Evidence-based recommendations for insulin intensification strategies after basal insulin in type 2 diabetes

Over the time due to progressive nature of diabetes, proactive intensification of the existing insulin therapy becomes imminent as it minimizes patients' exposure to chronic hypo/hyperglycaemia and reduces weight gain while achieving individualized glycaemic targets. This review focuses on the strength of evidence behind various options for intensification, primarily the insulins as also the GLP-1 analogues. The recommendations presented here are meant to serve as a guide for the physician managing type 2 diabetes patients requiring insulin intensification upon failing of basal insulin therapy.

Can plantar soft tissue mechanics enhance prognosis of diabetic foot ulcer?

AIM

To investigate if the assessment of the mechanical properties of plantar soft tissue can increase the accuracy of predicting Diabetic Foot Ulceration (DFU).

METHODS

40 patients with diabetic neuropathy and no DFU were recruited. Commonly assessed clinical parameters along with plantar soft tissue stiffness and thickness were measured at baseline using ultrasound elastography technique. 7 patients developed foot ulceration during a 12months follow-up. Logistic regression was used to identify parameters that contribute to predicting the DFU incidence. The effect of using parameters related to the mechanical behaviour of plantar soft tissue on the specificity, sensitivity, prediction strength and accuracy of the predicting models for DFU was assessed.

RESULTS

Patients with higher plantar soft tissue thickness and lower stiffness at the 1st Metatarsal head area showed an increased risk of DFU. Adding plantar soft tissue stiffness and thickness to the model improved its specificity (by 3%), sensitivity (by 14%), prediction accuracy (by 5%) and prognosis strength (by 1%). The model containing all predictors was able to effectively (χ² (8, N=40)=17.55, P<0.05) distinguish between the patients with and without DFU incidence.

CONCLUSION

The mechanical properties of plantar soft tissue can be used to improve the predictability of DFU in moderate/high risk patients.

Impact of lifestyle intervention in primary prevention of Type 2 diabetes did not differ by baseline age and BMI among Asian-Indian people with impaired glucose tolerance

AIM

To investigate whether the effectiveness of lifestyle interventions on the incidence of diabetes was influenced by the baseline age and BMI of the Asian-Indian participants with prediabetes.

METHODS

Pooled data, obtained from two of our Indian Diabetes Prevention Programmes (2006, n=236 and 2013, n=473; total N=709) which had similar baseline characteristics and intervention principles, were analysed. For the present secondary analysis we dichotomously categorized the participants' baseline age (<45 and ≥45 years) and BMI (<25.0 and ≥ 25.0 kg/m² ). Glycaemic status was ascertained at 6-monthly intervals by oral glucose tolerance tests. The incidence rates of diabetes and relative risk reduction in both the intervention and the control group were calculated for categories of baseline age and BMI. Interactions between the intervention and baseline age and BMI on diabetes risk were also analysed.

RESULTS

Incident diabetes was diagnosed in 227 of the total 709 participants (32.0%) [control group 139 participants (38.8%) vs intervention group 88 participants (24.2%)] during the median follow-up period of 2 years. The overall relative risk reduction was 35.4% (95% CI 19.3-48.3). Lifestyle intervention was equally effective in both age groups [relative risk reduction in those aged <45 years: 43.7% (95% CI 19.8-60.5) and in those aged ≥ 45 years: 28.9% (95% CI 5.3-46.6) P for interaction = 0.52] and in categories of BMI [BMI <25 kg/m² : 36.1% (95% CI 9.5-54.9); and BMI ≥ 25 kg/m² : 34.8% (95% CI 12.9-51.2); P for interaction = 0.95].

CONCLUSIONS

In Asian-Indian individuals with prediabetes, the effectiveness of lifestyle intervention was not modified by baseline age and BMI.

Rates and predictors of hypoglycaemia in 27 585 people from 24 countries with insulin-treated type 1 and type 2 diabetes: the global HAT study

AIMS

To determine the global extent of hypoglycaemia experienced by patients with diabetes using insulin, as there is a lack of data on the prevalence of hypoglycaemia in developed and developing countries.

METHODS

This non-interventional, multicentre, 6-month retrospective and 4-week prospective study using self-assessment questionnaire and patient diaries included 27 585 patients, aged ≥18 years, with type 1 diabetes (T1D; n = 8022) or type 2 diabetes (T2D; n = 19 563) treated with insulin for >12 months, at 2004 sites in 24 countries worldwide. The primary endpoint was the proportion of patients experiencing at least one hypoglycaemic event during the observational period.

RESULTS

During the prospective period, 83.0% of patients with T1D and 46.5% of patients with T2D reported hypoglycaemia. Rates of any, nocturnal and severe hypoglycaemia were 73.3 [95% confidence interval (CI) 72.6-74.0], 11.3 (95% CI 11.0-11.6) and 4.9 (95% CI 4.7-5.1) events/patient-year for T1D and 19.3 (95% CI 19.1-19.6), 3.7 (95% CI 3.6-3.8) and 2.5 events/patient-year (95% CI 2.4-2.5) for T2D, respectively. The highest rates of any hypoglycaemia were observed in Latin America for T1D and Russia for T2D. Glycated haemoglobin level was not a significant predictor of hypoglycaemia.

CONCLUSIONS

We report hypoglycaemia rates in a global population, including those in countries without previous data. Overall hypoglycaemia rates were high, with large variations between geographical regions. Further investigation into these differences may help to optimize therapy and reduce the risk of hypoglycaemia.

Direct mineral carbonation of steelmaking slag for CO2 sequestration at room temperature

Rapid increase of CO2 concentration in the atmosphere has forced the international community towards adopting actions to restrain from the impacts of climate change. Moreover, in India, the dependence on fossil fuels is projected to increase in the future, implying the necessity of capturing CO2 in a safe manner. Alkaline solid wastes can be utilized for CO2 sequestration by which its disposal issues in the country could also be met. The present work focuses to study direct mineral carbonation of steelmaking slag (SS) at room temperature and low-pressure conditions (<10 bar). Direct mineral carbonation of SS was carried out in a batch reactor with pure CO2 gas. The process parameters that may influence the carbonation of SS, namely, CO2 gas pressure, liquid to solid ratio (L/S) and reaction time were also studied. The results showed that maximum sequestration of SS was attained in the aqueous route with a capacity of 82 g of CO2/kg (6 bar, L/S ratio of 10 and 3 h). In the gas-solid route, maximum sequestration capacity of about 11.1 g of CO2/kg of SS (3 bar and 3 h) was achieved indicating that aqueous route is the better one under the conditions studied. These findings demonstrate that SS is a promising resource and this approach could be further developed and used for CO2 sequestration in the country. The carbonation process was evidenced using FT-IR, XRD, SEM and TG analysis.

Is there a genetic predisposition to new-onset diabetes after kidney transplantation?

Kidney transplant recipients may develop new-onset diabetes after transplantation (NODAT) and transplant-associated hyperglycemia (TAH) (NODAT or new-onset impaired glucose tolerance-IGT). We studied 251 consecutive renal transplant South Asian recipients for incidence of NODAT and its risk factors between June 2004 and January 2009. Pre-transplant glucose tolerance test (GTT) identified non-diabetics (n = 102, IGT-24, NGT-78) for analysis. Baseline immunosuppression along with either cyclosporine (CsA) (n = 70) or tacrolimus (Tac) (n = 32) was given. Patients underwent GTT 20 days (mean) post-transplant to identify NODAT, normal (N) or IGT. TAH was observed in 40.2% of the patients (40% in CsA and 40.6% in Tac) (P = 0.5). NODAT developed in 13.7% of the patients (12.9% in CsA and 15.6% in Tac) (P = 0.5). Overall, Hepatitis C (P = 0.007), human leukocyte antigen (HLA) B52 (P = 0.03) and lack of HLA A28 (A68/69) (P = 0.03) were associated with TAH. In the Tac group, higher Day 1 dosage (P <0.001), HLA A1 (P = 0.04), B13 (P = 0.03) and lack of DR2 (P = 0.004) increased the risk of TAH. In the CsA group, HLA A10 (P = 0.03), failure of triglyceride (P = 0.001) or low-density lipoprotein (LDL) (P = 0.03) to lower or high-density lipoprotein to rise (P = 0.001), and higher post-transplant LDL (P <0.001) and cholesterol levels (P = 0.02) were associated with NODAT or TAH. Post-transplant fasting plasma glucose on Day 1 had sensitivity-54.5%, specificity-50.1%, positive predictive value-18.1% and negative predictive value-84.8% for detecting NODAT. In conclusion, there is a genetic predisposition to NODAT and TAH in South Asia as seen by the HLA associations, and a predisposition exists to the individual diabetogenic effects of Tac and CsA based on HLA type. This could lead to more careful selection of calcineurin inhibitors based on HLA types in the South Asian population.

Projected and Observed Aridity and Climate Change in the East Coast of South India under RCP 4.5

In the purview of global warming, the present study attempts to project changes in climate and quantify the changes in aridity of two coastal districts in south India under the RCP 4.5 trajectory. Projected climate change output generated by RegCM 4.4 model, pertaining to 14 grid points located within the study area, was analyzed and processed for this purpose. The meteorological parameters temperature and precipitations were used to create De Martonne Aridity Index, to assess the spatial distribution of aridity. The original index values ranged from 13.7 to 16.4 mm/°C, characterizing this area as a semidry climate. The outcome from the changed scenario analysis under RCP 4.5 showed that, during the end of the 21st century, the aridity may be increased more as the index values tend to reduce. The increasing trend in the drying phenomenon may be attributed to the rising of mean annual temperatures.

DSPP Is Essential for Normal Development of the Dental-Craniofacial Complex

The craniofacial skeleton is derived from both neural crest cells and mesodermal cells; however, the majority of the bone, cartilage, and connective tissue is derived from the neural crest. Dentin sialophosphoprotein (DSPP) is a precursor protein that is expressed by the connective tissues of the craniofacial skeleton, namely, bone and dentin with high expression levels in the dentin matrix. Gene ablation studies have shown severe dental defects in DSPP-null mutant mice. Therefore, to elucidate the role of DSPP on the developing dental-craniofacial complex, we evaluated phenotypic changes in the structure of intramembranous bone and dentin mineralization using 3 different age groups of DSPP-null and wild-type mice. Results from micro-computed tomographic, radiographic, and optical microscopic analyses showed defective dentin, alveolar and calvarial bones, and sutures during development. The impaired mineralization of the cranial bone correlated well with low expression levels of Runx2, Col1, and OPN identified using calvarial cells from DSPP-null and wild-type mice in an in vitro culture system. However, the upregulation of MMP9, MMP2, FN, and BSP was observed. Interestingly, the null mice also displayed low serum phosphate levels, while calcium levels remained unchanged. Alizarin red and von Kossa staining confirmed the dysfunction in the terminal differentiation of osteoblasts obtained from the developing calvaria of DSPP-null mice. Immunohistochemical analysis of the developing molars showed changes in Runx2, Gli1, Numb, and Notch expression in the dental pulp cells and odontoblasts of DSPP-null mice when compared with wild-type mice. Overall, these observations provide insight into the role of DSPP in the normal development of the calvaria, alveolar bone, and dentin-pulp complex.

Identification of a hypoxia-regulated miRNA signature in bladder cancer and a role for miR-145 in hypoxia-dependent apoptosis

BACKGROUND

Hypoxia leads to the stabilisation of the hypoxia-inducible factor (HIF) transcription factor that drives the expression of target genes including microRNAs (miRNAs). MicroRNAs are known to regulate many genes involved in tumourigenesis. The aim of this study was to identify hypoxia-regulated miRNAs (HRMs) in bladder cancer and investigate their functional significance.

METHODS

Bladder cancer cell lines were exposed to normoxic and hypoxic conditions and interrogated for the expression of 384 miRNAs by qPCR. Functional studies were carried out using siRNA-mediated gene knockdown and chromatin immunoprecipitations. Apoptosis was quantified by annexin V staining and flow cytometry.

RESULTS

The HRM signature for NMI bladder cancer lines includes miR-210, miR-193b, miR-145, miR-125-3p, miR-708 and miR-517a. The most hypoxia-upregulated miRNA was miR-145. The miR-145 was a direct target of HIF-1α and two hypoxia response elements were identified within the promoter region of the gene. Finally, the hypoxic upregulation of miR-145 contributed to increased apoptosis in RT4 cells.

CONCLUSIONS

We have demonstrated the hypoxic regulation of a number of miRNAs in bladder cancer. We have shown that miR-145 is a novel, robust and direct HIF target gene that in turn leads to increased cell death in NMI bladder cancer cell lines.

Geographic differences in the associations between impaired glucose regulation and cardiovascular risk factors among young adults

AIMS

To assess geographic differences in the association between BMI, blood pressure and lipid levels with impaired glucose regulation among young adults from various geographical regions.

METHODS

This was a cross-sectional study including data from 6987 participants aged ≤ 30 years from India, Singapore, Australia, Greenland, Kenya and Tanzania. Impaired glucose regulation was determined by the 75-g oral glucose tolerance test. For each geographical region, BMI, blood pressure and lipids were examined and compared between participants with normal glucose tolerance and those with impaired glucose regulation. Multiple logistic regression models were used to assess the association between risk factors and impaired glucose regulation.

RESULTS

Indian and East African people had a higher prevalence of impaired glucose regulation compared with participants from other regions, despite their lower BMI. Compared with the other regions, blood pressure was lower among Indian and Singaporean people but higher in those from Greenland. Greenlanders had the highest, while Indian and East-African people, had the lowest level of HDL cholesterol. BMI was positively associated with impaired glucose regulation in all regions, and there were no statistically significant geographic differences. In the Indian, Singaporean and Australian participants, there was a positive association between blood pressure and impaired glucose regulation. Triglycerides were positively associated with and HDL cholesterol had no association with impaired glucose regulation in all geographical regions.

CONCLUSIONS

Higher BMI and triglyceride levels were positively associated with prevalent impaired glucose regulation in all geographical regions. There were geographic differences in the association between impaired glucose regulation and blood pressure and lipids, probably reflecting environmental and genetic factors.

DMP1-derived peptides promote remineralization of human dentin

Remineralization of dentin during dental caries is of considerable clinical interest. Dentin matrix protein 1 (DMP1) is a non-collagenous calcium-binding protein that plays a critical role in biomineralization. In the present study, we tested if peptides derived from DMP1 can be used for dentin remineralization. Peptide pA (pA, MW = 1.726 kDa) and peptide pB (pB, MW = 2.185), containing common collagen-binding domains and unique calcium-binding domains, were synthesized by solid-phase chemistry. An extreme caries lesion scenario was created by collagenase digestion, and the biomineral-nucleating potential of these peptides was ascertained when coated on collagenase-treated dentin matrix and control, native human dentin matrix under physiological levels of calcium and phosphate. Scanning electron microscopy analysis suggests that peptide pB was an effective nucleator when compared with pA. However, a 1:4 ratio of pA to pB was determined to be ideal for dentin remineralization, based on hydroxyapatite (HA) morphology and calcium/phosphorus ratios. Interestingly, HA was nucleated on collagenase-challenged dentin with as little as 20 min of 1:4 peptide incubation. Electron diffraction confirmed the presence of large HA crystals that produced a diffraction pattern indicative of a rod-like crystal structure. These findings suggest that DMP1-derived peptides may be useful to modulate mineral deposition and subsequent formation of HA when exposed to physiological concentrations of calcium and phosphate.

Hypertriglyceridaemic waist phenotype as a simple predictive marker of incident diabetes in Asian-Indian men with prediabetes

AIM

To determine prospectively the association of baseline hypertriglyceridaemic waist phenotype with incident diabetes in Asian-Indian men with impaired glucose tolerance.

METHODS

In a randomized 2-year diabetes prevention trial in 517 men with impaired glucose tolerance, 123 (23.8%) developed diabetes. Baseline anthropometric, metabolic and clinical variables were estimated. Associations of hypertriglyceridaemic waist phenotype (waist circumference ≥ 90cm and a serum triglyceride level of ≥ 1.7 mmol/l) with insulin resistance and incident diabetes were assessed using multiple linear regression and Cox's proportional hazard models, respectively.

RESULTS

Men with an isolated enlarged waistline and hypertriglyceridaemic waist phenotype had significantly higher BMI and percentage of total body fat compared with the group with normal waistline and triglyceride levels and the group with isolated hypertriglyceridaemia. The men with hypertriglyceridaemic waist phenotype had higher insulin resistance (mean ± sd homeostasis model assessment of insulin resistance value: 3.6 ± 1.5) compared with those in the isolated enlarged waistline, the isolated hypertriglyceridaemia or the normal waistline and triglyceride level groups (3.1 ± 1.4, 2.7 ± 1.0 and 2.5 ± 1.1, respectively, all P < 0.05 compared with hypertriglyceridaemic waist phenotype). Multiple linear regression analyses showed that hypertriglyceridaemic waist phenotype was significantly associated with insulin resistance after adjusting for age, BMI, family history, percentage of total body fat, smoking, alcohol intake, 2-h plasma glucose and HDL cholesterol level. Hypertriglyceridaemic waist phenotype was independently associated with incident diabetes after adjusting for the above confounders and gamma-glutamyl transferase (hazard ratio 1.49, 95% CI 1.01-2.21; P = 0.047). The association of hypertriglyceridaemic waist phenotype with incident diabetes was abolished when insulin resistance was introduced into the model (hazard ratio 1.39, 95% CI 0.092-2.10; P=0.12).

CONCLUSIONS

Hypertriglyceridaemic waist phenotype is a simple clinical proxy measurement for insulin resistance and is strongly associated with incident diabetes in Asian-Indian men with impaired glucose tolerance.

An appraisal of physico-chemical and microbiological characteristics of Nanmangalam Reserve Forest soil

A detailed evaluation was performed on the soils of Nanmangalam Reserve Forest (NRF) in order to understand its physico-chemical, microbiological and enzymatic characteristics. The results of analysis showed that soil pH was directly proportional to the soil depth and the soil moisture content was irreversibly related to varying soil depth. Soil organic carbon was positively correlated with (p < 0.01) with total nitrogen, total bacterial count, cellulytic microbes, nitrogen-fixing bacteria, microbial biomass carbon, dehydrogenase activity and soil respiration. During summer, microbial population in the organic layer was more diverse than in the deepest layer. Analysis showed that NRF had low organic carbon content (less than 1%), microbial biomass, nutrient and functional microbes. The overall results of the analysis reinstate that Nanmangalam forest soil is undergoing degradation.

Factors influencing endometrial thickness in postmenopausal women

Background:

Cut-off values for endometrial thickness (ET) in asymptomatic postmenopausal woman have been standardized. However, there are no comprehensive studies to document how various factors can influence the ET after the age of menopause.

Aim:

To study the various factors influencing the ET in postmenopausal women.

Subjects and Methods:

This was a prospective observational study. A total of 110 postmenopausal women underwent detailed history taking, clinical examination, and transvaginal scan for uterine volume and ovarian volume. The volumes were calculated by using ellipsoid formula: Width × thickness × height × 0.523. The variation in ET with respect to the influencing factors such as age, duration of menopause, parity, body mass index (BMI), medical illness like diabetes/hypertension, drugs like tamoxifen, presence of myoma, uterine volume, ovarian volume, and serum estradiol (in selected patients) were measured. Descriptive analysis was performed using SPSS software (version 16, Chicago II, USA) to obtain mean, standard deviation (SD), 95% confidence intervals (CIs) and inter quartile ranges. Comparison of means was carried out using analysis of variance.

Results:

The mean (SD) age of the patients was 55.4 (6.91) years (95% CI, 54.1, 56.7). The mean (SD) age at menopause was 47.95 (3.90) years (95% CI, 47.2, 48.7) and the mean (SD) duration of menopause was 7.27 (6.65) years (95% CI, 6.01, 8.53). The mean (SD) ET was 3.8 (2.3) mm (95% CI, 3.36, 4.23). Medical illness like diabetes and hypertension did not alter the ET. ET increased as BMI increased and it was statistically significant. The presence of myoma increased uterine volume significantly and was associated with thick endometrial stripe. Similarly, whenever the ovaries were visualized and as the ovarian volume increased, there was an increase in ET. When ET was > 4 mm (n = 37), they were offered endocel, of which 16 agreed to undergo the procedure. None were found to have endometrial cancer.

Conclusion:

This study suggests that parity, BMI, presence of myoma, tamoxifen usage, uterine volume, ovarian volume and serum estradiol influence the ET in postmenopausal women.

Understanding the safety of the new ultra long acting basal insulin

Hypoglycaemia is a key safety concern in diabetes management. It is potentially dangerous and the fear of hypoglycaemia may lead to sub-optimal dosing and inadequate glycaemic control. On the other hand, hypoglycaemia may generate adverse effects and disease complications, will compromise the quality of life and will substantially increase the economic burden of treatment budged. Today, treat to target clinical trial designs are mandate for clinical development of any newer anti-diabetic medication. While similar glycaemic targets are expected to be achieved by test and comparator, the newer molecules are definitely expected to show advantage over standard comparator in terms of reduction in frequency and severity of hypoglycaemia. An ultra-long acting basal analogue insulin degludec (IDeg), has been recently approved for the treatment of type 2 and type 1 diabetes mellitus (T2DM and T1DM). The pooled patient-level data for self-reported hypoglycaemia from seven phase 3a trials with IDeg has shown significantly lower episodes of nocturnal confirmed and numerical low overall confirmed hypoglycaemia with IDeg, compared to Insulin glargine (IGlar), which was more pronounced during maintenance phase of treatment in all populations. The most plausible explanation being that, the flat peakless profile of IDeg with least glycaemic variability leads to less hypoglycaemia and adds to the safety profile of this ultra-long acting insulin. The real life practice will further validate the findings of clinical trials.

DSPP contains an IRES element responsible for the translation of dentin phosphophoryn

The major phosphoprotein in dentin is the aspartic acid and serine-rich protein called dentin phosphophoryn (DPP). DPP appears to be synthesized as a part of a larger compound protein, dentin sialophosphoprotein (DSPP). DSPP has never been isolated or detected in dentin extracts. It is now evident that DSPP is a chimeric protein composed of 3 parts: dentin sialoprotein (DSP), DPP, and dentin glycoprotein (DGP). Previous reports have suggested that the BMP1 protease is responsible for processing DSPP. However, unequal amounts of these products are present in the dentin matrix. Here, we provide evidence for an internal ribosome entry site in the DSPP gene that directs the synthesis of DPP. This mechanism would account for unequal amounts of intracellular DSP and DPP. The internal ribosomal entry site (IRES) activity varied in different cell types, suggesting the presence of additional regulatory elements during the translational regulation of DPP. Further, we provide evidence that DPP is transported to the extracellular matrix (ECM) through exosomes. Using tissue recombination and lentivirus-mediated gain-of-function approaches, we also demonstrate that DPP is essential for the formation of well-defined tooth structures with mineralized dentin matrix.

Estimation of quality of life in haemodialysis patients

Since haemodialysis is an expensive treatment modality for chronic renal failure patients, it is very essential to assess the outcome of therapy in terms of quality of life. The primary objective of the study was to estimate the effect of patient counselling in quality of life of end stage renal disease patients opting haemodialysis using World Health Organisation Quality of life scale and to assess the variables affecting the quality of life of these patients. Quality of life was determined by World Health Organisation Quality of life scale questionnaire comprised of 26 items which measures four domains: physical, psychological, social and environmental domain. A total of 81 patients were selected and divided into test and control group and the test group patients received counselling regarding their disease, use of medications, importance of adherence and the complications experienced during and after dialysis. The quality of life data was collected at the interval of 1, 2, 3, 6 and 12 months and the patients were counselled at each interval. The demographic profiles revealed that majority of the patients were in the age group of 31-50 and there exists a male predominance. About the socioeconomic status, upper middle class people were mostly affected. Assessment of impact of patient counselling in the quality of life of haemodialysis indicated a significant improvement in each domain after counselling. And also found that the psychological domain showed a significant increase in the score compared to others. Patient counselling helped to gain benefits in terms of improvement in quality of life and delayed progression of renal failure. Early recognition and prevention is necessary to improve the quality of life of chronic renal failure patients. Patient counselling should be made mandatory by incorporating clinical pharmacist in the nephrology team to make the patient understand his illness and modifications in lifestyle also create a positive environment and result in better quality of life.

Primary prevention of Type 2 diabetes in South Asians--challenges and the way forward

Preventing diabetes is of enormous value, particularly for the South Asian countries, which have a huge healthcare burden from the onslaught of the disease. Type 2 diabetes has been proved to be preventable using lifestyle changes, even in South Asians despite their heightened risk profile. Strategies to improve awareness about diabetes and translation of preventive measures by innovative, culturally specific programmes have to be implemented at national levels. Integrated involvement of the government, community, media, healthcare and education services, and financial support from national and international organizations, are required. South Asian countries have initiated national programmes for diabetes prevention and management. It is also encouraging to note that joint ventures between developed countries such as the USA, UK and other European countries and centres of excellence in South Asia have been initiated to develop large-scale, community-oriented, pragmatic intervention strategies.

Cancer outcomes and all-cause mortality in adults allocated to metformin: systematic review and collaborative meta-analysis of randomised clinical trials

AIMS/HYPOTHESIS

Observational studies suggest that metformin may reduce cancer risk by approximately one-third. We examined cancer outcomes and all-cause mortality in published randomised controlled trials (RCTs).

METHODS

RCTs comparing metformin with active glucose-lowering therapy or placebo/usual care, with minimum 500 participants and 1-year follow-up, were identified by systematic review. Data on cancer incidence and all-cause mortality were obtained from publications or by contacting investigators. For two trials, cancer incidence data were not available; cancer mortality was used as a surrogate. Summary RRs, 95% CIs and I (2)statistics for heterogeneity were calculated by fixed effects meta-analysis.

RESULTS

Of 4,039 abstracts identified, 94 publications described 14 eligible studies. RRs for cancer were available from 11 RCTs with 398 cancers during 51,681 person-years. RRs for all-cause mortality were available from 13 RCTs with 552 deaths during 66,447 person-years. Summary RRs for cancer outcomes in people randomised to metformin compared with any comparator were 1.02 (95% CI 0.82, 1.26) across all trials, 0.98 (95% CI 0.77, 1.23) in a subgroup analysis of active-comparator trials and 1.36 (95% CI 0.74, 2.49) in a subgroup analysis of placebo/usual care comparator trials. The summary RR for all-cause mortality was 0.94 (95% CI 0.79, 1.12) across all trials.

CONCLUSIONS/INTERPRETATION

Meta-analysis of currently available RCT data does not support the hypothesis that metformin lowers cancer risk by one-third. Eligible trials also showed no significant effect of metformin on all-cause mortality. However, limitations include heterogeneous comparator types, absent cancer data from two trials, and short follow-up, especially for mortality.

Analysis of heavy metals in dying wetland Pallikaranai, Tamil Nadu, India

Pallikaranai wetland has high ecological significance as it has been a home for other associated biodiversities. This wetland is highly polluted due to the rapid industrialization, urbanization and dumping of solid waste. The water quality of the Pallikaranai wetland has been studied with reference to toxic metals. The metals analyzed include lead, chromium, iron, copper, nickel, zinc and cadmium. The heavy metal analysis in surface waters were in the following range; Cd: BDL--0.019 mg l(-1), Fe: BDL--1.52 mg l(-1), Cu: BDL--0.02 mg l(-1), Ni: BDL-0.60 mg l(-1), Pb: 0.03-1.13 mg l(-1), Zn: 0.002-0.14 mg l(-1) and Cr: 0.10-1.52 mg l(-1) respectively. The dominance of various heavy metals in the surface water of the Pallikaranai wetland followed the sequence: Pb > Cr > Fe > Ni > Zn > Cd > Cu. The quality of water has deterioted due to the various anthropogenic activities. Most of the metal ions were in higherconcentration compared to the standards. It has been observed that the quality of the surface water is not safe for aquatic and domestic life, hence necessary management actions should be taken to control the quality of the surface water.