Vitamin D deficiency

Vitamin D deficiency is common and may contribute to osteopenia, osteoporosis and falls risk in the elderly. Screening for vitamin D deficiency is important in high-risk patients, especially for patients who suffered minimal trauma fractures. Vitamin D deficiency should be treated according to the severity of the deficiency. In high-risk adults, follow-up serum 25-hydroxyvitamin D concentration should be measured 3–4 months after initiating maintenance therapy to confirm that the target level has been achieved. All patients should maintain a calcium intake of at least 1,000 mg for women aged ≤ 50 years and men ≤ 70 years, and 1,300 mg for women > 50 years and men > 70 years.     

Incipient non-arteritic anterior ischaemic optic neuropathy: a distinct clinical entity,the Singapore scene 3

We report five cases of non-arteritic anterior ischaemic optic neuropathy (NA-AION) where spontaneous resolution of the optic disc swelling occurred, and all relevant visual modalities were normal at presentation and remained so until resolution of the process after a median time of 9.6 weeks. This condition, which can be termed ‘incipient NA-AION’ or ‘threatened NA-AION’, should be recognised so that unnecessary investigations for other and more serious causes of optic disc swelling can be prevented.     

Comparison of two regimens of vitamin D supplementation for vitamin D-deficient neonates

INTRODUCTION

Vitamin D deficiency is common in pregnant women, and supplementation of vitamin D is necessary for the infants of these women. This study explored the efficacy of an alternative way of vitamin D supplementation in an area with a high prevalence of vitamin D deficiency in mothers.

METHODS

This was a non-randomised clinical trial conducted in 2010 in Yazd, Iran. Full-term healthy infants born to vitamin D-deficient mothers (n = 82) were divided into the high-dose regimen (HDR; single oral bolus 30,000 IU vitamin D₃, n = 34) and the standard-dose regimen (SDR; 400 IU/day vitamin D₃ within two weeks of life, n = 48) groups. 25-hydroxyvitamin D (25OHD) was measured using chemiluminescent immunoassays, and 25OHD level > 20 ng/mL was deemed sufficient.

RESULTS

Over 90% of infants in the HDR group attained vitamin D sufficiency within one month, while comparable sufficiency was reached in the SDR group only after four months. At two months, the proportion of infants attaining 25OHD > 30 ng/mL was 93.3% and 27.9% in the HDR and SDR groups, respectively (p = 0.003). None of our infants achieved 25OHD levels > 100 ng/mL.

CONCLUSION

For infants born to vitamin D-deficient mothers, oral supplementation of 30,000 IU vitamin D₃ during the first month of life, followed by a routine recommended dose of 400 IU/day, should be considered. The four-month lag for attaining vitamin D sufficiency in 90% of infants in the SDR group may have clinical implications and should be further investigated.     

Predictors of major lower limb amputation among type II diabetic patients admitted for diabetic foot problems

INTRODUCTION

Diabetes mellitus (DM) is the most common cause of amputations in Malaysia. This study aimed to identify the predictive factors for major lower limb amputation among patients with type 2 DM (T2DM) who were admitted to a hospital, in order to reduce its likelihood.

METHODS

This cross-sectional study involved 218 patients with T2DM who were admitted to Hospital Tengku Ampuan Afzan, Kuantan, Malaysia, for diabetic foot problems from June 2011 to July 2012. A form was developed to document the patients’ profiles, comorbidities, complications, investigations, treatment and clinical outcomes. The predictors for major lower limb amputations were determined using univariate and stepwise logistic regression analysis.

RESULTS

A total of 31 patients underwent major lower limb amputations (25 transtibial, 6 transfemoral). The following factors were found to be associated with the incidence of major lower limb amputations: T2DM duration ≥ 10 years, diabetic neuropathy, diabetic nephropathy, presentation with gangrene, diabetic foot conditions of Wagner grade 4 or 5, and necrotising fasciitis. Patients who underwent major amputations had significantly lower haemoglobin and albumin levels, and higher total white blood cell counts, erythrocyte sedimentation rates, and C-reactive protein, urea and creatinine levels. However, only T2DM duration ≥ 10 years, positive bacterial culture and albumin levels were significant on stepwise logistic regression analysis.

CONCLUSION

T2DM duration ≥ 10 years, positive bacterial culture and low albumin levels were found to be significant predictive factors for major lower limb amputation among patients with T2DM admitted for diabetic foot problems.     

Effects of vitamin A,C and E,or omega-3 fatty acid supplementation on the level of paraoxonase and arylesterase activity in streptozotocin-induced diabetic rats: an investigation of activities in plasma,and heart and liver homogenates

INTRODUCTION

This study was designed and conducted to evaluate the effects of vitamin A, C and E supplementation, and omega-3 fatty acid supplementation on the activity of paraoxonase and arylesterase in an experimental model of diabetes mellitus.

METHODS

A total of 64 male Sprague Dawley^® rats, each weighing 250 g, were randomly distributed into four groups: (a) normal control; (b) diabetic control; (c) diabetic with vitamin A, C and E supplementation; and (d) diabetic with omega-3 fatty acid supplementation. The animals were anaesthetised after four weeks of intervention, and paraoxonase and arylesterase activity in blood plasma, and liver and heart homogenates were measured.

RESULTS

Arylesterase activity in the heart and liver homogenates was significantly lower in the diabetic control group than in the normal control group (p < 0.01). Vitamin A, C and E supplementation, and omega-3 fatty acid supplementation significantly increased liver arylesterase activity (p < 0.05). No significant change was observed in paraoxonase activity and other investigated factors.

CONCLUSION

Vitamin A, C and E, or omega-3 fatty acid supplementation were found to increase liver arylesterase activity in streptozotocin-induced diabetic rats. These supplements may be potential agents for the treatment of diabetes mellitus complications.     

Unusual optic disc infarction in a case of arteritic anterior ischaemic optic neuropathy (AAION)

Herein, we report another case of arteritic anterior ischaemic optic neuropathy from Singapore, in which the initial optic disc swelling was extreme and the sequential disease resolved because the patient was already on maximum treatment. As the management of this biopsy-proven giant cell arteritis case was complicated by the presence of a number of other medical conditions, including end-stage renal failure, monitoring of the response to treatment proved problematic.     

Magnetic resonance imaging of diabetic foot complications

This pictorial review aims to illustrate the various manifestations of the diabetic foot on magnetic resonance (MR) imaging. The utility of MR imaging and its imaging features in the diagnosis of pedal osteomyelitis are illustrated. There is often difficulty encountered in distinguishing osteomyelitis from neuroarthropathy, both clinically and on imaging. By providing an accurate diagnosis based on imaging, the radiologist plays a significant role in the management of patients with complications of diabetic foot.     

糖尿病性周围神经病的治疗

糖尿病性周围神经病(DPN)是糖尿病最常见的神经系统并发症,发病机制尚未完全明了,治疗以针对发病机制的病因治疗和对症治疗为主。但随着对发病机制认识的不断加深,出现了一些新的治疗方法,针对不同发病机制进行综合性治疗可能是未来的研究方向。文章就DPN的常用治疗方法及其新进展进行综述。     

糖尿病性周围神经病的治疗

糖尿病性周围神经病(DPN)是糖尿病最常见的神经系统并发症,发病机制尚未完全明了,治疗以针对发病机制的病因治疗和对症治疗为主.但随着对发病机制认识的不断加深,出现了一些新的治疗方法,针对不同发病机制进行综合性治疗可能是未来的研究方向.文章就DPN的常用治疗方法及其新进展进行综述.     

多伦多临床评分系统在糖尿病周围神经病变中的应用价值

目的：评价多伦多临床评分系统（Toronto clinical scoring system，TCSS）及其神经病变分级在糖尿病周围神经病变（DPN）中的应用价值，探讨TCSS神经病变分级与糖尿病肾病、糖尿病视网膜病变分期之间的关系。方法：对209例2型糖尿病患者均进行TCSS检查，以神经电生理检查作为诊断DPN的金标准，与TCSS≥6分的结果进行比较，确定在该人群中TCSS诊断DPN的合适截断点。结果：TCSS≥6分的诊断正确率、灵敏度、特异度分别为76．6％，77．2％，75．6％，对应的约登指数及Kappa值分别为0．53及0．52，提示TCSS≥6分与神经电生理检查的一致性较好；TCSS神经病变分级与糖尿病肾病、糖尿病视网膜病变的分期呈线性正相关（P〈0．05）；该评分合适的截断点为5分或6分。结论：TCSS对DPN的诊断价值较高，其神经病变分级有临床应用价值。     

泌汗功能检测对糖尿病周围神经病变的早期诊断价值

目的 评估汗印法检测周围自主神经泌汗功能对2型糖尿病周围神经病变(DPN)早期诊断的价值.方法 采用密歇根糖尿病神经病变积分(DNS)将98例住院2型糖尿病患者分为有周围神经病变组(DN组)和无周围神经病变组(DC组),40例健康人志愿者为对照组(NC组).采用汗印法诊断膏贴(欧米诺,德国Miro VerbaDNStofie GmbH公司)对3组进行周围自主神经泌汗功能评估,观察3组膏贴变色时间,计算汗印法相对于DNS检测结果的灵敏度和特异度及变色时间与DNS评分的相关性.结果 NC、DC、DN组平均变色时间(min)分别为4.0±0.6、4.3±1.2和23.0±6.1,3组间比较均有显著性差异(P＜0.05).使用汗印法诊断膏贴DPN检出率为62.2%,高于DNS测得的57.1%(P＞0.05).相对于DNS评分法,汗印法诊断DPN的灵敏度为92.8%,特异度为78.5%,阳性预告值为93.2%,阴性预告值78.6%,诊断符合率达86.7%.DNS评分与汗印法诊断膏贴变色时间呈显著正相关(r=0.46,P＜0.05).结论 汗印法是一种客观、简易、可靠的检测方法,对糖尿病患者足部泌汗功能的检测有助于预测和早期发现DPN;汗印膏贴的量化特点可能用于评估DPN的严重程度.     

Association between the use of gel pads under patients’ knees and the incidence of peroneal neuropathy following liver transplantation

INTRODUCTION

There have been intermittent reports of peroneal neuropathy (PN) occurring after liver transplantation. Although PN may not be viewed as a serious complication by liver transplant (LT) recipients who require the transplant for survival, PN can significantly reduce quality of life. The incidence of PN appears to have increased after the use of gel pads was introduced. These gel pads, which are placed under patients’ knees during surgery, are used to reduce lower back strain and prevent contact between the peroneal nerve at the fibular head and the hard surface of the operating table. The aim of the present study was to investigate the association, if any, between the use of gel pads and the incidence of PN.

METHODS

The medical records of 261 adult LT recipients were retrospectively reviewed. The recipients were divided into gel pad (n = 167) and non-gel pad (n = 94) groups. The incidence and possible risk factors of PN were compared between the two groups.

RESULTS

The overall incidence of PN was 8.0% (21/261). The occurrence of PN was significantly higher in the gel pad group than in the non-gel pad group (10.8% vs. 3.2%; p < 0.05). Other possible risk factors were comparable between the two patient groups.

CONCLUSION

As the use of gel pads may increase the incidence of PN, we recommend against the use of gel pads under the knees of LT recipients.     

Advances in the management of diabetic macular oedema based on evidence from the Diabetic Retinopathy Clinical Research Network

The Diabetic Retinopathy Clinical Research Network (DRCR.net) performs studies on new treatments for diabetic retinopathy. This review aims to summarise recent findings from DRCR.net studies on the treatment of diabetic macular oedema. We performed a PubMed search of articles from the DRCR.net, which included all studies pertaining to the treatment of diabetic maculopathy. The main outcome measures were retinal thickening as assessed by central subfield thickness on optical coherence tomography and improvement of visual acuity on the Early Treatment Diabetic Retinopathy Study (ETDRS) chart. Findings from each study were divided into modalities of treatment, namely photocoagulation, bevacizumab, triamcinolone, ranibizumab and vitrectomy. While modified ETDRS focal/grid laser remains the standard of care, intravitreal corticosteroids or anti-vascular endothelial growth factor agents have also proven to be effective, although they come with associated side effects. The choice of treatment modality for diabetic macular oedema is a clinical judgement call, and depends on the patient’s clinical history and assessment.     

依帕司他联合前列地尔治疗糖尿病周围神经病变的临床观察

目的：观察依帕司他联合前列地尔治疗糖尿病周围神经病变（DPN）的疗效。方法：将76例DPN患者随机分为2组：治疗组39例,静脉滴注前列地尔10μg／d,口服依帕司他3次／天,每次50mg;对照组37例,口服维生素B1,每次10mg,3次／天代替依帕司他,其余同治疗组。2组均治疗4周。记录治疗前后主症状、体征及肌电图的改变。结果：治疗组临床疗效和神经传导速度改善均优于对照组（P〈0．01）。结论：依帕司他联合前列地尔治疗DPN安全有效,且临床疗效优于维生素B,联合前列地尔。     

糖尿病周围神经病变的外科治疗

 糖尿病周围神经病变(diabetic peripheral neuropathy,DPN)是糖尿病最常见的慢性并发症之一,占糖尿病患者总数的50%,其中最常见的类型是远端对称性多发性神经病变。疼痛是最突出的症状之一,也可出现感觉丧失、足溃疡、坏疽甚至截肢等。DPN病程通常不可逆转,非手术治疗虽然是标准治疗,但效果通常不显著。对于保守治疗无效的DPN患者,周围神经减压术提供了一种新的治疗方法。     

中医药治疗糖尿病周围神经病变

中医认为,糖尿病周围神经病变（DPN）的病因病机主要是气虚、阴虚、瘀血、痰浊等。主要采用中药制剂包括中药汤剂、中成药、中医注射液、针灸、中药外治以及联合治疗的方法,具有一定优势。但在临床资料收集、研究方法、疗效评价、研究深度上还存在不足。今后,应更加积极规范地开展中医药治疗该病的临床实验与基础研究。     

Vitamin D deficiency remains prevalent despite increased laboratory testing in New South Wales,Australia

INTRODUCTION

The aim of the present study was to assess the prevalence of vitamin D deficiency and toxicity, the frequency of 25-hydroxyvitamin D (25[OH]D) testing, and 25(OH)D variations with respect to patient gender, patient age and season in New South Wales, Australia.

METHODS

A retrospective analysis of pathology records was performed to ascertain patient age, patient gender, sample collection date, plasma or serum 25(OH)D levels, calcium and parathyroid hormone (PTH) levels, and test numbers between 2001 and 2010. Linear regression with Bonferroni correction was used to calculate and compare age- adjusted mean 25(OH)D levels. Relationships of 25(OH)D with PTH and calcium were tested using Spearman’s rank correlation.

RESULTS

25(OH)D testing increased by 730% over the ten-year study period. In 2010, many men (33%) and women (40%) were, to some degree, vitamin D deficient (≤ 50 nmol/L). Vitamin D toxicity was rare, with only one instance noted. 25(OH)D levels correlated positively with calcium and negatively with PTH levels. 25(OH)D levels decreased with age. In 2010, 25(OH)D levels were highest in February and lowest in September/October. Cyclical variation was observed for 25(OH)D levels between 2006 and 2010.

CONCLUSION

We found that vitamin D deficiency was prevalent in both men and women, with a higher prevalence in the latter, despite the substantial increased demand for 25(OH)D testing in our population over the decade. Vitamin D deficiency was associated with elevated PTH levels. Vitamin D toxicity was rare and only observed once during our study period. 25(OH)D levels decreased with age and varied with season, with the highest levels observed in late summer and the lowest in early spring.     

Xiaokening stimulates endothelial nitric oxide release in diabetic rats

INTRODUCTION

Diabetes mellitus induces microangiopathic changes that lead to endothelial dysfunction. This study investigated the effect of Xiaokening, a type of Chinese compound medicine, on the mesenteric arteriolar endothelial cell function of diabetic rats and its underlying mechanism.

METHODS

Diabetes mellitus was induced in rat models via intraperitoneal injection of 60 mg/kg streptozotocin and observed over three weeks. Mesenteric arterioles, which were isolated in a cannulated and pressurised state, were incubated with intravascular injections of 1, 3 or 5 g/L Xiaokening for 24, 48 or 72 hours. The effects of Xiaokening on the release of nitric oxide (NO) on the mesenteric arterioles were detected under shear stress of 1, 10 and 20 dyn/cm². Biochemical methods were used to determine the activities of superoxide dismutase (SOD) and xanthine oxidase (XO). The expressions of endothelial NO synthase (eNOS), SOD and XO in the mesenteric arterioles were assessed using Western blot.

RESULTS

Compared to normal rat arterioles, less NO was released in the mesenteric arterioles of diabetic rats. Xiaokening was found to have a concentration- and time-dependent effect on NO release; when the shear stress was increased, there was a gradual increase in the release of NO. Compared to normal arterioles, the expression of eNOS in the mesenteric arterioles of diabetic rats was lower. Incubation with Xiaokening increased SOD activity and expression, and decreased XO activity and expression in the mesenteric arterioles of the diabetic rats.

CONCLUSION

Xiaokening was able to significantly increase NO release and improve the endothelial function of mesenteric arterioles through antioxidative mechanisms.     

糖尿病周围神经病变筛查方法的临床研究

目的:探讨糖尿病周围神经病变(DPN)筛查流程的诊断价值,寻找经济、简便、快捷、准确的DPN筛查方法。方法:河南省人民医院糖尿病患者452例,对其进行神经肌电图和DPN的筛查。以神经肌电图作为"金标准",分析DPN筛查方法的敏感度、特异度、阳性预测值、阴性预测值和约登指数。结果:DPN中有症状组占69.91%,以神经肌电图检查为标准,DPN的灵敏度、特异度、阳性预测值、阴性预测值和约登指数分别为89.43%、63.09%、80.38%、78.0%和0.52。DPN筛查具有较高的灵敏度和特异度,适应在DPN早期临床筛查中应用。糖尿病患者存在着不同的DPN症状,以麻木最多。压力觉的灵敏度和特异度为19.44%和95.62%;振动觉的灵敏度和特异度为77.78%和60.87%;温度觉的灵敏度和特异度为35.19%和89.13%;针刺觉的灵敏度和特异度分别31.48%和84.78%。完成DPN表平均耗时5.89 min。结论:DPN筛查流程适应在DPN早期临床筛查中应用。