Prevalence of diabetic foot disorders and related risk factors among Egyptian subjects with diabetes.

INTRODUCTION: Multiple pathologies including diabetic neuropathy, peripheral vascular disease (PVD) and infection contribute to lower extremities amputation in diabetes. AIM: We examined the prevalence of diabetic foot problems and related risk factors in Egypt. SUBJECTS AND METHODS: Between July 2008 and December 2009, 1000 male and 1000 female consecutive adult patients with diabetes (≥ 18-year-old) attending the Alexandria University Diabetic Foot Screening Clinic were surveyed for history/presence of foot ulcers and/or amputations, skin/nail changes, joint mobility, sensory neuropathy (10 g-Semmes-Weinstein Monofilament) and peripheral vascular disease (PVD) using Ankle Brachial Index (ABI). RESULTS: The majority of patients had type 2 diabetes (96.75%) with a mean age of 57.30 ± 10.47 years and a mean disease duration of 11.76 ± 8.26 years. The mean body mass index was 32.84 ± 6.31 kg/m(2) with 29.55% being current or ex-smokers. In these subjects, 4.4% had a past history of non-traumatic amputation (male:female: 6.2% vs. 2.6%, p < 0.001); 6.1% had past history (10.3% vs. 7%, p = 0.009) and 8.7% had active foot ulceration (8.1% vs. 4.1% p < 0.001) with a male preponderance. The prevalence of sensory neuropathy was 29.3% (M:F: 30.7%: 27.9%) and peripheral vascular disease (PVD) was 11% (M:F 11.8%:10.2%). Diabetic foot complications were associated with disease duration (p < 0.001), history of coronary artery disease (p = 0.001), stroke (p = 0.009), PVD (p < 0.001), laser photocoagulation (p < 0.001), sensory neuropathy (p < 0.001) and renal replacement therapy (p < 0.001). On multivariate analysis, diabetes duration, foot fissures, Charcot's foot, limited joint mobility, PVD and sensory neuropathy remained independently associated with diabetic foot disorders. CONCLUSION: In Egypt, a mosaic of risk factors contributes to the high prevalence of diabetic foot disease in type 2 diabetes. These findings call for regular assessment of vascular, neuropathic and skin status to prevent these serious foot complications.

Similar glucose control with basal-bolus regimen of insulin detemir plus insulin aspart and thrice-daily biphasic insulin aspart 30 in insulin-naive patients with type 2 diabetes: Results of a 50-week randomized clinical trial of stepwise insulin intensification.

OBJECTIVE: This study aimed to demonstrate the non-inferiority of 50-week treatment with stepwise insulin intensification of basal-bolus insulin analogues [insulin detemir (IDet) and aspart (IAsp)] versus biphasic insulin aspart 30 (BIAsp30) in insulin-naive type 2 diabetes mellitus (T2DM) patients not controlled by oral glucose-lowering drugs (OGLDs). RESEARCH DESIGN AND METHODS: In this open-label multicentre, multinational, randomized, parallel-arm treat-to-target trial, 403 insulin-naive patients with T2DM in four African countries were randomized to either an IDet+IAsp (n = 200) or BIAsp1-2-3 (n = 203) treatment group. Stepwise insulin intensification was performed at the end of 14, 26 and 38 weeks, depending on HbA1c values. The primary endpoint was change in HbA1c after 50 weeks of treatment. Safety variables were hypoglycaemia incidence, occurrence of adverse events and weight gain. RESULTS: Non-inferiority of the IDet+IAsp versus BIAsp1-2-3 treatment regimen was demonstrated by their similar HbA1c levels at the end of trial (IDet+IAsp: baseline 8.6%, 50 weeks 7.4%; BIAsp1-2-3: baseline 8.7%, 50 weeks 7.3%; full analysis set difference: 0.1% [95% CI: -0.1, 0.3]; per protocol: 0.2% [95% CI: -0.1, 0.4]). At week 50, 40.3 and 44.9% of patients achieved HbA1c <7.0% with IDet+IAsp and BIAsp1-2-3, respectively. The rate of overall hypoglycaemia during the trial was also similar in both groups (IDet+IAsp: 9.4 events/patient-year; BIAsp1-2-3: 9.8 events/patient-year). CONCLUSION: Insulin initiation and intensification using IDet+IAsp was not inferior to BIAsp1-2-3 in insulin-naive patients with T2DM not controlled by OGLDs. Both regimens led to similar reductions in HbA1c values after 50 weeks of treatment.

Barriers to the delivery of optimal antidiabetic therapy in the Middle East and Africa.

BACKGROUND: The prevalence of type 2 diabetes is increasing worldwide, but developing nations will bear a disproportionate share of this burden. Countries in the Middle East and Africa are in a state of transition, where marked disparities of income and access to education and healthcare exist, and where the relatively young populations are being exposed increasingly to processes of urbanisation and adverse changes in diet that are fuelling the diabetes epidemic. Optimising diabetes care in these nations is crucial, to minimise the future burden of complications of diabetes. METHODS: We have reviewed the barriers to effective diabetes care with special relevance to countries in this region. RESULTS: The effects of antidiabetic treatments themselves are unlikely to differ importantly in the region compared with elsewhere, but economic inequalities within countries restrict access to newer treatments, in particular. Values relating to family life and religion are important modifiers of the physician-patient interaction. Also, a lack of understanding of diabetes and its treatments by both physicians and patients requires more and better diabetes education, delivered by suitably qualified health educators. Finally, sub-optimal processes for delivery of care have contributed to a lack of proper provision of testing and follow-up of patients in many countries. CONCLUSION: Important barriers to the delivery of optimal diabetes care exist in the Middle East and Africa.

Barriers to the delivery of diabetes care in the Middle East and South Africa: a survey of 1,082 practising physicians in five countries.

AIMS: Developing countries face a high and growing burden of type 2 diabetes. We surveyed physicians in a diverse range of countries in the Middle East and Africa (Egypt, Kingdom of Saudi Arabia, United Arab Emirates, South Africa and Lebanon) with regard to their perceptions of barriers to type 2 diabetes care identified as potentially important in the literature and by the authors. METHODS: One thousand and eighty-two physicians completed a questionnaire developed by the authors. RESULTS: Most physicians enrolled in the study employed guideline-driven care; 80-100% of physicians prescribed metformin (with lifestyle intervention, where there are no contraindications) for newly diagnosed type 2 diabetes, with lifestyle intervention alone used where metformin was not prescribed. Sulfonylureas were prescribed widely, consistent with the poor economic status of many patients. About one quarter of physicians were not undertaking any form of continuing medical education, and relatively low proportions of practices had their own diabetes educators, dieticians or diabetic foot specialists. Physicians identified the deficiencies of their patients (unhealthy lifestyles, lack of education and poor diet) as the most important barriers to optimal diabetes care. Low-treatment compliance was not ranked highly. Access to physicians did not appear to be a problem, as most patients were seen multiple times per year. CONCLUSIONS: Physicians in the Middle East and South Africa identified limitations relating to their patients as the main barrier to delivering care for diabetes, without giving high priority to issues relating to processes of care delivery. Further study would be needed to ascertain whether these findings reflect an unduly physician-centred view of their practice. More effective provision of services relating to the prevention of complications and improved lifestyles may be needed.

Clinico-radiological considerations in the treatment of frontal sinus mucoceles.

THE PURPOSE OF THIS STUDY: To review our experience in the management of frontal sinus mucoceles with emphasis on the presentation and role of preoperative imaging in the choice of the surgical approach. MATERIAL AND METHOD: A retrospective audit of patients with frontal sinus mucoceles who were treated by the first author (HSK) was carried out. All patients had a diagnosis of frontal sinus mucoceles confirmed on clinical findings, CT and Magnetic Resonance Imaging. The operative findings were also recorded. RESULTS: Fourteen patients with frontal sinus mucoceles were treated between January 2005 and June 2009. The mean age of the patients was 52.6 years (range 21-88 years). There were 9 males (64.3%) and 5 females (35.7%). The presenting symptoms of the patients in this series were periorbital swelling (35.7%), headache (35.7%), frontal swelling (21.4%) and proptosis (14.3%). The anterior table of the frontal sinus was eroded in 64.3% of patients and the posterior table in 50%. A complete intrasinus septum was found in only 14.3% of patients. One patient (7.1%) had a Type IV Kuhn cell. The operative findings were in keeping with the radiological features. CONCLUSION: The radiological features of the mucocele were crucial in the decision-making process for the choice of the surgical technique. The state of anterior and posterior table of frontal sinus, type of Kuhn cell and presence of a complete intrasinus septum all influence the choice of surgical approach.

Sinonasal T-Cell lymphomas: A clinicopathologic study of a possibly distinct entity.

BACKGROUND: Most cases of sinonasal lymphomas reported in the literature which show positive expression for Epstein-Barr virus are CD2+, CD3-, CD43+ and CD56+, and also show a germ-line T-cell receptor genotype. Five-year survival is usually around 50%. We report a group of patients with T-cell sinonasal lymphoma that showed distinct immunophenotypic and molecular profiles and a more aggressive behavior. PATIENTS AND METHODS: Nineteen cases representing approximately 75% of sinonasal lymphoma diagnosed and treated at our institution between 1988 and 1997 were studied. They comprised 12 males and 7 females, with an age range of 10 to 73 years (median 46 years). The remaining cases (about 25%) were B-cell lymphomas. The morphology of the cases was evaluated together with a limited immunophenotyping. In situ hybridization for EBV mRNA was performed in 18 cases. Polymerase chain reaction (PCR) for T-cell receptor (TCR) gene rearrangement was performed in 15 cases. Clinical follow-up information was available on 14 patients. All cases showed a pattern of large-cell lymphoma, and three exhibited an immunoblastic morphology. The tumors showed extensive soft tissue invasion, necrosis and ulceration. While perineural invasion was a prominent feature, perivascular invasion was not noticed. RESULTS: Seventeen tumors (84%) were CD3 positive. PCR analysis showed TCR gene rearrangement in 7 of 15 cases (46%). Fifteen cases (79%) were positive for EBV. The 14 patients with available clinical information had extensive local diseases, with stages ranging from IE to IIIE, where none showed positive bone marrow involvement. The 14 patients received chemotherapy with or without radiation therapy. Ten of the 14 patients (71%) died of the disease after a median of seven months, including all seven patients with positive TCR gene rearrangement. CONCLUSION: Our findings suggest that sinonasal T-cell lymphoma represents a heterogeneous group of diseases with different phenotypic, genotypic and biological characteristics. Cases that show TCR gene rearrangement may represent a more aggressive subtype of the disease.

Changes in hematologic parameters associated with liver transplantation.

Full text is available as a scanned copy of the original print version.

Hemophagocytic syndrome.

Full text is available as a scanned copy of the original print version.

Reference range values of hematological parameters in Saudi healthy adults.

Full text is available as a scanned copy of the original print version.

Mutation of p16, p21 or cyclin dependent kinase 4 is rare in acute lymphoblastic leukaemia.

Homozygous deletion of the p16 tumour suppressor gene (at frequencies ranging from 14% to 29%) have been implicated in the pathogenesis of acute lymphoblastic leukaemia (ALL) by several studies. We investigated the prevalence of this deletion in a group of 46 Arab patients with common ALL. Deletion of p16 was assessed in a multiplex PCR which amplified a 405 bp fragment from exon 2 of the p16 gene, and a 242 bp fragment of the ApoE lipoprotein gene which served as an internal control. Homozygous deletion of p16 in tumour cells could be readily detected in samples containing >75% blasts. Surprisingly, none of the cases in our study showed homozygous deletion of the p16 gene. We also investigated the possibility of other genetic alterations in the p16 gene or mutation in the p21 and CDK4 (not previously reported in ALL) genes which are part of the same signal transduction pathway. A heterozygous G --> A transition at nucleotide position 273 of the p16 gene was present in one patient, but did not result in an amino acid change. A C --> A transversion at codon 88 of the p21 gene, which results in replacement of a phenylalanine with a leucine at position 63, was detected in one patient. In another patient a G --> C transversion in exon 2 at codon 82 (5'-untranslated region of the CDK4 gene) was detected. Results of this study showed mutation of p16, p21 or CDK4 to be rare events in Arab ALL patients.

Application of polymerase chain reaction to detect rearrangement of immunoglobulin heavy chain genes in lymphoproliferative disease.

As part of our routine work-up in the diagnosis of lymphoproliferative disease, we used a rapid polymerase chain reaction (PCR) assay to amplify the DNA fragments of the framework 3 (FR3) region of the immunoglobulin heavy (IgH) chain genes. The assay does not involve hybridization, nested priming, or sequencing of the amplified PCR product. It was performed on 66 specimens of B-cell lymphoproliferative disease, including acute lymphoblastic leukemia, chronic lymphocytic leukemia, multiple myeloma, hairy cell leukemia and follicular lymphoma. Twenty-six specimens of negative controls, including acute myeloid leukemia, chronic myeloid leukemia in myeloid transformation and idiopathic thrombocytopenic purpura, were also analyzed. The assay was performed with 77% sensitivity and 100% specificity. The standard IgH chain gene rearrangement by Southern blot analysis is reserved for the remaining negative cases if clinically indicated.

Detection of BCL-2 gene rearrangement in follicular lymphoma by polymerase chain reaction and chemiluminescence technique.

The incidence of follicular lymphoma in Saudi Arabia is very low compared to that in Western countries. We analyzed 22 diagnosed cases, based on conventional morphology examination and immunohistochemistry, to detect the Bcl-2 gene rearrangement by polymerase chain reaction (PCR). The DNA was extracted from formalin-fixed paraffin-embedded lymph node tissues by the standard xylene treatment and proteinase K digestion method. Rearrangement of the major breakpoint region was evident in 8 of the 22 cases (36%), determined by visualization of a discrete band hybridized with a chemiluminescence-labeled specific probe. Although the number of cases is small, we believe it denotes a normal detection rate for PCR analysis, using DNA isolated from fixed tissue. With the exception of follicular lymphoma, non-Hodgkin's lymphoma (NHL) analyzed included diffuse large cell lymphoma, lymphoblastic lymphoma, chronic lymphocytic leukemia, mucosa-associated lymphoid tissue and mantle zone lymphomas. No Bcl-2 gene rearrangement was detected in any of these cases. No evidence of Bcl-2 minor cluster sequence gene rearrangement was detected in any of the 38 NHL cases analyzed.

Bone marrow morphologic findings in patients with human immunodeficiency virus (HIV) infection.

The hematologic, histologic and morphologic bone marrow findings of 18 patients with human immunodeficiency virus (HIV) infection were reviewed. The mean age of the patients studied was 27 years; age range was six to 63 years. The main bone marrow morphologic finding was hypercellularity (72%), which was mainly due to megakaryocytic hyperplasia with or without granulocytic or erythrocytic hyperplasia. Naked (denuded) megakaryocytic nuclei, which are considered an indicator of HIV infection, were present in 72% of the bone marrows examined. Reticuloendothelial iron blockade was identified in 78% of cases. Other less frequent findings included erythrocytic dysplasia (44%), plasmacytosis (28%), nonspecific granulomas (17%), Hodgkin's and non-Hodgkin's lymphoma (17%), lymphocytic aggregates (11%) and histiocytosis (6%) . The bone marrow findings in this series of HIV patients appear to be similar to what has been previously reported from other countries.

The Sebastian platelet syndrome. Report of the first native Saudi Arabian patient.

Sebastian platelet syndrome is an hereditary thrombocytopenia with giant platelets and inclusion bodies in the granulocytes consisting of dispersed filaments, clusters of ribosomes and a few segments of rough and smooth endoplasmic reticulum at the ultrastructural level, similar to those observed in Fechtner syndrome (a variant of the Alport syndrome)--Sebastian platelet syndrome lacks the additional clinical features such as high frequency deafness, congenital cataract, and chronic interstitial nephritis. Here we report the fourth case worldwide and the first of an Arabian ancestry.

Immunophenotyping of acute leukemia at King Faisal Specialist Hospital and Research Centre.

During a 20 month period, 133 bone marrow samples from an equal number of patients with acute leukemia were immunophenotyped. Patients ranged in age from two to 68 years with a mean of 23 years. Eighty-four (63.2%) were classified as acute lymphocytic leukemia (ALL) with the following immunologic subclassification: common ALL 83.3%, T-cell ALL 11.9%, null-cell ALL 2.4% and 2.4% differentiated B-cell ALL. Twenty-eight cases (21%) were classified as acute myeloid leukemia (AML) and 16 cases (12%) demonstrated biphenotypic features. Concordance with morphology and cytochemistry was observed in 129 cases (97%). Four cases (3%) manifested discrepancy between immunophenotyping, morphology and cytochemistry. We conclude that immunophenotyping by flow cytometry is a useful and reliable method for classification of acute leukemia, especially when interpreted in the light of morphology and cytochemistry.

Immunophenotyping of childhood acute lymphoblastic leukemia in Saudi Arabia: second look.

Geographical variations in the incidence of disease are of considerable theoretical and practical importance. It has been claimed that the distribution of acute lymphoblastic leukemia (ALL) phenotypes in Saudi Arabia is different from that recorded in the Western literature. One hundred and twelve (112) patients under 15 years of age, diagnosed as ALL between January 1992 and May 1994 had immunophenotypes performed on their blast cells. Common ALL (cALL) together with pre-B-ALL, formed 86.5% of the total; B-cell 3%, T-cell 6% and null cell 4.5%. These figures are not significantly different from the Western literature. A previous claim from this institution in 1990, that both null and B-cell ALL were significantly increased compared with elsewhere, is not supported by the present figures. Age and sex distribution, and FAB classification, L1 77%, L2 20% and L3 3%, were also of the same order as described elsewhere and, in particular, there was no increase in the frequency of L3 subtype.

Some genetic, clinical and immunologic interrelations in schistosomiasis mansoni.

The aim of the present work was to study the possible association of some class I, II MHC gene products with variations in the clinico-pathological outcome of human schistosomiasis mansoni as well as with the variability in immune responsiveness. The study was carried out on 47 patients with schistosomiasis mansoni and 20 healthy volunteers served as control group for the immunological parameters and 200 subjects for the genetic studies. The following were determined: class I, II HLA typing, serum IgG, IgM, C3c, immediate intradermal test and passive haemagglutination using S mansoni worm antigen, T lymphocyte subsets, delayed intradermal test and leukocyte migration inhibition using phytohaemagglutinin (PHA) and soluble egg antigen (SEA) of S mansoni. A statistically significant association was found between HLA-B5 and DR3 and with the occurrence of hepatosplenic disease; this phenotype also correlated with changes in T lymphocyte subsets and high immune reactivity, both humoral and cell mediated. HLA-DQI was also associated with failure to develop hepatosplenic disease. The present study consolidates also the view of the important role of host immune reactivity in the clinical outcome of schistosomiasis mansoni and demonstrates the contribution of the genetic impact on both clinical and immunological heterogeneity of the disease.

Immuno-metabolic factors in schistosomal hepatic fibrosis modulating atherogenesis.

Clinical expression of atherosclerosis is infrequent among patients with schistosomal hepatic fibrosis (SHF), besides, the latter disease is a disease with many immunological expressions. The aim of the present work was to search for a possible immunological and metabolic interaction which would modulate atherogenic mechanisms. The study was carried out on 31 patients with SHF and 20 non-schistosomal subjects (10 with evident clinical atherosclerosis and 10 without). All investigated subjects were males aged above 40 years, and were subjected to the following: serum lipoprotein pattern, total cholesterol, phospholipids, triglycerides, ApoA, ApoB, IgG, IgM, IgA, C3 + circulating immune complexes (CICs) and passive haemagglutination using S mansoni adult worm antigens. The results showed low levels of blood lipids in patients with SHF especially in those with porto-systemic collaterals; serum levels of IgG and IgM were significantly increased in all patients with SHF, while IgA was only increased in patients with collaterals who in turn showed the least incidence of clinically evident atherosclerosis; serum C3 was increased in patients with clinical atherosclerosis, both schistosomal and non-schistosomal. CICs have been higher in patients with SHF without atherosclerosis while decreased in atherosclerosis patients, both schistosomal and non-schistosomal. Our results may consolidate the view of a protective role of liver affection against atherogenesis as well as the important contribution of the immune mechanisms in this context.