Latent tuberculosis in patients with diabetes mellitus: prevalence, progression and public health implications.

BACKGROUND: Diabetes mellitus (DM) confers a higher risk for tuberculosis (TB). Yet, TB screening and chemoprophylaxis for latent TB infection (LTBI) in DM remains controversial. We conducted a cross-sectional study to elucidate LTBI prevalence and longitudinal follow-up to ascertain LTBI to active TB progression rate in DM. METHODS: 220 DM patients without previous TB from the outpatient diabetes clinic of the hospital were enrolled. T-Spot TB, tuberculin-skin-test (TST) and chest radiography (CXR) were performed. LTBI was defined by negative CXR with reactive T-Spot TB. Progression to active TB was confirmed by cross-checking against the TB registry. RESULTS: The prevalence of LTBI was 28.2% (62/220) by reactive T-Spot. None progressed to active TB from 2007-2013. Multivariate analysis revealed that any co-morbidity (p=0.016) was positively associated while metformin (p=0.008) was negatively associated with LTBI. CONCLUSIONS: Over a quarter of DM patients harbor LTBI. While the lack of demonstrable progression to active TB within the follow-up time frame up to this point does not unequivocally support a routine TB screening policy or anti-TB chemoprophylaxis for LTBI in a diabetic population for now, this preliminary evidence needs re-evaluation with longer follow-up of this enrolled cohort over the next decade.

24-Hour observational ward management of diabetic patients presenting with hypoglycaemia: a prospective observational study.

BACKGROUND: A 24 h observational ward was set up in the study hospital emergency department (ED) in September 2005 to manage a group of patients with specific conditions including hypoglycaemia that require only short focused inpatient care. AIM: To evaluate the efficacy and safety of the management of hypoglycaemia in the observational ward via criteria of successful discharge of patients from the observational ward within 24 h and the recurrence of hypoglycaemia after discharge. METHODS: Hypoglycaemic patients admitted to the observational ward had their treatment and evaluation performed within 24 h. A protocol based on current available literature was formulated. Data were collected prospectively and included patient demographics, the duration and type of diabetes mellitus, current medications and treatment given. Patients were discharged only after a set of strict discharge criteria was fulfilled, and were followed up by telephone interviews at 7 and 28 days after discharge. RESULTS: A total of 203 patients were recruited. Of these, 170 (83.7%) patients were discharged and 33 (16.3%) were transferred to an inpatient team for a longer period of treatment. The median length of stay in the observational ward was 23.0 h. Of the 170 patients discharged, 151 (88.8%) were contacted at 7 and 28 days after discharge. Six patients had symptoms of recurrent hypoglycaemia, two of whom reattended the ED and had to be admitted. The remaining four patients had mild symptoms that were self-managed at home. Two other patients reattended for conditions not related to hypoglycaemia. Nineteen patients could not be contacted, but there was no record of any reattendances at the ED among this group of patients. CONCLUSION: There are currently no recommendations regarding the length of stay in hospital for patients with severe hypoglycaemia. This study shows that selected patients can be treated effectively and safely in a 24 hour observational ward.

Thyrotoxicosis and acute abdomen--still as defying and misunderstood today? Brief observations over the recent decade.

BACKGROUND: Clinicians managing thyrotoxic patients with acute abdomen face challenging diagnostic and risky therapeutic dilemmas. AIM: To analyse the frequency of medical vs. surgical acute abdomen, and to characterize the poorly understood thyrotoxic medical acute abdomen phenomenon. DESIGN: Retrospective review of case notes. METHODS: All case files with a simultaneous diagnosis of thyrotoxicosis and acute abdomen admitted between 1994 and 2004 were traced and audited. RESULTS: Thirteen had a history of thyrotoxicosis while 12 were newly diagnosed. The commonest cause was Graves' disease. Twenty-three (92%) cases were thyrotoxic, of whom six (24%) had thyroid crisis, while two (8%) had subclinical thyrotoxicosis. The provisional diagnosis of acute abdomen was correct in 14 cases (56%), but discordant with the final diagnosis in 11 cases (44%). Eight cases (32%) without any demonstrable pathology were medical, vs. four (16%) with surgical acute abdomen, while 11(44%) had gastritis, hepatobiliary-pancreatic disorders or diverticulitis conservatively managed. The epigastrium and/or central abdomen (72.7%) were the commonest affected regions in medical acute abdomen. CONCLUSION: Although the majority of acute abdomen in thyrotoxicosis was medical in nature, our experience indicates that surgical conditions were not uncommon. Thus, serious causes requiring life-saving surgery should be excluded before attributing it to medical acute abdomen.