Monitoring thyroid function during amiodarone use.

Amiodarone is an antiarrhythmic drug used to treat cardiac tachyarrhythmias. It has many adverse effects, with thyroid dysfunction one of the most notable. Through various mechanisms, both thyrotoxicosis and hypothyroidism can occur secondary to amiodarone therapy. There are two types of amiodarone-induced thyrotoxicosis: type 1 occurs in those with pre-existing thyroid disease and is treated with thionamide, whereas type 2 occurs in those without and is treated with glucocorticoids. Patients with amiodarone-induced hypothyroidism may be given levothyroxine to replace thyroid hormone, but in some cases, the appropriate management may be cessation of amiodarone.

The Effect of Salacia Reticulata Extract Biscuits on Blood Sugar Control of Type 2 Diabetes Mellitus Patients: A Two-Period, Two-Sequence, Crossover, Randomized, Triple-Blind, Placebo-Controlled, Clinical Trial.

Background Traditional physicians in Sri Lanka and India use extracts from the plant Salacia reticulata,or Kothala Himbutu (KH) to treat diabetes. The effect of a KH biscuit, taken as a snack, on glycemic control was investigated in patients with type 2 diabetes. Methodology This triple-blind, randomized, placebo-controlled, two-period, two-sequence, crossover study was conducted in the Internal Medical Clinic, Teaching Hospital Anuradhapura. A research assistant opened computer-generated random numbers enclosed in a sealed envelope and performed treatment allocation. The group outcome was masked from the researchers, patients, and analysts. Both the placebo and the KH biscuit were identical. The primary outcome measure was HbA1c. Intention to treat analyses was used. Glycemic stability was assured in the run-in period, and patients with severe renal, liver, or heart disease were excluded. If patients needed insulin, they were withdrawn from the trial. Results From January 2014 to May 2016, 230 patients were screened, and 136 were randomized. Of them, 62 were allocated, 58 completed the placebo biscuit, 71 were allocated, and 69 completed the KH biscuit. After the washout period and crossover, 57 completed the KH and 65 completed the placebo biscuit. The baseline mean HbA1c level was 8.45% (68.9 mmol/mol) and 8.65% (71.0 mmol/mol) for the placebo-KH biscuit and KH-placebo biscuit groups. At the end of the trial, the HbA1c levels in the placebo-KH biscuit group and the KH-placebo biscuit group were 8.23% (66.4 mmol/mol) and 8.53% (69.3 mmol/mol), respectively. The unadjusted mean HbA1c reduced from the baseline with 0.10% (95% CI = -0.12, 0.32) after the placebo biscuit and 0.35% (95% CI = 0.10, 0.60) after the KH biscuit. After the placebo and KH biscuits, the HbA1c values were 8.46% (95% CI = 8.19, 8.73) (69 mmol/mol with 95% CI = 66, 72) and 8.19% (95% CI = 7.90, 8.48) (66 mmol/mol with 95% CI = 63, 69), respectively. The paired sample t-test shows that the reduction was not significant for placebo biscuits (p = 0.324), while it is significant for KH biscuits (p = 0.003). Analysis with multiple imputations confirmed a significant difference between the placebo and KH biscuit in reducing the HbA1c level. Conclusions KH biscuit taken as a snack reduces HbA1c by 0.25% compared to placebo without serious renal or liver adverse effects. The biscuit can be safely recommended as a snack to patients with type 2 diabetes.

Association of FTO and near MC4R variants with obesity measures in urban and rural dwelling Sri Lankans.

OBJECTIVES: To investigate the association between the fat mass and obesity related (FTO) gene rs9939609 and near melanocortin-4-receptor (MC4R) gene rs17782313 polymorphisms with obesity measures and metabolic parameters in urban and rural dwelling Sri Lankans. METHODS: 535 subjects (60.9% female) from the general adult population (ages 18-70 years) representative of both urban (28.4%) and rural areas of residence were recruited by multi-stage random sampling. Body mass index (BMI), waist circumference (WC) and waist-to-hip ratio (WHR) was obtained by standard methods. DNA extracted from whole blood was genotyped using real-time PCR. RESULTS: The FTO risk genotypes (AA+AT) were associated with higher BMI (p=0.03) and WC (p=0.05) measures as well as categorical obesity (BMI ≥27.5kgm-2 definition) (OR 1.69 95% CI 1.11-2.56, p=0.01). The near MC4R risk genotypes (CC+CT) were associated with greater BMI (p=0.03) as well as categorical obesity (BMI ≥25kgm-2 definition) (OR 1.57 95% CI 1.11-2.22, p=0.01). In addition the MC4R risk genotype carriers (CC+CT) had significantly higher fasting blood sugar (FBS) levels compared to the 'TT' genotype carriers independent of BMI (p=0.05). Urban living was associated with significantly greater BMI values for FTO risk genotypes compared to rural living (p=0.02). CONCLUSIONS: FTO and near MC4R variants are associated with obesity measures in Sri Lankan populations whilst urban living accentuates the obesogenic effect of the FTO polymorphism.

Rising HbA1c in the presence of optimal glycaemic control as assessed by self-monitoring - iron deficiency anaemia.

HbA1c can be affected by determinants other than glucose and an awareness of this is important to avoid unnecessary hypoglycaemia.

Acute Transient Stress Induced Adrenal Hypertrophy and Adrenal Medullary Hyperactivity.

OBJECTIVES: Adrenal gland hypertrophy can be related to acute stress with abnormal adrenal function tests. It may not always need treatment. MATERIAL AND METHODS: An acute presentation of adrenal gland hypertrophy following an abdominal emergency, with subsequent hypoadrenalism was investigated. RESULTS: Adrenal medullary and cortical function fully recovered without treatment. CONCLUSIONS: We postulate that the adrenal glands became enlarged and hypertrophied during an acute stress event, possibly caused by acute adrenal medullary hypersecretion and subsequent cortical hyposecretion. A wait and watch policy should be followed if no other clinical symptoms and signs of adrenal disease are present. CT scan remains an important diagnostic tool. LEARNING POINTS: Abnormal adrenocortical function tests and hypertrophy can occur in an acutely ill patient as a stress response.It is possible to have both hypersecretion and hyposecretion of adrenal hormones.A wait and watch policy should be followed if no other clinical symptoms and signs of adrenal disease are present in an acutely ill patient.

Hypoglyceamia in a Patient with a Solitary Fibrous Tumour.

OBJECTIVE: To illustrate an unusual mechanism causing hypoglycaemia. MATERIAL AND METHODS: A 76-year-old man presented with episodes of agitation and confusion and was resuscitated with oral glucose gel when found to be hypoglycaemic. RESULTS: A CT scan for an abdominal mass confirmed a solitary fibrous tumour (SFT). The sarcoma multidisciplinary team suggested conservative management. The patient's episodic hypoglycaemia was managed with diet modification including corn-based starch, scheduled snacks and dexamethasone. Glucose levels were within normal range at discharge from hospital. The patient was referred to the palliative care team for follow-up. CONCLUSION: SFTs causing non-islet cell tumour hypoglycaemia are difficult to treat. LEARNING POINTS: To be aware of rarer causes of hypoglycaemia and to consider unusual causes in acute presentations of hypoglycaemia, especially in patients who do not have diabetes.This case illustrates the importance of a thorough general physical and systemic examination, as identifying the abdominal mass is essential to the early diagnosis of this rare condition.Solitary fibrous tumours causing non-islet cell tumour hypoglycaemia are difficult to treat, and even when surgical resections are applicable, recurrence rates are high.

Dysautonomia: an Explanation for the Medically Unexplained?

OBJECTIVE: To identify dysautonomia as a collection of conditions with variable presentation that may be mistaken for medically unexplained symptoms. METHODS: Case series. RESULTS: Tilt table testing and 24 h electrocardiographic monitoring provided useful diagnostic tools to confirm the diagnosis. CONCLUSION: A greater awareness and recognition of the disorders that result from dysautonomia and recognition of the disability that results from these disorders will improve patients' quality of life. LEARNING POINTS: Dysautonomia is protean in presentation and clinicians need to have a high degree of suspicion as, if diagnosed, symptomatic improvement is possible leading to improved quality of life.Tilt table testing and 24 h electrocardiographic monitoring are useful diagnostic tools.Greater awareness and recognition of the disorders that result from dysautonomia with appropriate use of these tests by medical professionals is necessary.

Energy and nutrient intakes of Sri Lankan patients with type 2 diabetes mellitus: a cross-sectional survey.

BACKGROUND: Sri Lanka has a high prevalence of type 2 diabetes mellitus. Energy and macronutrient intakes of diabetic patients have not been previously studied in this population. We aimed to clarify the energy and nutrient intakes among a group of type 2 diabetic patients attending a tertiary care diabetes facility in Sri Lanka. METHODS: Nutritional and energy intake of 123 randomly selected patients with type 2 diabetes, aged 30-74 years was assessed using a 24-h dietary recall. RESULTS: The mean energy intake for all participants was 1438 (SD 412) Kcal/day. The mean proportions of total carbohydrate, protein and fat comprising total energy intake were 68.1, 11.5 and 20.2 % respectively. The mean carbohydrate intake of 249.7 g/day comprised 50 % of rice. The mean daily protein, fat and dietary fibre intake was 42.5, 33 and 18.1 g respectively with a major contribution from plant sources. There was no significant difference in energy and nutrient intakes among the male and female participants. CONCLUSION: The present study provides the first pilot data on the energy and macronutrient intakes of diabetes patients in Sri Lanka. We clarified that these patients consumed an energy restricted, high-carbohydrate low fat diet compared to western diabetic patients. A larger nationwide dietary survey is recommended to confirm our findings.

The impact of a decision support tool linked to an electronic medical record on glycemic control in people with type 2 diabetes.

AIMS: We retrospectively compared glycemic control and glycemic burden in type 2 diabetes patients treated by general physicians with access to decision support with those treated by general physicians without access to decision support. METHODS: A total of 875 patients [471 (53.8%) males] aged 54.3 [standard deviation (SD) 13.1] years followed up over 84 months. A total of 342 patients (39%) were managed with decision support, and effects on glycosylated hemoglobin (HbA1c) were assessed. RESULTS: There was no difference between groups in starting HbA1c [7.6 (SD 1.8) versus 7.5 (SD 1.5); p = not significant] at baseline. Patients treated with decision support were more likely to have planned review of HbA1c, adjustment of medication, prescription of statins, dietetic and nurse educator inputs (71.3% versus 58.5%; Chi squared = 14.7; p = .001). The mean HbA1c in the group treated with decision support was not significantly reduced within the first year [7.5% (SD 1.8) versus 7.6% (SD 1.5); p = not significant; 95% confidence interval (CI) -0.33 to 0.17], but statistically significant differences were apparent at year 2 [7.2% (SD 2.0) versus 8% (SD 3.4); p = .0001; 95% CI -1.3 to -0.5] and sustained through year 3 [7.2% (SD 2.0) versus 8.0% (SD 2.0); p = .0001; 95% CI -1.2 to -0.6], year 4 [7.2% (SD 2.3) versus 8.2% (SD 2.5); p = .0001; 95% CI -1.2 to -0.6], year 5 [7.0% (SD 2.3) versus 8.3% (SD 2.6); p = .001; 95% CI -1.5 to -0.8], year 6 [7.0% (SD 2.0) versus 8.2% (SD 2.4); p = .001; 95% CI -1.5 to -0.9], and year 7 [6.9% (SD 1.2) versus 8% (SD 1.8); p = .001; 95% CI -1.4 to -1.0]. CONCLUSION: Use of a decision support system showed benefits in adherence to clinical care pathways and achieving significant improvements in glycemic control.

Treating diabetes mellitus in Prader-Willi syndrome with Exenatide.

We report the use of Exenatide, a GLP-1 agonist, in the management of diabetes mellitus in a 19 year-old female with Prader-Willi syndrome. The beneficial effects of Exenatide in weight reduction and appetite suppression provide a promising strategy for the treatment of obesity and diabetes mellitus in Prader-Willi syndrome.

Compromised periodontal status in an urban Sri Lankan population with type 2 diabetes.

AIM: To determine the prevalence of periodontitis in an urban population of Sri Lankans with type 2 diabetes (T2DM) and to compare the data with those from a population of adults without diabetes. METHODS: Demographic data and a diabetes profile were recorded for a population of urban Sri Lankan adults with T2DM including duration of diabetes, blood pressure; percentage glycosylated haemoglobin, fasting blood glucose level, total cholesterol; triglycerides, low- and high-density lipoproteins. The clinical examination comprised an oral soft tissue examination, full-mouth probing depths (PD), gingival recession (GR), clinical attachment levels and bleeding on probing (BoP). RESULTS: Two hundred and eighty-five individuals with T2DM and 72 controls were examined. 33.3% of T2DM patients were diagnosed with chronic periodontitis compared with 21.7% of controls (p=0.077). Subjects with T2DM had significantly more sites with PD>or=4 and >or=5 mm (p<0.01), and higher mean GR and BoP scores (p<0.01). CONCLUSION: This urban Sri Lankan population of subjects with T2DM demonstrated a compromised periodontal status compared with non-diabetic controls.

The clinical impact of identifying metabolic syndrome in patients with diabetes: a cross-sectional study.

The objectives of the study were to determine whether identifying patients with metabolic syndrome (MetS) (as defined by International Diabetes Federation [IDF] criteria) among patients with diabetes would affect the decision to prescribe statin for primary prevention of cardiovascular disease (CVD), based on currently available public health guidelines. We analysed the most recent recorded CVD risk profiles obtained from electronic patient files from 304 general practices in England and Wales. Of 60,258 patients with diabetes, 11,005 men and women aged 30-74 years fulfilled criteria for primary CVD prevention and were not on lipid-lowering drugs. Outcome data were extrapolated to an estimated national diabetes prevalence of 3.6%. Identifying MetS in this group of patients would produce an additional 29,536 (8.4%; 95% CI: 7.7, 9.0), 104,288 (29.6%; 95% CI: 28.5, 30.7) and 147, 328 (41.9%; 95% CI: 40.8, 43.0) patients nationally who would not have been eligible otherwise for primary CVD prevention strategies with statins, based on the Joint British Societies', the National Institute for Health and Clinical Excellence and the General Medical Services contract guidelines, respectively. The sensitivity and positive predictive value of these different strategies to detect metabolic syndrome were 87.5% and 69.1%; 57.3% and 76.8%; and 37.8% and 70.2%, respectively. In conclusion, among individuals with diabetes, identifying patients with MetS may further increase the use of statin therapy for primary CVD prevention.

Erectile dysfunction among men with diabetes is strongly associated with premature ejaculation and reduced libido.

INTRODUCTION: Among men with diabetes, little attention has been given to premature ejaculation (PE), reduced libido, and their associations with erectile dysfunction (ED), despite the presence of physical and psychologic factors that could predispose to all three. AIM: To estimate the prevalence and inter-associations of ED, PE, and reduced libido among diabetic men and to describe the associated clinical, socioeconomic, and lifestyle parameters. METHODS: Cross-sectional observational study of 253 men with type 2 diabetes randomly selected from a clinic in Colombo, Sri Lanka. MAIN OUTCOME MEASURES: Erectile function was assessed using the five-item version of the International Index of Erectile Function scale. The presence of PE, reduced libido, sociodemographic, and lifestyle data was obtained using an interviewer-administered questionnaire. Clinical data were obtained from relevant physical examination, patient records, and laboratory tests, which included glycosylated hemoglobin, serum cholesterol, serum creatinine, and electrocardiogram. RESULTS: One hundred and eighty-five (73.1%) of the individuals had some degree of ED, while 84 (33.2%) had severe to complete ED. After excluding men with complete ED, the prevalence of PE was 68 (40.2%). The overall prevalence of reduced libido was 64 (25%). In the multivariate analysis, the strongest associations with ED were PE (odds ratio [OR] = 4.41, 95% confidence interval [CI] = 2.08-9.39) and reduced libido (OR = 4.38, CI = 1.39-13.82) followed by lower income (OR = 2.16, CI = 1.32-3.52), advancing age (OR = 2.06, CI = 1.44-2.95), and duration of diabetes (OR = 1.48, CI = 1.09-2.01). In addition, ED was univariately associated with lower educational level (P = 0.05), the presence of hypertension (P = 0.005), and no alcohol intake (P = 0.001). The only significant association of PE was the severity grade of ED. Associations of reduced libido in the multivariate analysis were ED (OR=1.61, CI = 1.23-2.70), advancing age (OR = 1.7, CI = 1.4-2.2), and absence of masturbation (OR = 3.3, CI = 1.2-8.8). CONCLUSIONS: ED was strongly associated with PE and reduced libido. Diabetic patients presenting with one of these three conditions should be screened for the other two.

Combining population health and baseline risk strategy by determining an age cutoff for initiating statins in patients with diabetes: a population-based study.

OBJECTIVE: Strategies for initiating statin use among adult patients with diabetes for primary cardiovascular disease (CVD) prevention include treating all patients (assuming diabetes is a coronary risk equivalent) or treating patients who are at risk of developing CVD. The aim of the study was to combine both strategies to derive an appropriate age cutoff for prescribing statins. By considering different strategies, we also aim to assess the effectiveness and efficiency of different strategies to reduce CVD events. RESEARCH DESIGN AND METHODS: This was a cross-sectional primary care population study using electronic patient files from 304 general practitioner practices in England and Wales. Of 60,258 patients with diabetes, 11,005 men and women aged 30-74 years fullfilled criteria for primary CVD prevention. Model outcomes were extrapolated to an estimated national diabetes prevalence of 3.6%. RESULTS: The age transition from a low-risk to a moderate-risk category for diabetic men and women occurred at ages 40.6 and 44.2 years, respectively, and sensitivity and specificity for fulfilling moderate CVD risk criteria were 97.9 and 61.8% for men and 92.0 and 77.0% for women. When applied to the national population, the age cutoff strategies were an effective and efficient strategy, potentially avoiding 11,094 events with a number needed to treat of 25.1. CONCLUSIONS: A strategy to treat all men and women with diabetes aged >40 and 45 years, respectively, with statins showed good compromise between high effectiveness and high efficiency for reducing CVD events. Strategy to intervene if cholesterol was >5 mmol/l was the least effective and efficient in preventing CVD events.