Proliferative diabetic retinopathy as the initial presenting feature of type 1 diabetes.

Summary: Type 1 diabetes mellitus (T1DM) is an autoimmune disorder caused by the destruction of the pancreatic beta cells, which produce insulin. Individuals with T1DM usually require at least 3-5 years to develop microvascular complications in comparison to people with type 2 diabetes (T2DM), who may develop complications even before the diagnosis of diabetes. We discuss a patient who presented with proliferative diabetic retinopathy subsequently diagnosed with T1DM and diabetic neuropathy following investigations. Diabetic retinopathy or other microvascular complications as the presenting feature of T1DM is rarely known or reported in the literature. A 33-year-old healthcare worker had been seen by the opticians due to 1-week history of blurred vision. The ophthalmology assessment had confirmed proliferative retinopathy in the right eye and severe non-proliferative retinopathy in the left eye with bilateral clinically significant macular oedema. His BMI was 24.9 kg/m2. The nervous system examination revealed bilateral stocking type peripheral neuropathy. The random venous glucose was 24.9 mmol/L. Plasma ketones were 0.7 mmol/L and HbA1c was 137 mmol/mol. On further evaluation, the anti-glutamic acid decarboxylase (GAD) antibody was positive, confirming the diagnosis of T1DM. He was started on aflibercept injections in both eyes, followed by panretinal photocoagulation. Subsequent nerve conduction studies confirmed the presence of symmetrical polyneuropathy. The pathogenesis of the development of microvascular complications in T1DM is multifactorial. Usually, the development of complications is seen at least a few years following the diagnosis. The occurrence of microvascular complications at presentation is rare. This makes the management challenging and extremely important in preventing the progression of the disease. Learning points: The pathogenesis of the development of microvascular complications in type 1 diabetes mellitus is multifactorial. The development of complications is seen at least a few years following the diagnosis. Occurrence of microvascular complications at presentation is rare. This makes the management challenging and extremely important to prevent the progression of the disease.

Active screening of patients with diabetes mellitus for pulmonary tuberculosis in a tertiary care hospital in Sri Lanka.

End TB strategy by the WHO suggest active screening of high-risk populations for tuberculosis (TB) to improve case detection. Present study generates evidence for the effectiveness of screening patients with diabetes mellitus (DM) for Pulmonary TB (PTB). A study was conducted among 4548 systematically recruited patients over 45 years attending DM clinic at the National Hospital of Sri Lanka. The study units followed an algorithm specifying TB symptom and risk factor screening for all, followed by investigations and clinical assessments for those indicated. Bacteriologically confirmed or clinically diagnosed PTB were presented as proportions with 95% CI. Mean (SD) age was 62·5 (29·1) years. Among patients who completed all indicated steps of algorithm, 3500 (76·9%) were investigated and 127 (2·8%) underwent clinical assessment. Proportion of bacteriologically confirmed PTB patients was 0·1% (n = 6,95%CI = 0·0-0·3%). None were detected clinically. Analysis revealed PTB detection rates among males aged ≥60 years with HbA1c ≥ 8 to be 0·4% (n = 2, 95%CI = 0·0-1·4%). The study concludes that active screening for PTB among all DM patients at clinic settings in Sri Lanka, to be non-effective measure to enhance TB case finding. However, the sub-category of diabetic males with uncontrolled diabetics who are over 60 years of age is recommended as an option to consider for active screening for PTB.

The Impact of SARS-Cov-2 Virus Infection on the Endocrine System.

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) virus has spread across the globe rapidly causing an unprecedented pandemic. Because of the novelty of the disease, the possible impact on the endocrine system is not clear. To compile a mini-review describing possible endocrine consequences of SARS-CoV-2 infection, we performed a literature survey using the key words Covid-19, Coronavirus, SARS CoV-1, SARS Cov-2, Endocrine, and related terms in medical databases including PubMed, Google Scholar, and MedARXiv from the year 2000. Additional references were identified through manual screening of bibliographies and via citations in the selected articles. The literature review is current until April 28, 2020. In light of the literature, we discuss SARS-CoV-2 and explore the endocrine consequences based on the experience with structurally-similar SARS-CoV-1. Studies from the SARS -CoV-1 epidemic have reported variable changes in the endocrine organs. SARS-CoV-2 attaches to the ACE2 system in the pancreas causing perturbation of insulin production resulting in hyperglycemic emergencies. In patients with preexisting endocrine disorders who develop COVID-19, several factors warrant management decisions. Hydrocortisone dose adjustments are required in patients with adrenal insufficiency. Identification and management of critical illness-related corticosteroid insufficiency is crucial. Patients with Cushing syndrome may have poorer outcomes because of the associated immunodeficiency and coagulopathy. Vitamin D deficiency appears to be associated with increased susceptibility or severity to SARS-CoV-2 infection, and replacement may improve outcomes. Robust strategies required for the optimal management of endocrinopathies in COVID-19 are discussed extensively in this mini-review.

Prevention and management of COVID-19 among patients with diabetes: an appraisal of the literature.

The coronavirus disease 2019 (COVID-19) pandemic has emerged as one of the greatest challenges faced by humankind in the recent past. People with diabetes and related comorbidities are at increased risk of its complications and of COVID-19-related death. Older age, multi-morbidity, hyperglycaemia, cardiac injury and severe inflammatory response are predictors of poor outcome. The complex interplay between COVID-19, diabetes and the effects of related therapies is being explored. Most patients experience a mild illness with COVID-19, while people with diabetes are at increased risk of severe disease. Optimising glycaemic control and adopting measures to prevent disease spread are critical aspects. The management of mild disease is supportive, while very many immunomodulatory and antiviral therapies are being investigated for the treatment of severe disease. Several of these agents have specific considerations for use in people with diabetes. Since mass population lockdowns are considered a key step in controlling disease spread, it follows that, in addition to the direct vulnerability to severe COVID-19, people with diabetes can be affected by limited access to healthcare, insulin, other medications and blood glucose monitoring equipment. Measures to prevent disease spread at the individual and community level are the key to mitigating the rapidly escalating pandemic, while agents for chemoprophylaxis and vaccines are being explored. People with diabetes should be recognised as a vulnerable group for complicated disease and are at risk during times of disturbed social systems. Strategies are needed to safeguard the health of patients with diabetes during the pandemic. This review summarises the current knowledge and perceived challenges for prevention and management of COVID-19 in people with diabetes.

High Prevalence of Overweight/Obesity in Urban Sri Lanka: Findings from the Colombo Urban Study.

BACKGROUND: South Asian countries face a double burden of malnutrition characterized by high prevalence of underweight, overweight, and obesity. Understanding the distribution of this public health problem is important to tailor targeted interventions for communities. The objective of the current study was to find out the prevalence of obesity in urban Sri Lanka and to identify sociodemographic factors associated with it. METHODS: Adult males and females residing in an urban government division of the Colombo District in Sri Lanka were included in this study (Colombo Urban Study). Stratified simple random sampling was used to select a sample of 463 from the total population. Sociodemographic data using an interviewer-administered questionnaire, anthropometric measurements, and serum samples were obtained for investigations. RESULTS: When the global BMI cutoffs were applied, the community prevalences of underweight, normal weight, overweight, and obesity were 7.7%, 39.6%, 37.0%, and 15.8%, respectively. When the Asian BMI cutoffs were applied, the respective prevalences were 7.7%, 26.8%, 34.3%, and 31.2%. The community prevalence for abdominal obesity was 58.1% when using Asian cutoffs. Females had a higher prevalence of both obesity and abdominal obesity. There was an ethnic difference in obesity rates with Moors having the highest rates (65.5%) followed by Sinhalese (52.3%) and Tamils (40.2%). The highest obesity prevalence was observed in the most educated group. Multiple regression analysis showed that high BMI was associated with female gender and family history of hypertension. Serum LDL negatively associated with BMI while the strength of this relationship was impacted by serum HBA1c levels. Finally, serum triglyceride level showed positive association with BMI, and the effect was more marked in Moors compared to Sinhalese. CONCLUSION: Two-thirds of adults in the studied urban population were overweight or obese. This highlights the urgent need for interventions to curb this epidemic. The gender, ethnic differences in obesity, its associations with educational status, and the interactions with metabolic comorbidities indicate that these interventions may need to be targeted towards different groups in the population.

Body weight perception among Sri Lankan cardiac patients.

BACKGROUND: Misperception of body weight by individuals is a known occurrence. However, it is a potential target for implementing obesity reduction interventions in patients with cardiovascular and metabolic diseases. The aim of this study was to describe the association between self-perception of body weight and objectively measured body mass index (BMI) among cardiac patients in a specialist cardiology institution in Sri Lanka. METHOD: During the study period, 322 (61 %) males and 204 (39 %) females were recruited from consecutive admissions to the Institute of Cardiology, National Hospital, Colombo, Sri Lanka. An interviewer-administered questionnaire was used to assess demographic characteristics, medical records and body weight perception. Weight, height and waist circumference (WC) were measured and Asian anthropometric cut-off points for BMI and WC were applied. RESULTS: The mean BMI of the study population was 23.61 kg/m(2). Body size misperception was seen in a significant proportion of the cohort. 85.2 % of overweight patients reported themselves to be of 'normal weight' or even 'underweight'. Moreover, 36 % of obese patients misperceived body weight as being of 'normal weight' while 10.9 % considered themselves to be 'underweight'. 61.9 % of males and 68.8 % of females with central obesity reported themselves to be 'underweight' or 'normal weight'. Among a subgroup with co-morbid metabolic diseases, significant under-perception of body size was seen. CONCLUSIONS: Significant body size misperceptions were noted in this group of cardiac patients. The disparity of perception was seen increasingly with increasing BMI. More than two thirds of overweight and more than half of obese patients believed themselves to have normal or less than normal weight.

Prevalence of hospital malnutrition among cardiac patients: results from six nutrition screening tools.

Malnutrition is highly prevalent among hospitalized patients, ranging from 30% to 50% depending on the patient population and the criteria used for diagnosis. Identifying early those who are malnourished and at risk of malnutrition and intervening at an early stage will improve patients overall prognosis and will reduce the costs to the state. Even though cardiac patients are at risk of malnutrition, data on the prevalence of malnutrition among cardiology inpatients is limited. The aim of the study was to assess malnutrition status of the newly admitted patients in a specialist cardiology institution in Sri Lanka by internationally recommended nutrition screening and assessment tools. During study period, 322 (61.22%) males and 204 (38.78%) females were recruited. Malnutrition status assessed by each screening tool had a wide variation. According to Mini Nutritional Assessment tool 69.6% were having possible malnutrition. Malnutrition Screening Tool 47.9% to be at risk of malnutrition. Subjective Global Assessments categorized only 4.2% as malnourished on the other hand Malnutrition Universal Screening Tool categorized 20.4% and 19.6% subjects as at medium risk and high risk of malnutrition respectively. Nutritional Risk Screening detected 6.3%, 25.1% and 24.9% patients to be mildly, moderately and severely malnourished respectively. Short Nutrition Assessment Questionnaire categorized 5.0% and 17.7% patients to be moderately malnourished and severely malnourished correspondingly. In conclusion, Although malnutrition was prevalent among this population, a wide variation in the nutritional status when assessed by widely used internationally recognized tools was observed.