The effect of tailored consumer medicine information on patients with type 2 diabetes mellitus: A randomised controlled interventional study.

INTRODUCTION: In patients with diabetes, better health communication is associated with better health outcomes including medication adherence and glycaemic control. The conventional patient information leaflet does not consider the cultural and behavioral perspectives of diverse patient populations. Consumer medicine information (CMI) is a written information about the prescription drugs developed by organisations or individuals other than a drug manufacturer that is intended for distribution to consumers at the time of medication dispensing. OBJECTIVE: This study aimed to evaluate the impact of CMI on medication adherence and glycaemic control among patients with type 2 diabetes in Qatar. METHODS: We developed and customised CMI for all the anti-diabetic medications used in Qatar. A randomised controlled trial in which the intervention group patients (n = 66) received the customised CMI with usual care, while the control group patients (n = 74) received usual care only, was conducted. Self-reported medication adherence and haemoglobin A1c (HbA1c ) were the primary outcome measures. Glycaemic control and medication adherence parameters were measured at baseline, 3 months, and 6 months in both groups. Medication adherence was measured using the 8-item Morisky Medication Adherence Scale (MMAS-8). RESULTS: Although the addition of CMI resulted in better glycaemic control, this did not reach statistical significance, possibly because of the short-term follow-up. The median MMAS-8 score improved from baseline (6.6 [IQR = 1.5]) to 6-month follow-up (7.0 [IQR = 1.00]) in the intervention group. In addition, there was a statistically significant difference between the intervention and the control groups in terms of MMAS-8 score at the third visit (7.0 [IQR = 1.0]) vs 6.5 (IQR = 1.25; P-value = .010). CONCLUSION: CMI for anti-diabetic medications when added to usual care has the potential to improve medication adherence and glycaemic control among patients with type 2 diabetes. Therefore, providing better health communication and CMI to patients with diabetes is recommended.

A retrospective study comparing the results of continuous glucose monitoring to self-blood glucose monitoring for pregnant women with type 1 diabetes mellitus.

BACKGROUND: Type 1 diabetes mellitus (T1DM) is associated with adverse maternal and fetal outcomes. Continuous glucose monitoring (CGM) during pregnancy is associated with better glycemic control in women with T1DM. However, no clear benefits have been demonstrated in reducing adverse feto-maternal outcomes in pregnant women with T1DM. DESIGN AND METHODS: This is a retrospective, single-center study of pregnant women with T1DM to evaluate the impact of CGM use on glycemic control and feto-maternal outcomes in pregnant women with T1DM. RESULTS: Of 265 women with T1DM, 92 (34.7%) used CGM, and 173 (65.3%) were managed with capillary blood glucose (CBG) monitoring. The mean (SD) age and BMI at the first visit were 29.4 (4.7) years and 27.2 (5.2) kg/m2, respectively. The mean (SD) HbA1c at the first-trimester visit was 63 (1) mmol/mol, and in the last trimester was 51 (1%). There was no difference in the mean changes in HbA1c between the two groups. Women using CGM had lower insulin requirements (1.02 + 0.37 vs. 0.87 + 0.04 units/kg, p = 0.01). The two groups had no significant differences in maternal or fetal outcomes. CONCLUSION: CGM use in pregnant T1DM women is not associated with improved fetomaternal outcomes.

Sustained corneal nerve loss predicts the development of diabetic neuropathy in type 2 diabetes.

Introduction: This study was undertaken to investigate whether sustained rather than a single measure of corneal nerve loss was associated with the onset of diabetic peripheral neuropathy (DPN) and the progression of neuropathic symptoms and deficits in individuals with type 2 diabetes (T2D). Methods: Participants underwent clinical, metabolic testing and assessment of neuropathic symptoms, vibration perception threshold (VPT), sudomotor function, and corneal confocal microscopy (CCM) at baseline, 1, 2, and 4-7 years. Sustained corneal nerve loss was defined as abnormal corneal nerve fiber density (CNFD, <24 fibers/mm2), corneal nerve branch density (CNBD, <21 branches/mm2), and corneal nerve fiber length (CNFL, <16 mm/mm2) persisting for ≥50% of the study duration. Results: A total of 107 participants with a mean duration of T2D of 13.3 ± 7.3 years, aged 54.8 ± 8.5 years, underwent baseline and follow-up assessments over a median duration of 4 years, ranging from 1 to 7 years. The DPN prevalence at baseline was 18/107 (16.8%), and of the 89 participants without DPN at baseline, 13 (14.6%) developed DPN during follow-up. Approximately half of the cohort had sustained corneal nerve damage, and corneal nerve measures were significantly lower in this group than those without sustained damage (p < 0.0001). Sustained corneal nerve damage was associated with the development of DPN (p < 0.0001), a progressive loss of vibration perception (p ≤ 0.05), an increased incidence of burning pain, numbness, or a combination of both (p = 0.01-0.001), and a borderline association with progressive sudomotor dysfunction (p = 0.07). Sustained abnormal CNFL effectively distinguished between participants who developed DPN and those who did not (AUC: 76.3, 95% CI: 65.9-86.8%, p < 0.0001), while baseline and other sustained measures did not predict DPN onset. Conclusion: Sustained abnormal CCM is associated with more severe corneal nerve damage, DPN development, and the progression of neuropathic symptoms and deficits. Regular CCM monitoring may enable the identification of those at greater risk of developing and worsening DPN who may benefit from more aggressive risk factor reduction.

Progressive loss of corneal nerve fibers is associated with physical inactivity and glucose lowering medication associated with weight gain in type 2 diabetes.

AIMS/INTRODUCTION: Limited studies have identified risk factors linked to the progression of diabetic peripheral neuropathy (DPN) in type 2 diabetes. This study examined the association of risk factors with change in neuropathy measures over 2 years. MATERIALS AND METHODS: Participants with type 2 diabetes (n = 78) and controls (n = 26) underwent assessment of clinical and metabolic parameters and neuropathy using corneal confocal microscopy (CCM), vibration perception threshold (VPT), and the DN4 questionnaire at baseline and 2 year follow-up. RESULTS: Participants with type 2 diabetes had a lower corneal nerve fiber density (CNFD), branch density (CNBD), and fiber length (CNFL) (P ≤ 0.0001) and a higher VPT (P ≤ 0.01) compared with controls. Over 2 years, despite a modest reduction in HbA1c (P ≤ 0.001), body weight (P ≤ 0.05), and LDL (P ≤ 0.05) the prevalence of DPN (P = 0.28) and painful DPN (P = 0.21) did not change, but there was a significant further reduction in CNBD (P ≤ 0.0001) and CNFL (P ≤ 0.05). CNFD, CNBD, and CNFL decreased significantly in physically inactive subjects (P < 0.05-0.0001), whilst there was no change in CNFD (P = 0.07) or CNFL (P = 0.85) in physically active subjects. Furthermore, there was no change in CNFD (P = 0.82), CNBD (P = 0.08), or CNFL (P = 0.66) in patients treated with glucose lowering medication associated with weight loss, whilst CNBD (P = 0.001) decreased in patients on glucose lowering medication associated with weight gain. CONCLUSIONS: In participants with type 2 diabetes, despite a modest improvement in HbA1c, body weight, and LDL there was a progressive loss of corneal nerve fibers; except in those who were physically active or on glucose lowering medication associated with weight loss.

Pheochromocytoma presenting with severe abdominal pain and abnormal liver enzymes.

Pheochromocytoma can present with right hypochondrial pain, elevated liver enzymes, and a misleading appearance on ultrasound scan mimicking hepatic mass due to the proximity of adrenal masses to the liver.

Mitigation of hypoglycemia during Ramadan using the flash glucose monitoring system following dose adjustment of insulin and sulphonylurea in patients taking multiple glucose-lowering therapies (The PROFAST-IT Study).

BACKGROUND AND HYPOTHESIS: Patients with type-2 diabetes mellitus (T2DM) on multiple glucose-lowering therapies who fast during Ramadan are at increased risk of hypoglycemia. We have assessed the utility of the flash glucose monitoring system after adjusting the dose of insulin and sulphonylureas to mitigate the risk of hypoglycemia in patients with T2DM who fast during Ramadan. PATIENTS AND METHODS: Patients with T2DM on either basal insulin or a sulphonylurea and at least 2 other glucose-lowering agents received structured education and adjustment of insulin or sulphonylurea dose according to the PROFAST Ramadan protocol. Glucose variability and episodes of hypoglycemia were assessed using the flash glucose monitoring system (Free Style Libre) before and during Ramadan. RESULTS: A total of 33 patients with T2DM (on sulphonylurea (SU+) (n = 21), on basal insulin (BI+) (n = 12) aged 50.8 ± 1.6 years with a diabetes duration of 13.1 ± 6.5 years were studied. The average sensor glucose was 154 ± 34 mg/dl (8.5 ± 1.88 mmol/l) with 65.2% in the target range before Ramadan and the average sensor glucose was 156 ± 36 mg/dl (8.6 ± 2.0 mmol/l) with 67.1% in the target range during Ramadan. The incidence of hypoglycemia in the whole group (2.9 v 2.9) and in the SU+ (3.7 vs 3.0) and BI+ (1.7 vs 2.9) groups and eHbA1c (P = 0.56, P = 0.93), average glucose (P = 0.56, P = 0.92) and time within range (P = 0.63, P = 0.73) did not change in the SU+ and BI+ groups, respectively, before and during Ramadan. CONCLUSION: Structured education with adjustment of the dose of glucose lowering medication alongside use of the FGMS can effectively mitigate the increased risk of hypoglycemia in patients with T2DM on multiple glucose-lowering therapies who fast during Ramadan.

A Prospective Study Comparing Two-Time Points of Thyroid Hormone Replacement during the Holy Month of Ramadan.

BACKGROUND: Muslims all over the world fast during the month of Ramadan from dawn until dusk. There is little data regarding the best timing of levothyroxine intake during the month of Ramadan where taking it on an empty stomach represents a challenge to most patients. Our study aims to compare two-time points of levothyroxine intake during Ramadan in terms of change in thyroid stimulating hormone (TSH), compliance, and convenience. STUDY DESIGN AND METHODS: This was an open-label, randomized, prospective trial. Adult patients known to have primary hypothyroidism with stable TSH for the last 6 months who intended to fast during the month of Ramadan were invited to participate in this prospective study. The study took place during Ramadan of H1438 (May-June 2017). All patients were randomly assigned to two groups. In group A (n= 50) patients took levothyroxine 30 minutes before breaking the fast at sunset (iftar), and in group B (n= 46) patients took it 30 minutes before an early morning meal before sunrise (suhour). RESULTS: TSH levels increased in both group A (from 1.99 to 3.28 mIU/L) and group B (from 1.54 to 3.28 mIU/L) after Ramadan fasting. There was no difference between the two groups. Compliance with intake instructions, all of the time, was reported in 41.6% of group A and 35.7% of group B patients. In both the groups, 95% of patients said it was convenient for them to take the medication at the assigned time. CONCLUSION: Choosing an optimal time for levothyroxine intake during the month of Ramadan remains a challenge. The current study did not provide any evidence on ideal time and dose of levothyroxine administration during fasting to manage hypothyroidism. Studies with a larger number of patients need to be done to further explore this issue.

A pilot study using flash continuous glucose monitoring in patients with type-2 diabetes on multiple anti-diabetic agents during Ramadan.

BACKGROUND: This study aims to examine the incidence of hypoglycaemia, based on activity, during Ramadan in patients with type 2 diabetes mellitus who were on were on three or more anti-diabetic medications. METHODS: Type 2 diabetes patients who fasted during Ramadan and were on three or more anti-diabetic medications were studied for two weeks using flash glucose monitoring. The patients were asked to document all episodes of hypoglycaemia and were classified as active or sedentary according to their daytime activity. RESULTS: The study included 16 patients of whom 10 were active and 6 were sedentary. There were 13 males and 3 females; mean age was 53.4 ±â€¯6.4 years; mean diabetes duration was 15 ±â€¯5.9 years, and mean HbA1C was 7.9 ±â€¯1.3%. Over the two weeks; there were 7.9 episodes of hypoglycaemia recorded per patient; 50% of which were asymptomatic. There was no difference at baseline in age, BMI, HBA1C, diabetes duration, and anti-diabetic medications between the active and sedentary groups. The active group had better glucose control; median blood glucose was (7.1 (5.1-8.5) vs 10.6 (9.6-11.5) mmol p < 0.01), mean estimated HBA1C was (6.2 ±â€¯1.2% vs 8.3 ±â€¯1.0%; p = 0.047). The active group had more episodes of hypoglycaemia compared to the sedentary group (11.6 vs 1.8 hypo episode per patient/two weeks; p = 0.019); most of which were asymptomatic. CONCLUSION: Patients with type 2 diabetes mellitus who are on three or more anti-diabetic medications should be warned about the increased risk of asymptomatic hypoglycaemia during Ramadan. Anti-diabetic medication adjustments during Ramadan should take into account the degree of activity. Flash glucose monitoring system can help patients to fast safely during Ramadan and detect asymptomatic hypoglycaemia.

Typhoid rhabdomyolysis with acute renal failure and acute pancreatitis: a case report and review of the literature.

We report a case of typhoid rhabdomyolysis with acute renal failure and acute pancreatitis in a 23-year-old Vietnamese male who was admitted to the intensive care unit with a 15-day history of fever followed by severe abdominal pain. On examination, the patient was febrile and his abdomen was diffusely tender. Serum creatinine was 533 micromol/L, pancreatic amylase 1800 U/L and lipase 900 U/L; the myoglobin blood level was high, which is associated with significant myoglobinuria. Blood, urine and stool culture yielded Salmonella enterica serovar typhi, which was sensitive to ceftriaxon, ampicillin and ciprofloxacin. Ceftriaxon was initiated for a total of 14 days. Subsequently, the patient maintained a good urine output with improved renal parameters and accordingly was discharged. In this report, we review the literature and discuss the pathogenesis of the disease thoroughly.