Current gaps in management and timely referral of cardiorenal complications among people with type 2 diabetes mellitus in the Middle East and African countries: Expert recommendations.

The upsurge of type 2 diabetes mellitus is a major public health concern in the Middle East and North Africa (MENA) and Africa (AFR) region, with cardiorenal complications (CRCs) being the predominant cause of premature morbidity and mortality. High prevalence of cardiometabolic risk factors, lack of awareness among patients and physicians, deficient infrastructure, and economic constraints lead to a cascade of CRCs at a significantly earlier age in MENA and AFR. In this review, we present consensus recommendations by experts in MENA and AFR, highlighting region-specific challenges and potential solutions for management of CRCs. Health professionals who understand sociocultural barriers can significantly increase patient awareness and encourage health-seeking behavior through simple educational tools. Increasing physician knowledge on early identification of CRCs and personalized treatment based on risk stratification, alongside optimum glycemic control, can mitigate therapeutic inertia. Early diagnosis of high-risk people with regular and systematic monitoring of cardiorenal parameters, development of region-specific care pathways for timely referral to specialists, followed by guideline-recommended care with novel antidiabetics are imperative. Adherence to guideline-recommended care can catalyze utilization of sodium glucose cotransporter 2 inhibitors and glucagon-like peptide 1 receptor agonists with demonstrated cardiorenal benefits-thus paving the way for overcoming care gaps in a cost-effective manner. Leveraging digital technology like electronic medical records can help generate real-world data and provide insights on voids in adoption of newer antidiabetic medications. A patient-centric approach, collaborative care among physicians from different specialties, alongside involvement of policy makers are key for improving patient outcomes and quality of care in MENA and AFR.

Berardinelli-Seip Syndrome and Essential Thrombocytosis: An Unusual Association.

Congenital generalized lipodystrophy (Berardinelli-Seip syndrome) is an autosomal recessive condition, presenting during infancy with generalized loss of fat. We report a 30-year-old female patient with diabetes who has acromegaloid features, prominent umbilicus, prominent muscles, prominent subcutaneous veins, and gross hepatomegaly. Near-total loss of subcutaneous fat was confirmed by whole-body magnetic resonance imaging and laboratory data revealed significant hypertriglyceridemia, uncontrolled diabetes mellitus, and heavy proteinuria with stage IIIa chronic kidney disease. Her blood film revealed thrombocytosis that on further evaluation by bone marrow biopsy was confirmed to be a myeloproliferative neoplasm (MPN); essential thrombocytosis (ET). She also had skin lesions that were proven to be reactive perforating collagenosis and necrobiosis lipoidica diabeticorum. She was managed conservatively and received interferon injections with fair general condition and control of her ET. However, her kidney function deteriorated furthermore to stage V chronic kidney disease requiring regular treatment with hemodialysis. We believe this is a unique case of Berardinelli-Seip syndrome with MPN that could be a coincidental association or part of a new syndrome.

Leptin and uric acid as predictors of metabolic syndrome in jordanian adults.

BACKGROUND/OBJECTIVES: Metabolic syndrome (MetS) is a set of interrelated metabolic risk factors that increase the risk of cardiovascular morbidity and mortality. Studies regarding the specificity and sensitivity of serum levels of leptin and uric acid as predictors of MetS are limited. The aim of this study was to evaluate the serum levels of leptin and uric acid in terms of their specificity and sensitivity as predictors of MetS in the studied Jordanian group. SUBJECTS/METHODS: In this cross sectional study, 630 adult subjects (308 men and 322 women) were recruited from the King Hussein Medical Center (Amman, Jordan). The diagnosis of MetS was made according to the 2005 International Diabetes Federation criteria. Receiver operating characteristic curves were used to determine the efficacy of serum levels of leptin and uric acid as predictors of MetS in the studied Jordanian group. RESULTS: Study results showed that for identification of subjects with MetS risk, area under the curve (AUC) for leptin was 0.721 and 0.683 in men and women, respectively. Serum uric acid levels in men showed no significant association with any MetS risk factors and no significant AUC, while uric acid AUC was 0.706 in women. CONCLUSION: Serum leptin levels can be useful biomarkers for evaluation of the risk of MetS independent of baseline obesity in both men and women. On the other hand, serum uric acid levels predicted the risk of MetS only in women.

Potassium Permanganate Poisoning: A Nonfatal Outcome.

Acute poisoning by potassium permanganate is a rare condition with high morbidity and mortality. Diagnosis of the condition relies on a history of exposure or ingestion and a high degree of clinical suspicion. Oxygen desaturation and the presence of methemoglobin are also helpful indicators. Since no specific antidote is available, treatment is mainly supportive. Few cases have been reported in the literature following potassium permanganate ingestion, whether intentional or accidental, and most of the patients in these cases had unfavorable outcomes, which was not the case in our patient. Our patient, a 73-year-old male, purchased potassium permanganate over the counter mistaking it for magnesium salt, which he frequently used as a laxative. Several hours after he ingested it, he was admitted to the endocrine department at King Hussein Medical Center, Jordan, with acute rapidly evolving shortness of breath. During hospitalization, his liver function tests deteriorated. Since he was diagnosed early and managed promptly he had a favorable outcome.

EVALUATION OF SEVERAL ANTHROPOMETRIC INDICES OF OBESITY AS PREDICTORS OF METABOLIC SYNDROME IN JORDANIAN ADULTS.

INTRODUCTION: anthropometric indices have all been tested for their relation to metabolic syndrome (MetS), but with no consistent cut-off points are yet established among different population group. OBJECTIVE: this study aims to evaluate the predictive power of several anthropometric indices of central obesity as predictors of MetS in a group of Jordanian adults. METHODS: in this cross sectional study, 630 adult subjects (308 men and 322 women) aged between 20-70 years were recruited at the King Hussein Medical Center in Amman (Jordan). The diagnosis of MetS was defined by the International Diabetes Federation criteria. Anthropometric measurements (waist circumference [WC]; waist to hip ratio [WHpR]; waist to height ratio [WHtR]; body mass index [BMI]) were performed and recorded following standard procedures. Receiver operating characteristic (ROC) curves were used to determine the efficacy of anthropometric measurements as predictors of MetS. RESULTS: the results indicated that, in men for identifying subjects with MetS risk, area under curve (AUC) from the ROC curves for WC was 0.851, AUC for WHpR was 0.842, AUC for WHtR was 0.85, and AUC for BMI was 0.83. In women, AUC for WC, WHpR, WHtR, and BMI were 0.866, 0.871, 0.872, and 0.831, respectively. CONCLUSION: it could be concluded that among anthropometric indices, both WHtR and WC had the strongest predictive power for identifying subjects with MetS in men and women. WHtR appears to be the best indicator of central obesity in women and individuals of short stature.

Introducción: han sido probados diversos índices antropométricos por su relación con el síndrome metabólico (SM), pero sin establecer puntos de corte entre diferentes grupos de población. Objetivo: este estudio tiene como objetivo evaluar el poder predictivo de varios índices antropométricos de obesidad central como predictores del síndrome metabólico en un grupo de adultos jordanos. Métodos: en este estudio transversal, 630 sujetos adultos (308 hombres y 322 mujeres) de edades comprendidas entre 20 a 70 años fueron reclutados en el Centro Médico Rey Hussein en Amman (Jordania). El diagnóstico de síndrome metabólico fue definido por los criterios de la Federación Internacional de Diabetes. Las medidas antropométricas (circunferencia de la cintura [WC]; relación cintura-cadera [WHpR]; relación cintura-altura [RCEst]; índice de masa corporal [IMC]) se realizaron y registraron siguiendo los procedimientos estándar. Se utilizaron curvas características del receptor (ROC) para determinar la eficacia de las medidas antropométricas como predictores de SM. Resultados: los resultados indican que, en los hombres, para identificar a los sujetos con riesgo de SM el área bajo la curva (AUC) de la curva ROC para WC era 0.851, AUC para WHpR era 0,842, AUC para RCEst fue de 0,85 y el AUC del IMC fue de 0,83. En las mujeres, el AUC para WC, WHpR, RCEst y el IMC fueron: 0,866, 0,871, 0,872 y 0,831, respectivamente. Conclusión: se puede concluir que entre los índices antropométricos, tanto RCEst como WC tenían el poder predictivo más fuerte para identificar a los sujetos con síndrome metabólico en hombres y mujeres. RCEst parece ser el mejor indicador de la obesidad central en mujeres y personas de baja estatura.

Evaluation of several anthropometric indices of obesity as predictors of metabolic syndrome in Jordanian adults / Evaluación de varios índices antropométricos de la obesidad como predictores del síndrome metabólico en adultos de Jordania

Introduction: anthropometric indices have all been tested for their relation to metabolic syndrome (MetS), but with no consistent cut-off points are yet established among different population group. Objective: this study aims to evaluate the predictive power of several anthropometric indices of central obesity as predictors of MetS in a group of Jordanian adults. Methods: in this cross sectional study, 630 adult subjects (308 men and 322 women) aged between 20-70 years were recruited at the King Hussein Medical Center in Amman (Jordan). The diagnosis of MetS was defined by the International Diabetes Federation criteria. Anthropometric measurements (waist circumference [WC]; waist to hip ratio [WHpR]; waist to height ratio [WHtR]; body mass index [BMI]) were performed and recorded following standard procedures. Receiver operating characteristic (ROC) curves were used to determine the efficacy of anthropometric measurements as predictors of MetS. Results: the results indicated that, in men for identifying subjects with MetS risk, area under curve (AUC) from the ROC curves for WC was 0.851, AUC for WHpR was 0.842, AUC for WHtR was 0.85, and AUC for BMI was 0.83. In women, AUC for WC, WHpR, WHtR, and BMI were 0.866, 0.871, 0.872, and 0.831, respectively. Conclusion: it could be concluded that among anthropometric indices, both WHtR and WC had the strongest predictive power for identifying subjects with MetS in men and women. WHtR appears to be the best indicator of central obesity in women and individuals of short stature (AU)

Introducción: han sido probados diversos índices antropométricos por su relación con el síndrome metabó- lico (SM), pero sin establecer puntos de corte entre diferentes grupos de población. Objetivo: este estudio tiene como objetivo evaluar el poder predictivo de varios índices antropométricos de obesidad central como predictores del síndrome metabólico en un grupo de adultos jordanos. Métodos: en este estudio transversal, 630 sujetos adultos (308 hombres y 322 mujeres) de edades comprendidas entre 20 a 70 años fueron reclutados en el Centro Médico Rey Hussein en Amman (Jordania). El diagnóstico de síndrome metabólico fue definido por los criterios de la Federación Internacional de Diabetes. Las medidas antropométricas (circunferencia de la cintura [WC]; relación cintura-cadera [WHpR]; relación cintura-altura [RCEst]; índice de masa corporal [IMC]) se realizaron y registraron siguiendo los procedimientos estándar. Se utilizaron curvas características del receptor (ROC) para determinar la eficacia de las medidas antropométricas como predictores de SM. Resultados: los resultados indican que, en los hombres, para identificar a los sujetos con riesgo de SM el área bajo la curva (AUC) de la curva ROC para WC era 0.851, AUC para WHpR era 0,842, AUC para RCEst fue de 0,85 y el AUC del IMC fue de 0,83. En las mujeres, el AUC para WC, WHpR, RCEst y el IMC fueron: 0,866, 0,871, 0,872 y 0,831, respectivamente. Conclusión: se puede concluir que entre los índices antropométricos, tanto RCEst como WC tenían el poder predictivo más fuerte para identificar a los sujetos con síndrome metabólico en hombres y mujeres. RCEst parece ser el mejor indicador de la obesidad central en mujeres y personas de baja estatura (AU)

Alarming high prevalence of metabolic syndrome among Jordanian adults.

OBJECTIVE: To evaluate the prevalence and the individual components of metabolic syndrome (MetS) in Jordanian adults. METHODS: In this cross sectional study, 630 adult subjects (308 men and 322 women) aged between 20-70 years were recruited from the clinics at the King Hussein Medical Center. The diagnosis of MetS was made according to the International Diabetes Federation (IDF) criteria-2005. Blood samples were collected after 10-12 hours overnight fasting and serum was obtained for biochemical analysis. RESULTS: The prevalence of metabolic syndrome according to IDF criteria was 51% (46.4% in men and 55.3% in women). Prevalence of increased waist circumference in the total sample was 71.6%, 46% for high blood pressure, 42.4% for elevated fasting blood glucose, 43.5% for low high density lipoprotein, and 50.2% for hypertriglyceridemia. CONCLUSION: The prevalence and individual components of MetS in Jordan were high. Screening of MetS is needed at national level to reduce the incidence of Type 2 diabetes mellitus (T2DM) and cardiovascular disease (CVD).

Impact of metabolic syndrome's components on the development of cardiovascular disease in a Jordanian cohort with metabolic syndrome.

OBJECTIVE: To assess the gender differences in the prevalence of diabetes, composite cardiovascular disease, and the components of metabolic syndrome (MS) in a Jordanian cohort with MS. Secondly, to evaluate the impact of number of MS components on prevalence of diabetes, ischemic heart disease (IHD), and stroke. METHODS: We carried out a cohort study among participants who fulfilled the National Cholesterol Education Program (Adult Treatment Panel III) criteria for MS recruited from December 2006-2007 from Endocrine Outpatient Clinics of the King Hussein Medical Centre, Amman, and Prince Rashid Military Hospital, Irbid, Jordan. Patients were divided into groups according to gender, presence, or absence of diabetes, and were evaluated for MS components, presence of IHD, and stroke. RESULTS: Three hundred and fifty-seven patients 207 males and 150 females were included, type 2 diabetes was present in 226 (132 males) patients. No intergroup differences were found on waist circumference, systolic blood pressure, diastolic blood pressure, or fasting blood sugar. Female group was having a worst lipid profile, higher triglyceride levels and low high density lipoprotein. Metabolic syndrome components were more in males. Diabetic males have more composite cardiovascular disease (CCVD) [relative risk (RR)=1.88, 95% confidence interval: 1.01-3.59]. No difference in prevalence of CCVD between female subgroups neither between the 2 genders with MS. The prevalence of diabetes mellitus, IHD, and stroke increased with increasing number of MS components. Diabetes was the strongest predictor for development of CCVD (RR=1.8) and IHD (RR=2.18). CONCLUSION: Females with MS have the worst lipid profile compared to the males, diabetic males have the worst CCVD end point. The prevalence of diabetes and IHD correlates with the number of MS components.

Primary hyperparathyroidism. A rare cause of spinal cord compression.

We report a case of a 62-year-old postmenopausal hypertensive lady who was treated for osteoporosis with calcium and Vitamin D. She presented with progressive lower limb weakness and paresthesia with sensory level at T4. Investigations revealed high parathyroid hormone 1152 ng/dl, calcium 10.9 mg/dl, and low phosphorus of 2.4 mg/dl after stopping calcium supplement. Chest x-ray showed an expansile mass lesion of the right 6th rib confirmed by chest CT. Thoracic MRI showed a mass lesion extending from the T3 vertebral body and compressing the spinal cord. There were multiple lytic lesions of the scalp, ribs, femur, and pelvis suggesting metastatic lesions. A neck ultrasound and SESTA MIBI parathyroid scan confirmed a right lower parathyroid adenoma. Excision biopsy of the rib lesion confirmed a vascular lesion with features of brown tumor BT. Decompression surgery of the thoracic spine was performed, and the histopathology confirmed BT. Two weeks later the patient underwent right parathyroidectomy that proved to be a parathyroid adenoma. She showed a remarkable improvement in her clinical condition and there were some regression of the bony lesions observed 12 months post parathyroidectomy. This case should alert physicians to the association of multiple brown tumors in PHPT and that the presentation may be an aggressive one mimicking metastasis, patients with osteoporosis warrant at least calcium profile to rule out a secondary cause.

Graves disease and papillary thyroid cancer. An association that can be missed.

Thyroid nodules are frequently found in association with Graves' disease. Papillary carcinoma can arise from these nodules. We report a 65-year-old gentleman who presented with classical features of Graves disease. Technetium 99 scintigraphy revealed diffuse goiter with a cold nodule over the isthmus. Papillary thyroid cancer was suggested by the enlarging thyroid gland, and by the presence of cold nodule, and was proven by fine needle aspiration biopsy of this nodule. The diagnosis was confirmed by histopathology of thyroid specimen after total thyroidectomy, which also showed local invasion; metastatic work up revealed pulmonary and liver metastasis. Despite treatment by total thyroidectomy, twice radioactive iodine I131 ablation and levothyroxine replacement in a thyroid stimulating hormone suppressive dose, he still harbors metastases with elevated thyroglobulin level. This case should raise the index of suspicion of the treating physician to consider similar association, and to prompt early diagnosis and surgical treatment to prevent dreadful consequences that might adversely affect the outcome.

Patterns of testicular cytology in men with primary infertility: any change since the Gulf War?

OBJECTIVE: To evaluate the patterns of testicular cytology in men with primary infertility, to compare the morphologic patterns between the periods 1990-1995, immediately after Gulf War II, and 1997-2001 and to determine whether there is a correlation between hormonal profile, testicular volume and morphologic pattern. STUDY DESIGN: Retrospective study of men with primary infertility. History, complete physical examination, hormonal assay and testicular ultrasound were evaluated. A total of 545 patients had samples for testicular cytology obtained from both testes. The patient's consent was obtained in all cases. Smears were interpreted under light microscopy after treatment with Diff-Quik. A total of 104 healthy, fertile subjects were used for comparison of the hormonal profile and testicular volume. RESULTS: The mean (+/- SD) age was 28.66 +/- 4.36 years and duration of marriage 4.4 +/- 4.36 years. There were 11.2% patients with normal cytology, 55.8% with hypospermatogenesis, 28.4% with testicular atrophy, 2.9% with Sertoli cells only and 1.7% with maturation arrest. A significant increase in hypospermatogenesis and decrease in the Sertoli cell-only pattern were noted in 1997-2001 when compared with 1990-1995. The mean left testicular volume was 10.53 +/- 5.51 mL3 in the infertile group vs. 15.2 +/- 4.97 in the fertile group (p < 0.003); right testicular volume was 10.84 +/- 4.77 vs. 15.15 +/- 5.31 (p < 0.003). The hormonal profile revealed higher luteinizing hormone and follicle-stimulating hormone levels in the infertile group vs. control group (8.53 +/- 9.03 and 16.44 +/- 19.243 vs. 6.98 +/- 4.53 and 7.37 +/- 6.63, respectively [p < 0.001]). Free testosterone was higher in the fertile group (39.69 +/- 12.76 vs. 20.28 +/- 8.5 [p < 0.000]). CONCLUSION: The majority of infertile males in our cohort had hypospermatogenesis; testicular atrophy was the next most common disorder. There was no major change in overall absolute numbers since the Gulf War. Testicular cytology by fine needle aspiration is a safe and well-tolerated complementary investigation for unexplained male infertility.

Hypothyroidism due to Hashimoto thyroiditis post struma ovarii excision.

Struma ovarii is a rare ovarian teratoma that may produce hyperthyroidism. The association with Hashimoto thyroiditis HT, however is rare and has been reported in only one case. We report a case of HT following the resection of struma ovarii tumor, after which the patient became frankly, hypothyroid with elevated thyroid stimulating hormone and low thyroxin levels. Her thyroid peroxidase antibodies were positive. She improved after initiation of levothyroxine replacement therapy. We believe her euthyroid status preoperatively was due to thyroid hormone secretion by struma ovarii itself.

Lipid profile in patients with coronary artery disease.

OBJECTIVE: To determine the lipid profile and to identify and stratify risk factors in diabetic and non-diabetic patients with proven coronary artery disease at King Hussein Medical Center, Amman, Jordan. METHODS: One hundred and ninety-two patients who were admitted to Queen Alia Heart Institute, Amman, Jordan, proving to have coronary artery disease (CAD) by angiogram, with a mean age of 54 +/- 22 years were studied. Seventy-seven patients were diabetics and 115 non-diabetics. Their lipid profiles (T-Cholesterol, high density lipoprotein level (HDL-C), low density lipoprotein level (LDL-C), triglyceride, glucose, glycosylated hemoglobin) and thyroid function test were compared to a control group of 162 individuals with no cardiac events or diabetes, mean age 48.9 +/- 18 years. Prevalence of hyperlipidemia was calculated. Patients with high thyroid stimulating hormone were excluded. RESULTS: The mean (+/- standard deviation) plasma cholesterol for the group with CAD is 231.43 +/- 57.99 mg/dl versus 202.8 +/- 36.58 in the control group (p<0.0003). High density lipoprotein 35.98 +/- 9.37 versus 44.43 +/- 8.34 (p=0.00011). Low density lipoprotein 146.75 +/- 50.93 versus 118.97 +/- 45.9 (p=0.003). Triglyceride level 246.95 +/- 142.1 versus 164 mg/l +/- 93.78 (p=0.0002). Thyroid stimulating hormone level was 1.55 +/- 0.9 versus 1.51 +/- 0.89 ng/l in control group (p=0.35 NS), HbA1c in diabetic group 7 +/- 2.3%. The prevalence of high plasma cholesterol, triglycerides (TG), LDL-C and low HDL-C was 60.9%, 68.3%, 63.5% and 48.4%. Inter-group comparison of patients with CAD (diabetics versus non-diabetics) revealed higher TG level in the diabetic group and statistically significant difference of the HDL and LDL levels between the 2 groups in favor of diabetic group explained by higher percentage of patients on anti-hyperlipidemic drugs than non-diabetics. More females with CAD were found in the diabetic group versus non-diabetic group (16.9% versus 6.1%. z=2.4027 p=0.00820). CONCLUSION: Jordanian patients with CAD have higher cholesterol, LDL-C, Triglyceride and lower HDL-C levels than the control group which comes in accordance of other studies. Hyperlipidemia remains the strongest risk factor for CAD. Diabetic females are at higher risk for CAD versus non-diabetics with the same lipid profile. Aggressive treatment of hyperlipidemia is of paramount importance to reduce the morbidity and mortality of cardiac events in diabetic and non-diabetic patients.

Diabetes and infarcted papillary thyroid cancer.

A young black Jordanian lady who has type one diabetes, chronic diabetic complication and ischemic heart disease, presented with a picture of diabetic keto-acidosis, precipitated by an acute neck swelling. This was suggestive of acute suppurative thyroiditis with abscess formation causing compressive symptoms. This unfortunate patient had an eventful course despite aggressive treatment by antibiotics and surgery and then succumbed of an acute cardiac event. The operative tissue biopsy revealed an abscess in an infarcted papillary thyroid cancer. We believe this is a rare presentation of such an association with a fatal outcome.