Self-reported hypoglycaemia in insulin-treated patients with diabetes mellitus: results from the Singapore cohort of the International Operations Hypoglycaemia Assessment Tool study

INTRODUCTIONHypoglycaemia constitutes a significant barrier to achieving glycaemic control with insulin in both Type 1 (T1DM) and Type 2 diabetes mellitus (T2DM). The International Operations Hypoglycaemia Assessment Tool (IO HAT) study was designed to determine the incidence of hypoglycaemia in insulin-treated patients with T1DM and T2DM.METHODSThe IO HAT study retrospectively and prospectively assessed the incidence of hypoglycaemia in patients with insulin-treated diabetes mellitus in nine countries. This sub-analysis included patients from Singapore with T1DM or T2DM who were aged ≥ 21 years and had completed two self-assessment questionnaires (SAQ1 and SAQ2).RESULTSOf the 50 T1DM and 320 T2DM patients who completed the SAQ1, 39 T1DM and 265 T2DM patients completed SAQ2; 100% and 90.9%, respectively, experienced at least one hypoglycaemic event prospectively. The incidence rates of any hypoglycaemia were 49.5 events per patient-year (EPPY) and 16.1 EPPY for T1DM and T2DM patients, respectively, in the four-week prospective period. Hypoglycaemia rate did not differ in terms of glycated haemoglobin level. The vast majority of T1DM or T2DM patients (92.0% and 90.7%, respectively) knew the overall definition of hypoglycaemia before study participation, although over half of the patients (T1DM 54.0%, T2DM 51.9%) defined hypoglycaemia based only on symptoms.CONCLUSIONHigh proportions of insulin-treated patients with diabetes mellitus in Singapore reported hypoglycaemic events prospectively, showing that they had underreported hypoglycaemic episodes retrospectively. Patient education can help in improving hypoglycaemia awareness and its management in the region.     

Use of mobile telephone short message service as a reminder: the effect on patient attendance

Background: Nonattendance for hospital outpatient appointments is a major burden on healthcare systems and the estimated financial loss can be high. Various reasons for patients not attending have been reported, including the patient/carer forgetting the appointment and confusion over the date and time of the appointment. Various reminder systems have been trialled across a variety of clinical settings. More recently, short message service (SMS) text messaging has emerged as a viable approach for delivering reminders to outpatients at a relatively low cost. Aims and objectives: To evaluate the effect of appointment reminders, sent as SMS text messages to patients’ mobile telephones, on attendance at outpatient clinics at the ITS Centre for Dental Studies and Research (ITS‐CDSR), Muradnagar, Ghaziabad, Uttar Pradesh, India. Materials and methods: The study was conducted at ITS‐CDSR in the Departments of Prosthodontics, Endodontics, Orthodontics and Paedodontics. Patients attending these departments for a period of 4 months and those who had provided a contact mobile number were sent an SMS reminder. Results: In this study, 206 subjects (male, 124; female, 82) participated, 96 (male, 57; female, 39) of whom were in the test group and 110 (male, 67; female, 43) of whom were in the control group. The rate of attendance on time was found to be significantly higher in the test group (79.2%) than in the control group (35.5%). Conclusion: The study results indicate that sending appointment reminders as text messages to patients is an effective strategy to reduce nonattendance rates.     

Persistent transgene product in retina, optic nerve and brain after intraocular injection of rAAV.

Recombinant adeno-associated virus (rAAV) is a promising vector for retinal application as it transduces photoreceptors and retinal pigment epithelium cells efficiently and in a stable fashion. Because rAAV also transduces retinal ganglion cells, we reasoned that ocular application of rAAV might result in delivery of transgenic protein to the CNS. Here we describe high levels of green fluorescent protein (GFP) persisting at least 6 months in optic nerves and brains of mice and dogs after intravitreal delivery of rAAV-GFP. There was no clinical or histological evidence of inflammatory response although a mild humoral Th-2 response to viral capsid proteins was detected. These findings have important implications with respect to therapeutic applications of rAAV.     

Effects of reserpine on blood-pressure responses evoked from the hypothalamus

Different areas of the hypothalamus were stimulated by a stereotaxic technique before and after reserpine in unanaesthetized cats. Reserpine in a dose of 1 mg./kg. body weight increased the threshold of stimulation of hypothalamic areas in cats giving an initial pressor response. It decreased the threshold of stimulation of areas of the hypothalamus in animals giving an initial depressor response. Reserpine thus appeared to affect the hypothalamus directly in two ways. It depressed the sympathetic centres in the diencephalon and facilitated the parasympathetic ones.     

Use of a "small-bubble technique" to increase the success of Anwar's "big-bubble technique" for deep lamellar keratoplasty with complete baring of Descemet's membrane

PURPOSE: To describe a quick and simple "small-bubble" technique to immediately determine the success of attaining complete Descemet's membrane (DM) separation from corneal stroma through Anwar's "big-bubble" technique of deep anterior lamellar keratoplasty (DALK) for complete stromal removal. METHODS: A partial trephination was followed by a lamellar dissection of the anterior stroma. Deep stromal air injection was then attempted to achieve the big bubble to help separate the stroma from the DM. To confirm that a big bubble had been achieved, a small air bubble was injected into the anterior chamber (AC) through a limbal paracentesis. If the small bubble is then seen at the corneal periphery, it confirms that the big-bubble separation of DM was successful because the convex nature of the bubble will cause it to protrude posteriorly, forcing the small AC bubble to the periphery. If the small AC bubble is not seen in the corneal periphery, this means that it is present in the centre, beneath the opaque corneal stroma, and therefore the big bubble has not been achieved. RESULTS: We used the small-bubble technique to confirm the presence of the big bubble in three (one keratoconus, one interstitial keratitis and one dense corneal scar) out of 41 patients who underwent DALK. The small-bubble technique confirmed that the big bubble was achieved in the eye of all three patients. Complete stromal removal with baring of the DM was achieved, and postoperatively all three eyes achieved best corrected vision of 6/6. CONCLUSION: The small-bubble technique can be a useful surgical tool for corneal surgeons attempting lamellar keratoplasty using the big-bubble technique. It helps in confirming the separation of DM from the deep stroma, which is important in achieving total stromal replacement. It will help to make the transition to lamellar keratoplasty smoother, enhance corneal graft success and improve visual outcomes in patients.     

Inner retinal abnormalities in X-linked retinitis pigmentosa with RPGR mutations

PURPOSE: To investigate in vivo the retinal microstructure in X-linked retinitis pigmentosa (XLRP) caused by RPGR mutations as a prelude to treatment initiatives for this common form of RP. METHODS: Patients with RPGR-XLRP (n = 12; age range, 10-56 years) were studied by optical coherence tomography (OCT) in a wide region of central retina. Overall retinal thickness and outer nuclear layer (ONL) and inner retinal parameters across horizontal and vertical meridians were analyzed and compared. RESULTS: Retinal architecture of all patients with RPGR mutations was abnormal. At the fovea in younger patients, the ONL could be normal; but, at increasing eccentricities, there was a loss of photoreceptor laminar structure, even at the youngest ages studied. At later ages and advanced disease stages, the ONL was thin and reduced in extent. Inner retinal thickness, in contrast, was normal or hyperthick. Inner retinal thickening was detectable at all ages studied and was strongly associated with ONL loss. CONCLUSIONS: Inner retinal laminar abnormalities in RPGR-XLRP are likely to reflect a neuronal-glial retinal remodeling response to photoreceptor loss and are detectable relatively early in the disease course. These results should be factored into emerging therapeutic strategies for this form of RP.     

A prospective comparison of the yield of EUS in primary vs. recurrent idiopathic acute pancreatitis

BACKGROUND: It is uncertain whether EUS should be performed after a single episode of idiopathic pancreatitis vs. recurrent episodes or if clinical factors can predict positive EUS findings. METHODS: Consecutive patients with a single episode of idiopathic pancreatitis or with recurrent episodes underwent EUS (with analysis of bile for bilirubinate and cholesterol crystals, when possible). The diagnostic yield was compared for patients with a single episode of idiopathic pancreatitis and recurrent episodes (stratified by cholecystectomy status). Predictors of positive EUS findings were sought. EUS was considered "positive" if it identified any possible cause of pancreatitis other than chronic pancreatitis. RESULTS: A total of 370 patients were studied (246 no-cholecystectomy group [134 single episode of idiopathic pancreatitis, 112 recurrent episodes] and 124 post-cholecystectomy group [67 single episode of idiopathic pancreatitis, 57 recurrent episodes]). Overall, EUS yielded a positive finding in 29.2%. For patients in the no-cholecystectomy group, positive EUS findings were not significantly more frequent in those with a single episode of idiopathic pancreatitis vs. those with recurrent episodes (31.3% vs. 32.1%; p = 0.89). In the post-cholecystectomy group, the yield was not significantly different for single episode of idiopathic pancreatitis (29.9%) vs. recurrent episodes (17.5%) ( p = 0.15). Chronic pancreatitis was the only abnormality identified in 30.9% of patients in the no-cholecystectomy group vs. 26.6% of those in the post-cholecystectomy group ( p = 0.24). It was the most common abnormality found in all 4 subgroups (range 16.4%-42.0%) and was approximately twice as frequent in patients with recurrent episodes vs. a single episode of idiopathic pancreatitis (no-cholecystectomy: 42.0% vs. 21.6%, p = 0.0008; post-cholecystectomy: 38.6% vs. 16.4%, p = 0.008). Analysis of bile revealed crystals in 38/80 (47.5%) patients in whom it could be performed. Patients with positive EUS findings tended to be older. CONCLUSIONS: In patients with idiopathic pancreatitis, the yield of EUS is not significantly different after an initial attack or after recurrent attacks. Therefore, it is reasonable to perform EUS after an initial attack of idiopathic acute pancreatitis, especially in older patients.