Characteristics and Treatment Patterns of Patients with Type 2 Diabetes Mellitus in the Middle East and Africa Cohort of the DISCOVER Study Program: a Prospective Study

INTRODUCTION

Despite the high prevalence of type 2 diabetes (T2D) and suboptimal glycemic control in the Middle East and Africa, comprehensive data on the management of T2D remain scarce. The main aim of this study is to describe the characteristics and treatment of patients with T2D initiating second-line glucose-lowering therapy in these regions.

METHODS

DISCOVER is a global, 3-year, prospective observational study of patients with T2D enrolled at initiation of second-line glucose-lowering therapy. Baseline characteristics and treatments are presented for patients from 12 countries divided into three regions: Mediterranean, Gulf Cooperation Council, and South Africa.

RESULTS

Among 3525 patients (52.5% male, mean age 54.3 years), mean time since T2D diagnosis was 6.2 years [across-region range (ARR) 5.8-7.5 years] and mean glycated hemoglobin levels were 8.7% (72.0 mmol/mol) [ARR 8.6-9.0% (68-75 mmol/mol)]. At first line, metformin was prescribed for 88.1% (ARR 85.4-90.3%) of patients and a sulfonylurea for 34.4% (ARR 12.7-45.4%). Sulfonylureas and dipeptidyl peptidase-4 inhibitors were prescribed at second line for 55.5% (ARR 48.6-82.5%) and 49.0% (ARR 3.7-73.8%) of patients, respectively. Main reasons for choice of second-line therapy were efficacy (73.2%; ARR 60.1-77.7%) and tolerability (26.8%; ARR 3.7-31.2%).

CONCLUSIONS

We demonstrate considerable inter-region variations in the management of T2D, likely affected by multiple factors (health system, physician behavior, and patient compliance), all of which should be addressed to optimize outcomes.

Diabetes and Ramadan: Practical guidelines

Ramadan fasting is one of the five pillars of Islam and is compulsory for all healthy Muslims from puberty onwards. Exemptions exist for people with serious medical conditions, including many with diabetes, but a large number will participate, often against medical advice. Ensuring the optimal care of these patients during Ramadan is crucial. The International Diabetes Federation (IDF) and Diabetes and Ramadan (DAR) International Alliance have come together to deliver comprehensive guidelines on this subject. The key areas covered include epidemiology, the physiology of fasting, risk stratification, nutrition advice and medication adjustment. The IDF-DAR Practical Guidelines should enhance knowledge surrounding the issue of diabetes and Ramadan fasting, thereby empowering healthcare professionals to give the most up-to-date advice and the best possible support to their patients during Ramadan.

Hepatitis C virus infection in a population with high incidence of type 2 diabetes: impact on diabetes complications

A growing number of reports suggest a connection between hepatitis C virus (HCV) infection and type 2 diabetes (T2D). However, the association of HCV infection with diabetes-related complications has not yet been clarified. The aim of this study was to determine the prevalence of HCV infection in T2D-patients in Kuwait which has a high incidence of type 2 diabetes, and to investigate the association between HCV viremia and diabetes-related complications. A total of 438 patients with T2D (325 Kuwaitis and 113 Egyptians), and 440 control subjects, were enrolled for this study. HCV infection was assessed by testing for serum HCV-specific antibodies, and by detection of HCV RNA. HCV viral load and hemoglobin A1c (HbA1c) levels were assessed in patients with and without diabetes complications. Thirty one (7%) out of 438 T2D-patients had evidence of HCV infection compared to 4 (1%) out of 440 control adults (p<0.0001). The prevalence of HCV infection in Kuwaiti and Egyptian T2D-patients was 3% and 18%, respectively. Most of the HCV sequences detected in T2D patients and control subjects were of genotype 4. The HbA1c levels in T2D-patients with HCV viremia were significantly higher than those in HCV-negative patients. HCV viremia, female sex, age, family history of diabetes were found to be independent risk factors for diabetes complications. The results suggest that T2D-patients in Kuwait have higher prevalence of HCV infection than controls, and that HCV viremia is associated with diabetes-related complications.

The metabolic syndrome: useful concept or clinical tool? Report of a WHO Expert Consultation

This article presents the conclusions of a WHO Expert Consultation that evaluated the utility of the 'metabolic syndrome' concept in relation to four key areas: pathophysiology, epidemiology, clinical work and public health. The metabolic syndrome is a concept that focuses attention on complex multifactorial health problems. While it may be considered useful as an educational concept, it has limited practical utility as a diagnostic or management tool. Further efforts to redefine it are inappropriate in the light of current knowledge and understanding, and there is limited utility in epidemiological studies in which different definitions of the metabolic syndrome are compared. Metabolic syndrome is a pre-morbid condition rather than a clinical diagnosis, and should thus exclude individuals with established diabetes or known cardiovascular disease (CVD). Future research should focus on: (1) further elucidation of common metabolic pathways underlying the development of diabetes and CVD, including those clustering within the metabolic syndrome; (2) early-life determinants of metabolic risk; (3) developing and evaluating context-specific strategies for identifying and reducing CVD and diabetes risk, based on available resources; and (4) developing and evaluating population-based prevention strategies.

Isolated bilateral pyramidal tract lesions? An unusual case of demyelination following trauma. A case report

This paper describes the case of a young woman who developed quadriparesis due to isolated bilateral pyramidal tract lesions suggestive of demyelination following trauma.

Risk factors for the development of diabetes mellitus in chronic hepatitis C virus genotype 4 infection

BACKGROUND AND AIM

A high occurrence of type 2 diabetes (T2D) in patients with chronic hepatitis C virus (HCV) infection has been reported in Kuwait and other countries. However, HCV genotype 4 has been underrepresented in all previous studies. Our aim was to investigate the viral and host risk factors associated with the development of T2D in patients with chronic hepatitis C genotype 4 infection in the absence of liver fibrosis and steatosis.

METHODS

The study population consisted of 181 HCV-positive patients and 170 control HCV-negative patients with T2D.

RESULTS

The prevalence of HCV-patients with T2D was 39.8%. There was no significant association of T2D with gender, nationality, obesity, HCV viral load, or antiviral therapy. Older age (>or= 50 years) and family history of diabetes were the only independent risk factor for T2D in HCV patients. However, the median age and the prevalence of obesity in HCV-positive patients with T2D were significantly lower than those in diabetic HCV-negative patients. By following-up HCV-patients receiving antiviral drugs, a significant decrease of fasting plasma glucose and glycosylated hemoglobin levels was observed in diabetic patients who achieved a sustained viral response (SVR).

CONCLUSIONS

The risk factors associated with the development of T2D in the general population cannot alone account for the high prevalence of T2D obtained in chronic HCV genotype 4 infection. In the absence of liver fibrosis and steatosis, the improvement in glycemic control obtained in SVR patients may imply direct involvement of HCV in the development of T2D.

Pituitary apoplexy: a rare cause of cerebral infarction. A case report

Pituitary apoplexy is usually the result of hemorrhagic infarction in pituitary adenoma. The clinical presentation of pituitary apoplexy varies widely and includes asymptomatic hemorrhage, classical pituitary apoplexy and even sudden death. Few cases of cerebral infarction associated with pituitary apoplexy have been reported in the literature. Pituitary apoplexy can cause narrowing of intracranial vessels by mechanical obstruction due to mass effect or by vasospasm resulting in cerebral ischemia. We report a case of pituitary apoplexy associated with cerebral infarction and the putative mechanisms.

Bilateral subdural hemorrhage following lumbar puncture in a case of suspected meningitis. A case report

Intracranial subdural hemorrhage is a rare complication of lumbar puncture. Caudal traction and tear of the subdural veins due to negative pressure caused by leakage of cerebrospinal fluid (CSF) following lumbar puncture (LP) is the mechanism. Prolonged headache or neurological symptoms following LP should warrant cross-sectional imaging to rule out subdural hemorrhage as it can be fatal. We report a case of subdural hemorrhage following LP in a patient with suspected meningitis and communicating hydrocephalus.

Magnetic Resonance Imaging in Balo's Concentric Sclerosis

Concentric high signal intensity zones on T2-weighted magnetic resonance images of brain strongly suggest Balo's concentric sclerosis (BCS), a rare but recognized variant of multiple sclerosis. Differentiating BCS from multiple sclerosis or neoplasm can be difficult clinically. The pathognomonic MRI appearance can dramatically influence the course of the disease, allowing earlier diagnosis and therapy of the disease which was once considered to have an invariably fulminant and fatal course.

Prevalence of metabolic syndrome among hypertensive patients attending a primary care clinic in Kuwait

OBJECTIVE

To determine the prevalence of metabolic syndrome among hypertensive patients using the criteria of the National Cholesterol Education Program's Adult Treatment Panel III in a primary care health center in Kuwait.

SUBJECTS AND METHODS

A population of 250 Kuwaiti hypertensive patients (129 males and 121 females) over the age of 40 were screened for metabolic syndrome by determining body mass index (BMI), waist circumference, levels of fasting plasma glucose and fasting plasma lipids (serum triglycerides, total cholesterol and high-density lipoprotein cholesterol). The study was carried out in the Mishref Family Practice Health Center, Kuwait, from January to July 2001.

RESULTS

The total number of patients who met the criteria for metabolic syndrome was 85 (34%), 55% of them were males and 45% females. Prevalence of the syndrome was 28.2% among 40- to 55-year-olds and 41.9% in those above the age of 55 years. Among the 250 hypertensive patients, type II diabetes mellitus was found in 52.8% (54% males and 46% females), impaired fasting glucose in 8% (70% males and 30% females), high plasma triglycerides in 44.8% (53% males and 47% females) and low high-density lipoprotein cholesterol in 63.2% (54% males and 46% females). Obesity measured as BMI = 30 kg/m(2) was noted in 46% (43% males and 57% females) and increased waist circumference in 58% (44% males and 56% females).

CONCLUSION

The prevalence of metabolic syndrome is high among hypertensives attending primary health care centers in Kuwait.