Vasculitis-panniculitis mimicking unresolved diabetic foot ulcer.

Summary: Diabetes foot ulcer (DFU) is a common long-term complication of diabetes. Intractable chronic wounds to standard care of diabetic foot raise the question of whether other factors intervene in disease development. We report a case of a 54-year-old male patient who came to Sardjito General Hospital with leg pain and previous history of multiple debridement and amputation for DFU referred from a remote hospital yet no improvement was evident in the surrounding lesion following treatment. Consequently, a histopathological examination was carried out proving the presence of other aetiologic factors, vasculitis and panniculitis existing in the lesion. In this case, we report a rare type of causative factor of foot ulcers among diabetic patients. Vasculitis suspected for polyarteritis nodosa accompanied by panniculitis is considered in this patient. The treatment of choice is corticosteroids or immunosuppressants based on the clinical condition, contrary to usual wound care in DFU. Based on the evidence, clinicians need to consider other causes than only macrovascular complications in a diabetic patient with DFU that is intractable to standard wound care. In this patient, vasculitis may be considered in forming diabetic foot ulcers alongside macrovascular complications. Learning points: A thorough examination is essential to rule out other processes in intractable DFU patients. Prompt management based on proper diagnosis is crucial to prevent peripheral arterial disease complications. Vasculitis and macrovascular complication are inseparable processes forming DFU in this patient.

The Association between Abdominal Obesity, Metabolic Syndrome and Survival Outcomes in Patients with Breast Cancer.

BACKGROUND: Obesity and metabolic syndrome (MetS) have been linked to the risk of developing certain cancers. This study aimed to analyze the association between obesity markers, MetS and survival outcomes of patients with breast cancer. METHODS: This study retrospectively investigated patients with hormone receptor-positive, human epidermal growth factor receptor 2-negative (HR+/HER2-), nonmetastatic breast cancer diagnosed between January 2010 and December 2019. Data on clinical conditions, body mass index (BMI), waist-to-hip ratio (WHR), MetS, time of metastasis and death were collected. RESULTS: A total of 223 breast cancer patient records were eligible for analysis. Obesity (BMI ≥ 25) was found in 38.1% of cases. Abdominal obesity measured as WHR ≥ 0.85 was found in 48.9%. Metabolic syndrome was detected in 56.1% of patients and was associated with older age (OR = 2.196, p = 0.005), postmenopausal status (OR = 2.585, p = 0.001), obesity (OR = 5.684, p = 0.001) and abdominal obesity (OR = 2.612, p = 0.001). Obesity was not associated with poor disease-free survival (DFS) or overall survival (OS), while abdominal obesity was modestly associated with poor DFS (HR = 1.539, p = 0.083) and OS (HR = 3.117; p = 0.019). Multivariate analysis revealed that WHR ≥ 0.85 was independently associated with unfavorable DFS (HR = 1.907, p = 0.027). Patients with MetS had a similar survival rate to those with normal metabolism. CONCLUSION: In Indonesian women with HR+/HER2- breast cancers, obesity and MetS were not associated with poor survival outcomes. The abdominal obesity marker (WHR) was more accurate in predicting unfavorable DFS.

Obesity, leptin, and deregulation of microRNA in lipid metabolisms: their contribution to breast cancer prognosis.

Obesity and Metabolic Syndrome have been associated with cardiovascular, diabetes and cancer incidence. Obesity is a state of inflammation. There are cross-talks between adipocyte, adipokines, pro-inflammatory cytokines, insulin, leptin, and other growth factors to initiate signals for proliferation, anti-apoptosis, and angiogenesis. Those networks lead to cancer initiation, promotion, progression, and metastasis. Post menopause women with breast cancer commonly have overweight, obesity, and metabolic syndrome, which are previously reported as conditions to be associated with breast cancer prognosis. MicroRNAs (miRNAs), small non-coding RNA that regulate gene expression, are known to play important roles either in metabolic or carcinogenesis process in patients with breast cancer. Some miRNAs expressions are deregulated in persons either with obesity, breast cancer, or breast cancer with co-morbid obesity. This literature review aimed at reviewing recent publications on the role of obesity, leptin, and microRNA deregulation in adverse prognosis of breast cancer. Understanding the influence of deregulated miRNAs and their target genes in patients with breast cancer and obesity will direct more studies to explore the potential prognostic role of obesity in breast cancer from epigenetic points of view.

Persistent Left Superior Vena Cava Identified After Hemodialysis Catheter Insertion: A Case Report.

INTRODUCTION: Central venous catheter (CVC) insertion is the most commonly performed clinical procedure when a patient initiates hemodialysis. Despite its clinical benefits, CVC insertion has several risks of complications. Thrombosis, venous stenosis, infection, arrhythmia, pneumothorax, and bleeding are among these complications. Malposition of the tip of the CVC can also occur with an incidence of up to 7%. One of several factors that could contribute to malposition is venous anatomy variation. Persistent left superior vena cava (PLSVC) is an extremely rare venous anatomical disorder but might have a significant clinical impact. CASE PRESENTATION: Here we report a PLSVC case that was identified in chest radiography after the insertion of a CVC catheter in a patient with end-stage renal disease (ESRD). A 40-year-old woman with a history of type 2 diabetes mellitus, hypertension, dyslipidemia, and obesity was presented in the emergency room with dyspnea for 1 week. Acute hemodialysis was required because of the ESRD and pulmonary edema. The PLSVC condition accompanied by various complications that occurred in this patient became a dilemma for the nephrologist in determining the diagnosis and proper CVC management. DISCUSSION: PLSVC is the most common congenital abnormality of the vena cava, even though it has a very small incidence. PLSVC occurs in about 0.1-0.5% of the total population and reaches 10% in individuals with congenital heart abnormalities. Most PLSVC presents along with normal superior vena cava and drains into the right atrium, which makes it very difficult to see the clinical signs and symptoms. Almost all PLSVC conditions are found incidentally during or after invasive procedures such as CVC insertion. CVC insertion in the PLSVC condition needs proper management to minimize the risk of complications. CONCLUSION: This case shows the importance of understanding the PLSVC condition, which, although very rare, is expected to increase the awareness of the nephrologist in making the diagnosis, determining appropriate management, and preventing complications, thereby improving patient safety.

Leptin, adiponectin and resistin concentration in obesity class I and II at Sardjito Hospital Yogyakarta.

AIM: to determine the level of different concentration of leptin, adiponectin and resistin among obesity class I and class II population. METHODS: cross sectional study was conducted from June 2006 until January 2007 on 57 patients with obese diabetic and non diabetic Native Javanese. They were divided into obese class I (body mass index [BMI] >25 kg/m2 to <30 kg/m2) and obese class II (BMI >30 kg/m2). Leptin, adiponectin and resistin level concentration were measured. RESULTS: leptin concentration in obese class I was 13.998 +/- 13.486 ng/ml; adiponectin was 3.98 +/- 1.78 microg/ml; resistin were 25.676 +/- 13.434 ng/ml. Leptin concentration in obese class II 31,074 +/- 26,158 ng/ml; adiponectin 4.75 +/- 1.88 microg/ml; resistin 25.46 +/- 12.26 ng/ml. Leptin concentration was significantly higher in obese class II than obese class I (p=0,002) and there was a positive weak correlation between BMI and leptin level, with Spearman correlation {coefficient correlation 0.363 (p=0.006)}. Adiponectin and resistin concentration was not significantly higher in obese class II than obese class I (p=0.156 and p=0.956). CONCLUSION: leptin concentration in obese class II was significantly higher than in obese class I but adiponectin and resistin were not different.

ACE gene insertion/deletion polymorphism among patients with type 2 diabetes, and its relationship with metabolic syndrome at Sardjito Hospital Yogyakarta, Indonesia.

AIM: To know the frequencies of insertion/deletion polymorphism in the angiotensin-converting enzyme (ACE) gene among patients with type 2 diabetes and its relationship with metabolic syndrome at Sardjito Hospital Yogyakarta. METHODS: We examined 69 patients with type 2 diabetes at Sardjito Hospital Yogyakarta, divided 2 groups based on ATP III criteria of metabolic syndrome. To determine the ACE genotype of the patients, a genomic DNA fragment on intron 16 of the ACE gene was amplified by polymerase chain reaction (PCR) using a forward primer 5'-CTG GAG ACC ACT CCC ATC CTT TCT-3' and reverse primer 5'-GAT GTG GCC ATC ACA RTC GTC AGA T-3'. II genotype 1 band on 490 bp (homozigot), DD genotype 1 band on 190 bp (homozigot) and ID genotype 2 band (heteroduplex) on 490 bp and 190 bp were separately detected on a 3% agarose gel containing ethidium bromide. RESULTS: Of 69 patients with type 2 diabetes, there were 51 females (73.91%) and 18 males (26.09%). Subjects with metabolic syndrome were 49 patients (71.02%) while without metabolic syndrome were 20 patients (28.98%). Subjects with II, DD, ID genotype were 57.97%, 23.19% and 18.84% respectively. The male subjects with II, DD, ID genotype were 55.56%, 27.78% and 16.67% respectively, and the female subject II, DD ID genotype were 58.82%, 21.57% and 19.61% respectively. The association between ACE I/D polymorphism and metabolic syndrome in type 2 diabetes, was not significant (p=0.204). CONCLUSION: The frequency of ACE I/D polymorphism among type 2 diabetes are 57.97% II, 23.19% DD, 18.84% ID. There is no association between metabolic syndrome and the component of metabolic syndrome and varians of the ACE gene among the type 2 diabetes patients.

The difference between mean plasma levels of von Willebrand factor and platelet aggregation in type 2 diabetes mellitus with and without peripheral vascular disease at Sardjito General Hospital, Yogyakarta.

AIM: To determine the differences in mean plasma values of von Willebrand factor and platelet aggregation in type 2 DM patient with or without peripheral arterial disease. METHODS: This is a cross-sectional study, conducted from August to December 2006, in Dr. Sardjito General Hospital Yogyakarta, on type 2 DM patients, aged 50 years and above, and signed the informed consent. The exclusion criteria are cardiac failure, renal insufficiency (creatinine clearance <30 ml/minute), malignancy, acute disease, decrease hepatic function, having ulcer or DM gangrene, amputation, taking multivitamine and/or antiplatelet, and smoking. All samples that matched inclusion criteria were divided into 2 groups: with peripheral arterial disease and without peripheral arterial disease. The data of subjects are presented as mean and standard deviation and proportion. Variables with numeric data are analized with the student t-test for normal distribution and with Mann-Whitney U-test for abnormal distribution. Significancy limit was set at p value of <0,05. Statistical analysis was done by using SPSS 11.5 software. RESULTS: There were 17 subjects having PVD. There were no significantly differences of mean vWF plasma levels (140.544 + 76,137% vs. 133.325 + 53,246%) and platelet aggregation (87.741 + 19.886% vs. 93.981 + 10.138%) between type 2 DM with and without PVD (p >0.05). CONCLUSION: There were no statistically difference in mean vWF plasma levels and platelet aggregation between type 2 diabetes mellitus with and without PVD.

Does insulin resistance correlate with routine blood examination? A review on erythrocytes of obese patients.

AIM: To identify whether hyperinsulinemia/insulin resistance affects the hematologic parameter of routine blood, especially the erythrocytes. METHODS: Cross sectional study was conducted on seventy one non-smoking obese patients who were not pregnant, not having lactating period, aged >22 years of age and visited the outpatient clinic of Endocrinology and outpatient clinic of Kidney and Hypertension division at the department of Internal Medicine Dr. Sardjito Hospital, Yogyakarta. Patients with cerebrovascular and blood disease; taking drugs affecting blood e.g.: cytostatics, and erythropoietin; and patients taking insulin, beta blocker, or steroids were excluded. Data on age, gender, body weight, and body height were recorded. Examinations on fasting blood glucose, fasting insulin, total cholesterol, triglycerides, high density lipoprotein (HDL), low density lipoprotein (LDL), and routine blood were performed in the condition of ten hours of fasting. All laboratory examination was conducted at Prodia Laboratory, Yogyakarta. RESULTS: Of seventy one obese patients, 51.5% were male, and 9.1% were diagnosed with diabetes mellitus (DM) during the study and the mean age was 47.09+5.74 years, the mean body mass index was 28.07+4.07 kg/m(2), the mean of hemoglobin level was 13.75+1.57 g%; the mean of leukocyte count was 7.86+1.19 103/mm(3); erythrocytes count was 4.93+0.44 106/mm(3); platelet count 300.28+80.57 103/mm(3); and hematocrite count 41.23+4.28. There were very weak and statistically insignificant negative correlation between Log HOMA IR and erythrocytes (r= -0.048; p=0.693) CONCLUSION: This study demonstrates that insulin resistance has a very weak correlation with erythrocytes counts and it is statistically insignificant.

Hypoadiponectinemia: a risk factor for metabolic syndrome.

AIM: To find out correlation between plasma adiponectin levels, insulin resistance and IDF criteria of Mets Patients. METHODS: A case-control study was conducted on Native Javanese people from June 2006 to January 2007 in Outpatients Clinic of Dr Sardjito Hospital. The case group involved patients aged between 20 to 55 years old. The diagnosis of metabolic syndrome was confirmed according to IDF criteria. Patients without metabolic syndrome with matching age and sex,were taken as control group. RESULTS: there were significant differences between case and control group for BMI (body mass index) (30.2 +/- 4.1 vs 26.9 +/- 4.7 kg/m2), waist circumference (93.5 +/- 7.9 vs 84.4 +/- 11.5 cm), triglyceride (207.4 +/- 101.8 vs. 119.3 +/- 71.5 mg/dL) , HDL cholesterol (48.6 +/- 9.4 vs. 59.9 +/- 11.8m g/dL), systolic blood pressure (132.8 +/- 17.9 mmHg vs 120.6 +/- 13.5 mmHg) and diastolic blood pressure (83.8 +/- 8.5 mmHg vs. 79.4 +/- 10.7), fasting blood glucose (128.3 +/- 40.8 mg/dL vs. 100.7 +/- 29.4 mg/dL), HOMA index (6.7 +/- 17.4 vs. 2.0 +/- 2.0) and adiponectin levels (3.8 +/- 1.4 vs. 5.9 +/- 2.5), respectively. For metabolic syndrome, hypoadiponectinemia showed the OR value of 6.0 (95% CI 2.13 to 16.98); insulin resistance showed the OR value of 5.7 (95% CI 1.3 to 25.02), after adjustment for waist circumference, TG, HLD, blood pressure, fasting blood glucose. CONCLUSION: Hypoadiponectinemia and insulin resistance represent independent risk factors for metabolic syndrome development.

Effects of dietary pattern and education on glycemic control in patients with type 2 diabetes mellitus at Dr. Sardjito Central General Hospital, Yogyakarta.

AIM: to recognize the effect of education and diet on glycemic control in patients with type 2 diabetes mellitus at Dr. Sardjito Central General Hospital, Jogjakarta. METHODS: a cross-sectional study was conducted in 88 patients with type 2 DM who had routine visit to the outpatient clinic in Endocrinology Division of Dr. Sardjito Central General Hospital, Jogjakarta. As inclusion criteria, patients who had routine visit in 3 month continuously with fasting plasma glucose (GDN) < or = 126 mg/dl was participated as a well glycemic control group, and the one with GDN > 126 mg/dl as poor glycemic control group. Data were recorded which included age, sex, period of DM, daily diet pattern, and education received. RESULTS: we found that glycemic control was not affected by sex (p=0.52) and age (p=0.38), but it was affected by period of DM (p=0.02). Glycemic control in the present study was affected by dietary pattern (p=0.01), but not by education (p=1.00). CONCLUSION: the present study has found significant correlation between regulation of dietary pattern and glycemic control (p=0.01).