Impact of Anaemia on HbA1c Interpretation Among Normogylcaemic Individuals With Diabetes Mellitus: A Clinical Laboratory Observational Study.

BACKGROUND AND AIM: Over the past decades, glycosylated haemoglobin (HbA1c) has been a gold standard for monitoring diabetes control over a long period, relative to blood glucose level (BGL) which measures short-term results. It is speculated that anaemia and factors that induce haemolysis may cause falsely elevated HbA1c leading to 'false positive' interpretations. This study aimed to investigate how anaemia impacts HbA1c. METHODS: This was a pathology-based observational pilot study using archived data of diabetic subjects monitored with both BGL and HbA1c in regional New South Wales (NSW), Australia. A total of 28,487 cases of blood glucose results were pooled and those with HbA1c and anaemia results were evaluated for correlation with the BGL results. Data collection was limited to de-identified information from the laboratory information system, hence details on the ethnicity and medical history were unavailable. Descriptive frequencies and Pearson correlations were performed. RESULTS: In the pooled data, 53.36% of individuals were females, and 50.54% had BGL ≥5.6 mmol/L. In the pilot dataset, the majority (64.86%) were males, 18.92% with BGL ≤5.6 mmol/L and 67.57% had HbA1c (≥6.5%). In the entire dataset, BGL was moderately and positively correlated with HbA1c (r = 0.6), whereas in the subset of individuals with normo-BGL and anaemia, the correlation was negative (r = -0.2). DISCUSSION: This pilot investigation observed a pertinent issue, which is a negative correlation between glycaemia and HbA1c in patients with anaemia. HbA1c was falsely increased despite normal blood glucose levels in individuals with anaemia. This advances the speculation that anaemia falsely increases HbA1c. Therefore, caution is necessary while interpreting HbA1c results for patients with anaemia, and new methods for interpretation are required.

Aeromedical retrievals for gastrointestinal disorders in rural and remote Australia: the need for improved access to specialist advice.

The Royal Flying Doctor Service (RFDS) provides medical care to populations without access to traditional health-care services. From 2014 to 2018 the RFDS conducted 6007 (≈1201/year) aeromedical retrievals for gastrointestinal (GI) disorders. More detailed research is needed to determine specific GI disorders that contributed to this caseload, and in particular inform whether the establishment of a GI specialist service is justified.

Evaluation of ADL and BMI in the management of diabetes mellitus at secondary and tertiary health facilities.

AIMS: Physical activities of daily living (ADL) constitutes one of diabetes management options. This study aimed to assess the extent that ADL and BMI are evaluated among diabetes patients in hospital practice. METHOD: This was a clinical observational baseline study in two hospitals. Audit of medical files was performed to assess if BMI and occupations were recorded (N = 112). Afterwards, 'N = 38' who consented to participate in prospective study were conveniently sampled to assess ADL in relation to accessible metabolic syndrome tests. A validated questionnaire was used to collect data, which were analysed using SPSS version 20. RESULTS: Audit shows 55/112 of clients' occupation were taken, of which 31% has BMI record. Those with lipid profile results are without blood pressure and vice versa. In the cross-sectional assessment, 74% are in physically demanding ADL occupations, but affirmed inactivity is 98% on leisure exercise. Further, 47% have BMI >25 kg/m2 and were consistently less active on all leisure ADL relative to those with BMI <25 kg/m2 (p < 0.02). CONCLUSION: This report highlights oversight in clinical practice, whereby accessible metabolic syndrome parameters and occupation of clients living with diabetes are being assessed inconsistently. This implies an unmet need in the integration BMI and occupational information to improve diabetes self-management.

Diet and lifestyle habits: Association with cardiovascular disease indices in a Nigerian sub-population.

BACKGROUND: There is inadequate evidence regarding the pattern of unhealthy lifestyle behaviours in Nigeria hence the aim of this study was to assess the pattern of lifestyle-related habits that predispose to risk of cardiovascular disease (CVD) indices in a Nigerian population. METHODS: A population-based cross-sectional study was carried out on 422 apparently healthy males and females ≥18 years old. The World Health Organisation (WHO) STEPwise questionnaire was used to collect information on tobacco use or smoking habits, alcohol consumption and dietary habits. Logistic regression analysis was employed. RESULTS: 22.8% and 30.2% of participants indicated that someone smoked in their home and/or in closed areas at workplace, respectively, in the past 30 days. 225/422 admitted to taking alcohol including 72% within the past 12 months. 52.8% of the participants consumed <5 servings of fruits and/or vegetables each day. Results further showed that participants with <5 servings of fruits and/or vegetables (OR: 1.06, CI: 1.01-1.13, p = 0.028) and high level of alcohol consumption (OR: 1.85, CI: 1.18-2.88, p = 0.007) were more likely to have hypertension. CONCLUSIONS: The relatively high prevalence of alcohol consumption and apparent unhealthy diet are of huge concern given the increasing prevalence of CVD indices in the population.

Outpatient cardiac rehabilitation: Effects on patient improvement outcomes.

OBJECTIVE: To determine if the Cardiac rehabilitation (CR) program had positive effects on the patient medically as well as effects on pathological risk factors, functional capacity, and mental health; and the extent to which targets for blood pressure (BP) control in patients with hypertension (HT) and diabetes mellitus (DM) are achieved. METHODOLOGY: CR participant data was collected from 1st June 2014 until 31st December 2015 (19 months), which included: demographics, medical history, social history, medications, lipid profiles and anthropometric measurements. Additional data was collected on The Patient Health Questionnaire (PHQ-9) factors, and on the participants 6min walk test (6MWT). Study participants were eligible to participate in the study if they attended 10 or more CR program sessions out of 12 at the Calvary Public Hospital Canberra. RESULTS: Seventy nine (79) participants participated in the study. Significant reductions in BP (n=79) (p=<0.05), blood LDL cholesterol levels (n=26) (p=<0.05), and improvements in participants PHQ-9 scores (n=79) (p=<0.001), and their 6MWT (n=78) (p=<0.001) were noted. Participants were also able to better manage their medication (p=<0.05). Importantly, results indicated that significant improvements (p=<0.05) were made in DM patients (n=18) diastolic BP, physical ability and depression and anxiety. CONCLUSION: A CR program can reduce risk factors associated with CVD, and improves mental health and physical fitness of participants. RESULTS: Indicated that the CR program reduces DM patient risk factors through improved physical fitness and reductions in depression and anxiety, leading to reduced risk of future cardiovascular and renal disease.

Cardiovascular disease risk factors in a Nigerian population with impaired fasting blood glucose level and diabetes mellitus.

BACKGROUND: Diabetes is a risk factor for cardiovascular diseases (CVDs) and there are reports of increasing prevalence of prediabetes in Nigeria. This study therefore characterised CVDs risk factors in subjects with impaired fasting glucose (IFG) and diabetes. METHODS: Data from 4 population-based cross-sectional studies on 2447 apparently healthy individuals from 18 - 89 years were analysed. Anthropometric, blood pressure and biochemical parameters were collected and classified. Individuals with IFG (prediabetes) and diabetes were merged each for positive cases of dyslipidaemia, high blood pressure (HBP) or obesity. Optimal Discriminant and Hierarchical Optimal Classification Tree Analysis (HO-CTA) were employed. RESULTS: Overall prevalence of IFG and diabetes were 5.8% (CI: 4.9 - 6.7%) and 3.1% (CI: 2.4 - 3.8%), respectively. IFG co-morbidity with dyslipidaemia (5.0%; CI: 4.1 - 5.8%) was the highest followed by overweight/obese (3.1%; CI: 2.5 - 3.8%) and HBP (1.8%; CI: 1.3 - 2.4%). The predicted age of IFG or diabetes and their co-morbidity with other CVD risk factors were between 40 - 45 years. Elevated blood level of total cholesterol was the most predictive co-morbid risk factor among IFG and diabetes subjects. Hypertriglyceridaemia was an important risk factor among IFG-normocholesterolaemic-overweight/obese individuals. CONCLUSION: The higher prevalence of co-morbidity of CVD risk factors with IFG than in diabetes plus the similar age of co-morbidity between IFG and diabetes highlights the need for risk assessment models for prediabetes and education of individuals at risk about factors that mitigate development of diabetes and CVDs.

Association between metabolic syndrome and 10-year risk of developing cardiovascular disease in a Nigerian population.

BACKGROUND: Prevalence of metabolic syndrome (MetS) and consequential cardiovascular disease (CVD) events are on the increase in Nigeria. The study aimed to identify the prevalence of 10-year CVD risk in a Nigerian population and assess its relationship with different indices of MetS. METHOD: A cross-sectional study was carried out on apparently healthy persons aged 18 years of age or older. Ten-year risk was calculated using the ATPIII/Framingham criteria. Subjects with risk score <10% were considered as having low risk, 10-20% moderate risk and >20% at high risk of developing CVD in 10 years. MetS was defined based on the Joint Scientific Statement on Harmonizing the MetS. RESULT: Of the 211 subjects, mean age was 51.3±17.3 years. Average risk of developing CVD in the next 10 years was 3.7±5.3%. Prevalence of low, moderate and high risk of developing CVD among study participants was 86.3% (95% CI 82.0-91.3%), 11.8% (95% CI 6.9-16.1%) and 1.9% (95% CI 0.0-3.8%), respectively. Prevalence of MetS was 26.7% (95% CI 21.0-33.3%). There was poor agreement between MetS and the CVD risk scores (kappa=0.209, p=0.001) CONCLUSIONS: The results showed that complementary use of MetS and CVD risk score is imperative, as there is indication of risk in individuals without MetS. Also a large proportion of the study population requires lifestyle intervention. These findings provide the evidence necessary to tailor public health interventions in this population, especially towards younger age groups.

Maximum accuracy obesity indices for screening metabolic syndrome in Nigeria: A consolidated analysis of four cross-sectional studies.

BACKGROUND: In sub-Saharan Africa, there is no precise use of metabolic syndrome (MetS) definitions and risk factors screening indices in many clinical and public health services. Methods proposed and used in Western populations are adopted without validation within the local settings. The aim of the study is to assess obesity indices and cut-off values that maximise screening of MetS and risk factors in the Nigerian population. METHOD: A consolidated analysis of 2809 samples from four population-based cross-sectional study of apparently healthy persons≥18 years was carried out. Optimal waist circumference (WC) and waist-to-height ratio (WHtR) cut points for diagnosing MetS and risk factors were determined using Optimal Data Analysis (ODA) model. The stability of the predictions of the models was also assessed. RESULTS: Overall mean values of BMI, WC and WHtR were 24.8±6.0kgm(-2), 84.0±11.3cm and 0.52±0.1 respectively. Optimal WC cut-off for discriminating MetS and diabetes was 83cm in females and 85cm in males, and 82cm in females and 89cm in males, respectively. WC was stable in discriminating diabetes than did WHtR and BMI, while WHtR showed better stability in predicting MetS than WC and BMI. CONCLUSION: The study shows that the optimal WC that maximises classification accuracy of MetS differs from that currently used for sub-Saharan ethnicity. The proposed global WHtR of 0.50 may misclassify MetS, diabetes and hypertension. Finally, the WC is a better predictor of diabetes, while WHtR is a better predictor of MetS in this sample population.

Association of physical activity with metabolic syndrome in a predominantly rural Nigerian population.

AIMS: Physical activity is an essential determinant of health. However, there is dearth of evidence regarding prevalence of physical activity in developing countries, especially its association with metabolic syndrome risk factors. This study assessed the association of physical activity with metabolic syndrome in a Nigerian population. MATERIALS AND METHODS: A cross-sectional study was carried out on apparently healthy persons who are ≥ 18 years old. The World Health Organisation (WHO) Global Physical Activity Questionnaire (GPAQ) was used to collect five domains of physical activity. Participants were classified as physically active or inactive based on meeting the cut-off value of 600 MET-min/week. Metabolic syndrome was diagnosed using the Joint Scientific Statement on Harmonizing the Metabolic Syndrome criteria. RESULTS: Overall prevalence of physically active individuals was 50.1% (CI: 45.6-54.7%). Physical inactivity is significantly more in females (p<0.01) and among participants >40 years old (p<0.0001). Whereas individuals with metabolic syndrome appeared more likely to be physically active (OR=1.48, CI: 0.71-3.09); physical inactivity showed to exist more among participants who were living in urban area (OR=6.61, CI: 3.40-12.85, p<0.001). Participants with prediabetes (OR=1.69, CI: 0.62-4.61) and diabetes (OR=1.91, CI: 0.65-5.63) were more likely to be physically inactive as compared to other metabolic syndrome risk factors. CONCLUSION: The high prevalence of physical inactivity in this study population is a clear indication that concerted efforts to improve physical activity may be required. However, it seems that metabolic syndrome is not improved by being physically active. This suggests that interventions directed at physical activity alone may not produce optimal efficacy in this study population.

Cardiovascular risks in prediabetes: preliminary data on "vasculopathy triad".

BACKGROUND: Subclinical cardiovascular disease is inherent in complications of diabetes mellitus. It occurs before the obvert manifestation of cardiovascular disease complication in diabetes, and involves vasculopathy triad or three major vascular events comprising stasis, endothelial dysfunction, and atherothrombosis. AIM: This study was to examine evidence of vasculopathy triad in prediabetes, biomarkers of stasis, endothelial dysfunction, and atherothrombosis in prediabetes were compared with apparently healthy group. MATERIALS AND METHODS: Eighty-one participants with results for plasma D-dimer, homocysteine, and whole blood viscosity were selected from a research database. The participants consisted of control (n = 44) and prediabetes (n = 37) based on clinical history and laboratory results. RESULTS: Multivariate analysis shows a significantly higher level of vasculopathy in prediabetes than in the control group (P > 0.0001). Blood viscosity (P < 0.04) and homocysteine (P < 0.03) are significantly higher in prediabetes than in controls. Average levels for plasma D-dimer are also higher in prediabetes than in control, but not statistically significant in this particular analysis. CONCLUSION: This study suggests a novel application of known idea, vasculopathy triad that could be used for assessment of subclinical cardiovascular disease in prediabetes.

Obstructive sleep apnea management with interactive computer technology and nutrition: two case reports.

We present two cases of obstructive sleep apnea (OSA) in which one of the subjects was managed with virtual scanning, which is a computer interactive diagnostic and therapeutic technology, and the other was treated with nutrition. We propose an oxidative stress concept as the biochemical basis of the two management options. It is important to consider the validity of virtual scanning Technology (which can be used to manage sleep apnea noninvasively) and to determine whether oxidative stress is the biochemical basis for this technology. It will be beneficial to develop a framework for integration into clinical practice.

Atherothrombosis and oxidative stress: the connection and correlation in diabetes.

BACKGROUND: Hyperglycaemia-induced depletion of reduced glutathione (GSH) causes erythrocyte oxidative stress (EOS), which leads to vascular events including exacerbation of thrombotic events evidenced by changes in D-dimer level. It would, therefore, appear that there is a complex link between GSH and D-dimer, which are part of an emerging array of biomarkers associated with diabetes. The objective of this study was to investigate evidence of correlation between levels of plasma D-dimer and erythrocyte GSH in diabetes disease progression. SUBJECTS AND METHODS: A cohort of 69 subjects were selected based on medical history plus clinical findings and equally divided into control, prediabetes and diabetes groups, matched for age and sex. Plasma D-dimer and erythrocyte reduced glutathione (GSH) were determined and separated into quartiles as a means of indicating disease severity. Statistical analysis was by Pearson's correlation coefficient. RESULTS: Of the three groups, only the diabetes group showed any correlation between GSH and D-dimer. Of importance is that for increasing GSH, the second quartile range of GSH (xbar +/- SD = 45 +/- 22 mg/100ml) showed a statistically significant negative correlation for ranked D-dimer (xbar +/- SD = 1055 +/- 828 microg/l; r = -0.88; P < 0.02). The fourth quartile GSH range (xbar +/- SD = 79 +/- 40 mg/100 ml) showed a statistically significant positive correlation with D-dimer (xbar +/- SD = 1055 +/- 828 microg/l; r = 0.91; P < 0.02). Thus, within the diabetes group only, the increasing level of oxidative stress as measured by GSH first indicates a reduction in D-dimer followed by a rise in D-dimer, which led to the proposal of a two-part process of atherosclerosis that reconciles previous contradictory findings. CONCLUSIONS: This study provides not only evidence of a correlation between oxidative stress level and fibrinolysis in diabetes, but also an explanation of why previous studies have found both hypo- or hyperfibrinolysis associated with diabetes.

The 'vitamin E regeneration system' (VERS) and an algorithm to justify antioxidant supplementation in diabetes--a hypothesis.

In studies of vitamin E effectiveness in diabetes, there are still controversies surrounding negative observational and positive experimental results. However, there is no controversy that antioxidant vitamin E is regenerated from its pro-oxidant tocopheroxyl radical by a network of interacting co-antioxidants. The network of interacting co-antioxidants has only been studied individually. The hypothesis we propose is that a vitamin E regeneration system (VERS) model based on the complex interactions of the co-antioxidants provides a rationale for vitamin E supplementation as a therapeutic adjunct in diabetes. Furthermore, the factors considered prior to the use of Vitamin E as a supplement in diabetes research and therapy, the effectiveness of vitamin E supplementation and the limitations have been identified in the literature. There is no single study of vitamin E supplementation or efficacy that has determined vitamin E levels in combination with all of the co-antioxidants that interact to regenerate oxidised vitamin E. Therefore, there is a lack of good evidence for or against vitamin E being unilaterally depleted in the antioxidant network. There is also lack of rationale for choice of co-antioxidant supplementation. In essence, the normal conditions for effective antioxidant activity of vitamin E supplementation have yet to be fully explored. We propose a coherent model of VERS, and recommend that VERS status needs to be assessed, as part of evidence-based clinical practice to determine whether vitamin E should be recommended for the diabetic patient. We also propose an algorithm, based on the antioxidant activity and confounding factors, to guide the formulation of a credible hypothesis for clinical trials in assessing the function of vitamin E and treatment outcomes. The proposed model hinges on pertinent questions that have to be addressed to avoid organising a clinical trial that has been identified as biased.

D-dimer identifies stages in the progression of diabetes mellitus from family history of diabetes to cardiovascular complications.

AIM: The aim of the study was to ascertain whether there is variation in the fibrinolytic/coagulation component of diabetes associated with disease progression to macrovascular complications and whether D-dimer can discriminate such variation. METHODS: A total of 343 participants were selected based on clinical status and divided into 7 groups: control, family history of diabetes, pre-diabetes with/without CVD, diabetes with/without CVD and CVD only. Plasma D-dimer was tested. Statistical analysis was performed on log normalised data by ANOVA, Fisher's LSD post hoc test. After the initial analysis, data were classified and re-analysed by quartiles, interquartile range and 95(th) percentile. RESULTS: An overall significant difference between groups (p<0.002) and a steady rise in D-dimer levels that became increasingly higher than control as the disease progressed from pre-diabetes to cardiovascular complications was observed. A statistically significant difference was observed between control versus diabetes (p<0.0005). Analysis of data by quartiles and percentiles gave qualitatively similar results, but a greater significant difference between control versus pre-diabetes at 3rd quartile and interquartile range (p<0.014). CONCLUSION: We report changes in D-dimer levels that may indicate diabetes disease progression to macrovascular complications. Using D-dimer in conjunction with other biomarkers to identify stages of disease progression, commencing from pre-diabetes and continuing to development of asymptomatic and clinical cardiovascular disease in diabetes mellitus, is worthy of consideration.

Changes in the erythrocyte glutathione concentration in the course of diabetes mellitus.

This study aims to evaluate the significance of the changes of erythrocyte reduced glutathione (GSH) in the course of diabetes mellitus including the pre-diabetes stage and cardiovascular disease co-morbidity. A total of 222 participants (female:male, 107:115) were selected and their erythrocyte GSH levels were measured. The participants were divided into four groups: (i) control; (ii) those with blood glucose level > or =5.6 mmol/l but < 6.9 mmol/l as pre-diabetes mellitus with no other pathology; (iii) diabetes without co-morbidity; and (iv) those with diabetes mellitus and cardiovascular disease. Statistical analysis was by ANOVA followed by a Fisher's LSD post hoc test. We observed that GSH concentration was significantly different between groups (P < 0.04). The Fisher's post hoc test indicated significant differences in erythrocyte GSH levels between the pre-diabetes mellitus and diabetes mellitus groups compared to control (P < 0.005 and P < 0.05, respectively). A statistically significant change (P < 0.001) involving an initial fall followed by a rise in erythrocyte GSH levels was observed when diabetes mellitus and diabetes mellitus+cardiovascular disease groups were combined and assessed with respect to period of diabetes. We conclude that oxidative stress is already present in the pre-diabetes stage as determined by the fall in GSH, representing the initial phase of oxidative stress in diabetes mellitus progression. This finding provides evidence that antioxidant markers such as GSH could be a useful tool for pre-diabetes mellitus screening.