Barriers to management of diabetes foot ulcer: Experiential note from a setting with free medical services.

The imperative need for behavioral agreement to overcome barriers of self-management of diabetes foot complication was recently articulated. A few journals have done parallel publications, which thereby stresses the significance of the issue. This article is to add to the "Overcoming barriers to self-management: the person-centred diabetes foot behavioural agreement". It presents experiential note with four tabulated cases of clients who have access to free state-of-the-art medical service; and non-adherence as a barrier to self-management is not due to affordances. It is to draw attention to the deliberately non-adherent patients where behavioral agreement process should be really driven by the client as in the real context of person-centered therapy.

Barriers in determining prevalence of type 2 diabetes mellitus among postpartum GDM: The research and retraining needs of healthcare professionals.

AIM: A large percentage of gestational diabetes (GDM) are undiagnosed, and prevalence of postpartum type 2 diabetes (T2DM) is unknown, especially in developing countries. This study assessed barriers to GDM diagnosis and postpartum follow-up; to determine educational needs. MATERIALS AND METHODS: This was a clinical observational study of records and procedures of antenatal services at two hospitals. Laboratory and medical records were reviewed for availability of data on anthropometrics, blood glucose, gestational age, urinalysis, and lipid profile for GDM register. Antenatal clinic protocol was observed for GDM diagnosis. BMI was derived and data were analyzed using SPSS version 20. RESULTS: Critical barriers attributable to health systems included lack of screening for blood sugar as part of routine antenatal protocol, and lack of GDM registers at both facilities. There was 6.5% registration of pregnancies in first trimester, 22% pre-pregnancy obesity, and 2.6% high blood pressure. Positive glucosuria cases were not followed-up for GDM diagnosis. CONCLUSIONS: There is neither concerted effort to diagnose GDM, nor systematic records of screening and postpartum follow-up. The gap in diabetology knowledge and practice calls for re-training of antenatal healthcare professionals. GDM screening checklist needs to be established and positive results entered into GDM registers for proper management during and after delivery.

Prediabetes and cardiovascular complications study (PACCS): international collaboration 4 years' summary and future direction.

OBJECTIVE: The prediabetes and cardiovascular complications studies proposes to develop a screening protocol for diabetes cardiovascular risk, and strategies for holistic management amongst others. Over 500 participants were recruited in the first 2 years of rural community research screening. Specific for this report, various published findings were reviewed. The objective is to summarize research outcomes and itemize limitations as they constitute basis of future directions. RESULTS: Affordability and availability are major confounding behavioural change wheel factors in the rural community. 4.9% prevalence of prediabetes, which may be lower or non-significantly different in urban areas. Hyperglycaemia co-morbidity with dyslipidaemia (5.0%), obesity (3.1%) and hypertension (1.8%) were observed. Limitation of the study includes participants being mostly over 60 years old, which has created impetus for the Global Alliance on Chronic Diseases agenda on vulnerability of older adults to diabetes being a new direction of the collaboration. Other directions in Australia and Nepal focus on patients with chronic kidney disease with or without cardiovascular complications. This report highlights the need to translational research.

Anthropometric indices: How they compare in screening of cardio- metabolic risks in a Nigerian sub-population.

BACKGROUND: The current anthropometric indices used for diagnosis of cardio-metabolic syndrome (CMS) in sub-Saharan Africa are those widely validated in the western world. We hereby aim to compare the sensitivity and specificity of these tools in identifying risk factors for CMS. METHOD: The study assessed body mass index (BMI), waist circumference (WC) and waist-to-height ratio (WHtR). Statistical analyses were performed to determine the sensitivity and specificity of WHtR in comparison with WC cut-off points recommended by the International Diabetes Federation (IDF) and the Third Adult Treatment Panel (ATPIII) as well as BMI cut-offs prescribed by the World Health Organisation (WHO). RESULT: WHtR had the highest area under the receiver operating characteristic (ROC) curve in screening CMS. WHtR >0.5 also showed highest sensitivity in both genders in identifying CMS and clusters of >2 CMS risk factors, but with lowest specificity and positive likelihood ratio (LR+). ATPIII WC cut-off revealed lowest sensitivity and highest specificity in screening CMS and >2 CMS risk factors in males (p<0.000l). IDF WC-threshold had the more stable sensitivity and specificity in males (p<0.0001) but not in females. CONCLUSION: WHtR>0.5 is more sensitive than WC and BMI recommended values in screening for CMS, but with the least positive likelihood ratio. However, more studies in other nations of sub-Saharan Africa are needed to assure evaluation of different cut points that will yield optimal specificity and sensitivity. This will help curb the problem of over-diagnosis of CMS risk factors and increase better health outcome of the population.

Prevalence of cardio-metabolic syndrome in Nigeria: a systematic review.

OBJECTIVE: This is a systematic review of the distribution of cardiometabolic syndrome (CMS) in Nigeria, the clinical definitions widely used and how it affects the proposition of a national prevalence of CMS that will advise management interventions. STUDY DESIGN: Systematic review of literature. METHODS: To present a comprehensive report of the distribution of CMS in Nigeria, extensive searches was carried out on PubMed, African Journals Online (AJOL), SCOPUS, EBSCOhost (CINAHL Plus), Google Scholar and Science Direct using terms: Nigeria, metabolic syndrome, cardio-metabolic syndrome, syndrome X, World Health Organization, International Diabetic Federation, National Cholesterol Education Program Adult Treatment Panel III, European Group for study on Insulin Resistance, American Association of Clinical Endocrinologist, American Heart Association/National Heart, Lung and Blood Institute. All published data between January 2002 and December 2013 were collated into a database. Information gathered and recorded for each source were the population sampled, age and number of population, locality, clinical definition used, longitude and latitude, and period of the study. RESULTS: Out of 32 studies, 9 (28.1%) adopted the WHO classification, 19 (59.4%) used the ATPIII definition, while the remaining 10 (31.3%) studies used the IDF definitions. Twenty (62.5%) were hospital-based studies on diabetic, hypertensive, HIV, asthmatic and thyroid disorder patients. The remaining 12 (37.5%) studies were population-based studies in urban, suburb and rural settings. The mean overall prevalence of CMS in Nigeria is 31.7%, 27.9% and 28.1% according to the WHO, ATPIII and IDF definitions, respectively. Most of the studies were from the Southern region. Age groups mostly studied were those from ≥35 years. CONCLUSION: The report of this review provides an essential overview on the current distribution of CMS in Nigeria. It provides an insight to direct future studies such as the need to (1) study rural communities where lifestyles are not westernized as in the urban areas, and (2) young adults, as well as (3) develop a consensus on the definition of CMS among the Sub-Saharan African populations.

Metabolic syndrome and prediabetes in ndokwa community of Nigeria: preliminary study.

BACKGROUND: Global prevalence of metabolic syndrome (MS) and diabetes is increasing, but the reference ranges for MS indices have yet to be established for sub-Saharan African countries. As part of the international research collaboration agenda for Prediabetes and Cardiovascular Complications Study (PACCS), a pilot study was conducted in one of the Ndokwa communities of Nigeria in 2013. AIM: The study was to obtain preliminary indication of prevalence and reference values of MS in the rural communities of a low-mid income country. MATERIALS AND METHODS: Seventy-four volunteer participants were recruited, after public lectures in high schools and churches in the community. Body mass index (BMI), blood pressure and waist circumference (WC), blood glucoselevel, and lipid profile were measured. Percentage prevalence MS was determined using commonest three criteria (Third Adult Treatment Panel (ATP III) 2001, International Diabetes Federation (IDF) 2005, and World Health Organization (WHO) 1999). RESULTS: When individual indices of MS are considered separately; the males seem healthier than females. However, the prevalence of high-density lipoprotein (HDL) cholesterol was higher in males than in females. Equal 3% prevalence of MS was seen in both genders using the WHO standard. Other criteria show prevalence of 8% females and 11% males (ATP III), 5% females and 8% males (IDF 2005 European), and 14% females and 17% males (IDF 2005 Ethnic). CONCLUSION: The prevalence of MS is higher in males than females; and relative to ATP III 2001 criteria, either the IDF 2005 European may underestimate MS, or the ethnic specific could overestimate the prevalence. Hence, it is important to define the criteria to be used.

Can Computer Meridian Diagnostic be useful in diagnosis and management of diseases?

The need for the development of appropriate guidelines for effective or safe use of antioxidants and herbs has always been a concern, especially for the alternative medicine practices. Computer Meridian Diagnostic (CMD) is one of emerging computer-based diagnostic technologies available to alternative medicine practitioners. However, case report of the agents monitored with CMD is uncommon; and concerted effort to bring this into conventional medical practice is yet to be. This hypothesis builds on an anecdotal observation of anti-stress effect monitored with CMD, with a view to highlight a potential tool that requires expatiation, as well as proof of concept and validation studies for possible integration in conventional and traditional medicine practices for therapeutic monitoring.

Serum bilirubin and lipoprotein-a: how are these associated with whole blood viscosity?

BACKGROUND: It has been demonstrated that oxidative stress can induce red blood cell rigidity and haemolysis, which in turn can cause hyperviscosity and hyperbilirubinaemia, respectively. However, haemolysis may be associated with a low level of haemoglobin, which reduces whole blood viscosity (WBV). Bilirubin can behave as antioxidant or oxidant, and one uncharted course for diagnostic pathology is how or whether bilirubinaemia and viscosity are associated. Further, oxidative stress is now being assessed using lipoprotein-a (Lp(a)), among other things but whether it is associated with blood viscosity has not been established. AIM: This study investigates the association and correlation of haemoglobin level and WBV with serum Lp(a) and bilirubin levels in a general population of patients. MATERIALS AND METHODS: Sixty-eight cases that were tested for Lp(a), concomitantly with full blood count and liver function, in our archived clinical pathology database were used in this study. WBV levels were determined using a validated formula. Multivariate and univariate analyses as well as correlation were performed. RESULTS: WBV was found to be significantly associated with bilirubin (P<0.02), but not with Lp(a). Haemoglobin concentration was inversely correlated with Lp(a) (P<0.04), but not with bilirubinaemia. CONCLUSION: This pilot study suggests that hyperbilirubinaemia and hyperviscosity are associated and positively correlated. Consideration of whether serum bilirubin (as an indirect index of oxidative stress) can be used in combination with WBV (as index of macrovascular effect of oxidative stress) to assess oxidative damage is recommended.

Low serum creatinine levels as risk factor of diabetes mellitus: prediabetes considerations.

OBJECTIVE: It has been reported that low serum creatinine level is a risk factor of diabetes. We hypothesize that should this be true, serum creatinine levels would be lower and more prevalent in prediabetes than in normal individuals. MATERIALS AND METHODS: 1017 glucose tolerance tests performed at South West Pathology Service of the New South Wales Health, Australia, in 2008 were sorted into normal (control), prediabetes and diabetes based on decisive interpretation. All cases with creatinine results in the control (n=48), diabetes (n=18) and prediabetes (n=36) groups were selected. RESULTS: Mean levels of serum creatinine levels in the controls (80 +/- 32 micromol/L), diabetes (82 +/- 26 micromol/L) and prediabetes (82 +/- 23 micromol/L) were not statistically significantly different. The prevalence of low levels of serum creatinine is less in prediabetes (11%) than in the control (23%). CONCLUSION: Further studies using a larger number and adjusting for confounding factors is needed to ascertain the role of low serum creatinine level as a risk factor of diabetes.

Biochemical basis of circadian rhythms and diseases: With emphasis on post-traumatic stress disorder.

Circadian rhythms affect several processes in the body physiology. This commentary revisits the topic of 'metabolic basis of diseases' with a view to shed light on how cellular energy requirements feed-forward to a sequential signaling of hormonal response, blood glucose metabolism, antioxidant activities, and pathophysiology. Attempt is made to explain how diseases that may not appear to be closely related, such as bone metabolism and vasculopathy, have an increase in oxidative damage as a common underlying biochemistry. Importantly, this article identifies oxidative damage as an outcome of sleep disturbance and hypothesize that sleep complaint is not merely one of many resulting symptoms of PTSD, but a core feature that arise from trauma and gives rise to the stress biochemistry, which in turn manifests symptomatically. Further, we suggest that the current non-pharmacologic and pharmacologic therapeutic options attenuate oxidative stress. Implication for clinical diagnosis and evaluations is also suggested.

Assessment of diabetic macrovascular complications: a prediabetes model.

Prediabetes is a condition that requires early intervention against diabetic macrovascular complications. This study aims to assess whether or not the likelihood of diabetes macrovascular complications occurring in prediabetes can be better estimated by a model combining a set of conventional and emerging biomarkers, with a view to improving cardiovascular disease (CVD) screening in individuals with elevated blood glucose levels associated with prediabetes. A total of 71 participants (female/male: 32/39) were divided into two groups - the prediabetic group (preDM: n=34) and the diabetic with cardiovascular complications group (DM+CVD: n=37). Blood glucose level (BGL), blood pressure (BP), total cholesterol (TC), high-density lipoprotein (HDL) and TC:HDL ratio, erythrocyte oxidative stress (as determined by reduced glutathione [GSH], malondialdehyde and methaemoglobin levels) and vascular events (D-dimer, homocysteine and whole blood viscosity) were measured. Statistical analysis was by binomial logistic regression modelling with forward likelihood ratio step procedures. A combination of BGL, BP, erythrocyte GSH and TC gave the best group identifications, with 28/34 (82.4%) and 29/37 (78.4%) members correctly identified in the preDM and DM + CVD groups, respectively. Six of the 34 (17.6%) prediabetes individuals were logistically identified as having diabetic macrovascular complications, but clinically did not qualify for CVD intervention under current screening models. The authors propose that a combination of BGL, BP, erythrocyte GSH and TC can provide a clinically acceptable standard for identifying CVD risk in individuals with prediabetes. This model provides a tool for early identification and targeted intervention in individuals with subclinical diabetes who are at risk of CVD.

Blood viscosity at different stages of diabetes pathogenesis.

Hyperglycaemia-induced oxidative stress is implicated as a cause of increased whole blood viscosity (WBV), which is a clinically modifiable risk factor for cardiovascular disease (CVD). However, whether or not there is variation in WBV at different stages of diabetes mellitus (DM) has yet to be confirmed. The sensitivity of underlying oxidative stress has also yet to be investigated. A total of 154 participants representing different stages of DM pathogenesis were selected for the study. Healthy control, prediabetes, DM and DM+CVD groups were compared for variation in WBV levels. The prevalence of oxidative stress, indicated by abnormal levels of erythrocyte glutathione, malondialdehyde and methaemoglobin, associated with high WBV was evaluated. The results showed a statistically significant difference in WBV between groups (P < 0.03). The level of viscosity was significantly lower in the control group relative to the prediabetes group (P < 0.01) and DM+CVD group (P < 0.04). There was no statistically significant difference between the DM+CVD and prediabetes groups. Greater than 76% prevalence of oxidative stress was shown to be associated with high WBV, reaching 95% prevalence in prediabetes. The study showed that WBV varies between individuals with different stages of diabetic macrovascular pathogenesis, including prediabetes. Redefining the criteria for use of WBV on the basis of sensitivity to underlying oxidative stress, rather than specificity to a disease condition, means that this easily performed test is an option to consider in an all-inclusive laboratory approach to early intervention against future diabetic macrovascular complications. This is particularly important for individuals with subclinical hyperglycaemia.

Position paper for health authorities: archived clinical pathology data-treasure to revalue and appropriate.

Archived clinical pathology data (ACPD) is recognized as useful for research. Given our privileged de-identified ACPD from South West Pathology Service (SWPS), attempt is made to estimate what it would cost any researcher without such privilege to generate the same data. The Ethics Committee of the Area Health Service approved a request for Dr. Uba Nwose to use de-identified ACPD acquired by the SWPS for clinical laboratory-based translational biomedical science research. 10-years (1999-2008) have been pooled to constitute the database. Data include blood sugar, cholesterol, D-dime, ESR, glucose tolerance, haematocrit, HbA 1 c, homocysteine, serum creatinine, total protein and vitamins [C & E] amongst others. For this report, the bulk-billed-cost of tests were estimated based on number and unit price of each test performed. AU$ 17,507,136.85 is the cost paid by Medicare in the period. This amount is a conservative estimate that could be spent to generate such 10-years data in the absence of ACPD. The health/pathology service has not given any financial research grant. However, the support-in-kind is worth more than celebrated competitive research grants. It calls for revaluatrion by academic, research and scientific institutions the use ofACPD. For the countries where such provision is non-existent, this report provides a 'Position Paper' to present to the directorates or institutes of health authorities to appropriate the value of ACPD and approve of their use as a research treasure and resource management tool.

Cardiovascular risk assessment in prediabetes: A hypothesis.

There are screening programs for future risk of cardiovascular disease (CVD) complications in diabetes, but not in subclinical diabetes. There is little or no risk and no differences between genders when a man or woman at age below 50 years presents blood pressure below 140/90 mmHg and total cholesterol/HDL less down 7.0. In the current screening programs, a hypothetical apparently non-diabetic and non-smoking person aged 49 years old; who present blood pressure 140/90 mmHg, fasting blood sugar 5.8 mmol/L and total cholesterol/HDL 6.5 has no risk of future CVD and does not require any intervention. However, by counting numbers, the person has two risk factors, hyperglycaemia and hyperlipidaemia. Furthermore, considering smoking as a factor and the propensity for hyperglycaemia-induced oxidative stress being a smoker-like effect of hyperglycaemia toxicity, the person actually has three risk factors, which qualifies the person for intervention. The issue is that a prediabetes sufferer is treated like a healthy person in the current screening programs. The problem here is that risk of CVD in prediabetes is inadequately assessed. We present a hypothesis that employs a combination of blood glucose level and an index of oxidative damage to improve CVD screening in prediabetes. We propose a longitudinal study to repeat the whole lipid modelling exercise in order to develop a separate model chart for the screening of future CVD in people with diagnosed or undiagnosed prediabetes. The proposal would also serve for people with undiagnosed diabetes.

Oxidative damage indices for the assessment of subclinical diabetic macrovascular complications.

Subclinical cardiovascular disease (SCVD), including complications in diabetes, is associated with oxidative damage and precedes future cardiovascular disease (CVD). Hence, assessment and management of oxidative damage is imperative. This study investigates biomarkers associated with CVD, diabetes and oxidative stress in order to determine a set of indices that could be useful to assess oxidative damage in diabetic macrovascular pathogenesis. A total of 266 participants were selected and divided into seven groups (control, family history of diabetes, prediabetes, prediabetes with CVD, diabetes mellitus [DM], DM+CVD and CVD) based on clinical history/status. Blood glucose (BG) level, erythrocyte glutathione (GSH), malondialdehyde, methaemoglobin, D-dimer, homocysteine, blood viscosity and cholesterol profile were determined. Factorial MANOVA and independent univariate analyses were performed. Prevalence of significant biomarkers was assessed following a 3.5-year retrospective study. Multivariate analysis showed statistically significant differences between groups (P < 0.0001) with post hoc tests identifying a statistically significant association for BG level (P < 0.0001), GSH (P < 0.0001), D-dimer (P < 0.02) and total cholesterol (P < 0.0001). Of the subjects who showed hyperglycaemia-associated progression in clinical and biochemistry status, 89% had low-level GSH and 44% had high-level D-dimer. Four individuals exhibited prediabetic status at some stage and would qualify for macrovascular disease intervention. The results of this study suggest that BG level, D-dimer, GSH and total cholesterol contribute significantly to a diabetic oxidative damage panel of markers that could assist in evidence-based pharmacological intervention with anti-aggregation and/or antioxidant agents against future CVD in diabetes.

Erythrocyte oxidative stress in clinical management of diabetes and its cardiovascular complications.

Diabetes mellitus is a chronic disease in its own right and is also regarded as a cardiovascular risk factor as well as a cardiovascular disease, due to its ability to progress to a stage of cardiovascular co-morbidity. The pathophysiology of cardiovascular complications in diabetes is reported to involve hyperglycaemia-induced oxidative stress. The erythrocyte has an array of endogenous antioxidants involved in quenching oxidant production and the exponential chain reactions in diabetes. When the erythrocyte is oxidatively stressed, as demonstrated by depleted reduced glutathione and/or increased malondialdehyde in its cell membrane, the risk of diabetes progression and its cardiovascular sequelae, including atherosclerosis and coronary artery disease, is increased. Virtually all studies that determined erythrocyte malondialdehyde and glutathione in diabetes show consistently increased and reduced levels, respectively. Furthermore, cardiovascular complications of diabetes are reported to commence at the prediabetes stage. Current coronary artery disease screening programmes based on the presence of two or more risk factors are failing to identify those with increased risk of diabetes and cardiovascular complications, thereby limiting early interventions. Screening that includes erythrocyte oxidative stress determination may provide an additional marker for both preclinical and advanced disease. In this review, a concise description of the involvement of erythrocyte oxidative stress in diabetes mellitus and its cardiovascular sequelae is presented. Antioxidant action and interaction in the erythrocyte are also described, with emphasis on why current coronary artery disease screening markers cannot be regarded as erythrocyte oxidative stress markers.