Health system costs of providing outpatient care for diabetes in people with TB in the Philippines.

BACKGROUND: Diabetes mellitus (DM) is a known risk factor for active TB. A key activity in the Philippines is to integrate TB services with other disease programmes, with a target of DM screening in 90% of TB cases. However, costs of providing DM outpatient services for TB patients are not well known. METHODS: We estimated the costs of providing integrated DM outpatient services within TB services from the health system perspective. Resources for outpatient DM services were valued using the bottom-up approach for capital goods, staff time and consumables. Resource quantities were obtained by interviewing 60 healthcare professionals in 11 health facilities in the Philippines. RESULTS: The mean cost per service ranged from USD0.53 for DM risk assessment to USD23.72 for oral glucose tolerance test. The cost per case detected for different algorithms varied from USD17.43 to USD80.81. The monthly cost per patient was estimated at USD8.95 to USD12.36. CONCLUSION: Our study provides the first estimates of costs for providing integrated DM outpatient services and TB care in a low- and middle-income country. The costs of DM detection in TB patients suggests that it may be useful to further investigate the cost-effectiveness and affordability of service delivery.

CONTEXTE: Le diabète (DM) est un facteur de risque bien établi pour la TB active. Aux Philippines, l'une des principales initiatives est d'intégrer les services de lutte contre la TB dans d'autres programmes de santé, dans le but de dépister le DM chez 90% des patients atteints de TB. Cependant, les coûts des services ambulatoires de traitement du DM pour les patients atteints de TB ne sont pas clairement définis. MÉTHODES: Nous avons évalué les coûts des services ambulatoires intégrés pour le traitement du DM dans le cadre des services de lutte contre la TB, du point de vue du système de santé. Les ressources pour les services ambulatoires de DM ont été évaluées en utilisant l'approche ascendante pour les biens d'équipement, le temps du personnel et les consommables. Les quantités de ressources ont été recueillies en interrogeant 60 professionnels de la santé dans 11 établissements de santé aux Philippines. CONCLUSION: Notre étude présente les premières estimations des coûts des services ambulatoires intégrés pour le traitement du DM et de soins de la TB dans un pays à revenu faible ou intermédiaire. Il est suggéré d'approfondir l'étude du rapport coût-efficacité et de l'accessibilité des services de détection de la DM chez les patients atteints de TB, compte tenu des coûts impliqués.

Diabetes mellitus in patients with liver cirrhosis.

In spite of the high prevalence of diabetes mellitus (DM) in patients with liver cirrhosis (LC) few studies have focused on the clinical implications of this association. We investigated the clinical and pancreatic-endocrine features of 34 patients who developed DM after LC (Group I). Results were compared with 34 carefully matched patients with only Type II DM (Group II). A standard meal test was performed in 26 patients with normal renal function from each group to assess beta-cell function. Group I patients, less frequently had retinopathy (14.7% vs. 45.5%, P < 0.05) and a family history of diabetes (23.5% vs. 58.8%, P < 0.01). Group I patients also showed signs of enhanced insulin resistance, reflected by higher insulin dose requirements in insulin-treated patients (0.87 +/- 0.10 vs. 0.62 +/- 0.05 IU/kg/day, P < 0.01) and increased basal C-peptide values (0.88 +/- 0.06 vs. 0.68 +/- 0.07 pmol/l, P < 0.05, respectively) than those in Group II. These results suggest that several clinical features, probably related to the hepatopathy, define DM occurring in patients with LC.

Symptomatic and hormonal hypoglycaemic responses to human and porcine insulin in patients with type I diabetes mellitus.

In recent years there has been great concern that human insulin (HI) may induce fewer hypoglycaemic warning symptoms than porcine insulin (PI). We addressed this issue in eight patients aged 25.6 +/- 3.3 (SEM) years with Type I (insulin-dependent) diabetes mellitus of 15.1 +/- 3.7 years duration who complained that hypoglycaemia unawareness had appeared after transferring from PI to HI. Acute induction of hypoglycaemia was induced on two occasions with semisynthetic HI and purified PI under double-blind conditions. Blood glucose was first clamped for 2 h at 4.4-6.7 mmol l-1 with an intravenous infusion of HI or PI at 50 mU kg-1 h-1 and 20% glucose at a variable rate. Thereafter, insulin infusion alone was maintained for 100 minutes. Heart rate, arterial pressure, reflex times, autonomic and neuroglycopenic signs and symptoms were assessed every 10 min. Arterialized venous blood samples were taken to measure blood glucose every 10 min and catecholamines, insulin, glucagon, growth hormone, and cortisol every 20 min. Autonomic symptoms first appeared at a plasma glucose level of 2.92 +/- 0.21 mmol l-1 with HI vs 2.92 +/- 0.48 mmol l-1 with PI (NS). There were no significant differences between the two studies concerning any of the above mentioned clinical parameters or the counterregulatory hormone responses. A differential effect of insulin species on the ability to perceive hypoglycaemia in patients who ascribed diminished perception of hypoglycaemia to the use of HI was thus not observed.

Characterization of the clinical features of five families with hereditary primary cutaneous lichen amyloidosis and multiple endocrine neoplasia type 2.

The hereditary conditions of primary cutaneous lichen amyloidosis and multiple endocrine neoplasia type 2 (MEN 2) are rare clinical entities. The initial reports of two families in which the two conditions coincided have led to the identification of at least eight additional families with this clinical syndrome. In this report we describe the clinical features in five of these eight families. The salient feature in these five families is the presence of unilateral (46%) or bilateral (64%) pruritic and lichenoid skin lesions located over the upper portion of the back. Family members describe these skin lesions as intermittently intensely pruritic leading to scratching and excoriation of the upper back region. The presence of MEN 2 has been documented in 97% of family members with this skin lesion, the one exception being a child who is at risk for development of MEN 2A in whom the diagnosis has not yet been made. Of family members who have MEN 2A, 27% do not have an identifiable skin lesion, although the skin lesion developed in one patient two years after a curative thyroidectomy for medullary thyroid carcinoma (MTC). Four of the five families have members with pheochromocytoma; one with five affected members has only MTC. The finding of this clinical syndrome in geographically diverse portions of the world and the lack of overlap with MEN 2A without the skin lesion suggest it is a distinct clinical variant of MEN 2A.

Cyclosporine's effect on insulin secretion in patients with kidney transplants.

Adverse effects of cyclosporine on glucose metabolism have been reported in patients with kidney transplantation, but steroids were present in all the immunosuppressive schedules evaluated. We have studied endocrine pancreatic function (OGTT measuring plasma insulin [IRI] and c-peptide [CP]) in 3 groups of patients, matched for age and body-mass index, 16-66 months after functioning Ktx. Seven patients were treated with CsA monotherapy (group I), 7 patients with CsA plus prednisone (group II), and 6 patients with azathioprine plus prednisone (group III). Seven healthy subjects formed the control group. OGTT was normal in all patients, except one in group II (impaired glucose tolerance). There were no significant differences between the 4 groups concerning fasting blood glucose and area under the glucose curve, as well as basal insulin levels, peak insulin response to glucose, and area under the insulin curve. Basal CP, peak CP response to glucose, and area under CP curve were lower in CG than in the 3 groups of patients. Basal CP in group II (4.4 +/- 2.2 ng/ml) was higher than in group I (2.8 +/- 0.6 ng/ml, P less than 0.05). Glucose/IRI molar ratio in group II (5.7 +/- 1.4, P greater than 0.05) was lower than in group I (7.3 +/- 1.8) and CG (8.0 +/- 2.1, P less than 0.025). Our results suggest that CsA at normal dosage has no clinically important effect on beta-cell function. The indirect evidence of insulin resistance observed in patients treated with CsA plus prednisone is ascribable to corticosteroid treatment.

Primary localized cutaneous amyloidosis and familial medullary thyroid carcinoma.

We have studied a family with an autosomal dominant inheritance of primary localized cutaneous amyloidosis (PLCA) and familial medullary thyroid carcinoma (MTC). Ten family members were screened for multiple endocrine neoplasia (MEN) 2; five were found to have MTC and two had C-cell hyperplasia. None had evidence of phaeochromocytoma or parathyroid abnormalities. Five of these seven patients presented characteristic interscapular hyperpigmented lesions, showing dermal amyloid deposits in two of the four patients in which a biopsy was performed. The data are analysed in the light of two recent reports of MEN 2A associated with identical lesions. We conclude that PLCA should be sought in MTC patients, even if no other endocrinopathies are present. This may be informative of the familial character of MTC in index cases and also of the tumour gene status in family members who are being screened.

Asymptomatic electronystagmographic abnormalities in patients with type I diabetes mellitus.

Only a few studies have investigated vestibular function in diabetes mellitus (DM), showing contradictory results. We have performed an electronystagmographic (ENG) evaluation of 46 individuals with type I DM and 37 healthy controls. No patient reported subjective vestibular symptoms. Duration of caloric-induced nystagmus (DN) was significantly lower (2.1 +/- 0.7 vs. 2.6 +/- 0.4 min, p less than 0.01), and central nystagmus frequency of caloric response also nonsignificantly tended to be decreased (37.4 +/- 16.5 vs. 41.7 +/- 12.7 beats/30s, p = 0.21) in DM patients, as compared to controls. The latter comparison achieved significance after exclusion of newly diagnosed diabetic patients (33.4 +/- 16.1 vs. 41.6 +/- 12.7 beats/s, p less than 0.05). Depressed caloric reactions were seen in 21.8% of patients. DN was lower in patients with microalbuminuria and retinopathy, but this was not observed after exclusion of newly diagnosed diabetic patients, all of whom had normal ENG responses and no chronic diabetic complications. The existence of a lower DN and central nystagmus frequency should be borne in mind when interpreting ENG tracings in patients with long duration type I diabetes mellitus.

Auditory function in young patients with type 1 diabetes mellitus.

Comprehension of the effect of diabetes mellitus on auditory function has been hindered by the fact that previous studies have evaluated hearing function in heterogeneous groups of patients with diabetes mellitus, thus giving conflicting results. We have performed audiometric studies in 46 consecutive patients. 13 with newly diagnosed type 1 diabetes mellitus (group 1) and 33 with type 1 diabetes mellitus of more than 3 years of duration (group 2), of 14 to 40 years of age. The results were compared to an age-matched control group. Pure-tone auditory thresholds were significantly higher in all frequencies 250-8,000 Hz in both groups when compared to the control subjects. Ten patients, all of which belonged to group 2, had auditory thresholds above 30 dB in at least one frequency, showing a conversational hearing loss that ranged between 11 and 44%. However, none of them referred subjective hypoacusia. Univariate analysis revealed significant associations between auditory thresholds and age, duration of disease as well as retinopathy, but not with neuropathy, HbA1c or hypoglycaemic episodes. Only age and duration of disease independently correlated with an auditory threshold using multiple regression. We conclude that type 1 diabetes mellitus can cause mild sensorineural hearing impairment which correlates with age and duration of disease.

Effects of thromboxane synthesis inhibitor triflusal on renal hemodynamics in microalbuminuric diabetic patients.

Triflusal (2-acetoxy-4-trifluormethylbenzoic acid) is a platelet-antiaggregant drug that selectively inhibits thromboxane synthesis with little effect on prostacyclin production. In this study, we evaluated the effect of 5-day administration of 900 mg/day triflusal on glomerular filtration rate (GFR), renal plasma flow (RPF), urinary albumin excretion (UAE), thromboxane B2 (TXB2), 6-ketoprostaglandin F1 alpha (PGF1 alpha), and PGE2 in nine normotensive insulin-dependent diabetic patients with UAE between 30 and 103 micrograms/min. Plasma TXB2 and plasma renin activity (PRA) were also determined. After administration of triflusal, we observed a reduction in microalbuminuria (59 +/- 25 vs. 33 +/- 22 micrograms/min, P less than 0.01), an increase in RPF (648 +/- 119 vs. 722 +/- 134 ml.min-1 x 1.73 m-2, P less than 0.01), and a reduction in filtration fraction (0.24 +/- 0.04 vs. 0.20 +/- 0.03, P less than 0.01). Triflusal produced a significant reduction in both plasma TXB2 (130 +/- 39 vs. 52 +/- 32 pg/ml, P less than 0.02) and urine TXB2 (523 +/- 249 vs. 312 +/- 11 pg/min, P less than 0.02), without changes in PRA and UAE of 6-keto-PGF1 alpha and PGE2. Metabolic control and arterial blood pressure did not change during the study. These results suggest that platelet-antiaggregant therapy can reduce microalbuminuria in diabetic patients. This effect could be mediated by a reduction in the transglomerular hydraulic pressure through a vasodilation of efferent arterioles secondary to renal thromboxane synthesis inhibition.

Fulminant liver failure and pancreatitis associated with the use of sulfamethoxazole-trimethoprim.

We report the case of a 26-yr-old patient with fulminant liver failure and acute hemorrhagic pancreatitis secondary to the use of trimethoprim-sulfamethoxazole (Bactrim DS). Our patient presented with skin rash and decreased C3 and C4 levels, which we believed was due to a hypersensitivity reaction secondary to the sulfonamide component (sulfamethoxazole). To our knowledge, this is the first case reported in which sulfamethoxazole-trimethoprim has been implicated as a cause of fulminant liver failure and acute hemorrhagic pancreatitis simultaneously, and emphasizes the need of discontinuing this medication as soon as there is evidence of liver and pancreatic dysfunction.

Fulminant idiopathic pseudomembranous colitis.

Pseudomembranous colitis is characterized by inflammatory plaques and pseudomembranes on the colonic mucosa. The disorder most commonly occurs after the use of antibiotics, which allow overgrowth of Clostridium difficile, a spore-forming, gram-positive rod that produces a toxin. Overgrowth of Staphylococcus aureus can also produce pseudomembranous colitis. In rare cases, pseudomembranous colitis is not associated with antibiotic use. When C. difficile is present, vancomycin or metronidazole usually produces a prompt response. In idiopathic cases, surgery may be required.