Characteristics and treatment patterns of patients with type 2 diabetes in Lebanon: the DISCOVER study.

BACKGROUND: Lebanon is part of the global DISCOVER study, a global, noninterventional, multicentre, prospective study with 3-years of follow-up. AIMS: The aim of this study is to describe real-world clinical practice in terms of type 2 diabetes mellitus (T2DM) disease management and treatment patterns within Lebanon. METHODS: Baseline demographic and clinical parameters were captured on a standardized case report form, according to routine clinical practice at each clinical site. RESULTS: We recruited 348 patients. At the initiation of second-line therapy, mean duration of diabetes was 6.7 [standard deviation (SD) 6.5] years; mean HbA1c and fasting plasma glucose levels were 8.5% (SD 1.6%) and 178.7 (SD 56.5) mg/dL respectively. Almost half the patients were hypertensive (45.1%) or had dyslipidaemia (48.6%). Metformin monotherapy was used as first-line therapy in 56.9% of the patients and upfront dual therapy in 25%. The primary reason for changing firstline therapy was poor glycaemic control. The main factors in choosing the second-line therapy were efficacy, tolerability and hypoglycaemia. CONCLUSION: Clinical inertia was evident in this cohort of patients as they had suboptimal glycaemic control at the time of enrolment and the initiation of second-line therapy. Treatment intensification is required to reduce diabetes-related adverse outcomes.

Hypoglycaemia assessment tool (HAT) study: subanalysis of the Lebanese cohort.

BACKGROUND: Diabetic hypoglycaemia affects medication adherence, patients' productivity and quality of life. It is also associated with an increased risk of cardiovascular complications. AIMS: To examine the impact of hypoglycaemia in insulin-treated patients in the Lebanese cohort of the Hypoglycaemia Assessment Tool (HAT) study. METHODS: The HAT study was an observational study covering a 6-month retrospective and a 4-week prospective period in 24 countries including Lebanon. Data were collected using self-assessment questionnaires and patient diaries from 1158 invited lebanese patients, aged ≥ 18 years, with type 1 or type 2 diabetes mellitus (T1DM/T2DM) treated with insulin for > 12 months. The primary endpoint was the proportion of patients experiencing ≥ 1 hypoglycaemic event during the 4-week follow-up period. RESULTS: After 4 weeks of follow-up, 177/225 [78.7%; 95% confidence interval (CI): 72.7-83.8] of patients with T1DM and 291/630 (46.2%; 95% CI: 42.2-50.2) patients with T2D experienced at least 1 hypoglycaemic event. Rates of nocturnal and severe hypoglycaemia were 10.7 (95% CI: 9.1-12.3) and 13.2 (95% CI: 11.5-14.9) events/patient-year for T1DM, and 3.3 (95% CI: 2.8-3.8) and 4.2 events/patient-year (95% CI: 3.6-4.8) for T2DM, respectively. Fear of hypoglycaemia was significantly associated with nocturnal and severe hypoglycaemia in both diabetes types (P < 0.001). CONCLUSION: The results suggest that the less-advanced healthcare systems in Lebanon are implicated in lower levels of patient knowledge about hypoglycaemia and related preventive measures. Treatment strategies and glycaemia goals should be individualized according to patient preference, medical benefits, and risk of hypoglycaemia.

Case-series of paraneoplastic Cushing syndrome in small-cell lung cancer.

The objective of this study is to report three cases of paraneoplastic or ectopic Cushing syndrome, which is a rare phenomenon of the adrenocorticotropic hormone (ACTH)-dependent Cushing syndrome. Three cases are reported in respect of clinical presentation, diagnosis and treatment in addition to relevant literature review. The results showed that ectopic ACTH secretion can be associated with different types of neoplasm most common of which are bronchial carcinoid tumors, which are slow-growing, well-differentiated neoplasms with a favorable prognosis and small-cell lung cancer, which are poorly differentiated tumors with a poor outcome. The latter is present in two out of three cases and in the remaining one, primary tumor could not be localized, representing a small fraction of patients with paraneoplastic Cushing. Diagnosis is established in the setting of high clinical suspicion by documenting an elevated cortisol level, ACTH and doing dexamethasone suppression test. Treatment options include management of the primary tumor by surgery and chemotherapy and treating Cushing syndrome. Prognosis is poor in SCLC. We concluded that in front of a high clinical suspicion, ectopic Cushing syndrome diagnosis should be considered, and identification of the primary tumor is essential. LEARNING POINTS: Learning how to suspect ectopic Cushing syndrome and confirm it among all the causes of excess cortisol.Distinguish between occult and severe ectopic Cushing syndrome and etiology.Providing the adequate treatment of the primary tumor as well as for the cortisol excess.Prognosis depends on the differentiation and type of the primary malignancy.

Effect of total contact cast in non-healing diabetic foot ulcers in Lebanese patients.

The aim of this study was to evaluate the effectiveness of total contact casting (TCC) in treating non-healing diabetic foot ulcers in Lebanese diabetic patients. Twenty-three diabetic patients were treated with TCC, and relevant data were collected retrospectively. Sixteen patients were analysed; the average duration of casting was 6 weeks, and 75% of the patients achieved complete ulcer closure without recurrence during one year of follow-up and without any complications. TCC appears to be an effective treatment of diabetic foot ulcers.

Endocrine dysfunction in a patient with PHACE syndrome, including port-wine stain of the right periorbital area.

OBJECTIVE: To report a case of PHACE syndrome-Posterior fossa brain abnormalities, Hemangioma (usually facial), Arterial anomalies, Coarctation of the aorta along with cardiac defects, and Eye abnormalities-in a 16-year-old female patient with a port-wine stain of the right periorbital area present since birth in conjunction with hypoplasia of the contralateral internal carotid artery. METHODS: Thyroid-stimulating hormone, free thyroxine, and growth hormone (GH) levels were measured, and insulin-induced hypoglycemia and arginine infusion tests were done. Radiologic investigations included sagittal enhanced T1-weighted magnetic resonance imaging of the brain and the pituitary gland as well as computed tomography and magnetic resonance angiography of the head and neck. RESULTS: The patient had a normal karyotype. Her height and weight were below the 5th percentile for her chronologic age, and she had amenorrhea. Laboratory investigations revealed both thyroid and GH deficiencies and confirmed the diagnosis of hypogonadotropic hypogonadism. The imaging studies showed a right intraorbital hemangioma as well as an enhancing mass in the right internal auditory canal at the cerebellopontine angle, consistent with a posterior fossa hemangioma. Initiation of both thyroid and GH replacement therapy improved her growth rate and yielded a good clinical outcome. CONCLUSION: In patients with facial or neck hemangiomas, PHACE syndrome should be suspected, and brain imaging and cardiac, ophthalmologic, and endocrinologic evaluations are recommended to screen for other potential PHACE abnormalities.

Prevalence and determinants of retinopathy in a cohort of Lebanese type II diabetic patients.

OBJECTIVE: Our aim was to determine the prevalence and the risk factors for diabetic retinopathy (DR) in a cohort of type II diabetic patients in Lebanon. DESIGN: Prospective observational cohort study. PARTICIPANTS: Five hundred consecutive patients with type II diabetes mellitus followed at the American University of Beirut Medical Center diabetes clinic were enrolled in the study. METHODS: All patients 18 years or older with diabetes mellitus who did not have gestational diabetes and who were able to complete the laboratory data and the retinal examination were invited to participate in the study; they were followed up for a period of 3 years. RESULTS: DR was present in 175 patients (35%), 130 (26%), and 45 (9%) having nonproliferative and proliferative DR, respectively. Clinically significant macular edema was present in 42 patients (8%). Microvascular and macrovascular diabetic complications, duration of disease, glycemic control, presence of hypertension (p < 0.003), systolic blood pressure (p = 0.04), and insulin use (p < 0.001) were individually significantly associated with a higher prevalence of DR on bivariate analysis. However, on multivariate regression analysis, only glycosylated hemoglobin >7% (odds ratio [OR] 2.81, 95% CI 1.06-7.43, p = 0.038), duration of diabetes (per 10 years, OR 9.0, 95% CI 4.0-20.0, p < 0.001), macroalbuminuria (OR 2.6, 95% CI 1.14-5.96 p = 0.023), and systolic blood pressure (per 10 mm Hg, OR 1.27, 95% CI 1.0-1.56, p = 0.037) were independent risk factors for DR. CONCLUSIONS: The elevated prevalence of DR in type II diabetic patients with high risk profiles calls for early medical intervention and education about DR and its identified controllable risk factors.

Prevalence and determinants of albuminuria in a cohort of diabetic patients in Lebanon.

BACKGROUND AND OBJECTIVES: Few data are available on the extent of albuminuria in diabetic populations in the Middle East generally and in Lebanon specifically. We conducted this study to determine the prevalence of albuminuria and its major risk factors in a cohort of diabetic patients in Lebanon. PATIENTS AND METHODS: Diabetic patients followed in the outpatient department at the American University of Beirut Medical Center (AUBMC) were included in a prospective observational study. AUBMC is a tertiary referral center and the outpatient department typically handles patients of low socioeconomic status with advanced disease. Patients were classified according to their urinary albumin-to-creatinine ratio (ACR) as having normoalbuminuria (ACR<30 mg/g creatinine), microalbuminuria (ACR=30 to <300 mg/g creatinine), or macroalbuminuria (ACR > or =300 mg/g creatinine). The three groups were compared to analyze the association between albuminuria and its risk factors. In addition, independent predictors of albuminuria were determined using multivariate logistic regression and presented as an odds ratio. RESULTS: Microalbuminuria and macroalbuminuria were present in 33.3% and 12.7% of 222 patients (mean age 56.4 years, mean deviation of diabetes 8.6 years, 58.7% women, 43.8% obese), respectively. Factors significantly associated with microalbuminuria included glycemic control, insulin use, and total and LDL cholesterol. Those associated with macroalbuminuria included in addition to glycemic control and insulin use, duration of diabetes, hypertension, elevated mean arterial pressure (MAP), and presence of neuropathy, retinopathy and peripheral vascular disease by bivariate analysis. Only glycemic control was an independent risk factor for both in addition to MAP and retinopathy for macroalbuminuria by multivariate analysis. CONCLUSION: Albuminuria is highly prevalent among this cohort of diabetic patients in Lebanon. Both glycemic control and blood pressure need to be better targeted in its management.