BACKGROUND

Non-Alcoholic Fatty Liver Disease (NAFLD) is common in Type 2 Diabetes Mellitus (T2DM). The FIB-4 index is one of the most-studied non-invasive biomarkers that combines age and laboratory parameters (platelet count, alanine-and aspartate- aminotransferase) to evaluate underlying hepatic fibrosis. This study aims to determine the diagnostic value of Fibrosis-4 (FIB-4) index scoring in screening for non-alcoholic fatty liver disease in patients with type 2 diabetes mellitus, which is a high-risk population in development of advance fibrosis.

METHODOLOGY

A single center, analytical cross-sectional study was conducted among adult T2DM patients with and without NAFLD seen at the Out-Patient Department (OPD) and those with NAFLD enrolled under the Liver Disease Databank of the Liver Disease and Transplant Center in collaboration with Research and Biotechnology Division at St. Luke’s Medical Center, Quezon City. Medical history was obtained by reviewing charts of eligible patients using data collection form. Liver ultrasound was used as the reference standard in the diagnosis of NAFLD. The FIB-4 index was calculated with this formula: age (years) x AST (U/L)/(platelets (10^9/L) x ALT (U/L)^1/2.

RESULTS

A total of 305 adult patients with type 2 diabetes mellitus were included in the study. The prevalence of non-alcoholic fatty liver disease based on ultrasound among diabetic patients is 76.07%. The median age (p = 0.0204), AST (p < 0.00001), ALT (p < 0.00001) were significantly higher in patients with NAFLD than those without. Platelet count (p = 0.0002) was significantly lower in patients with NAFLD than those without. The proportion of patients with low platelet count, high AST and high ALT were significantly higher in patients with NALFD than those without. In this study, the FIB-4 index cutoff score for screening of NAFLD is ≥0.76, which has an accuracy of 66.23%, sensitivity of 75%, specificity of 38.3%, PPV of 79.46% and NPV of 32.56% in detecting fatty liver.

CONCLUSION

A FIB-4 index value of ≥0.76 has an acceptable sensitivity for screening NAFLD even in the absence of fibrosis among patients with T2DM. However, due to its low specificity, additional tests to establish NAFLD diagnosis may be required.

Human ; Diabetes Mellitus ; Non-alcoholic Fatty Liver Disease ; Fibrosis

BACKGROUND

Non-alcoholic fatty liver disease (NAFLD) is prevalent in patients with Type 2 Diabetes Mellitus (T2DM) and is associated with chronic kidney disease (CKD). The aim of this cross-sectional study was to determine the association of Fibrosis-4 (FIB-4) index with CKD among T2DM patients with concomitant NAFLD.

METHODOLOGY

A single center, analytical cross-sectional study was conducted among 216 T2DM patients with concomitant NAFLD. Clinical data were obtained via retrospective review of medical charts. The outcome of interest was CKD which was based on self-report obtained from medical charts or estimated Glomerular Filtration Rate (eGFR)RESULTS

Higher FIB-4 index was found to be significantly associated with CKD. Patients with FIB-4 index of 1.45-3.25 (moderate risk) and >3.25 (high risk) have about 3 times higher odds of CKD. However, after controlling for the significant confounders, only those who belong to high-risk group was found to be associated with CKD.

CONCLUSION

This study has demonstrated that FIB4 index > 3.25, an index of liver fibrosis, is significantly associated with development of CKD in T2DM patients with concomitant NAFLD.

Human ; Diabetes Mellitus ; Non-alcoholic Fatty Liver Disease ; Chronic Kidney Diseases ; Renal Insufficiency, Chronic

Background and Objectives: Malnutrition is prevalent both at baseline admission and because of hospitalization. It is aggravated by adverse hospital practices and results in poor outcomes, reduced quality of life, and higher treatment costs. Improving quality of care involves nutritional intervention as a low-risk, cost-effective strategy which guides providers in improving practices systems-wise. This study aims to assess the quality of nutritional care and the nutritional status of critically- ill patients admitted in a low-resource setting.

Materials and Methods: This is a mixed methods study among adults admitted in intensive care units (ICUs) of a tertiary government hospital. Anthropometric and biochemical indicators were obtained through chart review. The degree of malnutrition was assessed using the Subjective Global Assessment. Quality indicators under Donabedian domains were assessed and compared to current standards. The length of ICU stay and mortality rate were recorded. Dietary prescription and provision practices of healthcare providers were supplemented by a focus group discussion (FGD). Factors causing provision interruptions were also identified.

Results and Discussion: Sixty-four ICU admissions were included. Staff-to-patient ratio was not ideal. Under process-related factors, out of 49% with actual anthropometric documentations (rest were estimates), 24% had normal body mass indices (BMI), 17% were underweight, and the rest were either overweight or obese. The baseline ICU malnutrition rate was 69%. Malnutrition screening, and assessment of risk and biochemical indicators were not done routinely. Majority (92%) had baseline dietary prescription but only 69% had specific energy and macronutrient breakdown, all done through predictive weight-based equations. Nutritional supplies arrived within 8 hours in 65% of patients. Feeding was initiated within 24-28 hours in 94% of patients. Commercial formula was the preferred type of enteral nutrition (EN). Total duration on nothing-by-mouth (NPO) (hours) throughout ICU stay was significant. Supportive measures to improve gastro-intestinal (GI) tolerance were not standardized. Common factors in delaying feeding initiation were hemodynamic instability, fasting for procedures and GI bleeding. Throughout the ICU stay, fasting for procedures, hemodynamic instability and mechanical ventilation (MV)-related factors were common. ICU mortality rate was 19% and average length of ICU stay was 5 days.

Conclusion: Malnutrition is still prevalent in our ICUs and is affected by suboptimal healthcare practices. Staff - to-patient ratios, malnutrition risk screening and assessment, dietary referrals, documentation and minimizing interruptions in nutritional care provision needs improvement. A system review and establishment of a nutrition team is imperative.

Malnutrition ; Nutrition Assessment ; Quality of Health Care

Sheehan’s syndrome is characterized by hypopituitarism following ischemic necrosis of the pituitary gland caused by postpartum hemorrhage and impaired blood supply to the enlarged pituitary gland during pregnancy. The worldwide prevalence has since decreased due to improvements in obstetric care. Behavioral change is a rare presentation and is often misdiagnosed and managed as psychosis. We report a 42-year-old woman presenting with behavioral changes associated with postpartum failure of lactation and amenorrhea. Hormonal work-up revealed panhypopituitarism; serum cortisol, 98.93 (NV: 138–690 nmol/L); free T4, less than 5.15 (NV: 11.5–23.00 pmol/L); free T3, less than 2.30 (NV: 2.89–4.88 pmol/L); FSH, 3.63 (NV: 30–135 mIU/mL); LH, 3.88 (NV: 13–80 mIU/mL); serum estradiol, 3.89 (NV: 10.41–35.0 pg/mL); IGF-1, 13.13 (NV: 56–194 ng/mL); and serum prolactin, 1.8 (NV: 2.6–24.8 ng/mL). Cranial MRI with contrast revealed an atrophic pituitary gland consistent with Sheehan's syndrome. The symptoms improved substantially upon replacement with steroids and thyroid hormones and she was able to resume her routine activities. The psychiatric features of hypopituitarism can be attributed to a combination of hypothyroidism, hypoglycemia, and hypocortisolism and have been shown to reverse with adequate hormone replacement.
Hypopituitarism ; Psychotic Disorders ; Hypopituitarism

INTRODUCTION: Diabetes mellitus is rapidly increasing worldwide but the greatest increase is expected in developing countries including the Philippines. It is of public health concern to monitor countrywide prevalence of diabetes as it leads to significant cardiovascular-related mortality as well as significant complications such end stage renal disease, blindness, lower leg amputations and blindness.
METHODOLOGY: This is a national survey to estimate the prevalence of diabetes and pre-diabetes using the criteria of the World Health Organization through a stratified multi-stage sampling design representing each of the 17 regions in the country.
RESULTS AND DISCUSSION: The national prevalence of diabetes in the year 2008 was 7.2% (6.5-7.9); impaired glucose tolerance 7.0% (6.1-7.8) and impaired fasting glucose was 2.2% (2.2-3.1). There was a greater prevalence of individuals with diabetes in the urban areas at 8.5% (7.5-9.5) compared to the rural areas at 5.7% (4.6-6.8). Diabetes is slightly more preponderant among females at 7.4% (6.4-8.3) compared to males at 7.0% (6.1-8.0).
CONCLUSION: The prevalence of diabetes mellitus in the Philippines is rising with the prevalence in 2008 at 7.2%. The prevalence of pre-diabetes exceeds that of diabetes mellitus at approximately 10.2%.

Human ; Male ; Female ; Aged ; Middle Aged ; Adult ; Glucose Intolerance ; Fasting ; Prediabetic State ; Diabetes Mellitus ; Amputation ; Kidney Failure, Chronic ; Blindness ; Glucose

BACKGROUND:The national prevalence of goiters in the Philippines was 3.7% in 1987 and 6.7% in 1993. Since then, there has been no follow-up survey on goiter prevalence, nor has there been any national survey on the prevalence of abnormal thyroid dysfunction. The PhilTiDeS is a survey on the prevalence of both goiters and thyroid disorders in the Philippines.
OBJECTIVES:To determine the prevalence of various categories of abnormal thyroid dysfunction among the Filipino non-pregnant adult population and to describe the prevalence of thyroid enlargement in the Philippines in relation to thyroid dysfunction status.
MATERIALS AND METHODS:The PhilTiDes was a substudy of the 2008 National Nutrition and Health Survey (NNHeS), which covered all 17 regions and 80 provinces of the Philippines. It included all Filipino adults 20 years and older, who are non-pregnant and non-lactating. A standard questionnaire was used to collect data on previous diagnosis and current treatment for thyroid disorders, and neck examination by trained field personnel was done to assess the presence of goiter. Blood was extracted, processed and sent to an accredited laboratory for free T4 and TSH testing using micro-particle enzyme immunoassay.
RESULTS: A total of 4897 persons had thyroid function tests. Of these, 417 (8.53%) had thyroid function abnormalities with the most common abnormality being subclinical hyperthyroidism occurring in 5.33%. The other categories had the following prevalence: true hyperthyroidism 0.61% ; true hypothyroidism 0.41%; and subclinical hypothyroidism 2.18%. Majority of the population 4480 (91.47%) had normal thyroid function tests. Of those with subclinical hyperthyroidism, 55% are females with mean age of 48 years (95% CI 45.9-50.1 years) compared with the volunteers with normal thyroid function who were younger (mean age of 43.1, 95% CI 42.5-43.6 years). Out of the 7,227 volunteers who responded to the survey and clinical examination, a total of 674 (8.9%) had goiters. Out of the 674 subjects with goiters, 379 had diffuse enlargement (56%) while the rest had nodular goiter (44%). Among the sub-population (n= 4897) who underwent thyroid function testing, 9% of those with normal thyroid function tests have goiters.
CONCLUSION: The prevalence of thyroid function abnormalities in the Philippines is 8.53% with the greatest proportion of volunteers having subclinical thyroid disease. There is a low prevalence of both true or overt hyperthyroidism and hypothyroidism. In the larger survey, it was found that 8.9% of volunteers who were examined had goiters. The etiology of these goiters will need to be ascertained in future studies.

Human ; Male ; Female ; Middle Aged ; Adult ; Goiter, Nodular ; Health Surveys ; Hyperthyroidism ; Hypothyroidism ; Immunoenzyme Techniques ; Philippines ; Prevalence ; Thyroid Diseases ; Thyroid Function Tests ; Volunteers

OBJECTIVE: To determine the prevalence of menstrual and reproductive dysfunction among subjects who have undergone radioiodine treatment for thyroid carcinoma.
METHODOLOGY: This study enrolled adult women with Differentiated Thyroid Carcinoma who received the treatment at age 40 years and below. Data was processed using SAS program and evaluated using Fischer's test and Wilcoxon test.
RESULTS: The study enrolled 46 women. Three reported cycle irregularities, 4 reported changes in amount of bleeding and 1 had amenorrhea. The prevalence rate of menstrual abnormalities was 15.2%. These women received a significantly higher dose of radioactive iodine (RAI) (120 vs. 110 mCi, p = 0.0064). Eleven women tried to conceive and there were 5 births to 5 different subjects after radiation. There were no congenital anomalies and 1 miscarriage. Four women were menopausal with an average age of 44.4 years old.
CONCLUSION: This study showed that the prevalence of menstrual disturbances after high dose radioactive iodine treatment among thyroid cancer patients is 15.2%. The affected group received a significantly higher dose of radioactive iodine compared to the unaffected group.

Human ; Female ; Adult ; Abortion, Spontaneous ; Amenorrhea ; Iodine ; Iodine Radioisotopes ; Menopause ; Menstruation Disturbances ; Prevalence ; Radiation ; Thyroid Neoplasms

Objective. Previous studies have demonstrated the role of genetic susceptibility in the pathogenesis of diabetic nephropathy. The study aimed to determine the frequencies of angiotensin I-converting enzyme (ACE) gene insertion/deletion (I/D) polymorphism in a pilot population of Filipino type 2 diabetic patients and normal controls. Methods. An analysis of the ACE gene polymorphism was performed in 42 diabetic patients with and without nephropathy, and 24 normal controls. The analysis was done using polymerase chain reaction, restriction enzyme digestion, and gel electrophoresis techniques to determine the polymorphism (II, DD or ID). Independent T-tests and chi-square tests were used to compare clinical characteristics, and logistic regression analysis was done to determine odds ratio for development of nephropathy. Results. The ID polymorphism of the ACE gene was more frequent (52.4%) in patients with diabetic nephropathy (n=21). In those without nephropathy (n=21), II was more common (61.9%). ID was the more frequent genotype in the normal controls (n=24) (58.3%). The odds of developing diabetic nephropathy were increased by 4.8 times in those with ID polymorphism, and 2.9 times in those with DD. Conclusion. The D allele was more common in patients with diabetic nephropathy, similar to the observation in South Indian patients. Since the study involved only a small pilot group, studies on a larger population is needed to establish the hypothesized role of the D allele in susceptibility to diabetic nephropathy in Filipinos.

Human ; Alleles ; Diabetes Mellitus, Type 2 ; Diabetic Nephropathies ; Electrophoresis ; Genetic Predisposition To Disease ; Genotype ; Indel Mutation ; Mutagenesis, Insertional ; Peptidyl-dipeptidase A ; ; Mesh Browser: Polymerase Chain Reaction Polymerase Chain Reaction ; Mesh Browser: Polymorphism, Genetic Polymorphism, Genetic

Tuberculosis (TB) of the thyroid gland is rare, with acute abscess formation being the least common form of presentation. As such, TB of the thyroid may be overlooked as an initial clinical impression. A careful approach by history, physical examination, laboratory testing and radiologic imaging may aid in defining the etiology of the thyroid abscess, but these remain nonspecific. An accurate diagnosis may only be made by histologic examination. We present a case of a tuberculous abscess of the thyroid gland in a 37-year-old female. TB of the thyroid should also be considered when evaluating patients presenting with a painful thyroid nodule.

Human ; Female ; Adult ; Abscess ; Physical Examination ; Thyroid Nodule ; Tuberculosis ; Viscera ; Thyroid Nodule

BACKGROUND: Secondary hyperparathyroidism (SHPT) can lead to significant morbidity, mortality, and additional healthcare resource ut i l i zat ion in chronic k idney disease. Baseline prevalence data is highly required. This study aims to determine the prevalence of secondary hyperparathyroidi sm (SPTH) in pat ient s wi th Type 2 diabetes undergoing hemodialysis.
MATERIALS AND METHODS: We reviewed all medical records of patients whose chronic kidney disease (CKD) was due to Type 2 diabetes mellitus and are undergoing chronic hemodialysis from 2000 to 2009. Excluded were those who underwent hemodialysis due to acute renal failure or for chronic renal failure due to other causes other than diabetic nephropathy (e.g. hypertensive nephropathy, chronic glomerulonephritis, etc). Data collected include age, sex, body mass index, bone markers, intact PTH, and urea reduction rate.
RESULTS: The age and sex adjusted period prevalence of secondary hyperparathyroidism was 28.9%, commonly seen in the 5th to the 6th decade of life. Patients with SPTH had higher serum intact PTH, higher total calcium level (mean 9.05 versus 8.6, p=.026) and a higher urea reduction rate (mean 54.1 versus 45.2, p=.045). There was a longer duration of hemodialysis sessions among those with secondary hyperparathyroidism (mean 2.4 years versus 1.78 years, p=.004). Dialysis was likewise more adequate.
CONCLUSION: Prolonged diabet ic kidney di sease is associated with secondary hyperparathyroidism for which a more aggressive monitoring of calcium and phosphorus imbalance is required.

Human ; Male ; Aged ; Middle Aged ; Acute Kidney Injury ; Diabetes Mellitus, Type 2 ; Diabetic Nephropathies ; Glomerulonephritis ; Hyperparathyroidism, Secondary ; Hypertension, Renal ; Kidney Failure, Chronic ; Nephritis ; Prevalence ; Renal Dialysis ; Urea