6%, lovastatin 5.8%, rosuvastatin 2.1%, and pravastatin 1.3%. Statin users' and nonusers' adherence was 56.5%, and 41.3% (P = 0.004), respectively. The adherence to medication plan of females and males was 55.7% and 51.6%, respectively (P = 0.004). CONCLUSION: Patients with diabetes who are at high risk of cardiovascular events, exposure to statin treatment is significantly less than perfect position both in females and males. Nearly one-fifth of the patients with type 2 diabetes are not using statins despite therapeutic necessities.

Untreated Giant Macroprolactinoma with Chronic Cerebrospinal Fluid Leakage: An Unusual Complication.

Macroprolactinoma has the potential to cause base of skull erosion and often extends into the sphenoid sinus. Rapid shrinkage of this invasive tumor following dopamine agonist therapy has been postulated to cause unplugging of the eroded area, leading to cerebrospinal fluid leakage. To the best of our knowledge, the occurrence of spontaneous cerebrospinal fluid leak in treatment-naive prolactinomas is very rare, the majority of which involve undiagnosed macroprolactinomas. We describe here a lady presented late with giant macroprolactinoma, complicated by cerebrospinal fluid leakage. This case raised the dilemma in the management pertaining to the role of either pharmacotherapy or surgical intervention, or combination of both. As she strictly refused surgery, she was treated with bromocriptine which was later changed to cabergoline. On follow-up, there was cessation of cerebrospinal fluid leak, marked reduction of serum prolactin level, and imaging evidence of tumor shrinkage. The majority of patients with medically induced cerebrospinal fluid leakage will require surgical procedures to overcome this complication; however, there are isolated cases of leakage resolution on continuing dopamine agonist therapy while awaiting surgery. The use of dopamine agonist does not necessarily cause worsening of cerebrospinal fluid leakage and instead may produce spontaneous resolution as in this case.

Challenges in the classification and management of Asian youth-onset diabetes mellitus- lessons learned from a single centre study.

It remains widely perceived that early-onset Type 2 Diabetes (T2D) in children and adolescents is rare and clinically distinct from Type 1 Diabetes (T1D). We studied the challenges of classifying subtypes of early-onset diabetes using clinical features and biomarkers, and management of these patients. We reviewed retrospectively the record of patients < 25 years old who attended the diabetes clinic in Penang General Hospital, Malaysia between 1st December 2012 and 30th June 2015. We examined their clinical features, C-peptide and pancreatic autoantibodies. Comparisons were made between T1D and T2D for magnitude, demographics, metabolic status and complications. We studied 176 patients with a mean age of 20 ± 3.7 years, 43.2% had T1D, 13.6% had T2D, and 13.6% had mixed features of both. When tested, pancreatic autoantibodies were positive in 59.4% of the T1D. T2D presented two years later than T1D at 14.3 years, 20% were asymptomatic at presentation, and 50% required insulin supplementation despite fasting c-peptide of > 250 pmol/L. HbA1C of ≤ 8.0% (64 mmol/mol) was achieved in 30.3% of T1D, 58.3% of T2D on OAD and 16.7% of T2D on insulin. The T2D had greater cardiovascular risk with higher body mass index, more dyslipidaemia, higher blood pressure and earlier onset of nephropathy. The overlapping clinical features, variable autoimmunity, and beta-cell loss complicate classification of young diabetes. Pancreatic autoantibodies and C-peptide did not always predict diabetes subtypes nor respond to insulin. The poor metabolic control and high cardiovascular risk burden among the T2D highlight the need for population-based study and focused intervention.

Drug-drug Interaction-related Uncontrolled Glycemia.

CONTEXT: The literature of drug-drug interaction (DDI)-related uncontrolled causality, and preventability of DDI-induced UCG (HbA1c >7%) in outpatients glycemia (UCG) among outpatients with Type 2 diabetes mellitus is still limited. AIMS: The aim of this study is to identify the prevalence, mechanism, severity, with Type 2 diabetes. SETTINGS AND DESIGN: A cross-sectional study was conducted in Penang General Hospital. METHODS: A computerized system for DDI checking was used to assess the severity and mechanism of DDIs. Drug interaction probability scale was used to evaluate the likelihood of DDIs. Preventability of DDIs has been determined by the instrument of Hallas. The UCG prevalence related to DDIs was further assessed. STATISTICAL ANALYSIS USED: SPSS 21.00 was used in this study. RESULTS: From 425 outpatients with HbA1c% test, their mean age was 58.7 ± 12.8 years. Only 225 (52.9%) cases had controlled glycemia while 200 (47.1%) cases with UCG. They had multiple comorbidities, with a mean number of 3.8 ± 2.2/patient and often prescribed with multiple medications, with a mean number of 6.33 ± 4.67/patient. It has been detected that 86 DDIs causing UCG in 46 patients (23%) with range of (1 - 4) DDIs per patient. Drugs with DDI-induced UCG were as follows: diuretics (79%), salbutamol (9.2%), cortisones (5.8%), and others (6%). The majority of these DDIs were categorized as possible (77.9%) and preventable (37%). CONCLUSION: Nearly one-quarter of UCG was induced by DDIs; most of these DDIs are possible, and more than one-third are preventable. It was concluded that thiazide diuretics have the highest prevalence of DDI-related UCG.