Development and validation of cost-effective SYBR Green-based RT-qPCR and its evaluation in a sample pooling strategy for detecting SARS-CoV-2 infection in the Indonesian setting

A low-cost SYBR Green-based RT-qPCR method to detect SARS-CoV-2 were developed and validated. Primers targeting a conserved and vital region of the N genes of SARS-CoV-2 were designed. In-silico study was performed to analyse the compatibility of the selected primer pair with Indonesian SARS-CoV-2 genome sequences available from the GISAID database. We determined the linearity of our new assay using serial dilution of SARS-CoV-2 RNA from clinical samples with known virus concentration. The assay was then evaluated using clinically relevant samples in comparison to a commercial TaqMan-based test kit. Finally, we applied the assay in sample pooling strategies for SARS-CoV-2 detection. The SYBR Green-based RT-qPCR method was successfully developed with sufficient sensitivity. There is a very low prevalence of genome variation in the selected N primer binding regions, indicating their high conservation. The validation of the assay using clinical samples demonstrated similar performance to the TaqMan method suggesting the SYBR methods is reliable. The pooling strategy by combining 5 RNA samples for SARS-CoV-2 detection using the SYBR RT-qPCR methods is feasible and provides a high diagnostic yield. However, when dealing with samples having a very low viral load, it may increase the risk of missing positive cases.

Factors Influencing Hypoglycemia in Type 2 Diabetes Mellitus Outpatients with State Health Insurance at Regional General Hospitals in Jakarta, Indonesia

BACKGROUND

Hypoglycemia is an acute episode that can lead to death in patients with diabetes mellitus (DM). This condition is preventable with patient education, and identifying factors influencing their occurrence is essential to creating effective and efficient education. It also leads to prevention and control by re-organizing the service system and diabetes policies. This study aimed to determine factors contributing to hypoglycemic episodes in type 2 DM outpatients covered by the state-provided Jaminan Kesehatan Nasional (JKN) health insurance.

METHODS

The study used a cross-sectional design and collected data from five regional general hospitals in Jakarta, Indonesia. The outpatients were sampled consecutively from two hospitals in September-November 2021, one in January-March 2022, and two others in April-June 2023. Interviews produced primary data related to experienced hypoglycemic episodes, and medical records provided secondary data on patients' clinical characteristics and treatments. Binary logistic regression analysis was employed to process the contributing factors statistically.

RESULTS

From 501 patients who met the inclusion and exclusion criteria, it was found that the prevalence of hypoglycemia was 53.3%. Factors that significantly increased hypoglycemic risk (p < 0.05) were high HbA1C levels (OR 1.9; 95% CI 1.2-2.9), comorbidities (OR 1.6; 95% CI 1.1-2.4), insulin/sulfonylurea therapy (OR 2; 95% CI 1-4), non-smoking habit (OR 2.2; 95% CI 1.3-3.6) and physically active lifestyle (OR 1.8; 95% CI 1.2-2.6).

CONCLUSION

The prevalence of hypoglycemia in type 2 diabetes mellitus (DM) outpatients with the state-provided health insurance Jaminan Kesehatan Nasional (JKN) at general hospitals in Jakarta is high. The diabetes self-management education (DSME) services provided by health professionals for these outpatients must be further improved.

Platelet Glycoprotein-Ib (GPIb) May Serve as a Bridge between Type 2 Diabetes Mellitus (T2DM) and Atherosclerosis, Making It a Potential Target for Antiplatelet Agents in T2DM Patients

Type 2 diabetes mellitus (T2DM) is a persistent metabolic condition that contributes to the development of cardiovascular diseases. Numerous studies have provided evidence that individuals with T2DM are at a greater risk of developing cardiovascular diseases, typically two to four times more likely than those without T2DM, mainly due to an increased risk of atherosclerosis. The rupture of an atherosclerotic plaque leading to pathological thrombosis is commonly recognized as a significant factor in advancing cardiovascular diseases caused by TD2M, with platelets inducing the impact of plaque rupture in established atherosclerosis and predisposing to the primary expansion of atherosclerosis. Studies suggest that individuals with T2DM have platelets that display higher baseline activation and reactivity than those without the condition. The expression enhancement of several platelet receptors is known to regulate platelet activation signaling, including platelet glycoprotein-Ib (GPIb). Furthermore, the high expression of platelet GP1b has been reported to increase the risk of platelet adhesion, platelet-leucocyte interaction, and thrombo-inflammatory pathology. However, the study exploring the role of GP1b in promoting platelet activation-induced cardiovascular diseases in T2DM patients is still limited. Therefore, we summarize the important findings regarding pathophysiological continuity between T2DM, platelet GPIb, and atherosclerosis and highlight the potential therapy targeting GPIb as a novel antiplatelet agent for preventing further cardiovascular incidents in TD2M patients.

Evaluation of the Use of Antimicrobial Therapy for Treating Diabetic Foot Infections in an Indonesia Referral Hospital: A Retrospective Cohort Study

BACKGROUND

Diabetic foot infection (DFI) is a common complication of hyperglycemia and is related to prolongation of hospitalization, mortality, high hospitalization costs and decreased quality of life. Antibiotic therapy is one of the most critical factors in the eradication of infection. This study aims to determine the appropriateness of antibiotic use based on the local and international clinical guidelines and its short-term effect on patients' clinical improvement.

MATERIALS AND METHODS

This retrospective cohort study was conducted using secondary data from DFI inpatients from 1 January 2018 to 31 May 2020, from Dr. Cipto Mangunkusumo Hospital (RSCM), the National Referral Hospital of Indonesia. The Gyssens algorithm was used to help assess the appropriateness of antibiotics. All subjects were type 2 Diabetes Mellitus (T2DM) adult patients diagnosed with DFI. The primary outcome was a clinical improvement of infection after 7 - 14 days of antibiotic use. The clinical improvement of infection was defined by a minimum of three of these criteria: reduced or no purulent secretions, no fever, the area around the wound did not feel warm, no or reduced local oedema, no local pain, reduced redness or erythema, and decreased leukocytes count.

RESULTS

A total of 113 (63.5%) eligible subjects from a total of 178 were recruited. Among the patients, 51.4% had a duration of T2DM for ≥10 years, 60.2% had uncontrolled hyperglycemia, 94.7% had a history of complications, 22.1% had a history of amputation, and 72.6% had ulcer grade ≥3. Based on the Gyssens algorithm, 54.0% of the subjects were given antibiotics appropriately, while the other 46.0% were not. The proportion of improved patients in the appropriate antibiotic group was higher but not statistically significant than those in the inappropriate group (60.7% vs. 42.3%, P = 0.079). However, the results of the multivariate analysis demonstrated that the appropriate use of antibiotics would increase clinical improvement by 2.6 times, compared to inappropriate use after controlling for the covariates (adjusted odds ratio: 2.616, 95% confidence interval: 1.117 - 6.126, P = 0.027).

CONCLUSION

Only half of the patients with DFI received appropriate antibiotics, although an appropriate antibiotic usage was independently associated with better short-term clinical improvement in DFI. This suggests that we should effort to improve appropriateness in antibiotics usage in DFI.

Absence of Association Between Serum Mutant p53 with HbA1c and Insulin in Brain Tumor Patients with Type 2 Diabetes Mellitus

AIMS

This study aims to determine the prevalence of Type 2 Diabetes Mellitus (T2DM) in primary Brain Tumor (BT) subjects and assess the relationship between serum mutant p53 serum and HbA1c and insulin.

BACKGROUND

T2DM is known to increase the risk of various types of cancer, which are thought to be caused by hyperglycemia, hyperinsulinemia, and inflammation. A cohort study that looked at more than 500,000 subjects with DM over 11 years showed an increased risk of different types of cancer, including brain tumors. However, several recent studies have shown the opposite. One of the important pathways in the pathogenesis of brain tumors is the p53 pathway, in which mutations in the TP53 gene can cause brain cell growth abnormalities.

OBJECTIVE

The first stage involved taking subject data for the period January 2017-November 2020 from the medical records of the RSUPN Dr. Cipto Mangunkusumo Hospital Indonesia to assess the prevalence of T2DM in BT subjects. The second stage was an observational study with a crosssectional design that collected primary data on subjects (n=86) to assess the relationship between serum mutant p53 serum and HbA1c and insulin.

METHODS

The analysis of serum mutant p53 serum and insulin was made using the ELISA method, while measurement of HbA1c was made using the boronate affinity method.

RESULT

The results show the prevalence of T2DM in BT subjects at Dr. Cipto Mangunkusumo Hospital Indonesia was relatively low (9%). Serum mutant p53 levels in T2DM (1.53 ng/mL ± 0.60) were significantly higher than in BT+T2DM and BT (P < 0.001). The HbA1c value was significantly lower in BT (5.15% ± 0.44) compared to BT+T2DM and T2DM (P < 0.001), while T2DM insulin levels (39.54 IU/mL ± 19.1) were significantly higher than BT+T2DM and BT (P < 0.001). There was no correlation between serum mutant p53 levels and HbA1c and insulin in the three groups.

CONCLUSION

The study concludes that the prevalence of BT with T2DM is relatively low (9%) and that serum levels of mutant p53 in T2DM subjects are higher than in subjects with BT, but there is no correlation between serum mutant p53 levels and HbA1c and insulin values. Further research needs to be conducted by analyzing p53 mutants from other specimens, such as brain tumor tissue.

"Phardiacare" Program for Improved Medication Adherence and Clinical Outcomes of Type 2 Diabetes Mellitus Patients in Community Health Centers

BACKGROUND

The role of pharmacists in middle-income countries such as Indonesia is still not optimal. In this study, we developed a program called "Phardiacare," a specific pharmacist-led program for Type 2 diabetes mellitus (T2DM) patients.

OBJECTIVE

The objective of this study is to assess the effectiveness of the application of the "Phardiacare" program in improving medication adherence and clinical outcomes in T2DM patients.

METHODS

The study was quasi-experimental, with a pretest-posttest design, and was conducted prospectively from July to October 2019 at the Matraman and Jatinegara District Health Center, Jakarta, Indonesia. The study comprised 33 T2DM patients in an intervention group (IG) who received the "Phardiacare" program and 33 patients in a control group (CG). Assessment was performed of HbA1c, FBG, LDL, HDL, total cholesterol, triglycerides, and blood pressure.

RESULTS

HbA1c after intervention in the IG was lower than that of the CG (p <0.05). Intra-group mean differences showed improvement in the clinical parameters of FBG, triglycerides, and diastolic blood pressure in the IG (p <0.05), but not in the CG. Other clinical parameters did not show significant improvement. The results of the multivariate analysis showed that the "Phardiacare" program had a 16 times greater effect in reducing levels of HbA1c in the IG [95% CI 3.995:67.113, p <0.001] compared to the CG, even after controlling for confounding variables.

CONCLUSION

The "Phardiacare" program was effective in improving patient medication adherence by decreasing HbA1c and FBG, but it did not have a significant effect on LDL, HDL, total cholesterol, and systolic blood pressure. Therefore, the involvement of pharmacists in the management of chronic diseases, especially T2DM, should be considered.

Cognitive Function in Type 2 Diabetes Mellitus Patients Taking Metformin and Metformin-Sulfonylurea

The most prescribed antidiabetic drugs in Indonesian primary health care are metformin or a combination of metformin and sulfonylurea. Studies on metformin have shown various impacts on cognitive decline in patients with type 2 diabetes mellitus, whereas sulfonylurea has been shown to reduce this impact. This study aimed to compare the impacts of metformin and metformin-sulfonylurea on cognitive function and determine what factors affected it. This cross-sectional study was conducted at Pasar Minggu Primary Health Care involving 142 type 2 diabetes mellitus patients taking metformin or metformin-sulfonylurea for > 6 months and aged > 36 years. Cognitive function was assessed using the validated Montreal Cognitive Assessment Indonesian version. The effects of metformin and metformin-sulfonylurea on cognitive decline showed no significant difference, even after controlling for covariates (aOR = 1.096; 95% CI = 0.523–2.297; p-value = 0.808). Multivariate analysis showed age (OR = 4.131; 95% CI = 1.271–13.428; p-value = 0.018) and education (OR = 2.746; 95% CI = 1.196–6.305; p-value = 0.017) affected cognitive function. Since a lower education and older age are likely to cause cognitive decline, health professionals are encouraged to work with public health experts to address these risk factors for cognitive function.

Low-cost SYBR Green-based RT-qPCR assay for detecting SARS-CoV-2 in an Indonesian setting using WHO-recommended primers

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is the causative agent for the ongoing coronavirus disease 2019 (COVID-19) pandemic. For laboratory diagnosis, low-cost detection of SARS-CoV-2 is urgently needed, particularly in developing countries with limited resources. Probe- or TaqMan-based real-time reverse transcription polymerase chain reaction (RT-qPCR) is currently the gold standard for diagnosing infected individuals, as recommended by the World Health Organization (WHO). However, this assay is expensive, making it difficult to use for diagnosis on a large scale. Therefore, in this study, we develop and validate an alternative approach for RT-qPCR diagnosis by employing the DNA intercalating dye SYBR Green. We evaluate and use two WHO-recommended primers, namely CCDC-N and HKU-ORF1b-nsp14. The compatibility of the two primers was tested in silico with Indonesian SARS-CoV-2 genome sequences retrieved from the GISAID database and using bioinformatic tools. Using in vitro-transcribed RNA, optimization, sensitivity, and linearity of the two assays targeting the N and Nsp-14 genes were carried out. For further evaluation, we used clinical samples from patients and performed the SYBR Green-based RT-qPCR assay protocol in parallel with TaqMan-based commercial assay. Our results show that our methodology performs similarly to the broadly used TaqMan-based detection method in terms of specificity and sensitivity and thus offers an alternative assay for the detection of SARS-CoV-2 RNA for diagnostic purposes.

Role of urinary H2O2, 8-iso-PGF2α, and serum oxLDL/β2GP1 complex in the diabetic kidney disease

Oxidant species is reported as a major determinant in the pathophysiology of diabetic kidney disease. However, reactive oxygen species (ROS) formation in the initial phase and progressing phase of diabetic kidney disease remains unclear. Therefore, we conducted this study to find out what ROS and their modified product are associated with eGFR in type 2 diabetes mellitus (T2DM) patients. A cross-sectional study was performed on 227 T2DM patients. The study subjects were divided into three groups based on their eGFR stage (Group 1, eGFR > 89 ml/min/1.73 m2; Group 2, eGFR = 60-89 ml/min/1.73 m2; and Group 3, eGFR < 60 ml/min/1.73 m2). Enzyme-linked immunosorbent assay (ELISA) was used to measure serum oxLDL/β2GPI complex and urinary 8-iso-PGF2α, while ferrous ion oxidation xylenol orange method 1 (FOX-1) was used to measure urinary hydrogen peroxide (H2O2). H2O2 significantly decreased across the groups, whereas OxLDL/β2GPI complex increased, but not significant, and there was no trend for 8-iso-PGF2α. Consistently, in the total study population, only H2O2 showed correlation with eGFR (r = 0.161, p = 0.015). Multiple linear regression analysis showed that significant factors for increased eGFR were H2O2, diastolic blood pressure, and female. Whereas increased systolic blood pressure and age were significant factors affecting the decrease of eGFR. We also found that urinary H2O2 had correlation with serum oxLDL/β2GPI complex in total population. This finding could lead to further research on urinary H2O2 for early detection and research on novel therapies of diabetic kidney disease.

The chemical constituents of Sterculia comosa (wall) Roxb woods for arginase inhibitory, antioxidant activity, and molecular docking against SARS CoV-2 protein

Flavonoids and phenols have an arginase inhibitory and antioxidant activity. The Sterculia genus has phenols and flavonoids content. This study aimed to investigate the arginase inhibitory and antioxidant activity of the chemical constituent of Sterculia comosa (wall) Roxb and also their binding affinities to arginase. The most active extract was methanol extract. This active extract was determined for its arginase inhibitory and antioxidant activity, determined the total phenols and total flavonoids, and identified chemical compound. The methanol extract has IC₅₀ 2.787 μg/ml for arginase inhibitory activity and IC₅₀ 4,199 μg/ml for DPPH scavenging activity. The total phenols 723.61 mg GAE/gr, total flavonoids content 28.96 mg QE/gr extract. The chemical constituent: KC4.4.6 ((-)-2-(E)-caffeoyl-D-glyceric acid) and KC4.4.5.1 (trans-isoferulic acid) have an arginase inhibitory activity KC4.4.6: 98,03 μg/ml and KC4.4.5.1: 292,58 μg/ml. Antioxidant activity with DPPH methods KC4.4.6: 48,77 μg/ml and KC4.4.5.1: 88,08 μg/ml. Antioxidant by FRAP methods KC4.4.6: 16,4 FeEAC mol/g and KC4.4.5.1: 15,79 FeEAC mol/g. The isolate trans-isoferulic acid predicted has good interaction to arginase. Isolate KC4.4.6. Predicted has good interaction to PLPro of SARS CoV-2 PLpro. However, both isolates did not show good interaction to 3CLPro, nsp12, and Spike protein of SARS CoV-2.

A Systematic Review of Randomized Controlled Trials of Antibiotic Use in Diabetic Foot Ulcer Infections: Focus on Clinical Cure

Background

Materials and Methods

Results

Conclusion

Comparison of Metformin-sulfonylurea and Metformin-acarbose Combination Therapies on Glycemic Outcomes: A Retrospective Cohort Study

OBJECTIVE

Pharmacological therapy for type 2 diabetes mellitus features various combinations of treatments, with different therapies providing different levels of effectiveness. In clinical settings, choices are driven by cost, effectiveness, and safety considerations, and these choices are still under question in Indonesia. This study aimed to compare the effectiveness of metformin-sulfonylurea and metformin-acarbose combination therapies on glycemic parameters in patients with type 2 diabetes mellitus.

METHODS

This study was carried out at Gatot Soebroto Army Hospital in Jakarta and utilized a retrospective cohort study design. Participants had consumed the same drug without switching for six months and were divided into a metformin-sulfonylurea group (n = 100) and a metformin-acarbose group (n = 100). The effectiveness of treatment was evaluated by considering hemoglobin A1c (HbA1c), two hours postprandial glucose, and fasting blood glucose.

RESULTS

After six months' consumption, there were no statistical differences between results for the metformin-sulfonylurea and metformin-acarbose groups in terms of change of HbA1c (p = 0.062), controlled two hours postprandial blood glucose (p = 0.649), and controlled fasting blood glucose (p = 0.282). Regular exercise was the most significant factor for constant/decreased HbA1c, whereas being male and following a diet were the most significant factors for controlled two hours postprandial blood glucose and fasting blood glucose, respectively.

CONCLUSION

Based on the analysis performed, there was no significant difference in the effectiveness of six months' consumption of metformin-sulfonylurea and metformin-acarbose on HbA1c, two hours postprandial blood glucose, and fasting blood glucose.

The effect of repeated education using live demonstrations and videos of how to use inhalation drugs on quality of life for COPD patients

Repeated education regarding the proper use of inhalers can reduce the error rate in inhaler-using patients and improve COPD patients' quality of life. This study investigates the effect of repeated education on the quality of life of COPD patients during the pandemic of COVID-19 from February to June 2020. Repeated education is provided using direct demonstrations to patients through educational media in the form of short videos made by the researchers for each inhaler type. This is a pre-experimental study design which was carried out prospectively at Grha Permata Ibu Hospital, Depok. The quality of life of 22 subjects was examined using the COPD assessment test (CAT) questionnaire. Each patient was given a direct verbal demonstration of the appropriate use of the inhaler. One month later, each patient was provided further education using less than 2 min of video sent to them online via the WhatsApp application. Final quality-of-life examination and assessment of inhaler technique were carried out three months after the initial examination. Assessment of proper inhaler technique was carried out using a specific checklist regarding the use of inhaler translated by the researcher. Before and after delivery of repeated education, the mean CAT score showed a decrease of two points, i.e., 12.8 ± 1.3 and 10.8 ± 2.0, respectively. This indicated that quality of life of the patients had significant improvement. However, as many as 63.6% of patients still made mistakes in using inhaler even though they had been educated. For DPI-type inhalers, mistake mostly happened at step "breath out gently, away from inhaler". For pMDI-type inhalers, mistake mostly happened at step "while holding breath, remove inhaler from mouth". It can be concluded that repeated education regarding proper inhaler technique with direct demonstrations and further maintained by videos can improve the quality of life in COPD patients.

The potential of metformin as an antineoplastic in brain tumors: A systematic review

Brain tumors are challenging to handle and cause severe mortality and morbidity. The primary therapy for brain tumors, a combination of radiotherapy, chemotherapy (i.e temozolomide), and corticosteroids, is considered inadequate to improve patients' clinical conditions and associated with many adverse effects. There is an urgent need for new compounds or repurposing of existing therapies, which could improve brain tumor patients' prognosis. Metformin, commonly used for type 2 diabetes medication, has been examined for its protective action in cancer, reducing cancer risk and cancer-related mortality. However, its effect on cancer is still in rigorous debate. This study examines recent studies on the effects of metformin in primary brain tumor patients through systematic reviews. The literature search was performed on PubMed, ScienceDirect, and SpringerLink databases for articles published between 2013 and 2020. We selected clinical studies comparing the therapeutic outcomes of brain tumor therapy with and without metformin. The clinical benefits of the drug were assessed through the overall survival (OS) and progression-free survival (PFS) of brain tumor patients. Those studies demonstrated that the combination of metformin with temozolomide given post-radiotherapy resulted in better OS and PFS. Nonetheless, the efficacy and safety of metformin need further clinical testing in the wider population.

Current updates on protein as biomarkers for diabetic kidney disease: a systematic review

BACKGROUND

In the past decade, researchers have been focused on discovering protein biomarkers for diabetic kidney disease. This paper aims to search for, analyze, and synthesize current updates regarding the development of these efforts.

METHODS

We systematically searched the ScienceDirect, SpringerLink, and PubMed databases for observational studies of protein biomarkers in patients with diabetes mellitus. We included studies published between January 2018 and April 2020, that were based on a population of patients with type-1 or type-2 diabetes mellitus aged ⩾18 years, with an observational design such as cross-sectional, case-control, or cohort studies. The dependent variable of the research results was in the form of protein biomarkers from urine, plasma, or serum.

RESULTS

Following the screening process, 20 research articles with available full text met the inclusion criteria. These could be categorized as glomerular biomarkers (ANGPTL4, beta-2 microglobulin, Smad1, and glypican-5); inflammatory biomarkers (MCP-1 and adiponectin); and tubular biomarkers (NGAL, VDBP, megalin, sKlotho, and KIM-1). The development of a panel of biomarkers showed more promising results than those for a single biomarker in diagnosing diabetic kidney disease.

CONCLUSION

All the biomarkers discussed in this review showed promising results for predicting diabetic kidney disease because they correlate with albuminuria, eGFR, or both. However, of the 11 protein biomarkers, none have prognostic value beyond albuminuria and eGFR.

Effect of Angiotensin Receptor Blocker and Angiotensin Converting Enzyme Inhibitor on Kidney Function and Blood Potassium Level in Indonesian Type 2 Diabetes Mellitus with Hypertension: A Three-Month Cohort Study

PURPOSE

National formulary restrictions in Indonesia (2019) require estimated glomerular filtration rate (eGFR) of less than 60 mL/min/1.73 m² to be able to prescribe telmisartan and valsartan and ACE-I intolerance to be able to prescribe irbesartan and candesartan. These restrictions are based on economic considerations and differ from American Diabetes Association (ADA) (2020) guidelines which allow equal use of angiotensin II receptor blockers (ARB) and angiotensin-converting enzyme inhibitors (ACE-I) without restriction. Since there is a need to evaluate the different effects of ACE-I and ARB in the Indonesian hypertensive type 2 diabetes mellitus (T2DM) population, we compare their effects on urine albumin-to-creatinine ratio (UACR), estimated glomerular filtration rate (eGFR), and blood potassium level.

PATIENTS AND METHODS

A prospective cohort study at RSUPN Dr. Cipto Mangunkusumo Hospital was conducted in 123 T2DM patients. We followed the study subjects prospectively for three months using a validated questionnaire, health record, and laboratory data.

RESULTS

After 3 months of observation, there were no significant changes, except increased BMI values (p = 0.046) in the ACE-I group, and decreased LDL value (p = 0.016) and HDL value (p = 0.004) in the ARB group. Multivariate analysis showed that the consumption of ACE-I or ARB was not associated with a decrease/constant of UACR or increase potassium level, even after adjusting by confounding variables. Interestingly, we found ARB was more likely to increase eGFR, but the significance was lost once the duration of ACE-I/ARB use was entered into the model. In addition, BMI >25 kg/m² was a significant factor associated with decreased/constant UACR, maleness was significant for increased eGFR, and declining systolic blood pressure for increase in potassium level.

CONCLUSION

ACE-I and ARB have a similar effect on UACR and blood potassium level, but ARB slightly increased eGFR compared to ACE-I within three months of consumption.

Adherence to Treatment and Glycemic Control in Patients with Type 2 Diabetes Mellitus: A 4-Year Follow-up PTM Bogor Cohort Study, Indonesia

PURPOSE

Large-scale evaluation of the treatment adherence in patients with type 2 diabetes mellitus (DM) in Indonesian is limited. We aim to evaluate the treatment adherence of Indonesian type 2 DM patients using national "big data" and investigate its association with glycemic parameters.

PATIENTS AND METHODS

We analyzed baseline and fourth-year data sets from 2011 to 2018 obtained from the Indonesian Ministry of Health Cohort Study of Non-Communicable Disease Risk Factors in Bogor, West Java (the PTM Bogor Cohort Study). This was a retrospective cohort study in which the sample was divided into two groups. One group adhered to treatment from primary health centers and followed the prescribed medicine/treatment regimen (treated group), while the other did not follow the treatment (untreated group). We evaluated changes in fasting blood glucose (FBG) and post-prandial blood glucose (PPBG) by controlling for other variables.

RESULTS

From 5690 subjects, 593 were type 2 DM diagnosed and 342 were eligible at the baseline. At 4-year observation, 212 eligible patients remained, consisting of 62 subjects who adhered to treatment, and more than double that number who were untreated (150 subjects). More significant decreases in FBG and PPBG were found in the treated group (FBG 80.6%, PPBG 90.3%) than in the untreated group (FBG 42.0%, PPBG 67.3%). The results of the multivariate analysis showed that after 4 years observation, treated patients have reduced FBG 3.304 times more and PPBG 3.064 times more than untreated patients, with control factors such as decrease in LDL levels and use of oral drugs.

CONCLUSION

There were less than half as many treated patients as untreated patients involved in the PTM Bogor Study Group. At the fourth-year follow-up, treated patients experienced three times more significant decreases in FBG and PPBG than those who were untreated, even after being controlled by several confounding factors. Given the importance of these findings, it is suggested that immediate strategic action be taken to improve Indonesian patients' adherence to treatment.

Effect of Pharmacist Intervention on Medication Adherence and Clinical Outcomes of Type 2 Diabetes Mellitus Outpatients in Primary Healthcare in Indonesia

OBJECTIVE

In Indonesia, the role of pharmacists in primary healthcare is still very limited or even absent. This study evaluates the effectiveness of programs delivered for type 2 diabetes mellitus (T2DM) patients by pharmacists in primary healthcare through counseling, short message service (SMS) reminders, and medication booklets.

METHODS

A quasi-experimental study with a pretest-posttest design was conducted from April to August 2018 at Merdeka and Dempo primary health-care centers, Palembang, South Sumatra Province, Indonesia. Counseling and medication booklets were distributed three times during the study period, while SMS reminders were sent once a week. Counseling was given for the management of diabetes mellitus (DM), including during the Ramadan fasting period, together with management for acute and chronic complications. The medication adherence level was measured using a medication adherence questionnaire (MAQ) and pill count adherence (PCA). The study sample comprised 80 T2DM patients, who were allocated into either the control group (CG) (n = 40) or intervention group (IG) (n = 40). Clinical outcomes were determined by measuring glycated hemoglobin (HbA1c), blood pressure, and lipid profiles.

FINDINGS

After the intervention, the IG showed significant improvements in most parameters, except for high-density lipoprotein cholesterol and systolic and diastolic blood pressure. HbA1c levels were reduced, while MAQ scores and PCA scores were improved. Lipid parameters were significantly reduced total cholesterol (TC), low-density lipoprotein cholesterol (LDL-c), and triglyceride (TG). Compared with the CG, most parameters were significantly improved in the IG. Pharmacist counseling significantly improved almost all clinical parameters (HbA1c, TC, LDL-c, and TG). Pharmacist counseling was 7.1 times greater in lowering HbA1c compared with no counseling, after adjusted by other variables. The variable that most influenced the lowering of HbA1c was infrequent ("not often") consumption of unhealthy foods (OR 14.9; 95% CI 3.5-63.7).

CONCLUSION

The pharmacist primary health-care intervention program implemented in this study significantly improved HbA1c, TC, LDL-c, TG, and medication adherence in outpatients with T2DM.

Sera Anti-P53 Antibody Provides New Information Which Explains the Link Between Diabetes and Cancer

INTRODUCTION

Abnormalities in glucose metabolism in diabetic patients may lead to an increased risk of certain cancers. Epidemiological studies and meta-analysis have shown that factors such as gender, age, obesity, and insulin resistance are related to cancer incidence. The anti-p53 antibody is a known cancer marker due to tumor-associated p53 accumulation. Many studies have aimed to unravel the link between diabetes and cancer. Here, we aimed to elucidate the impact of diabetes on malignancies by analyzing anti-p53 antibody in sera of type 2 diabetes mellitus (T2DM) patients.

MATERIALS AND METHODS

We conducted an observational study with a cross-sectional design. A total of 149 subjects comprised of 78 T2DM patients (32 with cancer risk and 46 subjects without cancer risk), 51 T2DM patients with cancer, and 20 healthy subjects as controls from multisites. The anti-p53 antibody was measured by enzyme-linked immunosorbent assay, while HbA1c was measured using the NGSP standardized method.

RESULTS

We observed an 8.3-fold (p<0.05) increase of anti-p53 antibody in the sera of T2DM patients and a 24-fold increase (p<0.001) in T2DM patients with cancer compared to healthy subjects. The anti-p53 antibodies significantly increased almost three times (p<0.05) in T2DM patients with cancer (0.72 U/mL±0.20) compared to T2DM patients (0.25 U/mL±0.05). Meanwhile, this antibody was almost undetectable in healthy subjects as a control group (0.03 U/mL±0.03). The anti-p53 antibody level was higher in T2DM with cancer risk patients. However, we did not find a significant difference for it in T2DM without cancer risk patients (0.19 U/mL±0.03) and T2DM with cancer risk patients (0.29 U/mL±0.08). Multivariate regression analysis showed that T2DM with cancer was the only one independent factor (beta=0.218, p=0.019) that could predict the increase of anti-p53 antibody, controlled by age, gender, BMI, DM duration, and HbA1c.

CONCLUSION

Our results showed that anti-p53 antibody almost not detected in healthy subjects, but 8.3-fold increase in the sera of T2DM patients and 24-fold increase in T2DM patients with cancer. Therefore, this biomarker provides new information which explains the link between diabetes and cancer.

Association between serum homocysteine level and cognitive function in middle-aged type 2 diabetes mellitus patients

Type-2 diabetes mellitus (T2DM) is strongly associated with various complications, including cognitive impairment. Diabetic complication is related with structural and functional changes of brain. Studies investigated that homocysteine as an independent risk factor of several organ complications. This marker might have a role in pathogenesis of cognitive impairment in T2DM patients. We aimed to know the association between serum homocysteine level and cognitive impairment in middle-aged T2DM populations. The study was a cross-sectional study involving 97 T2DM patients aged <60 years old. Cognitive assessment was based on validated Indonesian version of Montreal Cognitive Assessment (MoCA-INA) test. Besides, serum homocysteine level (Hcy) was measured based on standard laboratory assay. Filling out the questionnaire of MoCA-INA was conducted when patients came to take the blood sample. This study used independent t-test, chi-square and multivariate logistic regression model to analyze the data. There were 47 subjects (48.5%) with mild cognitive impairment (MCI). Delayed recall was the most impaired domain (94.8%). There was no significant mean difference of serum Hcy level in MCI and non-MCI group (11.99±3.27 μmol/L vs 12.36±4.07 μmol/L respectively, p = 0.62). Final model of logistic regression showed no association between serum Hcy and cognitive function after adjusting confounding variables (OR: 1.778; 95%CI: 0.69-4.54). Further investigation involving slight elderly T2DM patients with larger sample size should be conducted to confirm this finding.

Effect of Hospital Pharmacist Counseling on Clinical Outcomes of Type 2 Diabetes Mellitus Outpatients

Objective:

In Indonesia, the role of a hospital pharmacist in pharmaceutical care is still limited or even absent. This study aimed to determine whether counseling by a pharmacist could improve medication adherence, controlling the glycemic status, lipid profile, and blood pressure of type 2 diabetes mellitus (T2DM) outpatients.

Methods:

We conducted an interventional study at RSUD Kota Depok, a secondary public hospital, Indonesia, from April to October 2018. Counseling was given three times during the 4-month study. The study design was quasi-experimental with pretest-posttest group design on 77 respondents divided into intervention group (IGs) (n = 39 people) who received counseling and booklets from the hospital pharmacist and control group (CG) (n = 38 people) who were only given the booklets. We measured adherence with the Medication Adherence Questionnaire and conducted blood tests for fasting blood glucose (FBG), postprandial blood glucose (PPBG), glycosylated hemoglobin A1, lipid profiles (total cholesterol, low-density lipoprotein cholesterol, high-density lipoprotein cholesterol, and TG), and blood pressure measurements.

Findings:

In the IG, adherence parameters such as HbA1c and lipid profile improved, whereas in the CG, there were no statistically significant changes in clinical parameters and even nonadherence score increased (P = 0.008). IG showed statistically significant improvement in medication adherence, in parameters such as FBG, PPBG, and HbA1c, compared to CG. Based on the Chi-square test, IG also showed a statistically significant improvement in the number of controlled FBG (P = 0.05) and HbA1c (P < 0.001) compared to CG. In addition, a multivariate analysis showed that counseling by hospital pharmacist was 2.764 times (95% confidence interval [CI]: 1.096–6.794) and 9.964 times (95% CI: 3.434–28.917) better than no counseling in improvement of FBG and HbA1c, respectively. However, the significance disappeared after adjusted by type of medicine, duration of diabetes mellitus drug use, and medication adherence.

Conclusion:

Hospital pharmacist counseling is an important and significant factor in improving FBG and HbA1c levels of T2DM outpatients.

Urinary TGF-β1 was not independently associated with renal function in diabetes mellitus

BACKGROUND

Several clinical studies have shown increased level of urinary TGF-β1 in diabetic nephropathy patients and its correlation with urine albumin-to-creatinine ratio (UACR), but other studies showed different results. Because of this contradiction, this study aims to analyze the correlation between urinary TGF-β1 concentration and UACR, and also estimated glomerular filtration rate (eGFR) in type 2 diabetes mellitus (DM) patients by controlling some confounding factors.

METHODS

This was a cross-sectional study, and the samples were obtained using consecutive sampling technique. The study was performed on 99 subjects (62 DM normoalbuminuria patients, 27 DM albuminuria patients, and 10 non-DM patients as controls) at Pasar Minggu Community Health Center. Urinary TGF-β1 concentration was measured by ELISA, and UACR was measured using immunoturbidimetry and an enzymatic colorimetric method. The eGFR value was calculated based on serum creatinine using Chronic Kidney Disease Epidemiology Collaboration equation. The results were then subjected to be analyzed statistically.

RESULTS

There was an increase of urinary TGF-β1 in albuminuria (326.49±48.98) as compared to normoalbuminuria (290.54±30.71) and non-DM subjects (229.83±31.90), but the values did not differ statistically (P=0.790). In addition, no correlation was observed between urinary TGF-β1 and UACR (r=-0.084, P=0.410) and eGFR (r=0.155, P=0.125), but a correlation was found with SBP (r=-0.224, P=0.026). Linear regression analysis showed that urinary TGF-β1 and HbA1c could predict UACR, but only HbA1c could be considered as a significant predictor of UACR.

CONCLUSION

There is an increase of urinary TGF-β1 concentrations in albuminuria patients clinically, but not statistically. The concentration of TGF-β1 was not correlated with UACR and eGFR, but correlated with SBP. Since TGF-β1 could be interfered by many factors, including hypertension and its medication, urinary TGF-β1 might not be independently associated with renal function in diabetes.

The Correlation Between Urinary 8-Iso-Prostaglandin F2α and Hydrogen Peroxide Toward Renal Function in T2DM Patients Consuming Sulfonylurea and Combination of Metformin-Sulfonylurea

BACKGROUND

Renal dysfunction is a common complication in type 2 diabetes mellitus patients associated with oxidative damage which could be characterized by 8-iso-prostaglandin F2α and hydrogen peroxide level as oxidative stress markers.

OBJECTIVE

The aim of our study is to determine if there is a difference in 8-iso-prostaglandin F2α and hydrogen peroxide levels between sulfonylurea and combination of metformin-sulfonylurea in diabetic patients. We also wanted to determine if these oxidative stress markers correlate with the estimated Glomerular Filtration Rate (eGFR).

SUBJECTS AND METHODS

We conducted a cross-sectional study with inclusion of 55 patients with type 2 diabetes mellitus in Dr. Sitanala Tangerang Hospital, Indonesia with purposive sampling. The value of eGFR was obtained by serum creatinine levels, while the level of 8-iso-prostaglandin F2α was measured by ELISA and urinary hydrogen peroxide using FOX-1 (Ferrous Ion Oxidation Xylenol Orange 1).

RESULTS

There was no difference in 8-iso-prostaglandin F2α and hydrogen peroxide level between the two groups (p=0.088 and p=0.848). Moreover, there was no difference in eGFR values between the two groups, measured by Cockroft-Gault, MDRD, and CKD-EPI. 8-iso-prostaglandin F2α (n=55) was positively correlated with eGFR based on Cockroft-Gault (r=0.382; p=0.009), whereas urinary hydrogen peroxide (n=47) also generate significant positive correlation with eGFR based on the MDRD equation (r=0.326; p=0.021). Linear regression analysis showed that 8-iso-prostaglandin F2α is the most predictive factor and the only significant factor for eGFR in Cockroft-Gault, MDRD and also CKDEPI, even after controlled by gender, age, BMI, HbA1c, systole, and H2O2.

CONCLUSION

The two treatments did not have any significant differences in antioxidant activity. However, an increase of urinary 8-iso-prostaglandin F2. and hydrogen peroxide which correlates with eGFR in the total sample may play a significant role in the pathophysiology of diabetic nephropathy.

α-Glucosidase Inhibitory Activity from Ethyl Acetate Extract of Antidesma bunius (L.) Spreng Stem Bark Containing Triterpenoids

Background:

Buni (Antidesma bunius [L.] Spreng) has been used as a traditional antidiabetic agent in Asia.

Objective:

The mechanism of antidiabetic properties was studied in this study by determine its α-glucosidase inhibitory activity.

Method:

Inhibition of α-glucosidase was performed in all fraction of Buni stem bark with acarbose and miglitol as standards. The half maximal inhibitory concentration (IC₅₀) value of acarbose and miglitol was 5.75 and 59.76 μg/mL respectively while ethyl acetate (EtOAc) fraction was the most active fraction with IC₅₀ of 19.33 μg/mL. Three isolates (B1, B2, and B3) were found in the EtOAc fraction and elucidated by infrared, ¹hydrogen-nuclear magnetic resonance,¹³ carbon-nuclear magnetic resonance, and two-dimensional nuclear magnetic resonance.

Result:

The chemical structures of the isolates were identified by the spectrum then compared with literature which concluded that B1 is friedelin, B2 is β-sitosterol, and B3 is betulinic acid. Inhibition of the α-glucosidase assay showed IC₅₀ values of B1, B2, and B3 were 19.51, 49.85, and 18.49 μg/mL, respectively.

SUMMARY

α-Glucosidase inhibitory activity assay was performed in n-hexane, ethyl acetate (EtOAc), methanol fraction of Buni (Antidesma bunius (L.) Spreng) stem bark and miglitol

EtOAc fraction from the liquid chromatography has the highest inhibitory activity against α-glucosidase

The chemical structures of the isolates were identified by the spectrums infrared, ¹hydrogen-nuclear magnetic resonance,¹³ carbon-nuclear magnetic resonance, and two-dimensional nuclear magnetic resonance, then compared with literature which concluded that B1 is friedelin, B2 is β-sitosterol, and B3 is betulinic acid

Betulinic acid and friedelin showed the highest α-glucosidase inhibitory activity.

Abbreviations used: IC₅₀: Half maximal inhibitory concentration; H-NMR: Hydrogen-nuclear magnetic resonance; C-NMR: Carbon nuclear magnetic resonance; 2D-NMR: Two dimensional-nuclear magnetic resonance; EtOH: Ethanol; EtOAc: Ethyl acetate; MeOH: Methanol; CHCl₃: Chloroform; DMSO: Dimethyl sulfoxide; EtF: Ethyl acetate fraction; Na₂CO₃: Sodium carbonate; IR: Infrared; TGR5: Transmembrane G protein-coupled receptor 5; EC₅₀: Half maximal effective concentration

Marker of lipid peroxidation related to diabetic nephropathy in Indonesian type 2 diabetes mellitus patients

OBJECTIVE

Even though diabetes patients exhibit an increased oxidative stress, its correlation with diabetic nephropathy is not fully understood. The purpose of this study was to determine whether lipid peroxidation marker correlates well with eGFR and UACR in type 2 diabetes mellitus patients.

METHODS

We collected urine and serum samples of Indonesian type 2 diabetes mellitus outpatients with normo- and microalbuminuria at a Local Government Clinic (from ages: 39-74 years). Urinary 8-iso-PGF2α was measured by ELISA, the serum malondialdehyde by TBARS assay, and urinary albumin by BCG albumin assay. eGFR was calculated using the corrected-Cockcroft-Gault (CG), MDRD, and CKD-EPI equation. Other necessary data were obtained through questionnaires.

RESULTS

The results showed that the increasing level of malondialdehyde was mildly correlated with the decline in eGFR (MDRD). In contrary, there was a significant positive correlation between 8-iso-PGF2α concentration and eGFR based on the corrected-CG, MDRD study, and CKD-EPI equation (r=0.457, p<0.001; r=0.424, p<0.001; r=0.443, p<0.001). This relationship still persisted in the normoalbuminuric subjects (n=43) (r=0.491, p=0.001; r=0.461, p=0.002; r=0.455, p=0.002). The multivariate analysis showed that 8-iso-PGF2α together with fasting plasma glucose was the most predictive factor for the high 2-quantile eGFR (adjusted OR 1.001, (95% CI, 1.000-1.001)). However, there was no significant correlation between UACR with malondialdehyde (r=0.268, p=0.050) and 8-iso-PGF2α(r=-0.030, p=0.808). UACR itself was inversely correlated with eGFR based on the corrected-CG, the MDRD, and CKD-EPI (r=-0.232, p<0.05; r=-0.228, p<0.05; r=-0.232, p<0.05).

CONCLUSIONS

Increased 8-iso-PGF2α and malondialdehyde in type 2 diabetes mellitus patients may play a role in the pathophysiologic significance of diabetic nephropathy, even while considering the effect of potential confounders.

Evaluation of pyrogallol-induced cytotoxicity in catalase-mutant escherichia coli and mutagenicity in Salmonella typhimurium

We evaluated pyrogallol cytotoxicity using Escherichia coli strains that express mammalian catalase gene derived from catalase mutant mice (Cs(b)) and wild-type (Cs(a)), and pyrogallol mutagenicity by Ames test. Pyrogallol was more toxic to Cs(b) rather than to Cs(a) (p < 0.05), while catalase, superoxide dismutase and ascorbic acid decrease the toxic effect. Pyrogallol also showed mutagenic effect (mutagenic index = 3.8 for 10 micromol pyrogallol/plate) while ascorbic acid (19.4% reduction, p < 0.001) and naringin (35.1% reduction, p < 0.001) played a protective role against it. Pyrogallol cytotoxicity and mutagenicity seem to be attributable, at least in part, to reactive oxygen species formation. This study also suggests that newly established catalase mutant E. coli is probably useful in hazard identification of oxidative chemicals.

Oxidative stress biomarkers and lifestyles in Japanese healthy people

The urinary concentrations of 8-isoprostane and 8-hydroxy-2’-deoxyguanosine (8-OHdG), which are biomarkers of oxidative stress, were measured in 677 Japanese people without any diseases, and their correlations with lifestyle facotrs, lifestyle-related blood biochemical parameters, and dietary intake of antioxidative vitamins were investigated. The mean urinary concentration of 8-isoprostane and 8-OHdG was 0.58 ng/mg creatinine and 8.43 ng/mg creatinine, respectively. Mean urinary 8-isoprostane was significantly different in terms of age, gender, smoking and alcohol consumption but not different in terms of body mass index (BMI) and exercise. By multiple regression analysis, urinary 8-isoprostane was significantly influenced by smoking and age. On the other hand, mean urinary 8-OHdG showed differences only by age group. Multiple regression analysis revealed that urinary 8-OHdG was significantly influenced by age, smoking, body weight, levels of high-sensitivity C-reactive protein (Hs-CRP) and low density lipoprotein-cholesterol in females, although it was significantly influenced by body weight in males. The present study shows that urinary 8-isoprostane is associated with lipid peroxidation related-lifestyles such as smoking, and urinary 8-OHdG is associated with arteriosclerosis related-factors such as Hs-CRP. Our findings suggest that 8-isoprostane and 8-OHdG appear to be prospective biomarkers for early prediction of lifestyle related-disease risk at the population level.

Development of a new assay for evaluation of l-3,4-dihydroxyphenylalanine cytotoxicity in catalase-mutant Escherichia coli

The present study aimed to assess whether a newly constructed, catalase-deficient Escherichia coli strain that express mammalian catalase gene could be used to identify oxidative stress-generating chemicals. We tested l-3,4-dihydroxyphenylalanine (l-DOPA), a well-known agent that induces reactive oxygen species. We found that l-DOPA exposure reduced the survival of catalase-mutant E. coli in a dose-dependent manner, especially in the strains with lower catalase activities, implying the usefulness of these strains in assessment of oxidative chemicals.

Social support, self-efficacy and psychological stress responses among outpatients with diabetes in Yogyakarta, Indonesia

We attempted to study whether social support promotes self-efficacy and reduces stress responses of patients with diabetes in Yogyakarta, Indonesia. Diabetic outpatients at Dr. Sardjito Hospital voluntarily participated in a questionnaire survey. Data from 125 patients were subjected to analysis. The questionnaires included the scales and subscales of social support, self-efficacy, psychological stress response, and demographic measure. Data were analyzed by Spearman's rank correlation test to examine the relationships between parameters, Mann-Whitney U-test and Kruskal-Wallis test to compare the scales by characteristics, and structural equation modeling to explore the best-fit model. This study was performed in September 2003. It was found that augmentation of emotional support to patients significantly increased the 'active coping for the disease' and 'controllability of health', and that 'helplessness' was reduced significantly. Behavioral support affected only 'controllably of health'. Self-efficacy reduced stress response of the patients. It was also found that subjects who received support from their children significantly scored higher in perceived availability of social support than those without support from their children. To know their behavioral support better as well as emotional support may be one area to focus on in improving the health status of people with diabetes in Yogyakarta.

Cytotoxicity of lawsone and cytoprotective activity of antioxidants in catalase mutant Escherichia coli

Lawsone is an active naphthoquinone derivative isolated from henna (Lawsonia inermis L.), a widely used hair dye. Previous study on the toxicity of lawsone remains unclear since the involvement of oxidative stress and the kind of ROS (reactive oxygen species) involved have not been fully resolved yet. This present study reports the cytotoxic effects of lawsone and henna. We carried out CAT assay (a zone of inhibition test of bacterial growth and colony-forming efficiency test of transformant Escherichia coli strains that express mammalian catalase gene derived from normal catalase mice (Cs(a)) and catalase-deficient mutant mice (Cs(b))), Ames mutagenicity assay and H(2)O(2) generation assay. Lawsone generated H(2)O(2) slightly in phosphate buffer system and was not mutagenic in Ames assay using TA 98, TA 100 and TA 102, both in the absence and presence of metabolic activation. Lawsone exposure inhibited the growth of both Cs(a) and Cs(b) strains in a dose-dependent manner. Mean zone diameter for Cs(a) was 9.75+/-0.96 mm and 12.75+/-1.5 mm for Cs(b). Natural henna leaves did not show toxic effects, whereas two out of four samples of marketed henna products were shown toxicity effects. Catalase abolished zone of inhibition (ZOI) of marketed henna products, eliminated ZOI of lawsone in a dose-dependent manner and low concentration of exogenous MnSOD and Cu/ZnSOD eliminated the toxicity. Histidine and DTPA, the metal chelator; BHA and low concentration of capsaicin, the inducer of NADH-quinone reductase, effectively protected Cs(a) and Cs(b) against lawsone in this study. We suggest that lawsone cytotoxicity is probably mediated, at least in part, by the release of O(2)(-), H(2)O(2) and OH(-).