Delta Cortisol and Adrenal Insufficiency

The ACTH stimulation test is used to diagnose adrenal insufficiency (AI). This study evaluated the diagnostic performance of serum delta cortisol from ACTH stimulation tests and determined appropriate cut-off levels of serum 30-minute delta cortisol for the diagnosis of AI, allowing a reduction in the number of 60-minute cortisol tests. A 6-year retrospective study in 471 patients was conducted. The performance of the serum delta cortisol in diagnosing AI was assessd using a multivariable logistic regression model and the area under ROC curves (AuROC). Both serum 30-minute and 60-minute delta cortisol demonstrated equally high diagnostic accuracy for AI (AuROC for LDT : 0.91 vs 0.90 ; HDT : 0.91 vs 0.92, respectively). The 30-minute delta cortisol test was chosen to develop proposed diagnostic cut-off levels due to its simplicity. The proposed lower cut-off level for 30-minute delta cortisol was Δ 11.8 μg/dL for LDT and Δ > 10.5 μg/dL for HDT. These cut-off levels yielded high sensitivity and specificity > 90%. The 30-minute serum delta cortisol using the proposed cut-off levels provides diagnostic performance for AI equal to that of the 60-minute test and is more convenient, requires less time, less invasive and is cost-saving

Time to Treatment Intensification to Reduce Diabetes-Related Complications: A Post Hoc Study

Patients with type 2 diabetes mellitus (T2DM) can be affected by clinical inertia, leading to abysmal results. Studies on a suitable timeframe for treatment intensification remain scarce—especially outside of developed countries. This study aimed to explore the association between time to treatment intensification and diabetes-related complications. A database from a tertiary care hospital in Thailand was retrieved in order to conduct a retrospective cohort study for the years 2011–2017. This study comprised outpatients with T2DM presenting an HbA1c of ≥7.0%. Eligible patients were divided into three groups based on the time of treatment intensification: no delayed treatment intensification, treatment intensification within 6 months, and treatment intensification after 6 months. A Cox proportional hazards model was used to investigate the association between time to treatment intensification and diabetes-related complications. A total of 686 patients were included in the final analysis. During 6.5 years of median follow-up, the group with treatment intensification within 6 months was more strongly associated with diabetic nephropathy compared to the group with no delayed treatment intensification (adjusted HR 2.35; 95%CI 1.35–4.09). Our findings reveal that delaying treatment intensification by even 6 months can increase the likelihood of diabetic nephropathy compared to no delayed treatment intensification. We suggest that patients with T2DM whose blood glucose levels are outside the target range promptly receive treatment intensification

Effect of Clinical Inertia on Diabetes Complications among Individuals with Type 2 Diabetes: A Retrospective Cohort Study

Background and Objectives: Clinical inertia is a key obstacle that leads to suboptimal care in patients with type 2 diabetes mellitus (T2DM). It can occur at any stage of T2DM treatment. However, the effect of clinical inertia on diabetes complications has not been studied sufficiently. This study aimed to evaluate the effect of clinical inertia on the risk of diabetes complications among patients with T2DM. Materials and Methods: A retrospective cohort study was conducted at a tertiary teaching hospital in Thailand between 2011 and 2017. Outpatients with T2DM, aged 40–65 years, presenting an HbA1c greater than 7% were included in this study. Clinical inertia was identified when patients did not get treatment intensification at the index date and a subsequent prescription. The association between clinical inertia and diabetes complications, including a composite of macrovascular complications and a composite of microvascular complications, was determined using a Cox proportional hazard model. Propensity score methods were applied, to control confounding by indication. Results: Of 686 patients with T2DM, 165 (24.0%) experienced clinical inertia. Baseline low-density lipoprotein cholesterol, blood pressure, body mass index, the estimated glomerular filtration rate, and medication between the two groups did not differ significantly. Our study found that clinical inertia was associated with a significantly increased risk of diabetic nephropathy (adjusted HR 1.51, 95% CI 1.01–2.27). The results remained the same as when using propensity score methods. According to the post hoc analysis, lowering the HbA1c levels by 1% results in a significant decrease in the rate of diabetic complications (adjusted HR 0.92, 95% CI 0.86–0.99), the composite of microvascular complications (adjusted HR 0.91, 95% CI 0.84–0.98) and diabetic nephropathy (adjusted HR 0.89, 95% CI 0.80–0.98). Conclusions: Our results demonstrated a significant effect of clinical inertia on diabetic nephropathy. Patients with an HbA1c level over the target range should have their medication intensified to reduce the risk of diabetic nephropathy

Biphasic insulin aspart 30 treatment for people with type 2 diabetes: a budget impact analysis based in Thailand

<p><b>Objective:</b> To assess the financial consequences of different adoption rate of Biphasic Insulin Aspart (BIAsp) 30 instead of Biphasic Human Insulin (BHI) 30 for people with type 2 diabetes (T2DM) in Thailand from the payer’s perspective.</p> <p><b>Methods:</b> The Excel-based International T2DM Budget Impact Model over a 3-year period was used. The cohort was the T2DM patients who received treatment from government hospitals under the Universal Health Coverage Scheme. Demographic, the adverse events, and the costs were derived from published studies in Thailand. Efficacy was based on meta-analysis. Adoption rates were assumed to increase each year. Net budget impact (NBI) and one-way sensitivity were analyzed.</p> <p><b>Results:</b> Hypoglycemia costs were lower in BIAsp 30 compared with BHI 30. The NBI per year was 26,511,269 THB (771,349 USD) for year 1, 52,181,133 THB (1,518,218 USD) for year 2, and 76,189,608 THB (2,216,747 USD) for year 3. The NBI per insulin user per year was 33.45 THB (0.97 USD), 67.27 THB (1.96 USD), 101.49 THB (2.95 USD) from year 1 to year 3, respectively</p> <p><b>Conclusions:</b> Lower rate of hypoglycemia with BIAsp 30 than those treated with BHI 30 generates cost savings resulting in significant deduction in the additional acquisition cost of BIAsp 30. Therefore, the NBI per insulin user per year has become small.</p

Incidence and clinical outcomes of diabetes mellitus in HIV-infected adults in Thailand: a retrospective cohort study

Abstract Background Since 2005, Thailand has scaled up one of the largest antiretroviral treatment (ART) programs in South East Asia. Although diabetes mellitus (DM) incidence is increasing in low and middle-income countries, its burden and contributing factors in the HIV infected population are not well known. Methods Using the Thai National AIDS Program data over a period of 8-years, we identified patients diagnosed with DM based on the following records: 1) fasting plasma glucose equal to or greater than 126 mg/dl following the 2013 American Diabetes Association criteria or 2) diagnosis codes E11-E14 of the 2010 WHO International Classification of Diseases, or 3) anti-diabetic drugs. Incidence was the number of new cases divided by that of person-years of follow-up (PYFU). Competing risks survival regression, treating death without DM as a competing event, was used to identify factors associated with DM. The risk of death in patients diagnosed with DM was estimated using Cox regression models. Results Data of 763,666 PYFU from 199,707 patients (54.2% male; median age 36.2 years at registration with the program) were available and 8383 cases were diagnosed with DM, resulting in an incidence rate of 11.0 per 1000 PYFU. New DM diagnosis was more likely in men (adjusted sub-distribution hazard ratio 1.2), older patients (compared to patients 18 to 34 years old: 1.8 for 35 to 44; 3.0 for 45 to 59; 3.8 for ≥60), and if ART was initiated (1.3). In 2014, 1313 (16.6%) of 7905 diabetic patients had DM complications (11.5% microvascular complications and 6.9% macrovascular complications). Patients diagnosed with DM were at higher risk of death compared to the others. Conclusions DM incidence was higher in this Thailand cohort of HIV infected adults than in the general population. Risk factors were similar to those in the general population, in addition to starting ART

Additional file 1: Table S1. of Safety and efficacy of intralesional steroid injection for aggressive fibromatosis

Subjective interviews with patients regarding unfavorable side effects from steroid use. Swelling of extremities was the only positive presentation during or after the ILSI procedure. Table S2. Blood pressure change before and after procedure. Table S3. Fasting blood sugar before and after procedures. Table S4. Morning cortisol level and ACTH stimulation test. Figure S1. Serum triamcinolone level 24 h after intralesional steroid injection. (DOC 124 kb