INTRODUCTION: In the management of type 2 diabetes, insulin is often started late, when there is failure to achieve good control on maximum oral agents. Clinical inertia to insulin initiation and intensification is widely prevalent in our local setting resulting in poor control of diabetes. This study looked into a stepwise insulin combinations treatment algorithm used in an Endocrinology referral clinic at the University of Santo Tomas Hospital (USTH). It aimed to demonstrate the clinical course of the patients , determine the degree of HbA1c reduction, and show the associated extent of hypoglycemia and weight gain.

METHODS: This is a retrospective chart review of 104 patients that used the following stepwise treatment: Oral regimen; Regimen A: basal+oral; Regimen B: basal+premeal bolus TID±oral; Regimen C: premixed aspart 70/30 or lispro 75/25 TID or BID with prelunch bolus, ± oral; Regimen D: premixed 70/30 BID+premeal bolus TID ± oral; Regimen E: premixed 70/30 BI +premeal bolus TID+basal ±oral. All received automatic snacking two hours after main meals to prevent hypoglycemia. Patients were educated on proper diet and exercise. Data was analyzed using paired t-test, frequencies and percentages.

RESULTS: Most ended on the intensive insulin regimens D 57(55%), and E 18 (17%). Significant HbA1c reduction was demonstrated as follows: Regimen A (n=8):1.376±0.919 (p=0.000), Regimen B (n=18):2.320±2.177 (p=0.000), Regimen D (n=57):2.197±2.158 (p=0.000), Regimen E (n=18):2.684±1.689 (p =0.000). Overall mean weight gain was 1.070 ± 11.435 kg (p=0.335). Ten, nonsevere hypoglycemia events were reported.

CONCLUSION: The use of this stepwise insulin combinations treatment algorithm exerted significant HbA1c reduction, with minimal events of hypoglycemia, and statistically insignificant weight gain. Hence, this is a feasible tool that may be used as a guide for intensification of insulin treatment.

Human ; Male ; Female ; Aged ; Middle Aged ; Adult ; Insulin Lispro ; Insulin ; Diabetes Mellitus, Type 2 ; Regimen B ; Weight Gain ; Hypoglycemia ; Antineoplastic Combined Chemotherapy Protocols ; Diet ; Algorithms

INTRODUCTION: Postprandial lipemia characterized by a rise in triglyceride-rich lipoproteins after eating, is associated with increased risk of cardiovascular disease. Among diabetic patients, postprandial lipemia is often overlooked once fasting lipid parameters are within target. The aim of the study is to determine the correlation of glycemic control and postprandial hyperglycemia with postprandial lipemia among patients with type 2 diabetes mellitus (DM). The result of the study may have important implications on how dyslipidemia should be completely addressed.

METHODOLOGY: A clinic-based retrospective chart review of 102 patients with recorded fasting and postprandial blood measurements was performed. Subjects included adult patients with type 2 DM whose fasting lipid parameters were controlled with diet and/or medications. Plasma glucose and glycosylated hemoglobin (HbA1C) were independent variables while triglyceride, total cholesterol, low density lipoprotein (LDL) and high density lipoprotein (HDL) were dependent variables. Pearson correlation was used to determine the strength of relationships among the variables mentioned. A p-value

RESULTS: Of the 102 patients, 52.9% and 47.1% were achieving their target HbA1C and twohour postprandial plasma glucose, respectively. The postprandial level of plasma glucose, mean triglyceride, total cholesterol, LDL and HDL were 196.39 mg/dL, 189.06 mg/dL, 177.07 mg/dL, 122.40 mg/dL and 34.83 mg/dL, respectively. HbA1C has strong positive correlation with postprandial lipemia (Pearson's r=0.40) while the two-hour plasma glucose has moderate positive correlation (Pearson's r=0.34) with postprandial lipemia. Both relationships were considered significant (p-value <0.05).

CONCLUSION: A significant correlation of glycemic control and postprandial hyperglycemia with postprandial lipemia was observed. Our data suggest that despite achievement of optimal fasting lipid parameters, poor control of diabetes is positively correlated with abnormal elevation of postprandial triglyceride. Addressing both postprandial hyperglycemia and lipemia may improve cardiovascular outcome.

Human ; Male ; Female ; Aged ; Middle Aged ; Adult ; Hemoglobin A, Glycosylated ; Diabetes Mellitus, Type 2 ; Lipoprotein Triglyceride ; Lipoproteins ; Hyperlipidemias ; Dyslipidemias ; Hyperglycemia ; Cholesterol ; Cardiovascular Diseases

BACKGROUND: Osteoporosis in men is markedly underdiagnosed and undertreated despite higher morbidity and mortality associated with fractures. This study aimed to characterize adult Filipino men with osteopenia, osteoporosis and prevalent fractures. METHODS: A cross-sectional study of 184 Filipino men ≥50 years screened for bone mineral density was performed. Age, weight, body mass index (BMI), Osteoporosis Self-Assessment Tool for Asians (OSTA) score, smoking status, family history of fracture, diabetes mellitus, physical inactivity, and T-score were considered. RESULTS: Of the 184 patients, 40.2% and 29.9% have osteopenia and osteoporosis. Sixteen (21.6%) and 18 (32.1%) osteopenic and osteoporotic men have fragility hip, spine, or forearm fractures. Men aged 50 to 69 years have the same risk of osteoporosis and fractures as those ≥70 years. While hip fractures are higher in osteoporotic men, vertebral fractures are increased in both osteopenic and osteoporotic men. Mere osteopenia predicts the presence of prevalent fractures. A high risk OSTA score can predict fracture. A BMI <21 kg/m2 (P<0.05) and current smoking are associated with osteoporosis. CONCLUSION: A significant fraction of Filipino men with osteopenia and osteoporosis have prevalent fractures. Our data suggest that fractures occur in men <70 years even before osteoporosis sets in. Low BMI, high OSTA score, and smoking are significant risk factors of osteoporosis.
Adult* ; Asian Continental Ancestry Group ; Body Weight ; Bone Density* ; Bone Diseases, Metabolic ; Cross-Sectional Studies ; Diabetes Mellitus ; Forearm ; Hip ; Hip Fractures ; Humans ; Male ; Mortality ; Multiple Endocrine Neoplasia Type 1 ; Osteoporosis* ; Risk Factors ; Self-Assessment ; Smoke ; Smoking ; Spine ; Tertiary Care Centers*

Introduction: Postprandial lipemia represent an important risk factor for lifetime development of cardiovascular disease in patients with type 2 diabetes mellitus. Daily administration alone or combined statin and fi brate therapy has been shown to be an effective therapeutic approach but brings about serious logistics problem in our local setting. To address this concern, we report this observation where alternate day statin and fi brate treatment given alone or in combination in type 2 diabetes mellitus and similar effectiveness in lowering postprandial dyslipidemia has been obtained. Methodology: This is a retrospective case study in an endocrine clinic involving 53 patients seen from April 2014 to October 2015. The patients were on statin and fi brate combination (atorvastatin 20- 40mg and gemfi brozil 300-600 mg or fenofi brate 145-160mg), statin alone (atorvastatin 20-40mg) and fi brate alone (gemfi brozil 300-600mg/fenofi - brate 145-160mg) given on alternate days. Percent reductions of cholesterol, triglycerides, LDL for combined statin and fi brate; cholesterol and LDL for atorvastatin alone; and triglyceride for fi brate alone were determined. Results: In this preliminary report, 26 patients have available data. Follow-up period range was 4 to 48 weeks (mean 22.76+ 11.8 weeks). Alternate statin and fi brate (gemfi brozil) treatment yielded percent reductions from baseline as follows: cholesterol 7%, triglycerides 15%, and LDL 37% (P values= 0.02, 0.10 and 0.019, respectively). On the other hand, alternate statin and fi brate (fenofi brate) yielded percent reduction from baseline as follows: cholesterol 41% and LDL 20.4% (P=0.15 and 0.13, respectively). The population is small, the decrease did not yield signifi cant difference from baseline, however there is a tendency for triglyceride to decrease (P=0.09) with the combined statin and fenofi brate. With statin alone the percent reduction from baselinewere as follows: cholesterol 39% and LDL 62% (P= 0.29 and 0.11, respectively). No percent reduction of triglyceride is seen with fi brate given on alternate day with P= 0.19 The monthly cost reduction with combined alternate statin and fi brate treatment is at 34-48% while alternate day administration of the statin reduced cost by 60%. Conclusion This study showed lowering of postprandial total cholesterol, triglyceride and LDL with alternate statin and fi brate treatment, and total cholesterol and LDL with alternate day statin. The cost of treatment was also signifi cantly lowered with the alternate regimen. However, a follow through study with adequate sample size is recommended to support these observations.
Hydroxymethylglutaryl-CoA Reductase Inhibitors

Background: The high prevalence of type 2 diabetes mellitus (T2DM) in the Philippines has burdened the health care system. Therefore, we compared the standard of care Insulin 30/70 + Insulin Glulisine (Arm B) to a traditional insulin regimen NPH Insulin + Regular Insulin (Arm A) to test the concept that both insulin regimens provide comparable effectiveness and safety in real-world practice. Methods : This is a ‘proof-of-concept,’ prospective, randomized, open label pragmatic study of 40 consecutive Filipino T2DM patients from October 2015 to June 2016. The primary endpoint was a reduction in HbA1c at 12 weeks. The secondary endpoints were changes in Fasting Plasma Glucose (FPG), Post Prandial Glucose (PPG), Capillary Blood Sugar (CBS), weight and insulin dose at 12 weeks. ANCOVA and Fisher’s exact tests were used. Results : Patients in treatment arm A showed comparable glycemic control to arm B as measured by reductions in HbA1c (2.89% vs. 2.67%; P = 0.657), FPG (65.94 vs. 46.71 mg/dl; P = 0.57), PPG (76.49 vs. 86.96 mg/dl; P = 0.271) and CBS (115.15 vs. 145.95 mg/dl; P = 0.420). Both treatment arms reported similar weight gain (1.92 vs. 1.22 kg), experienced similar incidence of hypoglycemia (7 vs. 6 patients) and adverse events (AE) (8 vs. 8 patients). Conclusion The traditional combination of NPH Insulin + Regular Insulin offers comparable glycemic control and tolerance as the standard of care without any new safety signals in the Filipino T2DM population. With a lower price, it can be one of the strategies to reduce the fi nancial burden of antidiabetic treatment.
Insulin, Isophane ; Insulin ; Diabetes Mellitus, Type 2

Osteoporosis is a major public health concern leading to significant morbidity and mortality, especially in the elderly population. However, this disease is underdiagnosed and, as a result, undertreated. This cross-sectional study aims to determine the knowledge, attitudes and practices (KAP) of physicians in the diagnosis and management of osteoporosis, which would help identify key areas of improvement in the care of patients with this disease. One hundred and nine physicians answered an online questionnaire looking at their KAP on the diagnosis and management of osteoporosis, and their answers were analyzed using descriptive statistics, Pearson’s correlation and the Chi-square test. More than half of the participants obtained satisfactory scores on knowledge, and majority had neutral to positive attitude regarding osteoporosis. A statistically significant correlation was seen between having low knowledge and negative attitudes on osteoporosis screening and management.

Purpose: To connect didactic learning to clinical application is a challenging task both for the teachers and students. Target-Oriented Clinical Skill Enhancement (TOCSE) is a teaching and learning tool that integrates basic medical sciences at the clinical level. The authors sought to determine if TOCSE is effective in bridging didactic knowledge to clinical skill and enhancing the clinical performance of fourth year medical students.

Method: Between March 2021 and June 2021, in an online platform, the authors randomly allocated 141 fourth year medical students into the experimental (n=12 groups; n=63) and control groups (n=12 groups; n=78). Participants in the experimental group underwent the TOCSE module workshop while the control group utilized the standard method of teaching. The actively teaching faculty staff blinded of group allocation were invited to assess case presentations using a standardized rubric. A survey was done by the students (experimental and control) to evaluate how they perceived TOCSE to their performance and learning. Independent parametric t-test was performed to compare the clinical skill scores between the two groups.

Results: The experimental group had a mean clinical skill score of 35.29 (SD=2.64, excellent) while the control group had a mean clinical skill score of 31.96 (SD=4.04, satisfactory). The between-group comparisons using independent t-test indicated that the mean difference of -3.33 clinical skills scores between the experimental and control groups was statistically significant (t=-2.39, p=0.026, 95% CI=-6.22 to -0.45). Moreover, the perceived usefulness score (scale 10 as highest) among the TOCSE presenters (experimental groups) was 8.43 (SD=0.84) and scores among the TOCSE audience (control groups) was comparable at 8.36 (SD=0.71), both of which were interpreted as very helpful.

Conclusion: TOCSE is effective in bridging didactic knowledge to clinical skill and enhancing clinical performance of fourth year medical students.

Clinical Competence ; Refractive Surgical Procedures

INTRODUCTION: Pre-impaired  glucose  tolerance  (pre-IGT) or  compensated  hyperinsulinemia,  is  defined  as  normal glucose,  and  elevated  insulin  two  hours  after  a  75-gram oral glucose load.  It is characteristic of the early stages of diabetes  mellitus  (DM),  where  beta  cells  compensate  for  insulin resistance by increasing insulin secretion to maintain normoglycemia. With  continuing  beta  cell  failure,  insulin  secretion  eventually  fails,  leading  to  the  progression  to diabetes.    Nonalcoholic  fatty  liver  disease  (NAFLD),  a common feature of insulin resistance, is found in 50-75% and 42-55% of DM and pre-diabetes patients. We determined if
NAFLD was present in patients with pre-IGT.
METHOD: A study on the determination of NAFLD - diagnosed by liver ultrasound in pre-IGT patients at a university hospital.Descriptive statistics, Chi square test of independence, 2x2 Fischer  Exact  test,  Z  test  of  difference  in  proportion, were used  for  statistical  analysis  with  a  p-value  set  at  0.05?.IBMSPSS ver 21 was used as software.
RESULTS:The mean age of 22 patients was 29.95 years, with average BMI of 25.73 kg/m2;77.3% were female.  Average lipid  panels  were  within  optimal  limits;  kidney  and  liver functions were normal.  The mean insulin level was 58.36 uIU/mL. NAFLD was identified in eight of the subjects.
CONCLUSION: Although  pre-IGT  is  a  subclinical  phase  in  the  diabetes  spectrum,  36%  already  have  NAFLD.This prevalence  was  lower  compared  to  diabetics  and  pre-diabetics, but higher compared to the general population.There was a noticeable trend of increasing insulin levels with increasing severity of fatty liver.

Human ; Male ; Female ; Aged ; Middle Aged ; Adult ; Glucose Intolerance ; Insulin Resistance ; Non-alcoholic Fatty Liver Disease ; Hyperinsulinism ; Prediabetic State ; Insulin-secreting Cells ; Insulins ; Glucose ; Lipids