S3.1 MAGNITUDE OF CHILDHOOD DIABETES IN TRIPOLI MEDICAL CENTER, TRIPOLI, THE HOSPITALIZATION PATTERN OF PATIENTS WITH DIABETES IN ABU DHABI, UNITED ARAB …
Libyan Journal of Medicine, volume 2, Supplement 2 The Fifth Libyan Diabetes and Endocrinology Conference
Libyan J Med, AOP: 070525
Edited by: Salem A Beshyah, PhD FRCP Senior Consultant Endocrinologist, Sheikh Khalifa Medical City, Abu Dhabi, UAE
Contents:
PL1: Key Note Address: DIABETES IN THE ARAB WORLD: SIZE OF THE PROBLEM AND PUBLIC HEALTH CONSEQUENCES By Abdulfattah Lakhdar PL2 DIAGNOSIS AND MEDICAL TREATMENT OF PITUITARY TUMOURS By Salah E GERRYO PL3 STANDARDS OF MEDICAL CARE IN DIABETES By Mohsen ELEDRISI SA1 INSULIN PUMP THERAPY: THE EVIDENCE BASE AND CLINICAL PRACTICE By Mahmoud BENBARKA
SA2 DIABETIC EYE DISEASE: BEST PRACTICE IN SCREENING AND MANAGEMENT FOR 2007 By Salwa M Abugreen SA3 SUBCLINICAL THYROID DISEASE By Ahmed SWALEM ML1 The Ibn-Sina Medal Lecture 2007: DIABETES IN BENGHAZI: ACHIEVEMENTS AND CHALLENGES By Othman Kadiki ML2 Mohamed Al-Fitouri Medal Lecture 2007: DIABETIC NEUROPATHY: TIMELY RECOGNITION AND EFFECTIVE MANAGEMENT By Tarek M FIAD ML3 Dr Makkram Addawi Memorial Lecture: EVIDENCE-BASED MANAGEMENT OF THYROID NODULES By Fellani MOHAMED ML4 The LSDE Inaugural Lecture: METABOLIC COMPLICATIONS OF HIV INFECTION ON ANTIRETROVIRAL TREATMENT By Hisham
M ZIGLAM S11HYPERTENSION IN DIABETES: DRUGS AND TARGETS By Hawa Juma el Sherief S12 LIPID LOWERING IN DIABETES By Ali EL-HOUNI S13 DIABETES AND STROKE By Ibrahim M TREKI S14 HYPERBARIC OXYGEN THERAPY IN DIABETIC FOOT CARE By Issam M HAJJAJ S21 MEDICAL COMPLICATIONS OF OBESITY IN ADULTS By Salem BESHYAH and Ibrahim H A SHERIF S22 THERAPEUTIC LIFE STYLE MODIFICATION FOR OBESITY By Soad BOSSERI S23 USE OF ANTI-OBESITY DRUGS WITH SPECIAL REFERENCE TO DIABETES By Amna Ali SALHIN S24 SURGERY FOR SEVERELY MORBID OBESITY: AN OVERVIEW FOR PHYSICIANS By Rajab KERWAT S31 MAGNITUDE OF CHILDHOOD DIABETES IN TRIPOLI MEDICAL CENTER, TRIPOLI, LIBYA 19962006 By Suliman ABUSREWIL, Nadia ELGAZIR, Mohamed KARESTA, A ELGERBI, Ibtisam
ELKHAZEMI, Hend ELKHAZEMI, Ibtisam HADEED, Haima TURKI, Mohamed HWEIDI, Souad MADDAH S32 MODERN MANAGEMENT OF TYPE 1 DIABETES IN CHILDREN: AN OVERVIEW By Ahmed Sasi SHAMEKH S4 MOLECULAR BASIS AND CLINICAL IMPLICATIONS IN GENDER DIFFERENTIATION DISORDERS By Asma Deeb S35 SURGICAL ASPECTS OF AMBIGUOUS GENITALIA: REFLECTIONS ON THE TRIPOLI MEDICAL CENTRE EXPERIENCE By Bashir GHARMOOL WS1 Management of type 2 diabetes in 2007 WS11 ORAL ANTI-DIABETIC
DRUGS: WHICH ONE FOR WHOM? By Ahmed SWALEM WS12 PRACTICAL INSULIN THERAPY By Mahmoud BENBARKA WS21 MANAGEMENT OF DIABETES IN THE HOSPITALIZED PATIENT PARTICULARY IN THE PERIOPERATIVE PEROID By Amna SALHIN WS22 MANAGEMENT OF DIABETES IN THE INTENSIVE CARE SETTINGS By Abdulfattah Lakhdar WS23 GLYCOMETABOLIC STATE AT ADMISSION: IMPORTANT RISK MARKER OF MORTALITY IN PATIENTS WITH DIABETES MELLITUS AND ACUTE MYOCARDIAL INFARCTION By Kamal ABOUGLILA WS24 ROLE OF NEWER ANTI-MICROBIAL AGENTS IN SKIN AND SOFT TISSUE INFECTIONS IN DIABETES By Hisham M Ziglam OC1 AUDIT OF THE MANAGEMENT OF TYPE 1 DIABETES MELLITUS IN TRIPOLI CHILDRENS HOSPITAL 2000-2004 By Faten BEN RAJAB, Omran ZWIED, Amel AL-SHEPAAN and Enaas ERUK OC2 CLINICAL AND BIOCHEMICAL CHARACTERISTICS OF POLYCYSTIC OVARY SYNDROME IN BENGHAZI- LIBYA By Fatma I NAJEM, Rafik R ELMAHDAWEI and Ahmed M SWALEM OC3: PESCRIBING PATTERNS OF ANTIHYPERTENSIVE AGENTS IN HOSPITALIZED DIABETIC PATIENTS IN TRIPOLI, LIBYA By Aisha LAZREG, Salem ELHABROUSH and Musbah AGIL OC4 THYROID CANCER IN NORTH EASTERN LIBYA By Ahmed M Swalem, F M Bugrara M A Bumdas OC5 TYPE 2 DIABETES IN CHILDREN AND ADOLESCENTS IN TRIPOLI, LIBYA By Ibtisam HADEED,
Mohamed HWEIDI, Maha EL SHERIF, Milad DOUGHA and Suliman S ABUSREWIL OC6 ALLGROVE SYNDROME TRIPLE A SYNDROME ADDISON, ACHALASIA, ALACRIMA IN LIBYA By Om Almir ALGADAFI, Abulgasem EL-GERBI, Mohamed KRAESTA, Nuri MUJBER, Ibtisam HADEED and Suliman S ABUSREWIL P1 NEONATAL HYPERCALCAEMIA DUE TO PRIMARY HYPERPARATHYRODISM IN A FOURMONTH-OLD LIBYAN GIRL: CASE REPORT AND REVIEW OF THE LITERATURE By Faten BEN RAJAB, Zienab HASHISHI and Eman MESLATI P2: WITHDRAWN P3 POST KIDNEY TRANSPLANT DIABETES MELLITUS PTDM AMONG FOLLOW UP PATIENTS BENGHAZI, LIBYA By Amal M SHERMADDO and Fairouz M SHERMADDO
P4 CHARACTERISTICS AND OUTCOME OF DIABETIC PATIENTS ADMITTED WITH ACUTE MYOCARDIAL INFARCTION IN BENGHAZI, LIBYA By Abdulwahab M ALBARSHA, Ali M ELNEIHOUM and Abdulghani W ELTURKI
P5 THE INFANT OF DIABETIC MOTHERS IN TRIPOLI MEDICAL CENTER By Malak ELAZRAG, Zeinab ESHKURFO, Faiza OSMAN, M Khaled SHAMBESH and Suliman ABUSREWIL P6 ACCURACY OF FINE-NEEDLE ASPIRATION BIOPSY OF THYROID NODULES COMBINED WITH AN EVALUATION OF CLINICAL AND ULTRASONOGRAPHIC CHARACTERISTICS By Dheba Alamari OHEBA and Ibrahim H SHERIF
P7 PITUITARY AND OTHER INTRASELLAR TUMOURS IN TRIPOLI LIBYA: A STUDY OF AN
ENDOCRINE CLINIC POPULATION 1982-2004 By Dheba Alamari OHEBA, Laila SEBAII, Najwa RHAYM and Ibrahim H SHERIF
P8 PATTERN OF PITUITARY ADENOMA IN BENGHAZI, LIBYA By Rafik R ELMEHDAWI, A A AZIZ and Ahmed M SWALEM P9 THE HOSPITALIZATION PATTERN OF PATIENTS WITH DIABETES IN ABU DHABI, UNITED ARAB EMIRATES 2000-2006 By Salem A BESHYAH and Mahmoud M BENBARKA
PL1 DIABETES IN THE ARAB WORLD: SIZE OF THE PROBLEM AND PUBLIC HEALTH CONSEQUENCES Abdulfattah Lakhdar, Department of Diabetes Endocrinology, Whipps Cross University Hospital London, UK abdullakhdar@hotmailcom Diabetes has become one of the most common chronic diseases in the Arab region Prevalence rates of type 2 diabetes vary between 7 and 25 in the adult population Type 2 diabetes in younger age groups is also becoming more common People are presenting with Type 2 diabetes in their 20s and some even during adolescence and childhood Factors that have contributed to this increasing prevalence of diabetes in the Arab region might be explained by the significant social and economic changes the region has experienced Obesity is becoming more prevalent and people are becoming less active Furthermore, life expectancy in the region
has now increased, exceeding 65 years These factors are central as a cause of the current epidemic of Type 2 diabetes Diabetes in Arab countries accounts for a high mortality and morbidity rate as a result of its chronic complications Type 2 diabetes is the leading cause of ischaemic heart disease, end-stage renal disease and is likely the leading cause of blindness in the Arab world However, data on chronic complications of diabetes in the Arab world is scarce, concealing the real burden of diabetes in this part of the world The prevalence of diabetes has clearly been influenced by the rapid social economic developments in the Arab region that influenced life changes, leading to a large increase in the prevalence of Type 2 diabetes Such a pattern is best highlighted in Saudi Arabia over the recent time In 1997, the prevalence of Type 2 diabetes in one of Riyadhs regions was 22 and in 1985 a report of the prevalence of Type 2 diabetes was 49 in urban Saudi Arabia However, in 1997, the National Chronic Metabolic Survey reported the prevalence of Type 2 diabetes to be 123 and IgT to be 119 Such a change is also true for most of the Arab region Especially, as Arab communities share
the same ethnic origin, diet, cultural habits and have undergone the same social and economic changes over recent times However, the most dramatic change has occurred in the Gulf countries Many studies highlighted the relationship between obesity and being associated with Type 2 diabetes Obesity in Arab countries is a growing medical problem affecting a large number of people, including children Urban populations and women are more susceptible to obesity Studies in Saudi Arabia have shown around 50 of women aged between 40 and 50 years in urban areas are obese in contrast to only 24 of males in rural areas affected One study has shown that the prevalence of obesity in Arab men in Palestine, as defined by a BMI over 30, to be around 40 and in the same study the prevalence of central obesity, as defined by waist:hip ratio to be even higher, present in 60 of men The rate of obesity among Arabic diabetic populations is also very high with around 60 of diabetic subjects being defined as obese Further studies demonstrated high rates of obesity in females with up to 80 of women found to be obese, as defined by BMI over 30 There are several reasons for the incidence of obesity in this
population A high consumption of carbohydrate rich foods is common As the wealth in this society has increased, the majority of households now have help maids encouraging a sedentary lifestyle, especially for females A significant link between obesity, physical inactivity and watching television for more than 15 hours a week, has been demonstrated in a cross sectional National Epidemiological Survey of Bahraini people Of note, the same study demonstrated a link between obesity and education, with an increase in the prevalence of obesity as the level of education increased This pattern may reflect a possible perception of obesity being a sign of affluence among Arab people Coronary heart disease has emerged as the leading cause of mortality over a 20 year period of rapid social economic developments in the Arab region Arab populations have similar traditional risks of developing diabetes and cardio-vascular disease Diabetes is a costly disease In most Arab countries, specialised Diabetes Centres are few and not easily accessible to the majority of patients Diabetes nurse educators uncommon and podiatrists are almost unknown in most areas Most countries, however, in the Arab world
have a national diabetes programme, raising the awareness of diabetes, increasing research and greater practical collaboration, to diabetic complications, diabetes economics and its prevention In some countries, the cost of caring for persons with diabetes is two to four times that of non-diabetic people in the healthcare system While recognising the need to intervene actively and quickly, most countries are struggling to contain the rising tide of Type 2 diabetes, adding to the severe resource constraints National frameworks are needed to address diabetes prevention and good health and quality of the life of individuals with diabetes as well as prevention of complications through effective care and education
Plenary Lectures: PL2 DIAGNOSIS AND MEDICAL TREATMENT OF PITUITARY TUMOURS Salah E GERRYO Department of Medicine, Faculty of Medicine, Garyunis University, Benghazi, Libya drsalah_g@hotmailcom Pituitary adenomas are common benign monoclonal tumours accounting for approximately 15 of intracranial tumours The mean prevalence of clinically important pituitary adenoma is 250 per million of population with prolactinomas accounting for approximately 40 of cases However, incidental
pituitary adenomas had been described with increased frequency paralleling wider use of advanced diagnostic imaging modalities The clinical manifestations are variable but include symptoms and signs of excessive hormone secretion by functioning adenoma, symptoms and signs of pituitary failure and central mass effect Diagnostic work should include a assessment for autonomous hormone hypersecretion using standard basal and dynamic test and applying accepted criteria b assessment of pituitary reserve c high quality imaging study generally MRI scan performed without and with Gadolinium contrast Successful treatment of pituitary adenomas requires integrated interdisciplinary strategies since the primary treatment for each adenoma type vary In patients with prolactinomas, medical therapy with dopamine agonists is highly effective in the majority of patients and considered the mainstay of therapy For patient with other types of adenomas surgery remains the primary therapy of choice However, medical treatment have either primary or adjuvant role in selected patients for control of hormone hypersecretion and tumour growth In acromegaly, therapy with somatostatin receptor ligands SRL leads
to tumour shrinkage and normalization of IGF-1 in 50 and 70 of patient respectively Pegvisomant, a growth hormone receptor antagonist is used mainly in acrogemalic patient with resistance to or intolerance of SRL and is effective in 90 of patients In ACTH secreting adenomas, medical treatment is used preoperatively and in patients with surgical failure Drugs that modulate ACTH release are effective in about 20 of patients whereas agents that inhibit steroidogenesis lead to normalization of cortisol secretion in 50-70 of patient Whatever the choice of initial and adjuvant treatment, follow up of all patients with pituitary adenomas should be maintained indefinitely PL3 STANDARDS OF MEDICAL CARE IN DIABETES Mohsen ELEDRISI, National Guard Medical City, Eastern Province, Kingdom of Saudi Arabia Eledrisi@yahoocom Diabetes is a chronic disease that is associated with acute and chronic complications leading to significant morbidity, mortality and increased economic costs Patients with diabetes are at an increased risk for vascular disease, including microvascular complications retinopathy, neuropathy, and nephropathy and macrovascular complications coronary heart disease, cerebrovascular
disease and peripheral vascular disease Diabetes care is complex and requires that many issues beyond glucose control be addressed including primary and secondary prevention of complications There is a large body of evidence to show that improved glycaemic control reduces the risk of microvascular disease among patients with diabetes and is associated with lower risk of atherosclerosis and macrovascular disease Besides glucose control, intensive management of blood pressure and cholesterol levels has been shown to improve health outcomes for patients with diabetes Appropriate diabetes care requires a physician-coordinated team for continuing medical care and patient self-management education; this necessitates a multidisciplinary approach with a patient-centered strategy Life style changes including regular exercise and medical nutrition therapy should be prescribed to all patients In general, the aim in glucose control is as close to normal as possible HbA1c 65 without significant hypoglycemia while targets for blood pressure and low-density lipoprotein LDL cholesterol are 130/80 mmHg and 100 mg/dl 26 mmol/L respectively Angiotensin-converting enzyme inhibitors and statins
have an important role in the care of many patients with diabetes Other aspects of diabetes care include the use of aspirin in most patients, regular ophthalmologic, dental and foot examination, and influenza and pneumococcal vaccination
State of the Art Lectures:
SA1 INSULIN PUMP THERAPY: THE EVIDENCE BASE AND CLINICAL PRACTICE Mahmoud BENBARKA, Endocrinology Division, Department of Medicine, Sheikh Khalifa Medical City, Abu Dhabi, UAE benmah@skmcgovae Insulin has been available for therapeutic use for more than 80 years and remains a powerful pharmacologic tool with nearly unlimited potential to lower plasma glucose levels in patients with diabetes Required essentially by all patients with type 1 diabetes and many patients with type 2 diabetes, insulin is capable of restoring near-normoglycaemia which is the primary treatment goal to forestall the onset and progression of long-term complications Attainment and maintenance of near-normal glycaemic control can be achieved with the use of insulin replacement strategies designed to simulate the physiologic, non-diabetic patterns of insulin secretion in response to 24hour fasting and postprandial glucose profiles Normal insulin
secretion consists of 2 major components: a basal secretion and a meal-related secretion The role of continuous low-level basal insulin secretion into the portal circulation is to modulate the rate of overnight hepatic glucose production and glucose output during prolonged periods between meals Meal-related insulin secretion controls the postprandial elevations of blood glucose levels The primary objective of insulin therapy is to replace the prevailing lack of insulin type 1 diabetes or progressive deficit of insulin type 2 diabetes in a physiologically sound manner, mimicking normal insulin secretion patterns Ideal insulin replacement therapy should be modeled with a combination of preparations capable of reproducing both the basal fasting and the prandial/postprandial normal secretion profile Unfortunately no combination of available insulin preparations possesses the characteristics necessary to simulate normal insulin secretion However, recent advances in insulin manufacturing technology have resulted in insulin analogues with properties that may significantly improve insulin replacement therapy Continuous subcutaneous insulin infusion CSII - [Insulin Pump Therapy] - via small
programmable pump devices stands as a viable alternative to multiple daily injection [MDI] strategies Infusion pumps can deliver short-acting insulin continuously at specific rates according to glucose patterns basal component Preprandial insulin doses at mealtime or in response to hyperglycemia are promptly delivered by the patient at the touch of a button according to blood glucose monitoring results, carbohydrate and caloric content of the upcoming meal, physical activity, and other factors bolus dose or prandial component This form of insulin replacement closely approximates the basal/bolus physiologic pattern of secretion Compared with MDI regimens, continuous subcutaneous infusions have shown to improve glycaemic control, reduce the risk of hypoglycaemia, and allow more flexibility The use of CSII strategy is clearly not suitable for all patients; it is expensive and requires a significant amount of patient education, motivation, and involvement to consistently monitor glycaemic status throughout the day to optimally manage insulin requirements Insulin pump therapy has a promising future Newer pump designs and the current availability of continuous glucose sensing will not
only stimulate more pump use but will offer the hope for development of a closed-loop artificial pancreas in the form of either an external or an implantable sensor, feeding back to an external or implantable pump Intensive diabetes management can be achieved in adults, adolescents, and children with use of CSII Compared with MDI, CSII has better insulin pharmacokinetics, less variability in insulin absorption, and decreased risk of hypoglycaemia; it also offers patients greater flexibility in lifestyle Careful adjustment of basal and bolus doses and close follow-up, including patient education, are vital to the success of CSII therapy SA2 DIABETIC EYE DISEASE: BEST PRACTICE IN SCREENING AND MANAGEMENT FOR 2007 Salwa M Abugreen, Department of Ophthalmology, East Lancashire Hospitals, UK
s_abugreen@hotmailcom
The incidence of diabetes worldwide is rising dramatically with the prevalence in developed countries estimated to increase from 6 to 8 by 2025 This presents a significant challenge to the general physician as well as the ophthalmologist both in terms of identifying and screening the large numbers of patients affected and then successfully identifying those who require
referral for the management of sight-threatening disease Screening for diabetic eye disease is cost-effective in that detection of retinopathy at a time when it is asymptomatic, followed by intervention, often leads to improved outcomes The management of diabetic eye disease is rapidly evolving, not
only due to advancements in vitreoretinal techniques but also extensive research into pharmacological methods attempting to either prevent the onset or halt the progression of diabetic retinopathy Evidence based treatment of diabetic eye disease includes the issues Firstly, Reducing the progression of retinopathy A number of large randomized controlled clinical trials have proven the benefit of good glycaemic, and blood pressure control as well as laser photocoagulation in slowing down the deterioration of retinopathy and maculopathy The control of lipids has been shown in observational studies to decrease the incidence of exudative maculopathy Secondly, Treatment of proliferative diabetic retinopathy After 20 years 60 of Type 1 diabetics and 20-30 of Type 2 might be expected to have developed proliferative retinopathy The Diabetic Retinopathy Study DRS showed that panretinal
photocoagulation PRP reduced the risk of severe visual loss by 50 in treated eyes and this remains the main treatment for many patients with proliferative disease Thirdly, treatment of diabetic maculopathy: After 15 years it is estimated that 20 of Type 1 diabetics and 25 Type 2 diabetics taking insulin and 14 Type 2 diabetics onto taking insulin will have maculopathy This can be classified into focal or diffuse types, where focal maculopathy is described as well circumscribed areas of retinal oedema, with or without exudates, often surrounding leaking microaneurysms Maculopathy may also be classified into ischaemic, non-ischaemic or mixed types Fluorescien angiography is extremely helpful in guiding laser treatment and documenting ischaemia especially when the oedema is diffuse SA3 SUBCLINICAL THYROID DISEASE Ahmed SWALEM, The Endocrine Unit, 7th October Hospital and Department of Medicine, University of Garyounis, Benghazi, Libya aswalem51@yahoocom Subclinical thyroid disease is a common clinical problem and is defined as an abnormal serum thyroid-stimulating hormone TSH level reference range : 045-45 uU/ml and free thyroxine and triiodothyronine FT4,FT3 levels within their
reference ranges There are many controversial issues regarding screening, evaluation, and management of subclinical thyroid disease The prevalence of subclinical hypothyroidism in general population is 4-10 and up to 20 -26 in women older than 60 years and 5 in women of reproductive age Causes of subclinical hypothyroidism include chronic autoimmune thyroid disease, radioactive iodine therapy, thyroidectomy, and antithyroid drugs In most cases there are no systemic manifestations but some individuals may have nonspecific symptoms such as fatigue and weight gain, as well as depressive feelings and mild cognitive disturbances Peripheral tissues function tests frequently indicate a lowered degree of thyroid hormone deficiency such as cardiac dysfunction and an increase in serum LDLcholestrole Although population screening for subclinical hypothyroidism has not been recommended unanimously because of insufficient evidence to support population based screening, expert panels of most professional societies have endorsed routine screening of men and women beginning at age 35 years and every 5 years , pregnant women, and individuals older than 60 years There is good evidence that
subclinical hypothyroidism is associated with progression to overt disease, particularly when thyroid antibodies are present There is no general agreement on treatment of subclinical hypothyroidism Many authorities recommend treatment of cases with a TSH level 10 uU/ml and against treatment when TSH is between 45- 10 uU/ml because of insufficient evidence of benefit There is only fair evidence to support an association between subclinical hypothyroidism and adverse outcome in pregnancy However most authorities recommend screening serum TSH levels in patients who are pregnant or who are planning to become pregnant and thyroxine treatment during pregnancy to maintain serum TSH levels within the normal reference range The prevalence of subclinical hyperthyroidism is 2 in general population and is caused by Graves disease in the majority of cases Other causes include multinodular goiter, autonomous toxic nodules, or exogenous levothyroxine Subclinical hyperthyroidism is associated with atrial fibrillation, reduced bone density, cardiac dysfunction, and progression to overt hyperthyroidism in patients with known thyroid disease There is little evidence that early treatment of cases
with complete suppression of TSH 010 uU/ml alters the clinical course of the disease, but no sufficient evidence to support treatment when TSH is partially suppressed 010- 045 uu/ml , instead they should be monitored and observed
Medal/Memorial/Special Lectures:
ML1 The Ibn-Sina Medal Lecture 2007: DIABETES IN BENGHAZI: ACHIEVEMENTS AND CHALLENGES Othman Kadiki, Benghazi Diabetes Clinic, Benghazi, Libya, E-mail: dr_kadiki@hotmailcom Prevalence data are based on a multistage cluster sample from Benghazi area using 75 g oral glucose tolerance test The sample included 314 men and 554 women The overall prevalence of IGT was 85 95 confidence interval CI 58-113 men 86 95 CI 77-96, women 8595 CI 50 119, and that of diabetes was 141 95 CI 109-171 men: 163 95 CI 145-183; women: 130 95 CI 100-161 Diabetes was present in 194 95 CI 154-205 men 227 95 CI 202254, women 176 95 CI 141-191 in 30-64 years age range Prevalence of diabetes was slightly higher in urban than in rural areas 145 vs 135 The prevalence of newly diagnosed diabetes in urban and rural areas was 36 and 73 respectively and that of known diabetes were 109 and 63 respectively Associated risk factors with diabetes and IGT were
age, family history of diabetes, hypertension, BMI, WHR and serum cholesterol Incidence data of Type 2 diabetes are based on analysis of files during the period 1981 to 1990 A total of 8922 NDDM cases males 4081 females 4841 were registered during the study period The overall incidence rate of NIDDM cases was 019 percent and was significantly higher in females 021 than in males 017 P001 Incidence rates increased with each higher age group and peaked in 50-54 years age group Among Type 2 patients the prevalence of hypertension was 225 and the prevalence of overweight was 594 Prevalence of complications among 945 Type 2 patients were neuropathy 471, retinopathy 305, nephropathy 258, ischemic heart disease 14,9, peripheral vascular disease 152, cataract 131 diabetic foot 18 In conclusion diabetes in Libya is emerging as an important public health challenge to health care providers for primary and secondary prevention of the disease About 226 of Libyans above 20 years of age are glucose intolerant, increasing urbanization and life expectancy of Libyans are expected to lead to increase of the number of people with glucose intolerance A Libyan national diabetes programme existed since
1984 Diagnostic facilities, insulin and oral hypoglycaemic drugs are free of charge However there are many deficiencies in the Libyan national diabetes programme to be rectified Health planners in most of the developing countries are largely unaware of the magnitude of the problem of non-communicable disease and diabetes ranks low in their list of priorities ML2 Mohamed Al-Fitouri Medal Lecture 2007: DIABETIC NEUROPATHY: TIMELY RECOGNITION AND EFFECTIVE MANAGEMENT Tarek M FIAD, Department of Endocrinology, Russells Hall Hospital, Dudley, DY1 2HQ, West Midlands, UK E-mail: tarekfiad@doctorsorguk Diabetic neuropathy DN is not a single entity but rather a number of syndromes affecting both peripheral and autonomic nervous systems The pain of DN is a common cause of morbidity and death among patients with diabetes, generating a huge economic and social burden Neurological complications occur equally in T1DM and T2DM being observed in approximately 60 of subjects, although symptomatic DN is seen in about 20 of patients Distal symmetrical neuropathy is the commonest form of DN, accounting for 75 of cases Asymmetrical neuropathies may involve cranial nerves, thoracic or limb nerves; are
of acute onset resulting from ischaemic infarction of vasa nervosa Asymmetric neuropathies in diabetic patients should be investigated for entrapment neuropathy Diabetic amyotrophy, initially considered to be a sequelae of metabolic changes, and later ischaemia, is now attributed to immunological changes In addition to chronic hyperglycaemia, the incidence of neuropathy is associated with potentially modifiable cardiovascular risk factors, including a raised triglyceride level, body-mass index, smoking, and hypertension Early diagnosis of distal symmetric sensorimotor polyneuropathy, may decrease patient morbidity by allowing for potential therapeutic interventions The Diabetes Control and Complications Trial DCCT reported a 60 percent reduction in neuropathy in the intensively treated groups after five years Therefore, Good glycaemic control is the first priority for both prevention and management of DN However, even with good glycaemic control, up to 20 of patients will develop DN Accordingly, early recognition and assessment are critical to optimize management The choice of therapeutic agents in treating DN are limited and different agents may be appropriate for different
patients, and patients may try multiple agents before finding one that works for them Combination therapies, particularly those that combine centrally acting
agents with peripherally acting agents, may provide increased pain relief but remain largely unstudied ML3 Dr Makkram Addawi Memorial Lecture: EVIDENCE-BASED MANAGEMENT OF THYROID NODULES Fellani MOHAMED, Regina General Hospital, Regina, Saskatchewan Canada E-mail: fellani55@hotmailcom Thyroid nodules are common problems The clinical importance of these nodules rests with the needs to exclude thyroid cancer that occur in 5 10 of all thyroid nodules, depending on age, gender, radiation exposure history and family history of thyroid cancer The risk of malignancy for thyroid nodules is higher in younger age groups, as well as in patients older than the age of 60 Male to female ratio for thyroid nodule to be malignant is 5:1 respectively Also the risk of malignancy is higher among patients with solid and cold nodule versus cystic, mixed and hot one There are continuous controversies regarding the management of thyroid nodules Since the introduction of fine needle aspiration biopsy FNAB as a procedure for the investigation of
thyroid nodules in the 1970s, lesser number of patients with thyroid nodules has been referred for surgery At the same time more thyroid nodules have been discovered by the introduction of Ultrasonography, now more cases may undergo FNAB There is no sharp demarcation or line that can separate between which nodules is clearly malignant or benign The suspicious cytology on FNAB of thyroid nodule represents a challenging dilemma for the Endocrinologist In this presentation well try to shed some light on the management of thyroid nodules in general, as well as the proper and most widely acceptable approach and recommendation for managing patients with thyroid carcinoma Keeping in mind there still will be some minor variation from one school of thought to another The extent of surgery, the role of post operative radioactive iodine ablation therapy, as well as suppressive dose of thyroid hormone replacement will also be discussed under the same topic ML4 The LSDE Inaugural Lecture: METABOLIC COMPLICATIONS OF HIV INFECTION ON ANTIRETROVIRAL TREATMENT Hisham M ZIGLAM, Acute Medicine and Infectious Diseases, Manchester Royal Infirmary, Oxford Road Manchester, UK E-mail:
hishamziglam@gmailcom Highly active antiretroviral therapy HAART has had a significant impact on the natural history of human immunodeficiency virus HIV infection, leading to a remarkable decrease in its morbidity and mortality, but is frequently associated with clinical and metabolic complications Metabolic complications of HIV therapy have emerged as a vexing problem for individuals living with HIV infection and their clinicians These adverse effects threaten health and quality of life as well as adherence to HIV treatment Gradually we detect more and more anthropometric, metabolic and coagulation changes, closely resembling changes seen in the metabolic syndrome SIR, syndrome of insulin resistance, well known from cardiology and internal medicinedyslipoproteinaemia, insulin resistance, abdominal obesity A combination of these disorders is clinically significant due to their role in the development of atherosclerosis and their by no means negligible involvement in the onset of ischaemic heart disease In view of the much lower mean age of HIV-positive subjects the earlier mentioned complications should be expected in much lower age categories than with HIV-negative individuals
Assessment of these complications should be done at least every year Treatment options concern antiretroviral therapy with the search for the least toxic drug but with equal antiviral efficacy, symptomatic treatment statin, fibrates, thiazolidinediones, metformin and lifestyle modifications first of all, stopping cigarette smoking Collaboration between HIV specialists and other health professionals ie endocrinologists will be required to accomplish these goals ________________________________________________________________________________________________ Abstracts of Symposia: Symposium 1: REDUCING THE CARDIOVASCULAR RISK IN DIABETES S11HYPERTENSION IN DIABETES: DRUGS AND TARGETS
Hawa Juma el Sherief, The Endocrine Unit, Department of Medicine, Tripoli Medical Centre, POBox 62004, Tripoli, Libya E-mail: hawa_elsharif@yahoocom Hypertension is a major and modifiable risk factor for macrovascular and microvascular complications It affect 20-60 of people with diabetes Data from well designed randomized clinical trials have demonstrated the effectiveness of aggressive treatment of hypertension in reducing diabetes complications All patients with diabetes should have routine blood
pressure measurements at each scheduled diabetes follow-up visit Aggressive blood pressure control should be attempted in all diabetic patients and guidelines recommend a target blood pressure 130/80 mmHg for people with diabetes American Diabetes Association recommends therapeutic lifestyle change TLC for a maximum of 3 months if blood pressure is 130139 mmHg systolic or 80 89mmHg diastolic Medication should be initiated after 3 months if TLC does not decrease the blood pressure If average blood pressure is 140/90 mmHg or if there is albuminuria or target organ damage, simultaneous pharmacological and lifestyle modification therapy should be initiated Hypertension in diabetic subjects is usually difficult to treat and most patients will require more than one medication to achieve adequate hypertension control Because large number of studies in patients with diabetes demonstrating improvement in a range of outcomes, including progression of nephropathy, cardiovascular events, and mortality, the first-line therapy will likely be an angiotensin-converting enzyme ACE inhibitor or angiotensin II receptor blockers ARBs Other strategies include the use of diuretics or -blockers
Non-dihydropyridines calcium channel blockers NDCCBs can be used when ACE inhibitors, ARBs, or -blockers are not tolerated or are contraindicated or when a second or third drug is required Treatment decisions should be individualized based on the clinical characteristics of the patient, including comorbidities, tolerability, personal preference, and cost S12 LIPID LOWERING IN DIABETES Ali EL-HOUNI, Division of Endocrinology, Department of Medicine, Tawam Hospital/ Johns Hopkins Medicine, Al-Ain, Abu Dhabi, UAE E-mail: Elhouni@yahoocouk For far too long, diabetologists have been guilty of regarding diabetes mellitus as simply a disorder of carbohydrate metabolism, and insulin as involved only in maintaining euglycemia These concepts were never sustainable Diabetic ketoacidosis, after all, is the consequence of abnormal fatty acid metabolism Even so, most physicians think of coronary heart disease CHD in diabetes as being the consequence of hyperglycemia There is a good reason to go beyond that view It is well documented, but not widely appreciated, that the incidence of microvascular disease differs little in diabetes around the world By contrast, the incidence of macrovascular
disease differs considerably, being much higher in societies in which a high proportion of energy comes from dietary fat rather than carbohydrates Differences in prevalence of atherogenic dyslipidemias most likely explain these marked differences in coronary risk Diabetes mellitus is considered a CHD equivalent and, both CARE trial and Heart Protection Study found significant improvement in outcomes with statin therapy even at LDL-cholesterol values below 100 mg/dL 26 mmol/l The CARDS study found similar benefits of statin therapy in patients with an LDL-cholesterol above and below 120 mg/dL 31 mmol/L Thus the ATP-III goal LDC-cholesterol is similar to that in patients with CHD: less than 100 mg/dL 26 mmol/l, and perhaps more aggressive target LDL-cholesterol goals of 75 to 80 mg/dL 19 to 21 mmol/l may be appropriate in high risk groups In this lecture, the following objectives will be addressed; epidemiology of hyperlipidemia CHD, pathogenesis of atherosclerotic plaque, diabetic dyslipidemia and NCEP ATP III recommendations S13 DIABETES AND STROKE Ibrahim M TREKI, Endocrinology and Metabolism Clinic, South Walkerville Medical Center, 3282224 Walker Road, Windsor, ON N8W 3P6
Canada Email: ibrahimtreki@yahooca Stroke has been defined as major outcome in uncontrolled Diabetic patients This has been shown in many studies Stroke risk is about 12 in patients with A1C 8 which is 1 elevation from high normal A1CThis number get doubled with A1C 9High plasma blood sugars have been associated with poor outcomes after acute stroke Hyperglycemia in non diabetic patients has been also associated with poor outcome and increased mortality interestingly, this risk is more than diabetic patients This was mainly in ischemic stroke patients Uncontrolled Admission blood sugar has been associated with poor neurological out- comes, an increase in the size of brain infarction
and increased stay in hospital Even in patients who received thrombolysis with recombinant tissue Plasminogen Acitivator rt-PA for acute ischemic strokes, high admission blood sugar are associated with significantly lower odds for a desirable clinical outcomes and significantly higher odds for symptomatic ICH, regardless of rt-PA treatment Hypertension, Microalbuminuria and hyperlipidemia are independent risk factors for stoke They play a role also in diabetic patients Controlling Blood sugar to a
range less than 7mmol/l 126mg/dl has been shown important in improving neurological outcomes Insulin has been used and shown to decrease complications as well as has hypotensive effects on both systolic and diastolic Blood pressure acutely Tighten blood sugar is important factor in improvising out comes in stroke patients Treatment with high dose with satin has about 26 reduction in recurrence of stroke or TIA SPARCL study even in normal cholesterol patients Treating patients with ACE inhibitors has been associated with 32 risk reduction S14 HYPERBARIC OXYGEN THERAPY IN DIABETIC FOOT CARE Issam M HAJJAJI, National Centre for Diabetes Endocrinology, Tripoli, Libya E-mail: issam@drcom No abstract provided
Symposium 2: OBESITY IN ADULTS S21 MEDICAL COMPLICATIONS OF OBESITY IN ADULTS Salem BESHYAH and Ibrahim H SHERIF, Department of Medicine, Al-Fateh University, Tripoli, Libya A and Division of Endocrinology, Department of Medicine, Sheikh Khalifa Medical City, Abu Dhabi, United Arab Emirates Beshyah@yahoocom The prevalence of obesity is increasing worldwide at an alarming rate in both developing and developed countries This has been predictably attributed to the environmental
and behavioral changes brought about by economic development and modernization Currently more than 1 billion adults are overweight - and at least 300 million of them are clinically obese Childhood obesity is already epidemic in some areas and on the rise in others Obesity accounts for 2-6 of total health care costs in several developed countries The true costs are undoubtedly much greater as not all obesity-related conditions are included in the calculations Overweight and obesity lead to adverse metabolic effects on blood pressure, lipids and insulin resistance This has been confirmed despite the use of different BMI cut-offs points However, the presence of many medical conditions involved in the development of obesity may confuse the effects of obesity itself Debilitating health problems associated with obesity include respiratory difficulties, chronic musculoskeletal problems, skin problems and infertility The more life-threatening problems fall into four main areas: cardiovascular problems; conditions associated with insulin resistance such as type 2 diabetes T2DM; certain types of cancers, especially the hormonally related and large-bowel cancers; and gallbladder disease The
likelihood of developing T2DM and hypertension rises steeply with increasing body weight and fatness Confined to older adults for most of the 20th century, this disease now affects obese children even before puberty Over 85 of people with diabetes are type 2, and of these, 90 are obese or overweight This is increasingly becoming a developing world problem Raised body mass index BMI also increases the risks of cancer of the breast, colon, prostrate, endometroium, kidney and gallbladder Chronic overweight and obesity contribute significantly to osteoarthritis, a major cause of disability in adults Although obesity should be considered a disease in its own right, it is also one of the key risk factors for other chronic diseases together with smoking, high blood pressure and high blood cholesterol S22 THERAPEUTIC LIFE STYLE MODIFICATION FOR OBESITY Soad BOSSERI, Diabetes and Endocrinology Department, Suri Seri Begawan Hospital, Kuala Belait,, Brunei Darussalam e-mail s_bosseri@yahoocom Lifestyle interventions including diet and moderate physical activity can reduce the risk of developing type 2 diabetes by as much as 60 and also resulted in decrease in cholesterol and blood pressure,
the gain from lifestyle modification is greater than any individual therapy
Recognition of the importance of lifestyle intervention should drive allocation of resources required for care and self management training, implementation of which demands knowledgeable and competent personnel The greatest health gain for a country usually comes from changing the behavior of the average family rather than focusing on high risk group Regular physical activity is important for everyone It doesnt significantly affect rate of weight loss in the early phases but it plays an important role in weight maintenance, the maintenance of weight loss is more challenging than short term weight loss Effective exercise doesnt have to be done in a single block of time nor does it always have to be formally regulated in any way, but could be incorporated in the activity of daily living Play facilities for children help strengthen long term attitude to physical activities Nutrition changes are often difficult to achieve A key component of the success of its delivery is sensitivity to the cultural background and identifying the availability of healthy food choices The importance of healthy food and drink
should be taught from a young age and strict control need to be established with regard to the availability of food and drinks for school children The ideal diet should provide appropriate energy and nutrients for optimal growth, development and health, while helping to maintain or achieve ideal body weight Facilities and programmes to promote healthy lifestyle will only have impact if the users are motivated and willing to change their behaviour S23 USE OF ANTI-OBESITY DRUGS WITH SPECIAL REFERENCE TO DIABETES Amna Ali SALHIN, Diabetes and Glandular Disease Clinic, San Antonio, Texas, USA E-mail: asalhin@hotmailcom Obesity continues to increase in prevalence, causing an increasing number of health problems worldwide Obesity plays a central role in constellation of morbidities including cardiovascular diseases, diabetes and other metabolic disorders Lifestyle changes are the primary approach to weight loss, but in reality it is hard to achieve and maintain Anti-obesity drugs can be useful adjuncts to diet and exercise in the treatment of obese individuals with type 2 diabetes Different classes of anti-obesity drugs are available and others are still in clinical trials Rimonabant is
the first selective cannabinoid-1CB1 receptor blocker studied for the treatment of obesity in type 2 diabetes and dyslipidemia The Endocannabinoid system plays an important role in adipose tissue, glucose metabolism and insulin resistance It consists of endocannabinoid signaling molecules which activate CB1 receptor in the brain influences feeding behavior and energy balance and peripherally stimulates adipogenesis and inhibits adiponectin RIO Rimonabant in Obesity trials showed subjects taking rimonabant 20mg daily had significant improvement in weight, waist circumference, hemoglobin A1C and lipids New diabetes drugs that are now available and have shown to cause weight loss include Pramlintide, a synthetic analog of human Amylin a peptide hormone produced by pancreatic beta cells in conjunction with insulin It impacts glucose control by slowing gastric emptying, regulation of postprandial glucagon and reduction of food intake, and Exenatide, a synthetic peptide that is a Glucagon -Like Peptide-1GLP-1 receptor agonist causes dose dependent weight loss in type2 diabetics not controlled on oral agents Orlistat is a drug that inhibits pancreatic lipases, in diabetic patients
orlistat has shown to cause weight loss and a decrease in A1C Obese patients with diabetes may also benefit from Sibutramine, which reduces food intake and causes early satiety by blocking norepinephrine and serotonin reuptake into nerve terminals Side effects and contraindications to these drugs do exist; therefore treatment should be tailored to patients individual needs S24 SURGERY FOR SEVERELY MORBID OBESITY: AN OVERVIEW FOR PHYSICIANS Mr Rajab KERWAT, Department of Surgery, Queen Marys Sidcup NHS Trust Hospital, Frognal Avenue Kent, DA14 6LT and Guys St Thomas Hospital Foundation Trust, London, St Thomas Hospital, Lambeth Palace Road, London SE1 7EH Mobile phone: 00447876680428 Fax: 00441689 873223 EMail: Kerwatrm@hotmailcom General and overview of the background lead to resurgence of the surgical management of morbid obesity including epidemiological view of the problem The current British guidelines are discussed which is in general a reflection of western approach to the management The rational and the advantages of surgery are highlighted and discussed including patients selection, pathway and multidisciplinary approach A comparison is put between the two common
surgical
interventions, including the pros cons of each The presentation will aim to inform the audience about this important aspect of care for this increasingly common global problem
Symposium 3 DIABETES AND ENDOCRINOLOGY IN CHILDREN AND ADOLESCENTS: S31 MAGNITUDE OF CHILDHOOD DIABETES IN TRIPOLI MEDICAL CENTER, TRIPOLI, LIBYA 1996-2006 Suliman ABUSREWIL, Nadia ELGAZIR, Mohamed KARESTA, A ELGERBI, Ibtisam ELKHAZEMI, Hend ELKHAZEMI, Ibtisam HADEED, Haima TURKI, Mohamed HWEIDI, Souad MADDAH Department of Paediatric Endocrinology, Tripoli, Medical Centre, Tripoli, Libya dr_abusrewil@yahoocouk Childhood Diabetes is common disease and is increasing, with wide geographical distribution This study involves a large cohort of 2413 diabetic children and adolescents being diagnosed and followed at Diabetic Clinic, Department of Pediatric Endocrinology, Tripoli Medical Center TMC Of these, 1446 patients were diagnosed at Tripoli Medical Center between September 1996 and December 2006 The remaining patients were diagnosed at Tripoli Diabetic Center before TMC was opened In this study, we describe various parameters such as, age, sex, weight , height, thyroid function at diagnosis and
yearly after, residence, nationality, family history of DM, school performance, HbA1c at the time of diagnosis, screening for hepatitis and HIV, and screening for other autoimmune diseases, any associated illness, and the occurrence of complications Data analysis showed equal sex distribution Just over half of our patients were from Tripoli District 51 and most of them were Libyan nationals 972 29 of them presented in diabetic ketosis and most patient were admitted at the time of the diagnosis for initial stabilization 164 had family history of type 1 diabetes and 334 had family history of type 2 diabetes 5 of the patients had associated autoimmune conditions 07 of patients were found to be positive for hepatitis 50 of children were treated by intensive insulin regimen 6 had diabetic micro vascular complications The task of managing childhood diabetes is good metabolic control, preventing morbidity and mortality and assuring good quality of life S32 MODERN MANAGEMENT OF TYPE 1 DIABETES IN CHILDREN: AN OVERVIEW Ahmed Sasi SHAMEKH, Princess Royal University Hospital, Farnborough, UK Type 1 diabetes mellitus T1DM, one of the most common chronic diseases in childhood, is caused by
insulin deficiency resulting from the destruction of insulin-producing pancreatic beta cells In the USA there are 125,000 children under age of 19 year with diabetes In UK there are at least 20000 children under age of 16 year with diabetes There is slow but steady increase in the in the number of cases diagnosed per year in most countries especially in the younger age group There are unique challenges in caring for children and adolescents with diabetes that differentiate children and young people from adult care These include the obvious differences in the size of the patients, developmental issues such as the unpredictability of a toddlers dietary intake and activity level, and medical issues such as the increased risk of hypoglycaemia and diabetic ketoacidosis Because of these considerations, the management of a child with type 1 diabetes must take into account the age and developmental maturity of the child Although most children with type 1 diabetes present with the classic signs and symptoms of hyperglycaemia without accompanying acidosis, a significant number present with diabetic ketoacidosis Children and young people with T1DM should be offered continuous care by
paediatric diabetes team to optimise their glycaemic control and reduce the risk of complications S4 MOLECULAR BASIS AND CLINICAL IMPLICATIONS IN GENDER DIFFERENTIATION DISORDERS Asma Deeb, Imperial College London Diabetes Centre, Abu Dhabi, United Arab Emirates asmadeeb@yahoocouk Sex differentiation disorders are wide spectrum of diseases in which genetic and environmental factors interplay Advances in Genetics led a revolution in understanding many disease processes and initiated discovery of new therapies for various genetic and endocrine disorders The genotype-phenotype correlation phenomenon operates in some of these disorders but not in others This correlation concept is a useful diagnostic measure and is also a powerful tool for genetic counselling Clinical conditions resulting from defects in various steps of sex determination
and differentiation are extensive and common forms of these conditions will be discussed Congenital adrenal hyperplasiaCAH is a family of disorders characterized by enzyme defects in the steroidogenic pathway Deficiency of 21 hydroxylase enzyme is its commonest form It results from deletion or mutations in the active gene CYP21 located in chromosome
6p In CAH, genotype and phenotype correlate well with a clear relationship between clinical disease severity and the type of CYP1 mutation In the contrary, androgen insensitivity syndrome AIS, which is a disorder caused by mutation in the androgen receptor, lacks such a correlation Classical presentation of some of the commonest intersex disorders will be presented and an overview of the underlying molecular mechanisms will be discussed The genotype-phenotype correlation of various disorders will be highlighted S35 SURGICAL ASPECTS OF AMBIGUOUS GENITALIA: REFLECTIONS ON THE TRIPOLI MEDICAL CENTRE EXPERIENCE Bashir GHARMOOL Departments of Paediatric Surgery, Tripoli Medical Center, Tripoli, Libya E-mail: dbmgharmool@yahoocom When a baby is born one of the first questions often asked is is it a boy or a girl? the answer is not always simple Developmental disorders of sexual differentiation may cause ambiguity of external and internal genitalia of the newborn This has a great impact on the parents First of all they have to cope with the fact that their child has a disorder and is not as healthy as they hoped for Secondly, they have to deal with the uncertainty of the gender Usually
parents have heard of these congenital anomalies, which make them feel uncertain Their sadness, disbelief and uncertainty may make it difficult to deal properly with the situation During the last ten years, a multidisciplinary team working in Tripoli Medical Center has managed many children born with ambiguous genitalia this team consists of the following medical specialists: endocrinology, surgery and urology In this presentation, we will reflect on our experience with the surgical treatment of 20 children born with genital developmental disorders over the last ten years These patients are classified into five categories: femal pseudohermaphrodite ovarian tissue only, male pseudohermaphrodite testicular tissue only, true hermaphrodite both ovarian and testicular tissue present, mixed gonadal dysgenesis testicular tissue and streak gonad and gonadal dysgenesis two streak gonads Four surgical procedures play an important role in the treatment of children with ambiguous genitalia: clitoral reduction/recession, Vaginoplasty and gonadectomy, and this presentation will in particular focus on the results and the controversial subject of timing of feminizing genitoplasty CAH Our short-
term results in girls born with ambiguous genitalia suggest that for most patients, the results of surgery to construct female genitalia are good However, long-term surgical results and results of psychosexual functioning of these patients are not yet available and further studies focusing on long-term psychosexual outcomes are needed ________________________________________________________________________________________________ Abstracts of Clinical Workshps: WS1 Management of type 2 diabetes in 2007 WS11 ORAL ANTI-DIABETIC DRUGS: WHICH ONE FOR WHOM? Ahmed SWALEM, Department of Medicine, Garyounis University Benghazi, Libya E-mail: aswalem51@yahoocom Type 2 diabetes T2D is a multifunctional metabolic disease characterized by insulin resistance and insulin deficiency The former is represented by decreased insulin-stimulated glucose uptake in skeletal muscle, augmented endogenous glucose production mainly by the liver, and enhanced lipolytic activity in adipose tissue The latter is due to functional defect in -cell function and progressive loss of -cell mass These two defects are intimately linked Understanding the defects is important because addressing them forms the cornerstone
of therapy of this disease When lifestyle modification LSM and diet therapy fail to achieve the desired glycemic goals, the conventional approach is to begin with an oral anti-hyperglycemic agent There are five classes of anti-hyperglycemic agents These classes improve glucose metabolism by different mechanisms
and their effects are additive Sulfonylureas SFU are insulin secretagogues and their main mechanism of action is augmentation of insulin secretion from B-cells Their use yield a mean absolute A1C reduction of 1-2 They are well tolerated and may cause dose-dependent hypoglycemia and weight gain More recently there has been concerns about their effect on aggravation of myocardial ischemia Meglitinides repaglinide and nateglinide are non-SFU insulin secretagogues and work similarly to SFU but have a more rapid onset and shorter duration of action causing greater insulin secretion which may be appropriate for control of postprandial hyperglycemia Repaglinide, which is more effective than nateglinide, cause A1C reduction of 12 and may cause weight gain and hypoglycemia to a lesser degree than SFU Bigunides, like metformin which is commonly referred to as an insulin sensitizer,
act mainly by decreasing hepatic glucose production and consistently lowers A1C by 1-2 and causes weight loss and other beneficial effects on lipids, fibrinolytic and endothelial functions thereby decreasing vascular risk factors Transient gastrointestinal disturbances may be seen in some people and is contraindicated in patient with major organ failure Thiazolidinediones TZDs are true insulin sensitizers and act through activation of peroxisome prolefersator-activated receptor- PPAR- to induce carbohydrate and lipid metabolism leading to improved glycemic control and reduction of cardiovascular risk factors such as inflammatory markers, lipids, endothelial dysfunction, and BP Treatment with TZDs cause reduction of A1C by 1-2 Fluid retention, edema, and aggravation of heart failure are the common side effects of these agents Alpha-glucosidase inhibitors -GIs act by inhibiting an enzyme on the enterocyte brush border that breaks down complex starch, delaying intestinal absorption of carbohydrates and particularly attenuating postprandial glucose elevation -GIs are less effective than other agents as they reduce A1C by 05-1 and have significant side effects such as bloating,
abdominal pain, and diarrhea frequently leading to cessation of drug use The choice of initial drug is mainly influenced by the severity of fasting hyperglycemia, degree of obesity, and the presence and magnitude of hyperglycemic symptoms Other factors such as age, education, motivation, presence of co-morbid conditions such as hyperlipidemia or heart disease, efficacy, preservation of -cell function, the degree of glucose control desired, side effects, dosing frequency, and cost should all be considered Most endocrinologists prefer metformin as the optimal first-line agent, particularly in obese people as long as there is no contraindication SFUs may be used as initial therapy particularly in thin patients or patients who have contraindications to other agents eg heart failure Megltinides may be a good choice as initial therapy for people with irregular or infrequent meals eg Ramadan fasting GIs may best benefit those patients with mild hyperglycemia particularly those with marked postprandial excursions who are able to tolerate the significant side effects First line therapy with TZDs cannot be considered evidence based in the absence of convincing outcome data and in light of
side effects and cost Therapy with LSM and a single agent infrequently achieves target glycemic goals, and if it does, the effect is usually not sustained A more rational approach would be combination therapy with drugs with different mechanisms of action Again metformin is at the center of combination therapy to which other drug classes are added Initial therapy might be with submaximal doses of two drugs As the diabetic abnormalities progress, maximal doses of the drugs are used and addition of other class of oral agents or insulin may be needed to achieve the target glycemic goal In choosing combinations of oral agents their effects on the components of T2D should be considered WS12 PRACTICAL INSULIN THERAPY Mahmoud BENBARKA, Division of Endocrinology, department of Medicine, Sheikh Khalifa Medical City, Abu Dhabi, UAE Benmah748@skmcgovae Diabetes mellitus is the most common metabolic disorder affecting humans Type 2 diabetes which accounts for approximately 90 is caused by the dual defects of insulin resistance and beta-cell secretory dysfunction Type 1 diabetes which is autoimmune in etiology is responsible for about 10 of diabetic individuals and is treated only with insulin
replacement Longitudinal studies investigating the natural history of type 2 diabetes have shown that beta-cell dysfunction begins many years before the disease is diagnosed and is progressive, declining as subjects transition from normal glucose tolerance NGT to impaired glucose tolerance IGT, with further decreases in beta-cell function occurring as subjects transition to diabetes The natural history of type 2 diabetes is characterized by progressive decline in beta cell function over time means that additional pharmacotherapy is necessary to achieve and maintain adequate glycaemic control The United Kingdom Prospective Diabetes Study [UKPDS] demonstrated that the percentage of subjects who
maintained target glycaemic levels with 1 drug decreased from 50 at 3 years to less than 25 after 9 years of follow-up and that time, however, combination oral agent therapy also fails, and insulin therapy is needed for many patients to maintain glycaemic control Initiation of insulin therapy will require more extensive patient education in regard to not only insulin use, but also the potential risk for hypoglycemia and how to manage it Patients also need to know how to adjust insulin doses
during illness Patients need close follow-up to monitor progress and adjust insulin doses Type 2 diabetes is a progressive disease characterized by declining beta-cell function Healthcare providers need to recognize that over time many patients with type 2 diabetes will require insulin to achieve therapeutic targets Studies have shown that tight glucose control will prevent the onset or progression of the chronic complications of diabetes Simple regimens for the initiation and intensification of insulin therapy will allow more type 2 diabetes individuals to be treated successfully with insulin to achieve appropriate goals and improve the long-term outcomes for these people
Workshop 2: DIABETES IN CRISES WS21 MANAGEMENT OF DIABETES IN THE HOSPITALIZED PATIENT PARTICULARY IN THE PERIOPERATIVE PEROID Amna SALHIN, Diabetes and Glandular Disease Clinic, San Antonio, Texas, USA E-Mail asalhin@hotmailcom Hyperglycaemia is associated with adverse outcomes for hospitalized patients with and without diabetes The number of hospital discharge forms with diabetes listed as a diagnosis increased more than 50 in the United States during the 1990s By 2002, diabetes accounted for more than 49
million hospitalizations, costing an estimated 40 billion dollars With emerging evidence that hyperglycaemia is an independent risk factor for adverse outcomes and good glycaemic control improves mortality, critical care outcomes, and length of hospital stay, yet in many hospitals, treatment of hyperglycaemia remains suboptimal which has led medical organizations including American Diabetes Association ADA and American Association of Clinical Endocrinologist AACE to issue consensus guidelines for hyperglycaemia control in hospitalized patients In noncritical care setting, ADA guideline for pre-prandial glucose level is 90-130mg/dl and a maximum of 180mg/dl Insulin is the primary treatment of hyperglycaemia; oral agents have significant limitations and are often contraindicated, sliding scale insulin should not be used as monotherapy but as a correction-dose in addition to basal and prandial insulin Surgery in diabetics is associated with increased risk of infection, impaired wound healing, increased hospital stay and hospital mortality, glucose level and A1C in the preoperative period can be a predictive of postoperative complications All diabetic patients undergoing surgery should
have comprehensive preoperative evaluation, risk assessment of hyper/ hypoglycaemia and should receive instructions regarding insulin dose adjustments Special conditions where continuous intravenous insulin infusion is required include complex surgeries cardiovascular, neurosurgical, organ transplant, prolonged NPO status after abdominal surgeries, total parenteral nutrition TPN and high dose glucocorticoid therapy Glucose level should be monitored using point-of care POC Inpatient hyperglycaemia is recognized as a patient safety issue therefore, implementing safe, effective systems for improving glycaemic control require multidisciplinary team approach; discharge planning should be initiated well in advance to ensure continuity of care and appropriate plans for follow-up WS22 MANAGEMENT OF DIABETES IN THE INTENSIVE CARE SETTINGS Abdulfattah Lakhdar, Department of Diabetes Endocrinology, Whipps Cross University Hospital London, UK abdullakhdar@hotmailcom A large single centre trial of post-operative surgical diabetic patients showed significant improvement in survival when continuous infusion of Insulin was used to Maintain glucose between 80 and 110 mg/dl 44 61 mmol/l Patients
with severe Sepsis were studied supporting the role of glycaemic control using continuous Infusion of Insulin and glucose in such setting Following initial stabilisation of patients, blood glucose maintained at 150 mg/dl 83 mmol/l The best results were obtained when glucose was maintained between 80 and 110 mg/dl 44 and 61 mmol/l Achieving a goal of 150 mg/dl 83 mmol/l also improved outcome when compared to higher levels but with reduced risk of hypoglycaemia Glycaemic target at the intensive care unit is 110
mg/dl 61 mmol/l Components of intravenous Insulin therapy will include potassium that should be monitored and given as necessary, short-acting Insulin in concentrations of 1 u/ml or 05 u/ml, an infusion pump adjustable and accurate bedside blood glucose monitoring done hourly and if stable, every two hours The ideal IV Insulin protocol should be easily ordered, effective, safe and easily implemented A multi-disciplinary team that include nursing, pharmacy and medical staff, appropriate forms and education should support the implementation protocol Bedside glucose monitoring is essential, backed by a strong quality assurance programme Specific situations rendering capillary
tests inaccurate are common in the critically ill patient and include shock, hypoxia, dehydration, extremes in haematocrit, elevated bilirubin and triglycerides and certain drugs Various protocols do exist: DIGAMI studied in acute MI setting, Van den Berg studied in critical care setting, Portland protocol used in surgical setting, Markowitz studied in postoperative heart surgery patients and Yale protocol studied in medical intensive care setting The Van den Berg protocol involves intravenous Insulin therapy to maintain blood glucose between 80 and 110 m/dl with clear guidance to the appropriate action according to the blood glucose result The Portland protocol involves the peri-operative use of Insulin for ICU and ward settings, aiming at various target levels of blood glucose The protocol starts during surgery and continuous during the ICU stay Insulin is administered as an infusion via a pump, piggybacked to normal saline with clear guidance for action according to the blood glucose target Post-discharge from ICU, diet and subcutaneous Insulin is administered and titrated similarly as in ICU protocol To convert to subcutaneous Insulin, establish 24-hour Insulin requirements,
give one half of the amount as basal and the rest as pre-prandial boluses before the main meals, based on carbohydrate intake An effective Insulin therapy must provide both basal and nutritional coverage to achieve target goals; hospitalised patients often require high Insulin doses to achieve desired target blood glucose levels In addition to basal and nutritional Insulin requirements, patients often require supplemental or correction doses and treatment of unexpected hyperglycaemia WS23 GLYCOMETABOLIC STATE AT ADMISSION: IMPORTANT RISK MARKER OF MORTALITY IN PATIENTS WITH DIABETES MELLITUS AND ACUTE MYOCARDIAL INFARCTION Kamal ABOUGLILA, Diabetes Centre, University Hospital of North Durham, Newcastle, United Kingdom e-mail abouglila2000@yahoocom Type 2 diabetes is an important cause of cardiovascular morbidity and mortality accounting for 20 of the total number of patients admitted for suspected myocardial infarction MI Patients with diabetes have a two-fold increase in hospital mortality when compared with those without diabetes Long-term follow-up reveals a continuously increasing excess mortality, mostly due to fatal re-infarctions and congestive heart failure The difference
in mortality and morbidity between patients with and without diabetes remained despite improved therapeutic modalities that have resulted in a decline in the overall morbidity and mortality following acute MI Intensive treatment with insulin caused a 40 reduction in cardiovascular events in the Diabetes Control and Complications Trial This indicates that regardless of a causal relationship, improved metabolic care reduces the progression of the athero-thrombotic process The concept of initiating treatment with insulin infusion to rapidly attain a normalized blood glucose has support from the first DIGAMI Diabetes Insulin Glucose infusion in acute MI trial and the study in patients in intensive care by Van den Berghe et al In the DIGAMI trial, patients with diabetes and acute MI received intense insulin treatment initiated by insulinglucose infusion during the first 24 h after MI The 1 year mortality was reduced by 30 in the intensively treated group After an average of 34 years, there was an 11 absolute mortality reduction among these patients In summary, long-term outcome in diabetic patients with MI is predicted by age, previous myocardial damage, and not the least the actual
glucometabolic state Institution of intense insulin treatment reduces this risk considerably WS24 ROLE OF NEWER ANTI-MICROBIAL AGENTS IN SKIN AND SOFT TISSUE INFECTIONS IN DIABETES Hisham M Ziglam, Acute Medicine and Infectious Diseases, Manchester Royal Infirmary, Oxford Road Manchester, United Kingdom Email: hishamziglam@gmailcom
Foot complications are common among diabetic patients Foot ulcers are amongst the more serious consequences Skin and soft tissue infections SSTIs and complicated SSTIs cSSTIs, particularly those caused by Gram-positive pathogens, are among the most common human bacterial infections The emergence of resistance to antibiotics such as methicillin and vancomycin has compromised treatment options for these infections and stimulated the search for new antimicrobial therapies While vancomycin has been the gold standard to treat MRSA infections, newer therapeutic options have been developed over the last 5 years These include new glycopepetides, daptomycin, tigecycline and linezolid, which is the focus for this presentation Newer-generation carbapenems, such as ertapenem, are characterised by a broad-spectrum of activity against Gram-positive and -negative
aerobes and anaerobes, and are resistant to hydrolysis by many beta-lactamases With their long half-lives, these agents have an advantage of less frequent dose administration with more rapid bactericidal activity and less likelihood for development of resistance However, because of their proven activity against highly resistant organisms, these antibacterial agents should be reserved only for life-threatening situations and/or when resistant pathogens are suspected Rational antimicrobial use coupled with awareness of infection control measures is paramount to avert the emergence of multidrug-resistant organisms ________________________________________________________________________________________________ ABSTRACTS OF FREE COMMUNICATIONS ORAL PRESENTATIONS: OC1 AUDIT OF THE MANAGEMENT OF TYPE 1 DIABETES MELLITUS IN TRIPOLI CHILDRENS HOSPITAL 2000-2004 Faten BEN RAJAB, Omran ZWIED, Amel AL-SHEPAAN and Enaas ERUK Tripoli Childrens Hospital, Omar Mokhtar Street, Tripoli, Libya fatenben83@yahoocom Aim: To assess diabetic control in our patients and comparing the results with insulin therapy occurrence of acute complications Settings: A retrospective audit of glycaemic control in
patients diagnosed with type 1 diabetes mellitus during a 5 year period 1/1/2000 to 31/12/2004 The clinic at Tripoli Childrens Hospital is run by a consultant and specialists with dieticians support The attendance at the clinic was once to twice monthly Patients and Methods: Medical records of patients who would have had diabetes for at least six months were examined They were divided to three groups according to insulin regimens Insulin dose ranges from 051 unit/kg/day Most of them received higher insulin doses at morning Data were analyzed in terms of age, gender, insulin regimen, HbA1c level and occurrence of severe hypoglycemia and diabetic ketoacidosis acidosis DKA Severe hypoglycaemia was defined as hypoglycaemia requiring attendance to casualty or blood sugar 45 mg as measured by patients own glucose meter Results: There were 104 patients aged from 1 year to 17 years Female to male ratio was 15:1 70 patients 673 received premixed biphasic insulin Human Mixtard 30 twice daily, 19 patients 183 received NPH Insulin once daily and 15 patients 144 received Mixtard twice daily with additional soluble insulin before the main meal HbA1c results were as follows: 11 had an HbA1c
7 5 received NPH insulin, 5 received Mixtard 30 and one received Mixtard 30 with soluble insulin before the main meal 34 patients had HbA1c between 7-9 27 received Mixtard 30, 4 received NPH and 3 received Mixtard 30 with soluble insulin before main meal 27 HbA1c 9 2 received NPH, 15 received Mixtard 30 and ten received Mixtard 30 with soluble insulin before main meal 32 patients 31 did not have any HbA1c results on record either because the parents failed to do the test or due limited facility Severe hypoglycemia we considered recurrent attacks as one complication for each patient occurred in 21 patients 202 from 104 6 patients 545 out of 11 with HbA1c 7 30 patients 382 out of 34 with HbA1c 7-9 , one patient 37 out of 27 with HbA1c 9 and 1 patient 312 out of 32 who they did not have any HbA1c results on record Diabetic ketoacidosis occurred in 29 patients 278 from 104 20 patients 740 out of the 27 patients with HbA1c 9 7 patients 205 out of 34 with HbA1c 7 -9 , no one had DKA from those with HbA1c 7 , and 2 patients 625 out of 32 who they did not have any HbA1c result on record
Conclusion: Suboptimal glycaemic control is still common in our diabetic patients Poor
glycaemic control as measured by HbA1c is associated with increased risk of DKA OC2 CLINICAL AND BIOCHEMICAL CHARACTERISTICS OF POLYCYSTIC OVARY SYNDROME IN BENGHAZI- LIBYA Fatma I NAJEM, Rafik R ELMAHDAWEI, and Ahmed M SWALEM The Medical Department, 7th of October Hospital and Faculty of Medicine, Garyounis University, Benghazi, Libya E-mail: rafikal2002@yahoocom Background: Polycystic ovary syndrome PCOS is a common endocrine condition affecting women in their reproductive age It is characterized by chronic anovulation, hyperandrogenism and polycystic ovaries on ultrasound There has been no published data regarding this syndrome in Libyan patients Objectives: to assess the frequency of different clinical and biochemical features of PCOS in our population and compare it with published series Materials and methods: a retrospective study of patients records at the endocrine clinic in Benghazi was under taken and the patients fulfilling the Rotterdam ESHRE/ASRM criteria were included Obesity was defined according to WHO definition Clinical features, associated diseases, family history, horomonal levels and transabdominal pelvic ultrasonography data were analysed Results: 318 PCOS
patients were included The with mean age at presentation was 258 15-44 years Majority 67 were in the age group 20-29 years 235 were over weightBMI: 250-299 while 57 were obese BMI:/ 30 93 had oligo/amenorrhoea, 91 were hirsute and 60 of the married patients were fertile, acanthosis nigricans was encountered in 157 of the cases and acne seen in 12 74 had ultrasound features of polycystic ovaries 965 of ultrasounds Diabetes mellitus was diagnosed in 9 of the patients of who their fasting blood glucose levels were available Total serum testosterone was raised in 26 of the cases free testosterone and other androgens were not checked and serum prolactin was raised in 31 Galactorrhoea was seen in 88 of the cases Thyroid disease frequency among the patients and their family members was 53 and 38 respectively History of diabetes and hypertension among first degree relatives was seen in 16 and 8 of the patients Conclusion: Anovulation and hirsutism are the dominant features of PCOS in our patients, polycstic ovary morphology ultrasound features is absent in up to one quarter of the cases possibly due to the predominant use of transabdominal ultrasound Obesity is common over half of the
patients We suspect that prevalence of diabetes, hypertension and thyroid disease are underestimated in our patients OC3: PESCRIBING PATTERNS OF ANTIHYPERTENSIVE AGENTS IN HOSPITALIZED DIABETIC PATIENTS IN TRIPOLI, LIBYA Aisha LAZREG, Salem ELHABROUSH and Musbah AGIL Endocrine Department, Tripoli Medical Centre and Tripoli Diabetic Centre, Faculty of Medicine Al- Fatah University, Tripoli, Libya E mail: Aisha_lazreg@yahoocom Objectives: To describe the prescribing trend of antihypertensive drugs for diabetic hypertensive patients admitted to the endocrine unit at Tripoli Medical Centre between June and September 2005 There mean age was 5314 years; 14 had type 1 DM and 86 had type 2DM The mean duration of diabetes was 107 years and mean duration of hypertension was 65 years They were 43 men and 57 women Mean BMI was 317 Kg/m Results: There were more obese women than men 754 versus 651 Microalbuminuria was present in 9 and macroalbuminuria in 46 20 patients had mild renal failure and 5 with moderate renal failure depending on calculated creatinine clearance 6 of patients were on diet only, 34 were on insulin, 58 were on oral hypoglycemic agents and 2 were on combined insulin and
oral hypoglycemic agent Hypertension was treated with a one drug 58, two drugs 34 or three drugs 8 Systolic BP 130 mmHg was achieved in 32, 36 and 63 of those receiving one, two and three drugs respectively Whereas diastolic BP 80mmHg was found in 30, 33 and 62 of those receiving one, two or three drugs respectively Calcium channel blockers were used in 52, Angiotensin converting enzyme inhibitors ACEIs in 49, B-blocker in 18, methyldopa in 9, angiotensin
receptor blockers ARBs in 3 of patients 3 were on no therapy for their hypertension 6 out of 9 patients with microalbuminuria 666, 25 out of 46 macroalbuminuric patients 543 9 out of 20 mild renal failure patients 45 , and 4 out of 5 with moderate renal failure 80 did receive ACEI 64 there systolic blood pressure was 130 mmHg, and 67 their diastolic blood pressure was 80mmHg With significantly higher female patients with less adequately controlled BP as 702 Females systolic BP130mmHg versus55 males systolic blood pressure 130mmHg Conclusions: low rate of usage of ACEIs and ARBs were observed in our diabetic population in contrast with current trends and international recommendations OC4 THYROID CANCER IN NORTH EASTERN LIBYA
Ahmed M Swalem, F M Bugrara M A Bumdas Endocrine Unit, University Department of Medicine, 7th October Hospital, Benghazi Libya aswalem51@yahoocom Introduction: Thyroid cancer accounts for less than 1 of all human malignant disease Little is known about thyroid cancer in Libya although nodular thyroid disease is common Objectives : to assess the numbers and types of thyroid cancer in NE Libya diagnosed over a ten year period and to assess the locally available facilities to manage such cases Methods: retrospective analysis of case records from the three major hospitals in Benghazi and the clinics affiliated to them over a ten year period 1996-2006 Results: A total of eighty seven cases of thyroid cancer were detected over the ten year period The F: M ratio was 44 : 1 Most cases 78 were in the age group 20-60 years 968 of cases presented with asymptomatic neck swelling : single nodule 7965 , multinodular goiter 156, and diffuse goiter in 46 One case 168 presented with toxic goiter and another case 168 presented with cervical lymphadenopathy without goiter Diagnostic aids included ultrasonic examination of the neck in all cases, CT scan and radioactive iodine scan in some cases, and
fine needle aspiration cytology and excisional biopsy in all cases Most common histological type was papillary carcinoma in 632, followed by follicular 172, medullary 49, anaplastic in 22, and other types in five case 2 insular type, 1 Hurthle cell type, 1 sequamous type, and 1 metastatic No metastases were detected with the available diagnostic facilities in 862 of cases at the time of presentation 138 of cases had metastases : 9 cases 103 in cervical lymphnodes, 5 cases 57 cervical lymphnodes and local infiltration, and two cases had distant metastases : one lung and one spine metastases All cases were treated by surgery lobectomy, hemithyroidectomy , or total thyroidectomy followed in many cases by radioactive iodine ablation and TSH-suppresion therapy and chemotherapy Some diagnostic facilities are available and fairly reliable such as ultrasonography, CT and a MRI scans Thyroglobulin test is not always available, radioactive iodine scanning and therapy are not available Cytology and histopathology reports are sometimes doubtful All surgeons were involved in these cases and sometimes a named surgeon is preferred Cure rates could not be assessed as most cases were followed-up
abroad Conclusions: Clinical presentations and histological types of thyroid cancer in north eastern Libya are not dissimilar from those in the world literature Incidence rates can of thyroid cancer cannot be calculated assessed from this study The results of this study should be confirmed by further studies with improved diagnostic facilities The locally available facilities to manage cases of thyroid cancer are inadequate and there is an urgent need to improve them OC5 TYPE 2 DIABETES IN CHILDREN AND ADOLESCENTS IN TRIPOLI, LIBYA Ibtisam HADEED, Mohamed HWEIDI, Maha EL SHERIF, Milad DOUGHA and Suliman S ABUSREWIL Department of Paediatric Endocrinology, Tripoli, Medical Centre, Tripoli, Libya dr_abusrewil@yahoocouk Backgrounds: Type 2 diabetes in children is an emotionally changing issue and an emerging public health problem Traditionally type 2 Diabetes is a disease of adults, but in the last 2decades, it has been increasingly recognized in children and adolescents Furthermore, as we are actually facing a constant growth in the prevalence of obesity in children and adolescents, type 2 diabetes will predictably be found more frequently in other population outside its classical
high risk group Objectives: We aimed to identify and characterize type 2 diabetes in Tripoli and the surrounding districts and to assess the outcome of treatment of type 2 diabetes in children and adolescents Patients and methods: In this study we reviewed 343 children who were being diagnosed to have diabetes over the last 2 years 2005-2006 at the Department of Pediatric Endocrinology Diabetes, Tripoli Medical Centre Records were reviewed for age, sex, Body mass index BMI,
mode of presentation, family history of diabetes and history of drug intake Laboratory investigations included serum C-peptide, serum Insulin and autoantibodies Results: We found that 25 out 343 children 73 were satisfying the ADA recommendation for the diagnosis of type 2 diabetes There were 17 female 68 and 8 males 32 The mean age was 134 years; ranging between 10 and 15 Mean BMI was 296kg/m2 Family history of diabetes was present in all patients There was no history of relevant drug intake of diabetogenic nature Conclusion: Type 2 diabetes during childhood and adolescence is not rare in our community Physicians in general and pediatricians in particular must be aware of this problem As a result of this
audit, all teenagers diagnosed to have diabetes in our clinic are carefully assessed and all those who were diagnosed in the past with the similar demographic characteristics are being re-scrutinized OC6 ALLGROVE SYNDROME TRIPLE A SYNDROME ADDISON, ACHALASIA, ALACRIMA IN LIBYA Om Almir ALGADAFI, Abulgasem EL-GERBI, Mohamed KRAESTA, Nuri MUJBER, Ibtisam HADEED and Suliman S ABUSREWIL Paediatric Endocrine Department, Tripoli Medical Center, Tripoli, Libya dr_abusrewil@yahoocouk Triple A syndrome is an extremely rare syndrome It is an autosomal recessive disorder characterized by Adrenal Insufficiency, Alacrima and Achalasia We have studied 15 patients from different families and different geographical locations of Libya, They have presented to our clinic with classical signs and symptoms of adrenal insufficiency, ocular symptoms and achalsia which developed subsequently The diagnosis was based on clinical grounds some laboratory studies such as electrolytes disturbance as a result of adrenal crisis due to cortisol and mineralocorticoid deficiency Base line ACTH was high, and cortisol level was low Serum rennin aldosterone levels were low too Barium swallow demonstrates Achalasia of
esophagus Careful replacement therapy with glucocorticoid, topical lubricant for the eyes artificial tears and dilatation of the esophagus was performed for dysphagia For the achalasia per se definite improvement of symptoms were achieved by surgical correction Triple A syndrome is treatable syndrome once it is diagnosed, but our impression it is very much under diagnosed in Libya
POSTER PRESENTATIONS: P1 NEONATAL HYPERCALCAEMIA DUE TO PRIMARY HYPERPARATHYRODISM IN A FOUR-MONTH-OLD LIBYAN GIRL: CASE REPORT AND REVIEW OF THE LITERATURE Faten BEN RAJAB, Zienab HASHISHI and Eman MESLATI The Childrens Hospital, Omar Mokhtar Street, Tripoli, Libya E-mail: fatenben83@yahoocom Background: Neonatal primary hyperparathyroidism can begin as soon as parathyroid gland functional in the first trimester of pregnancy, become hyper plastic It is result of a homozygous, in activating mutation in a calciumsensing receptor Case study: We report a 4 month-old Libyan girl who presented with failure to thrive, severe dehydration and constipation since early neonatal period She was found to have severe hypercalcemia She is a girl of consanguineous parents However, there was no family history of same
illness Her investigations showed high Calcium level Serum Calcium level reached up to 20 mg/dl with ionized Ca up to 38 mmol/dl, low Phosphorus level 30 mg , high alkaline phosphate 1308 IU/l Her serum intact parathyroid hormone level is very high 1640 pg/ml She had radiological evidence of metabolic bone disease including subperiosteal bone resorption, generalized rarefaction in long bones, cysts formation and deformities of forearm bones CT scan of brain was normal, CT scan of abdomen showed bilateral nephrocalcinosis Isotope scan showed generalized uptake indicate parathyroid hyperplasia She was treated with normal saline to rehydrate her and to increase urinary Calcium excretion Loop diuretics Frusemide and Predinsolone were also used Her serum Ca level improved down to 90 mg on the third day of treatment She was reviewed by the surgeons who offered her parents total parathyroidectomy with re-implantation of parathyroid gland portion into the forearm Unfortunately, the patient died after one month of diagnosis because of gramnegative septicemia before she had her operation Comments: Severe neonatal hyperparathyroidism is rare condition with around 50 cases reported in the
international literature To our knowledge, this is the first patient to be reported in Libya
P2: WITHDRAWN P3 POST KIDNEY TRANSPLANT DIABETES MELLITUS PTDM AMONG FOLLOW UP PATIENTS BENGHAZI, LIBYA Amal M SHERMADDO and Fairouz M SHERMADDO, Departments of Medicine and Biochemistry, Faculty of Medicine, University of Garyounis, Benghazi, Libya Background: Diabetes and impaired glucose tolerance occurring as a complication of organ transplantation have been recognized for many years About 20 of non diabetic patients develop hyperglycaemia after transplantation Diabetes development after transplantation has been shown to have a similar effect on morbidity and graft survival as pre-transplantation diabetes Patients and Methods: For estimation of PTDM among active follow up patients to BNC till the end of 2005, period of follow up ranged from 22 months February 2006 to 212 months March 1988 Diagnosis of PTDM was according to American Diabetes Association ADA Criteria WHO 1999 Possible risk factors were examined including sex, age, immunosuppressive treatment, HCV Positivity, body mass index BMI, family history and history of acute rejection Time of diagnosis of PTDM also was studied,
state of graft function and type of treatment for PTDM Results: PTDM was diagnosed in 26 out of 155 167 10 patients were females and 16 were males Family history was positive in 4 patients 153 History of acute rejection in was found in 5 patients 185 HCV were positive in 16 patients 6153 Age was above 40 years at time of diagnosis in 17 patients 654 Out of them 15 patients had Living Related Kidney Transplant LRKTx and 11 had Living Unrelated Kidney Transplant LURKTx The mean BMI was 24070 kg/m2, only one patient had a BMI above 30 kg/m2 Mean random plasma glucose was 520250 mg/dl and no patient presented with DKA or HHS Time of diagnosis of PTDM is 3 months in 10 patients, 3 months 6 months in 4 patients, 6 months 1 year in 4 patients, 1 year 5 years in 6 patients and 5 years in 2 patients PTDM developed in 23 patients out of 127 on Cyclosporin A CSA as their main anti-rejection therapy, Azathioprine as main treatment in one out of 17 patients, Tacrolimus Prograf as main treatment in 2 out of 9 patients All patients were on steroids in their immunosuppressive protocol The daily dose of steroids ranged from 60 to 40 mg immediately post-transplant reducing to between 5 and
75 mg as a maintenance dose Renal function was normal in 11, impaired in 9 patients Serum Creatinine less than 2 and of chronic allograft nephropathy CAN in 6 patients Medical treatment for hyperglycaemia was not needed in 3 patients From those who needed insulin, 2 of them received insulin for 2 weeks 5 weeks one of them develop hyperglycemia10 months later Conclusion: PTDM is a recognized complication with negative impact on graft function survival However, it is invariably permanent and remission may occur spontaneously Multiple risk factors for PTDM are involved P4 CHARACTERISTICS AND OUTCOME OF DIABETIC PATIENTS ADMITTED WITH ACUTE MYOCARDIAL INFARCTION IN BENGHAZI, LIBYA Abdulwahab M ALBARSHA, Ali M ELNEIHOUM and Abdulghani W ELTURKI Department of Medicine, Faculty of Medicine, Garyounis University and Department of Medicine, The 7th of October Hospital, Benghazi, Libya Introduction: Diabetic patients are two to four times at more risk of developing CAD than nondiabetic patients Diabetes was present in 10-30 of patients with acute myocardial infarction AMI and is associated with increased morbidity and mortality despite thrombolytic therapy Aims: The aim of the study is to
evaluate the demographic features, clinical presentation, in-hospital course and management in diabetic patients with AMI admitted to the coronary care unit CCU of 7th October hospital, Benghazi Materials and methods: A retrospective study in which the medical records of diabetic patients admitted to the CCU with AMI in the year 2005 were reviewed Data collection included demographic data, cardiovascular history, diabetic history, other risk factors, clinical presentation, and clinical course Treatments received at hospital and at discharge were also recorded A comparison was made between diabetics and non-diabetics using statistical analysis with chi-square test Results: A total of 157 patients were admitted to the CCU with AMI 81 patients 516 had diabetes all type 2 for average of 133 89 years There were more females in the diabetic group 32 395 vs 12 16 and the diabetic patients were more likely to be hypertensive 3746 vs 24 32 There was no difference in presenting
symptoms nor in symptom duration between the two groups However the diabetic patients were more likely to present with complications 358 vs 197, p 002 particularly acute heart failure 198 vs 53, p 0005 There was
no difference in treatment prescription between diabetics and non-diabetics both in-hospital and at discharge There was no significant difference in the rate of thrombolytic use between the two groups 54 667 vs 45 592 , p 005 Diabetic patients have longer duration of stay than non-diabetics 69 vs 56 days, p 001 There was no difference in the rate of in-hospital complications or death between the two groups in this hospital setting 10123 vs 9118 Conclusion: Over half of our patients admitted with AMI had diabetes with more risk to present with complications and to have a more prolonged hospital stay than nondiabetics The overall management of diabetic patients with AMI was good with high rates of use of therapies The high rate of diabetes in our cohort, calls for more aggressive management of risk factors in diabetic patients P5 THE INFANT OF DIABETIC MOTHERS IN TRIPOLI MEDICAL CENTER Malak ELAZRAG, Zeinab ESHKURFO, Faiza OSMAN, M Khaled SHAMBESH and Suliman ABUSREWIL Departments of Paediatric Endocrinology and Obstetrics, Tripoli Medical Centre, Tripoli, Libya malakelazrag@hotmailcom Diabetes is an important disease among Libyan pregnant women Infants of diabetic mothers IDM face
multiple proplems which can be avoided by better glycaemic control during pregnancy and good management after delivery In the past, nearly one third of these IDM are lost This study was performed over a period of 18 months 112005 - 3062006 in Tripoli Medical Centre, a secondary and tertiary referral centre for the Tripoli and the western provinces of Libya 122 infants of diabetic mothers were seen This represented a 1 of the total number of babies seen in the neonatal unit 72 of mothers had type 1 diabetes T1DM, 11 had type 2 diabetes T2DM and 17 had gestational diabetes mellitus GDM Fifteen percent of them were prima gravida Hypertension was present in 46 of the mothers 93 was delivered at term and 7 delivered prem The mode of delivery was by caesarean section in 80 and normal vaginal in the remaining 20 The Just under half 47 had macrosomia defined as birth weight of 4 kg No complications were observed in 72 of these infants, whereas, 173 had hypoglycaemia, 11 had respiratory distress syndrome, 22 had high bilirubin 15mg/d No congenital anomalies were detected in this cohort Average stay in the nursery was three days P6 ACCURACY OF FINE-NEEDLE ASPIRATION BIOPSY OF THYROID NODULES
COMBINED WITH AN EVALUATION OF CLINICAL AND ULTRASONOGRAPHIC CHARACTERISTICS Dheba Alamari OHEBA and Ibrahim H SHERIF Department of Medicine, Division of Endocrine and Diabetes, Tripoli Medical Center and Faculty of Medicine, Alfateh University, Tripoli, Libya dr_alamari@yahoocom Background: Thyroid nodules are the commonest thyroid abnormality Despite the fact that most are benign, the fear of malignancy is the principal concern of both the physician and the patient Fine needle aspiration biopsy FNAB cytology is sensitive for detecting malignancies FNAB is an operator interpreter-dependent procedure whose diagnostic accuracy has deficiencies especially in diagnosis the indeterminate results Objectives: We aimed to evaluate the accuracy of FNAB in our hands and to assess the ability of clinical examination and to assess the role of ultrasonography in the preoperative diagnostic management of patients with solitary or dominant thyroid nodules Study Design: this study was performed in Tripoli Medical Center endocrine clinic on 445 patients with thyroid nodules between September 1999 and January 2007 Clinical examination, ultrasound US and FNAB were done for all patients The
clinical factors studied are growth rate, size, consistency, and mobility of lesions US factors such as hypo echoic, ill defined margins, presence of calcifications as described in the literature as high risk for cancer Surgery was performed on 129 patients Clinical, US and cytological findings were correlated with the final results ie histological for these patients Results: In all operated patients, satisfactory smears were obtained 10 of them were repeated several times 2-4 till became satisfactory and classified as benign, suspicious or malignant The clinical factors studied, we found predictive significance for tumor consistency and not for other factors, with clinical sensitivity in detecting malignancy of 777 , The U/S factors as examination were sensitive in detecting malignancy sensitivity of 85,
specificity 566, and diagnostic accuracy of 61 Among the 129 cases, 25 were malignant; the diagnostic yield of FNAB in detection of malignancy in nodular thyroid disease was 77 84 patients were colloid, 17 were follicular adenomas, one was colloid with micro follicular adenoma, one case of Hashimotos thyroiditis, one case was subacute granulmatous thyroiditis FNAB sensitivity
was 40, specificity of 99 and diagnostic accuracy of 875 , false positive results of 1, false negative results of 60 Conclusion: We conclude that the limitations of FNAB are based mainly on the difficulty of differentiation of follicular adenomas from well differentiated follicular carcinomas The high false-negative results in our study may be attributed to sampling errors most malignant lesions were 3cm, to interpretive errors by cytopathologists or the small number of operated patients We suggest that we should combine clinical, ultrasonographic and FNAB to select patients with nodular thyroid disease for surgery P7 PITUITARY AND OTHER INTRASELLAR TUMOURS IN TRIPOLI LIBYA: A STUDY OF AN ENDOCRINE CLINIC POPULATION 1982-2004 Dheba Alamari OHEBA, Laila SEBAII, Najwa RHAYM and Ibrahim H SHERIF Endocrine Division, Medical Department, Tripoli Medical Centre and Faculty of Medicine, Alfateh University, Tripoli, Libya dr_alamari@yahoocom Backgrounds: Pituitary tumours are the most common cause of the syndromes of pituitary hormone hypersecretion and hyposecretion in adults They account for about 10 of all intracranial neoplasms In Libya, data on prevalence and types of tumors in the
pituitary region are lacking Objectives: To determine the types of pituitary tumours, clinical diagnoses, management and outcome in our endocrine clinic population Patients and Methods: This study is a retrospective analysis of all patients with pituitary tumours or lesions in the pituitary area whose records contained the necessary information and who were seen at the endocrine clinic over the past 22 years 1982 2004 A total of 89 records were included in this analysis Data analysed were: age at diagnosis, sex, clinical, radiological diagnosis, types of tumours, functional status of the tumour, type and complication of surgery and pituitary hormone deficiency Results: The mean age of the patients was 356137 range 675 years The majority were in the age group 17-38 years There were 45 females and 44 males Twenty seven of these tumours were non-functioning 303 and 24 tumors were prolactinsecreting 27 of whom 18 were females Twenty tumours were growth hormonesecreting 225 of whom 13 were males 7 were craniopharyngiomas 79 and the remaining were other lesions 56 cases were classed radiologically as macroadenomas 629 with suprasellar extension in 13 of them There were 22 micro-adenomas
247, 2 empty sella syndrome 22, a single acase of hypothalamic tumour Interesting observations include a single case of full blown Cushing disease with normal MRI findings, a case of long standing primary hypothyroidism with secondary pituitary enlargement who was referred as pituitary tumor, and a case of true TSH-secreting pituitary adenoma Surgery was performed for 53 595 patients [29 patients had transcranial surgery 326, 10 patients had transsphenoidal surgery 112, one patient had bilateral adrenalectomy for Cushing disease In 14 patients 157, the type of surgery could not be ascertained Interestingly, 2 cases of presumed tumours were confirmed histopathlogically to be granulomatuos disease sarcoidosis and one case had pituitary adenocarcinoma 38 patients 426 had hypopituitarism of whom 26 patients developed panhypopituitarism postoperatively One patient had developed hypopituitarism following radiotherapy 24 patients 269 are still on regular follow up and 17 patients had been followed for periods between 310 years,17 cases had been followed for less than 2years 29 patients 325 were lost to follow up and 2 cases were confirmed dead one of them of because of Bronchogenic
carcinoma Conclusion: In this single clinic series, non functioning pituitary tumours were the commonest; men and women were affected almost equally Women were predictably seen more often for prolactin- secreting tumours On the other hand; GH secreting tumors, non functioning pituitary tumors and craniopharyngiomas affected more men Macroadenomas occur more frequent than microadenomas among our patient population probably reflecting the referral pattern and macroadenomas were seen more in men Panhypopituitarism at presentation, reflecting the mass effect, was less often and affected more males P8 PATTERN OF PITUITARY ADENOMA IN BENGHAZI, LIBYA Rafik R ELMEHDAWI, A A AZIZ and Ahmed M SWALEM
Department of Medicine, Faculty of Medicine, Garyounis University and Department of Medicine, 7th of October Hospital, Benghazi, Libya E-mail: Rafikal2000@yahoocom Introduction: Pituitary adenomas are the most common cause of pituitary hormone hypersecretion and hyposecretion syndromes in adults They account for around 10 of all intracranial neoplasms Objectives: to evaluate the frequency of different types of pituitary adenomas and their clinical characteristics among patients attending an
endocrine clinic in Benghazi Materials and methods: A retrospective analysis of patients records between 1988 and 2004 was conducted Results: Over a period of 16 year, 90 subjects were diagnosed to have pituitary adenoma 756 were females and 244 were males 567 of the patients had macroadenoma and 433 had microadenoma Prolactin secreting adenoma was the most common pituitary mass lesion 722 Headache was the most common symptom present in 70of patients of whom 70 had macroadenoma In 40 of the patients, the headache was accompanied by visual disturbances, however in most of the cases the headache was due to different problem rather than due to the adenomas 30 of female patients presented with amenorrhea and 20 with oligomenorrhoea, while 45 of the males presented with impotence Conclusion: Functioning pituitary adenoma constitutes more than 90 of cases Prolactin secreting pituitary adenoma is the most common pituitary mass lesion Females represent more than 2/3 of cases in most types of pituitary adenomas Our results are consistent with most of the published data world wide P9 THE HOSPITALIZATION PATTERN OF PATIENTS WITH DIABETES IN ABU DHABI, UNITED ARAB EMIRATES 2000-2006 Salem A
BESHYAH and Mahmoud M BENBARKA Division of Endocrinology, Department of Medicine, Sheikh Khalifa Medical City, POBox 51900, Karamah Street, Abu Dhabi, United Arab Emirates E-mail: beshyah@yahoocom Backgrounds: Diabetes mellitus DM is increasingly becoming a major public health issue in many newly developed countries and particularly in the United Arab Emirates UAE where over 24 of the UAE nationals have diabetes The Sheikh Khalifa Medical City SKMC had had a clear admission policy and a fully computerized medical records system since its inception in 2000 Access to this database allowed a golden opportunity to study the hospitalization pattern and assess the contribution of different disease processes to the overall morbidity and mortality Objectives: We aimed to 1 describe the contribution of diabetes to admissions to hospital, 2 crudely assess the outcome of hospitalization episodes of people with diabetes ie leaving the hospital alive or dying in hospital and 3 attempt to identify the speciality- based DM-related clinical activities Methods and Patients: This is a descriptive retrospective study The computerized records of the SKMC were accessed to extract data sets for the
period between 122000 and 3172006 specifically for those with diabetes as a primary or secondary diagnosis There were a total 51,169 episodes during the study period Their data describing age, gender, admission source, length of stay, diagnosis, speciality and outcome were analysed Results: The proportion of diabetic patients of the total admissions was 191 for the whole period There was a linear trend of 158, 177, 191, 178, 186, 205 and 215 over the years 2000 to 2006 The average length of stay was 109, 107 and 77 median: 5, 4 and 3 days for those patients with DM as a primary diagnosis, those with DM as a secondary diagnosis and the total patient population respectively Diabetes was the primary diagnosis in 1,227 patients 671 men 556 women with a mean age of 425 years There was 193 patients younger than 12 years; 138 aged 12-20, 121 aged 21-30 years, 61 aged 30-40 years, 122 aged 40-50 years, 239 aged 50-60 years, 206 aged 60-70 years, 101 aged 71-80 and 46 over 80 years of age They were mainly UAE-nationals 1066 They were admitted from the emergency room 873; directly from home 198; clinic 38 or other sources 29 Reasons for admissions were attributed to diabetes per se ie
hyperglycaemia 90, ketoacidosis 291, other comas 7 Other causes included cardiovascular disorders 92, ophthalmic 76, renal 88, neuropathic 30 and other specific problems 57 The majority were discharged home 1146 Others were either transferred elsewhere 16, left against medical advise 39 or died in hospital 26 Those who died in hospital were 688 years of age and spent a median of 30 days in hospital 1-208 days mostly under general medicine 13 and critical care 8 dying of cardiovascular 9, renal 7, metabolic 6 or other 3 complications In the ketoacidosis subgroup, 84 episodes occurred in children 12 years On the other hand, diabetes was a secondary diagnosis in 8,540
patients 3,494 women; 2,794 UAE nationals Their mean age was 584 median 590 years Age distribution was as follows: 43 younger than 12; 34 between 12-20; 265 aged 21-30; 375 aged 31-40; 1426 between 41-50; 2443 were 51-60 years; 2331 were 61-70; 1209 were 71-80 and 609 patients were older than 80 years of age They were admitted as a medical emergency 6018, directly from home 2318 or from clinic 109 or other routes 95 Patients were admitted under general internal medicine 3114, cardiology 2302, haematology 1808,
nephrology 454, general surgery 388, Ophthalmology 362, neurological sciences 262, medical and surgical oncology 304; Urology 124, critical care 160, gastroenterology 136, respiratory medicine134, vascular surgery 124, plastic surgery 114, ENT 60, Rehabilitation Medicine33, Thoracic Surgery 24, Rheumatology 23 endocrinology 13, dermatology 4, Infection disease 3 Of this group the majority were discharged home well 3968, left against medical advise 166, were transferred elsewhere 374 and 330 died in hospital aged 654 years having been under general 138, intensive care 103, special medicine 31 cardiology 25 and surgical care 33 for average period of 44o days [median 114 1-1805 days] Conclusions: Diabetes is an increasing cause for hospitalization affecting particularly middle-aged adults This mainly reflects medical and cardiovascular complications of diabetes
Source:ljm.org.ly
