Do we achieve LDL-cholesterol targets in routine clinical practice? Evidence from a tertiary care hospital in Sri Lanka

Background: Statins are widely used for primary and secondary prevention of cardiovascular disease (CVD). European Society of Cardiology / European Atherosclerosis Society (ESC/EAS) guidelines recommend LDL-cholesterol targets based on CVD risk.Objectives: This study aimed to determine whether LDL-cholesterol targets recommended by2016 ESC/EASare achieved in routine clinical practice.Methods: This paper is based on baseline data of patients recruited to a controlled clinical trial conducted at a tertiary care hospital. Participants have been on atorvastatin for >2 months. Demographic and clinical data were obtained using clinic records and interviewer administered questionnaires. LDL-cholesterol was assessed using Friedewald equation (when triglyceride was <400mg/dL) or by direct measurement (when triglyceride was ≥400mg/dL). Each participant’s CVD risk level and appropriate LDL-cholesterol target (very-high CVD risk:<70mg/dL; high CVD risk:<100mg/dL; low to moderate CVD risk:<115mg/dL) was determined according to 2016 ESC/EAS Guideline.Results: 101 patients were studied. (Women: 76.2%; mean-age: 61.2:±9.3years). Prevalence of coronary heart disease, ischaemic stroke, diabetes, hypertension and smoking was 30.7%, 4%, 77.2%, 80.2% and 4%, respectively. According to CVD risk level 80.2%, 15.8% and 4% were in very-high, high and moderate risk categories, respectively. Most were on atorvastatin 10mg (45.5%) followed by 20mg (43.6%), 40mg (8.9%), 30mg (1%) and 5mg (1%). Median duration of treatment was 41-months. Overall, only 12.9% had achieved target LDL-cholesterol (very-high risk: 7.4%; high risk: 37.5%, moderate risk: 25%; p=0.003). Men did better than women in achieving target LDL-cholesterol (men: 29.2%, women: 7.8%; p=006). There was no difference based on age, comorbidities or atorvastatin dose.Conclusions: In the study population majority has failed to achieve LDL-cholesterol targets recommended by 2016 ESC/EAS. Failure to achieve targets was more common among women and those having very-high CVD risk. Reason for suboptimal target achievement has to be studied further.Acknowledgement: Funded by University of Sri Jayewardenepura Research Grant (ASP/01/RE/MED/2015/54) and Ceylon College of Physicians Research Grant (2014)

Diabetic patients; their knowledge, practices and attitudes regarding oral health

Objectives: To assess the knowledge, attitudes and practices regarding oral health among patients attending the diabetic clinic at Colombo South Teaching HospitalMethods: A descriptive cross-sectional study among 427 patients attending the diabetic clinic was carried out using an interviewer administered pretested questionnaire.Results: Of the 427 patients, majority (74%) were females above 50 years of age. Of the patients 56% recognized an association between diabetes and oral health. Only 15% knew that they were more prone to oral fungal infections due to diabetes though 89% knew that diabetes resulted in delayed wound healing. Oral cancer (72%) was mainly recognized as a complication of poor oral hygiene but majority were unaware of the risk of endocarditis. Regarding attitudes, 98% believed that diabetics should be vigilant regarding their oral hygiene. While 29% believed that a dentist should be visited at least twice a year, only one patient practiced this. A majority (93%) was of the attitude that brushing teeth twice a day is important to maintain good oral hygiene and 92 % claimed to practice this. Overall study population had moderate knowledge (64%) good attitudes (77%) and moderate practices (73%) with regard to their oral health. All patients were willing to receive advice and information regarding oral hygiene or be directed to relevant dental clinics during their diabetic clinic visit.Conclusions: Educating diabetics regarding oral health is a timely need as diabetes is a major health burden in Sri Lanka.

Development and validation of a reference marker for identification of aerobic and anaerobic bacteria associated with diabetes chronic wound ulcers using PCR denaturing gradient gel electrophoresis

Introduction: Diabetes chronic wounds consist with a diverse microbial community and unculturablespecies may be highly prevalent.Objectives: This study aimed to establish a bacterial reference marker consisting of a group ofchronic wound related bacteria, using polymerase chain reaction-denaturing gradient gelelectrophoresis (PCR-DGGE) for profiling of bacteria in diabetes chronic wound infections.Methods: DNA was extracted from the known wound bacterial strains. PCR–DGGE was performedusing eubacterial specific primers targeting V2-V3 region of 16S rDNA. DGGE was performed usinga 30-55% denaturing gradient. Migration position of each organism was detected on DGGE gel andimportant organisms were selected. Equal volume from PCR products of each selected organism wasmixed, diluted with gel loading dye in 1:1.5 ratio and used for all DGGE gels. The ladder was thensubjected to species identification of fifteen tissue debridement specimens obtained from diabeteschronic wound ulcers. The identification efficacy was tested by sequencing.Results: DNA of bacterial pathogens which showed different migration distances on the gel werecombined and used as a reference panel. This bacterial ladder consisted of eleven different bacterialspecies including Bacteroides sp., S. aureus, Acineto bacter sp., P. aeruginosa, Streptococcus Group Aand Group B sp., E. faecalis, Providencia sp., Veillonella sp., E .coli and Enterobacter sp. Accordingto the reference panel, Pseudomonas species were abundant. Further the results were confirmed bysequencing.Conclusion: Reference marker allows comparative analysis of DGGE patterns and can be used as atool for presumptive identification of polymicrobial microbiota in chronic wound infections

Coexistence of Primary Hyperaldosteronism and Graves’ Disease, a Rare Combination of Endocrine Disorders: Is It beyond a Coincidence—A Case Report and Review of the Literature

Background. Primary hyperaldosteronism is a known cause for secondary hypertension. In addition to its effect on blood pressure, aldosterone exhibits proinflammatory actions and plays a role in immunomodulation/development of autoimmunity. Recent researches also suggest significant thyroid dysfunction among patients with hyperaldosteronism, but exact causal relationship is not established. Autoimmune hyperthyroidism (Graves’ disease) and primary hyperaldosteronism rarely coexist but underlying mechanisms associating the two are still unclear. Case Presentation. A 32-year-old Sri Lankan female was evaluated for new onset hypertension in association with hypokalemia. She also had features of hyperthyroidism together with high TSH receptor antibodies suggestive of Graves’ disease. On evaluation of persistent hypokalemia and hypertension, primary hyperaldosteronism due to right-sided adrenal adenoma was diagnosed. She was rendered euthyroid with antithyroid drugs followed by right-sided adrenalectomy. Antithyroid drugs were continued up to 12 months, after which the patient entered remission of Graves’ disease. Conclusion. Autoimmune hyperthyroidism and primary hyperaldosteronism rarely coexist and this case report adds to the limited number of cases documented in the literature. Underlying mechanism associating the two is still unclear but possibilities of autoimmune mechanisms and autoantibodies warrant further evaluation and research