Diffuse interstitial skeletal hyperostosis (DISH) in type 2 diabetes

A 58 years type 2 diabetic woman, school teacher by profession, presented with backache, neck pain and generalised weakness since last few months. Pain was mild with stiffness and neck pain was particularly associated with extension of the neck towards back. There was no focal neurological deficit on central nervous system examination. X-ray of lumbo- sacral spine showed prolific osteophytes and new bone formation in the body of lumbar vertebrae. Cervical X-ray showed 'Melting candle-wax' appearance at the anterior to the cervical vertebrae. In view of clinical and radiological association the case was diagnosed as DISH syndrome. It is being presented for its rarity.

Impact of Joint National Committee VII recommendations on diabetic microvascular complications

AIMS AND OBJECTIVE

To determine the impact of the Seventh Report of the Joint National Committee recommendations on microvascular complications in South Indian type 2 diabetic patients.

MATERIAL AND METHODS

In this study, 457 type 2 diabetic patients and 500 age-matched healthy control subjects, with no history of hypertension were enrolled. Based on blood pressure measurements, they were assigned as Group I: Normal (SBP < 120 and DBP < 80 mmHg); Group II: Prehypertension (SBP 120-139 or DBP 80-89 mmHg); Group III: Stage I hypertension (SBP 140-159 or DBP 90-99 mmHg) and Group IV: Stage II hypertension (SBP > or = 160 or DBP > or = 100).

RESULTS

Blood pressure readings in controls and diabetics were: normal in 46.8% and 16.2% (chi2 = 101.1, p < 0.0001), prehypertension in 33.2% and 52.5% (chi2 = 35.7, p < 0.0001), stage I hypertension in 15.2% and 26.3% (chi2 = 17.3, p < 0.0001), stage II hypertension in 4.8% and 5% respectively. Prevalence of retinopathy increased with increasing incidence of hypertension (trend chi2 = 10.7, p < 0.01). In the multivariate analysis, cholesterol was associated with prehypertension, and cholesterol and family history of hypertension were associated with stage I hypertension. Albuminuria, family history of hypertension and serum triglycerides were associated with stage II hypertension.

CONCLUSION

More than half of the diabetic subjects were prehypertensives. As expected prevalence of other complications increased with increasing levels of blood pressure. This emphasizes the need to have regular check up for hypertension to reduce the morbidity from other complications.

Mechanisms of signal transduction mediated by oxidized lipids: the role of the electrophile-responsive proteome

Cellular redox signalling is mediated by the post-translational modification of proteins by reactive oxygen/nitrogen species or the products derived from their reactions. In the case of oxidized lipids, several receptor-dependent and -independent mechanisms are now emerging. At low concentrations, adaptation to oxidative stress in the vasculature appears to be mediated by induction of antioxidant defences, including the synthesis of the intracellular antioxidant glutathione. At high concentrations apoptosis occurs through mechanisms that have yet to be defined in detail. Recent studies have revealed a mechanism through which electrophilic lipids, formed as the reaction products of oxidation, orchestrate these adaptive responses in the vasculature. Using a proteomics approach, we have identified a subset of proteins in cells that we term the electrophile-responsive proteome. Electrophilic modification of thiol groups in these proteins can initiate cell signalling events through the transcriptional activation of genes regulated by consensus sequences for the antioxidant response element found in their promoter regions. The insights gained from our understanding of the biology of these mechanisms will be discussed in the context of cardiovascular disease.

Low risk threshold for acquired diabetogenic factors in Asian Indians

India is facing an epidemic of type 2 diabetes, with high prevalence in urban areas. Urbanisation and associated life style changes adversely affect the risk factors for diabetes unmasking the high genetic tendency existing in the population. Various epidemiological studies in Indians have shown that the increasing prevalence of diabetes could be attributed to a high genetic risk and lower risk thresholds for acquired risk factors such as age, obesity, abdominal adiposity and a high percentage of body fat. Diabetes occurs at a younger age in Indians compared to Whites. The risk of diabetes increases with a body mass index (BMI) of >23 kg/m(2) and waist circumference of 85 cm for men and 80 cm for women in Asian Indians. For a given BMI, Asian Indians have higher central adiposity. There is also evidence of higher insulin resistance amongst Indians, and this is partly explained by higher body fat percentage. A large proportion of urban adults has the metabolic syndrome also which predisposes them to both diabetes and cardiovascular diseases. Recognition of these conditions and institution of early preventive measures are urgently needed.

Creating a pandemic of prediabetes: the proposed new diagnostic criteria for impaired fasting glycaemia

AIMS/HYPOTHESIS

In November 2003 the American Diabetes Association expert committee on the diagnosis and classification of diabetes mellitus suggested a revision of the diagnostic criteria for IFG, lowering the diagnostic threshold from 6.1 to 5.6 mmol/l. The aim of the present study was to evaluate the consequences of this change with respect to: (i) the prevalence of IFG in five different countries; (ii) the concordance between IFG and IGT (classification of individuals); and (iii) the cardiovascular risk profile of these groups. Finally we discuss the likelihood that intervention for cardiovascular risk and prevention strategies developed for individuals with IGT are applicable to subjects with IFG.

METHODS

The first part of the study is based on the population-based Danish Inter99 study, where 6265 individuals, aged 30 to 60 years and without previously diagnosed diabetes, underwent an oral glucose tolerance test. The second part is based on the DETECT-2 project, in which studies from China, India, France and USA were used to analyse the impact of the proposed revision of the diagnostic criteria in different ethnic groups.

RESULTS

The proposed change in diagnostic criteria would increase the prevalence of IFG in Denmark from 11.8 to 37.6%. The proposed IFG category would identify 60.0% of all subjects with IGT compared to 29.2% with the old criteria, but among individuals with the new IFG category only 18.5% would also have IGT. Individuals with isolated IFG had lower insulin levels and a lower cardiovascular risk profile with the proposed criteria compared with the current WHO criteria. Data from the DETECT-2 study confirmed the marked increase in the prevalence of IFG, and the estimated number of individuals in the age range 40 to 64 years with IFG in urban India, urban China and the USA would increase by 78%, 135% and 193% respectively.

CONCLUSIONS/INTERPRETATION

The proposed revised diagnostic criteria will lead to a dramatic increase in the prevalence of IFG, but the concordance rate between IFG and IGT remains low. This new IFG group will have a more favourable cardiovascular risk profile than the current IFG group as defined by the WHO. This seriously questions whether the existing intervention strategies are applicable to the new category of individuals with IFG.

Detecting undiagnosed diabetes in urban Asian Indians--role of opportunistic screening

BACKGROUND

The aim of the study was to determine the proportion of incidental to symptomatic diagnosis of diabetes and to compare the profile of symptomatic and incidentally diagnosed diabetic subjects.

METHODS

One thousand newly diagnosed diabetic subjects (WHO criteria) were studied. Clinical, demographic, anthropometric details, blood pressure, glycaemic and lipid parameters were recorded. Reasons for medical check up were noted.

RESULTS

Among the 1000 subjects, 29% were symptomatic for diabetes and 71% were incidentally diagnosed to have diabetes. Symptomatic subjects were younger, had higher glycaemia and prevalence of hypertension.

CONCLUSION

The results show that majority of type 2 diabetic subjects remain asymptomatic and opportunistic screening for diabetes would be required for the early diagnosis of the disorder.

Flow mediated dilatation and carotid intimal media thickness in South Indian type 2 diabetic subjects

OBJECTIVE

The aims of this study were to determine: (1). endothelial function in type 2 diabetic subjects with and without diabetic microvascular complications using flow mediated dilatation method (FMD); (2). influence of other variables on FMD; and (3). the correlation between FMD and carotid intimal media thickness (IMT).

RESEARCH, DESIGN AND METHODS

In this cross-sectional study, flow mediated dilatation (FMD) and intimal media thickness (IMT) were determined using high resolution ultrasonography in 20 non-diabetic subjects, in 23 type 2 diabetic subjects without any complications and in 23 type 2 diabetic patients with nephropathy and retinopathy.

RESULTS

Age-adjusted mean (S.D.) FMD value in diabetic subjects (8.9 +/- 5%) was lower (P < 0.0001) when compared with the group of control subjects (18.8 +/- 7.5 %. However, there was no difference in the age-adjusted FMD values between diabetic subjects with and without complications (7.3 +/- 3.3 % versus 10.5 +/- 5.9 %). FMD levels did not vary significantly between sexes in both non-diabetic and diabetic groups. FMD correlated negatively with carotid IMT (r = -0.23, P < 0.05). In multiple linear regression analysis, age adjusted FMD was associated only with type 2 diabetes with complications (P = 0.012). The variance explained was 21.9%.

CONCLUSION

Abnormal FMD and increased carotid IMT were present in type 2 diabetes. Both these parameters negatively correlated with each other supporting an association between impaired FMD and atherogenesis. As these abnormalities existed even in diabetic subjects with no microvascular complications, it is likely that they preceded the development of these complications.

Use of glimepiride and insulin sensitizers in the treatment of type 2 diabetes--a study in Indians

AIM

Short-term efficacy of glimepiride, metformin and pioglitazone in newly diagnosed type 2 diabetes was compared with a group treated with diet and exercise. Effects on insulin secretion and sensitivity were also assessed.

METHODS

New type 2 diabetic subjects, aged 30-60 years with BMI < 30 kg/m2 were selected. Subjects having glycosylated haemoglobin (HbA1c) of < 8.5% were advised diet and exercise (control group). Others having HbA1c > or = 8.5 to 11.0% were randomized to receive glimepiride (group 2), metformin (group 3) and pioglitazone (group 4). At the final review between 12-14 weeks, changes in plasma glucose, HbA1c, lipid profile, HOMA insulin resistance (HOMA-IR), beta cell function (HOMA-BF) and insulinogenic index (delta I/G) were measured. Comparisons were made using appropriate statistical analyses.

RESULTS

Seventy-seven of the 97 subjects randomized equally into four groups, were available for review. Glycaemic parameters improved in all groups. Mean cholesterol decreased significantly in groups treated with metformin and pioglitazone. HDL-cholesterol increased with pioglitazone. Insulin resistance decreased significantly with metformin and pioglitazone, beta cell fuhction also showed improvement

CONCLUSIONS

Glycaemic control was seen in all study groups, the improvement was better in drug treated groups than in the control group. Glimepiride improved insulin secretion including the early phase secretion and reduced plasma triglycerides. Metformin and pioglitazone had beneficial effects on lipid levels, improved insulin sensitivity and improved insulin secretion also.

Temporal changes in prevalence of diabetes and impaired glucose tolerance associated with lifestyle transition occurring in the rural population in India

AIMS/HYPOTHESIS

The rural Indian population is undergoing lifestyle transition due to socio-economic growth. This study was done to determine the temporal changes in prevalence of diabetes and IGT that could have occurred in a rural population in India as a result of the lifestyle transition.

METHODS

A cross-sectional study of 1213 Asian-Indian subjects aged 20 years or over was done to look for the prevalence of diabetes and IGT using the 1999 WHO criteria. The temporal changes were assessed in comparison with a similar study conducted 14 years previously. The factors associated with the temporal changes were also analysed.

RESULTS

Nearly a three-fold increase in age- and sex-adjusted prevalence of diabetes (from 2.20% to 6.36%) was seen in 2003 when compared with a similar study done 14 years before. Prevalence of IGT did not change significantly (7.44% in 1989 vs 7.18% in 2003). Improvement in living conditions had occurred during the period, occupational changes were seen, the number of manual labourers had decreased and economic conditions had improved. BMI and waist circumference had increased. After correcting for age, sex and differences in time periods, waist circumference and physical inactivity showed significant associations with the increased prevalence of diabetes.

CONCLUSIONS/INTERPRETATION

Demographic transition due to improved living conditions in rural India was associated with a three-fold increase in the prevalence of diabetes. Increased upper body adiposity and physical inactivity showed significant association with this phenomenon.

Specific problems of the diabetic foot in developing countries

As in many developed countries, diabetic foot disease is also resulting in major debilitating complications with severe morbidity and possible amputations in many developing countries. The developing countries, however, have certain specific cultural and social habits that may put a person with diabetes at a higher risk. The high prevalence of neuropathy promotes recurrence of foot infections and these are seldom treated adequately. Lack of facilities in nearby hospitals and unsatisfactory metabolic control are major contributory factors for foot problems. Regular inspection of the feet for signs of neuropathy and other risk factors would play a major role in the prevention of these complications. Patient education for foot care and early institution of preventive measures by the medical practitioners, particularly in view of the high prevalence of neuropathy, will help in reducing the morbidity and economic burden from diabetic foot.

Regional differences in risk factors and clinical presentation of diabetic foot lesions

BACKGROUND

Problems associated with the diabetic foot are worldwide. However, there may be regional variation among risk factors and clinical presentation. Prospective comparative data concerning this topic are rare.

AIM

To determine differences in underlying risk factors and clinical presentation of foot problems among people with diabetes in different regions.

PATIENTS AND METHODS

Six hundred and thirteen consecutive patients with diabetic foot lesions from three centres [Soest-Germany (GER), Dar-es-Salaam, Tanzania (TAN) and Chennai, India (IND)] were included during the period June 1998 through December 1999. Diabetes-related data, risk-factor profiles, and lesion-related data were collected for each patient. Due to varying proportions of recurrent lesions among the centres, only data from patients with newly presenting diabetic foot lesion were analysed.

RESULTS

Of the 613 patients sampled, 368 (60%) were treated for newly presenting diabetic foot lesion. In all three centres, patients were predominately male and had Type 2 diabetes. The average diabetes duration until the onset of the initial foot lesion was 14 years in GER and 12 years in IND, but only 5 years in TAN. The corresponding patient ages were 71, 56 and 51 years. Neuropathy was common to patients in all three centres. Peripheral vascular disease (PVD) was a frequent risk factor in GER (48%). In TAN and IND it was far less common (12 and 13%), probably due to younger patient populations, shorter diabetes duration and lower proportions of smokers. Inadequate footwear was the most common cause of foot lesions in GER (19%), while lack of footwear, irregular foot care and burns were the primary precipitating factors among patients in TAN and IND.

CONCLUSION

Similarities in different regions of the world among people with diabetes suffering newly presenting foot lesions include a predominance of males and patients with Type 2 diabetes, as well as a high frequency of diabetic neuropathy. However, differences concerning age, diabetes duration, peripheral vascular disease, and precipitating factors contributing to injury are also observed.

025.Ovaries: up in a POF of smoke

Premature ovarian failure (POF) or premature menopause is a common disorder, defined by the occurrence of menopause under the age of 40 years and is characterised by amenorrhoea, hypoestrogenism and elevated gonadotrophins. Worldwide it affects 1% of all women and occurs in 0.1% before the age of 30 years. The major problems associated with POF are the loss of fertility at an early age and the psychological problems associated with this. In addition there are the physiological effects of reduced oestrogen, which include an increased risk of osteoporosis. POF is a heterogeneous disorder and the cause of most cases is unknown. A significant proportion (20-30%) of women with POF have a genetic predisposition. Our primary goal is to identify genes involved in POF. In most cases, the menopause is due to the loss of follicles, and it stands to reason that suitable candidate genes for POF development would be genes that regulate the rate of follicle loss. We have identified two common gene mutations, a 769G>A transition in the inhibin alpha gene in approximately 5% of POF patients associated with POF at a very early age, and mutations in FOXL2 in approximately 5% of patients. FOXL2 is thought to act downstream of inhibin which suggests that other candidate genes may arise from the analysis of the activin signalling pathway. Functional studies will help us to understand more about the molecular basis of POF. Each mutation has been associated with less than 10% of POF cases and POF is likely to be caused by mutations at many different loci. It is hoped that determining the molecular basis of POF will lead to the development of genetic tests to predict the development of POF, and eventually lead to treatment that will return fertility to these women.

Markers of endothelial dysfunction in hyperglycaemic Asian Indian subjects

OBJECTIVE

The aims of this study were the following: (1). to determine the levels of endothelin-1(ET1), soluble adhesion molecules like intracellular adhesion molecule-1 (sICAM-1), and vascular cell adhesion molecule-1 (sVCAM-1) in different stages of glucose intolerance and to identify a suitable marker of endothelial dysfunction and (2). to determine the possible association of these biochemical parameters with diabetic complications and with impaired glucose tolerance (IGT).

RESEARCH DESIGN AND METHODS

In this cross-sectional study, plasma ET1, sICAM-1, and sVCAM-1 were measured by enzyme-linked immunosorbent assay (ELISA) in 20 nondiabetic subjects, in 15 subjects with IGT, in 21 Type 2 diabetic subjects without any complication, and in 21 Type 2 diabetic patients with nephropathy and retinopathy.

RESULTS

Median ET1 levels were significantly elevated (P=.004) in IGT subjects (0.31 fmol/ml) when compared with the nondiabetic subjects (0.11 fmol/ml). Subjects with nephropathy (0.50 fmol/ml) had significantly higher (P=.002) ET1 values when compared with those without complications (0.40 fmol/ml). The levels of sICAM-1 and sVCAM-1 did not show any significant difference among the groups. ET1 showed correlation with age, body mass index (BMI), systolic blood pressure (SBP), diastolic blood pressure (DBP), fasting plasma glucose (FPG), 2 h post glucose (2hPG), waist-to-hip ratio (WHR), total white blood corpuscles count, glycosylated haemoglobin (HbA1c), triglycerides (TG), very-low-density lipoprotein cholesterol (VLDLc), and hypertension (HTN). In the multiple linear regression analysis, plasma ET1 was significantly associated with the presence of Type 2 diabetes either with or without complications (P<.0001 and P=.0098, respectively), WHR (P=.0063), and sVCAM-1 (P=.0051). The total variance explained by the above-mentioned parameters was 55%.

CONCLUSION

Elevated levels of ET1 were present in subjects with IGT and in Type 2 diabetic subjects. Such associations with sICAM-1 or sVCAM-1 in these subjects were not seen. ET1 could be an early marker of endothelial dysfunction, which appeared to occur even in the subclinical stages of hyperglycaemia.

Global policy: aspects of diabetes in India

Diabetes has already been described as an epidemic, but predictions for future increases in prevalence, especially in developing countries, point to a major healthcare crisis for the future. Very little is known about the economic impact of diabetes in the developing world where predicted increases in prevalence are greatest. This paper discusses the implications of a recent study of the economic aspects of diabetes in India. The study aims were to estimate the costs of diabetes care and to assess the awareness of patients and healthcare professionals about the prevention and treatment of diabetes. The findings confirm reports from earlier studies of the high costs of treatment amongst all socio-economic patient groups resulting in a serious burden on both patients and state resources alike. Both patients and medical practitioners displayed a lack of comprehension of the need for constant disease monitoring and consistent approaches to tight glycaemic control. The long term economic implications are worrying. With the Indian diabetic population predicted to rise to >80.9 million by the year 2030, immediate health policy restructuring and investment will be needed if the best use is to be made of the scarce healthcare resources.

Insulin secretion and action show differences in impaired fasting glucose and in impaired glucose tolerance in Asian Indians

BACKGROUND

The aim of the study was to compare the abnormalities in insulin secretion and insulin sensitivity in impaired fasting glucose (IFG) and in impaired glucose tolerance (IGT).

METHODS

Glucose tolerance was determined by oral glucose tolerance test in 289 non-diabetic subjects selected for this study (M : F, 160 : 129, mean age 42.2 +/- 11.0 (SD) years, mean body mass index (BMI) 24.9 +/- 4.2 kg/m(2)). Diabetic subjects were excluded from the study. The association of insulin resistance and beta-cell function (calculated by HOMA model) with IFG and IGT was studied using linear and multiple logistic regression analyses. Subjects with normoglycaemia (NGT) were used as controls.

RESULTS

Insulin resistance was significantly more in IFG and in IGT than in NGT. beta-cell dysfunction was significantly higher in IFG than in IGT. IFG was associated with both insulin resistance (OR = 9.11, p < 0.001) and beta-cell dysfunction (inverse correlation, OR = 0.103, p < 0.001), while only insulin resistance was significantly associated with IGT (OR = 1.24, p = 0.005).

CONCLUSIONS

In urban South Asian Indians, IFG differed from IGT in having combined insulin resistance and beta-cell dysfunction, while IGT was associated only with insulin resistance.

Age- and sex-specific prevalence of diabetes and impaired glucose regulation in 11 Asian cohorts

OBJECTIVE

To report the age- and sex-specific prevalence of diabetes and impaired glucose regulation (IGR) according to revised World Health Organization criteria for diabetes in Asian populations.

RESEARCH DESIGN AND METHODS

We performed 11 studies of 4 countries, comprising 24,335 subjects (10,851 men and 13,484 women) aged 30-89 years who attended the 2-h oral glucose tolerance test and met the inclusion criteria for data analysis.

RESULTS

The prevalence of diabetes increased with age and reached the peak at 70-89 years of age in Chinese and Japanese subjects but peaked at 60-69 years of age followed by a decline at the 70 years of age in Indian subjects. At 30-79 years of age, the 10-year age-specific prevalence of diabetes was higher in Indian than in Chinese and Japanese subjects. Indian subjects also had a higher prevalence of IGR in the younger age-groups (30-49 years) compared with that for Chinese and Japanese subjects. Impaired glucose tolerance was more prevalent than impaired fasting glycemia in all Asian populations studied for all age-groups.

CONCLUSIONS

Indians had the highest prevalence of diabetes among Asian countries. The age at which the peak prevalence of diabetes was reached was approximately 10 years younger in Indian compared with Chinese and Japanese subjects. Diabetes and IGR will be underestimated in Asians based on the fasting glucose testing alone.

Metabolic syndrome in urban Asian Indian adults--a population study using modified ATP III criteria

AIMS/HYPOTHESIS

To determine the prevalence of the Metabolic syndrome (MetS) using modified ATP III criteria in urban Asian Indian adults.

METHODS

475 subjects (age 20-75 years) from a population data base were studied for the MetS using ATP III criteria but with a modified waist circumference (WC) appropriate for Indians. Presence of >or=3 of the following; raised WC (Men >or=90 cm, Women >or=85 cm), triglycerides (TG) >or=1.7 mmol/l), HDL-Cholesterol (HDL-C)-<1.0 mmol/l for men, <1.3 mmol/l for women, fasting plasma glucose (FPG)>or=6.1 mmol/l and blood pressure (BP)>or=130/>or=85 mm of Hg, or using BP medication, indicated the MetS. Insulin resistance (IR) was calculated using the Homeostasis Model Assessment (HOMA) equation. Factor analysis was used to identify clusters of correlated abnormalities.

RESULTS

MetS was present in 41.1%. WC was increased in 31.4%, TG in 45.6%, low HDL-C in 65.5%, hypertension in 55.4% and raised FPG 26.7%. MetS was present in 27.9% of subjects with FPG<6.1 mmol/l and its prevalence increased to >70% with higher FPG values. MetS was more common in women than in men (46.5 vs. 36.4%, chi(2)=4.6, P=0.03) and in older people. Four distinct clusters of abnormalities were identified with some gender variations. IR was more prevalent in MetS and was a component of two clusters but it was not a core component in factor analysis.

CONCLUSIONS

MetS is common in Asian Indians. Its prevalence is age-related, and is more common in women. HOMA-IR or fasting plasma insulin was not a core component of the MetS.

Association of limited joint mobility and high plantar pressure in diabetic foot ulceration in Asian Indians

AIM

To investigate the association of limited joint mobility (LJM) and plantar foot pressure in Asian Indian diabetic subjects.

SUBJECTS AND METHODS

The LJM and plantar pressure were measured in 345 consecutive subjects attending the foot clinic. The study groups were: Control-non-diabetic controls (n=50), DM-diabetic patients without neuropathy (n=100), DM+N-diabetic neuropaths (n=110) and DM+NU-diabetic neuropaths with past history of foot ulceration (n=85). Joint mobility was assessed using a goniometer. Plantar pressure was measured using the RS-Scan platform system. All subjects were able to walk comfortably unaided at their own pace. Data obtained on the metatarsal heads were used for analysis. Neuropathy status was assessed using the biothesiometer.

RESULTS

The diabetic patients had higher prevalence of LJM and higher plantar pressure than control subjects (P<0.0001). Among the diabetic patients, those with neuropathy and history of plantar ulceration had higher LJM and plantar pressure compared to non-neuropaths (P<0.001).

CONCLUSIONS

Both LJM and high plantar pressure appear to be important determinants of foot ulceration in susceptible neuropathic South Indian diabetic patients.

Quality of life and diabetes integration among subjects with type 2 diabetes

Diabetes integration indicates that a person with diabetes makes an appropriate emotional adjustment to the requirements of diabetic way of life. Diabetes integration and a sense of well-being are expected to be correlated. The aim of diabetes treatment should be to enable a patient to adjust himself to his being a diabetic person. This should ensure a sense of well-being. Aims of this study was to assess the role of diabetes integration and psychological factors in patients with type 2 diabetes.

METHOD

A sample of 227 type 2 diabetes patients participated in the study. They were all in the upper middle class social stratum. Diabetes integration scale yields one composite score of adjustment, has 19 items applicable to both type 1 and type 2 diabetic subjects. The psychological well-being scale has 22 items, measures depression (6 items), anxiety (6 items), energy (4 items), positive well-being (6 items) and a general sense of well-being score by the whole test of 22 items.

RESULTS

The psychological well-being subscales and the whole scale scores significantly correlated with diabetes integration scale (all P values were < 0.0001). However, we found that diabetes integration and the psychological well-being subscales were not significantly correlated with metabolic and other medical indices. There were gender differences in depression (p < 0.04), anxiety (p < 0.0001), energy (p = 0.004), positive well-being. (p = 0.02) and general sense of well-being (p < 0.0001), men fared in a better than women subjects. No such gender differences were found in diabetes integration score.

CONCLUSION

Diabetic patients who integrate themselves and emotionally adjust to diabetes experience a psychological sense of well-being.

Impaired fasting glucose and impaired glucose tolerance in urban population in India

AIMS

To study prevalence of impaired fasting glucose (IFG) and impaired glucose tolerance (IGT) in urban Indians and their demographic and anthropometric characteristics.

METHODS

Data on capillary blood glucose (OGTT), anthropometric and demography details were available in 10 025 subjects (M : F 4711 : 5314) aged > or = 20 years. Glucose tolerance was categorized as normal, isolated IFG, isolated IGT, IFG + IGT and diabetes using the fasting and 2-h blood glucose (2hBG; 75-g glucose load) values. Subjects with known diabetes were excluded.

RESULTS

Age-standardized prevalences of IFG, IGT and newly detected diabetes were 8.7%, 8.1% and 13.9%, respectively. IFG was more prevalent in women (9.8%) than in men (7.4%) (chi2 = 13.62, P = 0.0002), while the gender differences in IGT (men 8.4%, women 7.9%) and diabetes (men 13.3%, women 14.3%) were not significant. Body mass index and waist circumference were higher in glucose-intolerant groups than in normal glucose tolerance (NGT). Prevalence of diabetes, IGT and IFG + IGT increased with age. Among the IFG, 4% had diabetes and 27.1% had IGT using 2hBG criteria. In IFG, the fasting and 2hBG values were not correlated.

CONCLUSIONS

Prevalences of IFG and IGT were similar in urban Indians and an overlap occurred in only less than half of these subjects. IFG was more common in women. Subjects with IFG were older and had more adverse anthropometric characteristics in comparison with NGT. IFG did not show an increasing trend with age.

Persistent microalbuminuria in type 1 diabetic subjects in South India

AIM

There are only a few reports on the prevalence of microalbuminuria (MAU) in type 1 diabetic subjects in India. This study was done to assess the prevalence of MAU in South Indian diabetic subjects.

MATERIAL AND METHODS

MAU was estimated by measuring albumin/creatinine ratio in an early morning urine sample on three occasions using immunoturbidimetry (> 30 microg albumin/mg creatinine) in South Indian patients. Kidney function tests were done in 95 type 1 DM, (M:F, 56:39). Persistent proteinuria was detected in 17 (17.9%) and they were excluded from the study. Further details were taken only in the remaining 78 subjects. Persistent MAU was seen in 22 (28.2%) and other 56 subjects had normoalbuminuria (NAU) (71.8%).

RESULTS

There was no significant difference in the age, duration of DM and the average HbAlc between MAU and NAU. MAU developed at the age of > or = 20 years, even in subjects with onset of diabetes at a younger age. Diabetic retinopathy was present in 3 (13.6%) and ECG abnormalities were seen in one patient with MAU. None of the subjects in NAU group had these abnormalities. Prevalence of MAU increased with increasing duration of diabetes, MAU was present in 3 patients (10.3%) with duration of diabetes < or = 5 years, in five patients (23.8%) with duration of diabetes> 5 to < or = 10 years and in 14 (50%) patients with duration of diabetes > 10 years. Hypertension was present in 5 (22.7%) of MAU and only in one subject with NAU.

CONCLUSION

It is observed that MAU occurs in type 1 diabetes after the age of 20 years and it is present in a large proportion of the study subjects.

Plasma homocysteine concentration and coronary artery disease in Asian Indians

OBJECTIVE

This study was done (a) to evaluate the relationship between the plasma total homocysteine (tHcy) levels and coronary artery disease (CAD) in Asian Indians and (b) to see the relationship between tHcy and glucose intolerance.

METHODS

Fasting concentrations of plasma tHcy was measured in 137 men, aged > or = 25 years who underwent coronary angiography while investigating for chest pain. Among them 71 had no CAD and 66 had CAD. Fasting plasma glucose (FPG) and glycosylated haemoglobin (HbA1c) were estimated. Total Hcy was measured using the Elisa method (Axis Biochemicals ASA-Oslo, Norway) in fasting EDTA plasma.

RESULTS

The subjects with CAD were significantly older but had similar body mass index (BMI), waist-hip ratio (WHR), FPG and HbA1c values compared with the non-CAD subjects (P < 0.001). The median tHcy and the percentages of abnormal values were similar in non-CAD and CAD groups. No significant differences were seen in the four subgroups with respect to the mean tHcy or the percentage of abnormal values. The highest tHcy values were seen in the non-diabetic, non-CAD group (group 1--control).

CONCLUSION

This preliminary data indicates that tHcy concentrations are not elevated in subjects with CAD and probably there is no association between total homocysteine and CAD in Indians. Homocysteine values were not influenced by the glucose tolerance status. Measurement of homocysteine concentrations may be more appropriate when the blood levels of vitamin B12 and folate are also measured.

Temporal changes in prevalence of type 2 diabetes and impaired glucose tolerance in urban southern India

The prevalence of type 2 diabetes and impaired glucose tolerance (IGT) is increasing in urban areas of developing countries, especially in India. This is a report of the temporal changes in the prevalence of diabetes and IGT in urban areas of Chennai (Madras), India, in adults aged > or =20 years, with an emphasis on identifying the risk factors responsible for the changes. Three urban diabetic surveys conducted in 1989, 1995 and 2000 were compared for the age-standardized prevalence, anthropometric, demographic and lifestyle characteristics of the glucose-intolerant groups. Multiple logistic regression analyses were used for the identification of risk variables associated with diabetes and IGT. The trend was statistically significant for diabetes (chi(2)=18.0, P<0.001) and for IGT (chi(2)=48.2, P<0.001). The period between 1989 and 1995 showed a 40% rise in the prevalence of diabetes and a further increase of 16.4% in the next 5 years. Age increased in each survey for both genders. Waist girth and waist:hip ratio were significantly higher in women, in the 2000 survey. There was no change in the mean body mass index with time in both genders. An increase in IGT was seen in year 2000, especially so in subjects aged <40 years. The prevalence of diabetes and IGT is increasing in India. Increasing age and positive family history showed associations with diabetes.

Early recognition of diabetic neuropathy: evaluation of a simple outpatient procedure using thermal perception

OBJECTIVE

To determine the effectiveness of Tip-therm, a temperature discriminator, in making an early diagnosis of distal symmetrical polyneuropathy in diabetic patients and to compare its effectiveness with the Semmes-Weinstein monofilament and biothesiometry, which are established methods of diagnosing neuropathy in diabetic patients.

PATIENTS AND METHODS

From the diabetic subjects who came to the hospital for review, 910 consecutive cases were selected. All were tested with the Semmes-Weinstein monofilament (10 g monofilament) and biothesiometry and also by using the Tip-therm for comparison.

RESULTS

Out of the 241 patients who had no sensation to the monofilament only four (1.7%) felt Tip-therm whereas 237 (98.3%) patients could not feel Tip-therm. Among 298 patients diagnosed as having neuropathy by biothesiometry, only eight (2.7%) patients exhibited sensation with Tip-therm while 290 (97.3%) patients could not feel it.

CONCLUSION

A simple device, Tip-therm, which tests for temperature discrimination, was compared with two validated methods for detection of neuropathy-a monofilament and biothesiometry. Tip-therm appears to be an inexpensive, highly sensitive, and specific device for detection of diabetic neuropathy when compared with biothesiometry and a monofilament.

Prevalence of overweight in urban Indian adolescent school children

The prevalence of diabetes mellitus (DM) and cardiovascular disease (CVD) is increasing in urban India. Overweight in adolescence is a marker of overweight in adult age, and it shows an association with the above diseases. There have been meagre data from India on the prevalence of childhood obesity. The objective of the study was to quantify the prevalence of overweight and its risk factors in adolescent children in urban India. School students in the age group of 13-18 years (n = 4700, M:F 2382:2318) were studied. Body mass index (BMI) was measured. Data on physical activity, food habits, occupation of parents and their economic status, birth weight of the children and age at menarche in girls were obtained by questionnaire. Age-adjusted prevalence of overweight was 17.8% for boys and 15.8% for girls. It increased with age and was higher in lower tertiles of physical activity and in higher socio-economic group. Birth weight and current BMI were positively associated. The study highlighted the high prevalence of overweight in adolescent children in urban India. Life style factors influenced BMI in adolescent age.

Prevalence of pathogens in diabetic foot infection in South Indian type 2 diabetic patients

AIM

To determine the prevalence of pathogens in diabetic foot infections, in relation to parameters like Wagner's grading, duration of diabetes and healing time.

MATERIAL AND METHODS

A group of 654 (M:F, 433:221) type 2 diabetic patients with foot ulcers were studied. Specimens like pus, wound exudate and tissue were processed for smear for Gram's staining, aerobic and anaerobic culture, and biochemical identifications.

RESULTS

In 654 diabetic patients, 728 pathogens were isolated. Aerobic pathogens were isolated in 437 (66.8%) patients and anaerobic pathogens were isolated in 217 (33.2%). As Wagner's grading increased, the prevalence of anaerobic pathogens also increased. Neuropathy was common in diabetic patients infected with both aerobic and anaerobic pathogens. Ulcers infected with anaerobic pathogens showed a longer healing time than ulcers infected with aerobic pathogens. There was no significant difference in peripheral vascular disease (PVD) in patients selected for the study. Among aerobic pathogens, Enterobacteriaceae family (48%), Staphylococcus species (spp) (18.2%), Streptococcus spp (16.8%) and Pseudomonas spp (17%) were seen frequently. Among anaerobes Peptostreptococcus spp and Clostridium spp formed 69.4%. Gram-negative anaerobes like Bacteroides spp and Fusobacterium spp were present in 30.6%. Healing time was longer when strict aerobic pathogen Pseudomonas spp and strict anaerobic pathogens were present (136.1 +/- 28.6 and 136.4 +/- 34.7 days, respectively).

CONCLUSIONS

Diabetic foot infection is polymicrobial in nature. The healing time of wound infected with anaerobic pathogens was higher than those infected with aerobic pathogens. Anaerobic pathogens increased with the Wagner's grading. Presence of neuropathy increased the risk of foot infection.

Is increased apolipoprotein B-A major factor enhancing the risk of coronary artery disease in type 2 diabetes?

OBJECTIVES

An association of Apolipoprotein B (Apo B) with coronary artery disease (CAD) independent of LDL cholesterol (LDLc) concentrations has been reported in white population. This analysis was taken up to study whether the higher CAD risk in Asian Indians with diabetes could be explained by possible alterations in Apo B and Apolipoprotein A1 (Apo A1) concentrations.

METHODS

The study group consisted of four hundred and forty seven men aged > or = 25 years, 167 with CAD and 280 with no CAD, classified by coronary angiography. Plasma lipid profile including total cholesterol, LDLc, Apo A1 and Apo B were done. Glucose tolerance was evaluated in all.

RESULTS

Age, BMI, Apo B, and Apo A1 were significantly associated with CAD in a multiple regression analysis. Hyper Apo B was more common than hyper LDLc in CAD (73.6% vs 20.4%, chi2 = 157, P < 0.001). Apo B concentrations were increased in diabetic subjects even in the presence of normal levels of LDLc and in the absence of CAD.

CONCLUSIONS

The study has shown that the apolipoproteins B and A1 provide better information regarding the risk of CAD. Apo B abnormalities exist in large percentages of CAD subjects despite having normal levels of LDLc. Diabetes per se enhances the Apo B concentrations and this could probably be one of the mechanisms of accelerated CAD in diabetes. Hyper Apo B may be an index of CAD risk.

Epidemiology of type 2 diabetes in Indians

Prevalence of diabetes is increasing globally. India have the maximum increase during the last few years. Type 2 diabetes mellitus is the commonest form of diabetes. The prevalence of type 2 diabetes mellitus is 2.4% in rural population and 11.6% in urban population. Prevalence of impaired glucose tolerance is also high in the urban population. Subjects under 40 years of age have a higher prevalence of impaired glucose tolerance than diabetes. The important risk factors for high prevalence of diabetes include: High familial aggregation, obesity specially central one, insulin resistance and lifestyle changes due to rapid urbanisation. Diabetes Research Centre, Madras carried out many studies regarding the risk factors involved in causing type 2 diabetes mellitus. The results of these studies are mentioned here in this article to have a glimpse of overall risk factors involved in causation of diabetes mellitus.

Impact of poverty on the prevalence of diabetes and its complications in urban southern India

AIM

The impact of poverty on the profile of diabetes and its complications was studied.

METHODS

A comparative study of low income group (LIG) (family income Rs. < 30,000/annum (approx. 432 pounds sterling) and high income group (HIG) (family income Rs. greater-than-or-equal 60,000/annum (approx. pounds sterling) subjects of > or = 40 years was done in Madras, India. By screening 1748 LIG subjects (M/W 844/904) 301 diabetic subjects were identified and 218 underwent tests for diabetic complications. Population data available in 635 (M/W 309/326) HIG subjects from the survey were used for comparison of glucose tolerance profile. Complications were studied in 221 diabetic HIG subjects.

RESULTS

Age-standardized prevalences of diabetes (12.6% vs. 25.5%; chi(2) = 56.9, P < 0.0001) and impaired glucose tolerance (IGT) (8.9% vs. 19.0%) were significantly lower (chi(2) = 57.7; P < 0.0001) in the LIG. Hypertension was more common in LIG (53.7% vs. 40.0% in HIG; chi(2) = 34.9; P < 0.0001). LIG subjects were more physically active; 73.8% did not go to school. Parameters significantly associated with diabetes were body mass index (BMI), age, higher income, waist--hip ratio and physical inactivity. Higher income, BMI and age were associated with IGT. Diabetic LIG subjects had a higher prevalence of cardiac disease, neuropathy and cataract and a lower prevalence of retinopathy than HIG subjects. The risk variables such as hyperglycaemia, dyslipidaemia, hypertension, smoking and alcohol consumption were more in the LIG group.

CONCLUSIONS

The urban poor in the developing world has a lower prevalence of diabetes than the urban poor in developed societies. However, they have higher rates of complications of diabetes.

Costs incurred by families having Type 1 diabetes in a developing country--a study from Southern India

The aim of the study was to estimate the direct family costs of Type 1 diabetes in India. The study was carried out with the participation of the families of 209 Type 1 DM patients (M:F 126:83, mean age 26.6+/-12.7 years). The annual family income varied from Rs. 10,000 to 600,000/- (US$ 212-12,765) with a median of Rs. 60,000/- (US$ 1276). A median figure of Rs. 13,980 (US$ 310) was spent annually on diabetes by the families of patients; range Rs. 2046-87,150 (US$ 45-1936). Fifty six percent of patients were not earning. The median percentage of income spent on diabetes was 22% for the entire group, varying from 59% in the low socioeconomic group, 32% in the middle socioeconomic group, 18% in the upper middle income group and 12% in the high-income group. Patients managed on an outpatient basis alone incurred an expenditure of 16% of income while 23% of income was spent on those requiring hospitalisation.

A comparative study of sialic acid-rich proteins in rat bone and dentin

Four sialic acid-rich (SA-rich) proteins found in bone and dentin, osteopontin (OPN), bone sialoprotein (BSP), bone acidic glycoprotein-75 (BAG-75), and dentin matrix protein 1 (DMP1), share some common features. We used SDS-PAGE and Western immunoblots to analyze and compare SA-rich proteins in bone and dentin extracts from rats with a single chromatographic procedure. OPN was detected in dentin extracts, with a relative level less than one-seventieth of that in bone. Both bone and dentin BSP demonstrated an extremely broad distribution pattern, probably due to a high degree of heterogeneity in post-translational modifications. BAG-75 in both bone and dentin was detected as an 83 kDa band, dramatically distinct from that of DMPI. Using a polyclonal antibody raised against a purified bone 57 kDa protein (a portion of DMPI), we detected 150 kDa protein bands in bone fraction; the same bands were recognized by antirecombinant rat DMPI antibody. Bands from dentin migrating at about 150 kDa in earlier fractions and progressing to 200 kDa in later fractions showed a clear immunoreactivity to the anti-57 kDa antibody. We conclude that the majority of DMPI in rat bone is processed into fragments, whereas that in dentin remains intact.

Endothelial NOS-dependent activation of c-Jun NH(2)- terminal kinase by oxidized low-density lipoprotein

Oxidized low-density lipoprotein (oxLDL) is known to activate a number of signal transduction pathways in endothelial cells. Among these are the c-Jun NH(2)-terminal kinase (JNK), also known as stress-activated protein kinase, and extracellular signal-regulated kinase (ERK). These mitogen-activated protein kinases (MAP kinase) determine cell survival in response to environmental stress. Interestingly, JNK signaling involves redox-sensitive mechanisms and is activated by reactive oxygen and nitrogen species derived from both NADPH oxidases, nitric oxide synthases (NOS), peroxides, and oxidized low-density lipoprotein (oxLDL). The role of endothelial NOS (eNOS) in the activation of JNK in response to oxLDL has not been examined. Herein, we show that on exposure of endothelial cells to oxLDL, both ERK and JNK are activated through independent signal transduction pathways. A key role of eNOS activation through a phosphatidylinositol-3-kinase-dependent mechanism leading to phosphorylation of eNOS is demonstrated for oxLDL-dependent activation of JNK. Moreover, we show that activation of ERK by oxLDL is critical in protection against the cytotoxicity of oxLDL.

Lack of association of insulin resistance and carotid intimal medial thickness in non-diabetic Asian Indian subjects

OBJECTIVE

Atherosclerosis is associated with insulin resistance (IR) and dyslipidaemia. Impaired glucose tolerance (IGT) is characterised by IR and is associated with a higher risk of atherosclerosis. The objective of the present study was to test whether early atherosclerosis indicated by intimal medial thickness (IMT) of common carotid artery (CCA) and internal carotid artery (ICA) is higher in IGT than in normoglycaemic subjects (NGT) and to look for an association of IMT with IR and dyslipidaemia.

STUDY DESIGN AND METHODS

Ninety-nine randomly selected non-diabetic subjects aged >or=35 years (48 NGT and 51 IGT) were studied. Measurements of body mass index (BMI), waist/hip ratio (WHR), blood pressure, cholesterol-total, HDL, LDL, VLDL, triglycerides (TG), lipoprotein (a), apolipoprotein-A1 (Apo A1) and apolipoprotein-B (Apo B) and ratio of Apo A1/Apo B were estimated. Insulin resistance (HOMA-IR) was calculated using the fasting plasma insulin and glucose values. IMT of CCA and ICA were measured using high-resolution beta-mode ultrasonography.

RESULTS

Subjects with IGT and NGT were matched for BMI and WHR; HOMA-IR was higher in IGT vs NGT (7.92+/-4.2 vs 6.07+/-3.76, p = 0.028). Age-adjusted IMT values were similar in NGT and IGT (CCA 0.59+/-0.17 and 0.63+/-0.22 mm and ICA 0.44+/-0.10 and 0.45+/-0.10 mm, respectively). Further analyses were done in the total group. Multiple linear regression analyses showed that CCA-IMT was significantly associated with age and negatively associated with Apo A1/Apo B ratio. ICA-IMT was associated with age only. IMT was significantly correlated with cholesterol-total and LDL-cholesterol and apolipoproteins. It was not associated with IR.

CONCLUSION

In southern Indians, IGT did not influence the IMT. Although insulin resistance was higher in IGT, it was not associated with higher IMT. Conventional risk factors such as cholesterol, LDL-cholesterol and apolipoproteins showed association with IMT in the insulin-resistant population.

Association of proinsulin and insulin resistance with coronary artery disease in non-diabetic south Indian men

AIMS

To evaluate the association of plasma proinsulin and insulin resistance (IR) with coronary artery disease (CAD) in non-diabetic subjects.

METHODS

In this case control study, 41 normoglycaemic men with angiographic evidence of CAD were compared with 41 control men matched for age and glycaemia and with no history or evidence of cardiac diseases. Estimations of plasma glucose, lipids, fasting plasma specific insulin (SI) and proinsulin (PI) were performed. IR was calculated by the homeostasis model assessment (HOMA) method. Multiple logistic regression analysis was performed to test the association of the variables with the prevalence of CAD.

RESULTS

Subjects with CAD had a higher body mass index (BMI) (25.4 +/- 4.3 vs. 22.9 +/- 3.2 kg/m2, P = 0.003) and waist to hip ratio (WHR) (0.95 +/- 0.05 vs. 0.89 +/- 0.09, P = 0.001) and a lower high-density lipoprotein (HDL) cholesterol level (0.97 +/- 0.2 vs. 1.1 +/- 0.2 mmol/l, P = 0.002). They also had higher mean SI values (107.5 vs. 62.3 pmol/l, P = 0.002), PI values (19.3 vs. 5.7 pmol/l, P < 0.0001), PI/SI ratios (21.4 vs. 10.3, P < 0.0001) and HOMA IR (4.2 vs. 2.4, P = 0.004) compared with non-CAD subjects. These variables were associated with CAD in the unadjusted multiple regression analysis. In the multiple regression with the forward entry of the variables, WHR and PI only showed independent association with CAD.

CONCLUSIONS

Subjects with CAD had higher levels of obesity and WHR. CAD showed an association with low HDL cholesterol, circulating PI, PI/SI ratios and IR.

High prevalence of diabetes and impaired glucose tolerance in India: National Urban Diabetes Survey

AIMS/HYPOTHESIS

There has been no reported national survey of diabetes in India in the last three decades, although several regional studies show a rising prevalence of diabetes. The aim of this study was to assess the prevalence of diabetes and impaired glucose tolerance in six major cities, covering all the regions of the country.

METHODS

Using a stratified random sampling method, 11216 subjects (5288 men; 5928 women) aged 20 years or above, representative of all socio-economic strata, were tested by OGTT. Demographic, anthropometric, educational and social details were recorded using a standard proforma. Physical activity was categorised using a scoring system. Body mass index (BMI) and waist-to-hip ratio (WHR) were calculated. Glucose tolerance was classified using the 2-h values (WHO criteria). Prevalence estimations were made taking into account the stratified sampling procedure. Group comparisons were done by t-test or analysis of variance or Z-test as relevant. Univariate and multiple logistic regression analyses were used to study the association of variables with diabetes and impaired glucose tolerance.

RESULTS

Age standardised prevalences of diabetes and impaired glucose tolerance were 12.1% and 14.0% respectively, with no gender difference. Diabetes and impaired glucose tolerance showed increasing trend with age. Subjects under 40 years of age had a higher prevalence of impaired glucose tolerance than diabetes (12.8% vs 4.6%, p < 0.0001). Diabetes showed a positive and independent association with age, BMI, WHR, family history of diabetes, monthly income and sedentary physical activity. Age, BMI and family history of diabetes showed associations with impaired glucose tolerance.

CONCLUSIONS/INTERPRETATION

This national study shows that the prevalence of diabetes is high in urban India. There is a large pool of subjects with impaired glucose tolerance at a high risk of conversion to diabetes.

Bone marrow biopsy and bone scan to detect skeletal metastases

This study correlates the findings of bone marrow biopsy with those of bone scan in patients with common cancers and highlights the comparable sensitivities of the two methods at the authors' institution. The results show that bone scintigraphy may be slightly more sensitive than bone marrow examination for the detection of carcinomatous metastases. This experience suggests that institutions should devise clinical pathways based on their testing sensitivities and patient characteristics. These considerations will ultimately result in better and more cost-effective treatment of these patients.

Intestinal mitochondrial dysfunction in surgical stress

BACKGROUND

Surgical stress is associated with altered intestinal function. Our earlier study using a rat model indicated that oxidative stress plays an important role in this process. Since mitochondria are crucial to cellular function and survival and are both a target as well as a source of reactive oxygen species, the present study looks at the changes in enterocyte mitochondria during surgical stress.

METHODS

Surgical stress was induced by opening the abdominal wall and handling the intestine as done during laparotomy. Mitochondria were prepared from the isolated enterocytes at different time periods after surgical stress. The effect of surgical stress on enterocyte mitochondrial ultrastructure, respiration, anti-oxidant enzyme activity, thiol redox status, calcium flux, permeability, and matrix enzymes was then studied.

RESULTS

Surgical stress resulted in alterations in mitochondrial respiration and thiol redox status. It was also associated with altered mitochondrial matrix enzyme activity, decreased superoxide dismutase activity, induction of mitochondrial permeability transition, and swelling, as well as impairment of mitochondrial calcium flux. These alterations were seen at a maximum of 60 min following surgical stress and were reversed by 24 h.

CONCLUSIONS

Laparotomy and mild intestinal handling itself results in enterocyte mitochondrial damage. Since mitochondria are important cellular organelles, this damage can probably lead to compromised intestinal function.

Nitric oxide protects the intestine from the damage induced by laparotomy and gut manipulation

BACKGROUND

The intestine is highly susceptible to free radical-induced damage, and our earlier work has shown that surgical stress induces the generation of oxygen free radicals in enterocytes, resulting in intestinal damage along with ultrastructural changes. Since nitric oxide (NO) is an important mediator of gastrointestinal function, this study looked at the effect of NO on surgical stress-induced intestinal alterations.

MATERIALS AND METHODS

Control rats and rats pretreated with the NO donor l-arginine were subjected to surgical stress by opening the abdominal wall and handling the intestine as done during laparotomy. Enterocytes were isolated and homogenate prepared, and the protection offered by l-arginine against damage due to surgical stress was determined and compared with normal controls. Protection to structural as well as functional aspects of the intestine was also examined.

RESULTS

Intestinal manipulation affected intestinal structure as assessed by electron microscopy. Functional impairment of the enterocyte was also evident, with increased xanthine oxidase activity resulting in production of superoxide anion. This impairment is more dramatic in the crypt cells. Increased protease activity was also seen following laparotomy and handling. Pretreatment with the NO synthase substrate l-arginine prevented these damaging effects. Arginine protection was abolished in the presence of the NO synthase inhibitor NG-nitro-l-arginine methyl ester, indicating the role of NO.

CONCLUSION

Stress in the small intestine due to any surgery can affect enterocyte structure and function. These damaging effects can be prevented by NO, an important modulator of cellular function.

Novel Sp family-like transcription factors are present in adult insect cells and are involved in transcription from the polyhedrin gene initiator promoter

We earlier documented the involvement of a cellular factor, polyhedrin (polh) promoter-binding protein, in transcription from the Autographa californica nuclear polyhedrosis virus polh gene promoter. Sequences upstream of the polh promoter were found to influence polh promoter-driven transcription. Analysis of one such region, which could partially compensate for the mutated polh promoter and also activate transcription from the wild-type promoter, revealed a sequence (AcSp) containing a CACCC motif and a loose GC box resembling the binding motifs of the transcription factor Sp1. AcSp and the consensus Sp1 sequence (cSp) specifically bound factor(s) in HeLa and Spodoptera frugiperda (Sf9) insect cell nuclear extracts to generate identical binding patterns, indicating the similar nature of the factor(s) interacting with these sequences. The AcSp and cSp oligonucleotides enhanced in vivo expression of a polh promoter-driven luciferase gene. In vivo mopping of these factor(s) significantly reduced transcription from the polh promoter. Recombinant viruses carrying deletions in the upstream AcSp sequence confirmed the requirement of these factor(s) in polh promoter-driven transcription in the viral context. We demonstrate for the first time DNA-protein interactions involving novel members of the Sp family of proteins in adult insect cells and their involvement in transcription from the polh promoter.

Intestinal dysfunction in liver cirrhosis: Its role in spontaneous bacterial peritonitis

Spontaneous bacterial peritonitis is a common illness in patients with cirrhosis and ascites that occurs without any apparent focus of infection. Bacterial translocation plays an important role in spontaneous bacterial peritonitis and it is evident from a variety of studies that the gut is a major source of this bacteria. Gut motility alterations, along with bacterial overgrowth and changes in intestinal permeability, probably play a role in this bacterial translocation. The present review looks at the role of the intestine in spontaneous bacterial peritonitis induced by liver cirrhosis and the factors influencing bacterial translocation in this disease.

Various Presentations of Postcholecystectomy Bile Leak Diagnosed By Scintigraphy

Hepatobiliary scintigraphy is an established method for the diagnosis of a bile leak from the biliary system. A bile leak should be considered in any patient after cholecystectomy who has unexplained abdominal pain after operation. Three patients with bile leak diagnosed by scintigraphy are described, one of whom had an unusual pattern of hepatic subcapsular collection of the bile. The second patient had a bile leak through the postsurgical drainage tube, whereas the third patient had a more typical pattern of leakage into the peritoneal cavity.

Foot care economics--cost burden to diabetic patients with foot complications: a study from southern India

OBJECTIVE

To estimate the direct cost burden of diabetic patients with foot complications.

METHODS

An illustrative sample of 270 subjects with type two diabetes were seen at the clinic selected for the study. Among them 164 were without any complication (Group I) and 106 patients were with foot complications (Group II). In the latter group 83 (Group IIA) required in-patient (IP) care and 23 (Group IIB) required out-patient (OP) care. Annual expenses on medical care were estimated by a questionnaire method. Validation of the questionnaire data was verifying the amount spent by checking up the bills.

RESULT

Group I spent Rs.4373 (US $ 104 Approx.), Group II spent Rs.15450 (US $ 343 Approx.), Group IIA spent Rs.7200 (US $ 171 Approx.) and Group IIB spent Rs.16910 (US $ 403 Approx.) in the study year. In the total sample of 270 subjects 61% were without foot problems, 22% had foot problems requiring OP treatment only (Group IIA), and 78% had foot problems requiring IP treatment (Group IIB).

CONCLUSION

Group IIB spent significantly greater percentage of their income than Group IIA, and both groups spent greater percentage of their income than Group I. All differences were statistically significant.

Differentiation of embryonic mesenchymal cells to odontoblast-like cells by overexpression of dentin matrix protein 1

Cells of the craniofacial skeleton are derived from a common mesenchymal progenitor. The regulatory factors that control their differentiation into various cell lineages are unknown. To investigate the biological function of dentin matrix protein 1 (DMP1), an extracellular matrix gene involved in calcified tissue formation, stable transgenic cell lines and adenovirally infected cells overexpressing DMP1 were generated. The findings in this paper demonstrate that overexpression of DMP1 in pluripotent and mesenchyme-derived cells such as C3H10T1/2, MC3T3-E1, and RPC-C2A can induce these cells to differentiate and form functional odontoblast-like cells. Functional differentiation of odontoblasts requires unique sets of genes being turned on and off in a growth- and differentiation-specific manner. The genes studied include transcription factors like core binding factor 1 (Cbfa1), bone morphogenetic protein 2 (BMP2), and BMP4; early markers for extracellular matrix deposition like alkaline phosphatase (ALP), osteopontin, osteonectin, and osteocalcin; and late markers like DMP2 and dentin sialoprotein (DSP) that are expressed by terminally differentiated odontoblasts and are responsible for the formation of tissue-specific dentin matrix. However, this differentiation pathway was limited to mesenchyme-derived cells only. Other cell lines tested by the adenoviral expression system failed to express odontoblast-phenotypic specific genes. An in vitro mineralized nodule formation assay demonstrated that overexpressed cells could differentiate and form a mineralized matrix. Furthermore, we also demonstrate that phosphorylation of Cbfa1 (osteoblast-specific transcription factor) was not required for the expression of odontoblast-specific genes, indicating the involvement of other unidentified odontoblast-specific transcription factors or coactivators. Cell lines that differentiate into odontoblast-like cells are useful tools for studying the mechanism involved in the terminal differentiation process of these postmitotic cells.

Association between ACE gene polymorphism and diabetic nephropathy in South Indian patients

OBJECTIVE

To study the association of ACE gene polymorphism and diabetic nephropathy in South Indian subjects.

SETTING

Outpatient clinic of a specialized hospital.

PATIENTS

The study included 109 South Indian type 2 diabetic patients (72 males and 37 females; age 56.7 plus/minus 9.0 years, mean plus/minus SD). The patients were subdivided into two groups: nephropathic (n=86) and normoalbuminuric patients (n=23).

INTERVENTIONS

Genomic DNA was isolated from the peripheral blood leukocytes. To determine the ACE genotype, genomic DNA was amplified by PCR initially using a flanking primer pair and, subsequently when necessary, with a primer pair that recognizes the insertion specific sequence for confirmation of the specificity of the amplification reactions.

MAIN OUTCOME MEASURES

ACE genotype distribution in the two study groups.

RESULTS

In the nephropathic patients, ID and DD genotypes were present in 52.3% and 27.9% of the patients, respectively as compared to 34.8% and 21.7% respectively in those with normoalbuminuria. The D allele was present in 80.2% of the nephropathic patients and 56.5% of the normoalbuminuric patients (chi-squared=4.28, P=0.039; odds ratio 3.12). Therefore, the higher percentage of II genotype in the normoalbuminuric group was 43.5% as compared to the 19.8% in nephropathic patients.

CONCLUSIONS

This study showed a positive association between the D allele (ID and DD genotype) of the ACE polymorphism and diabetic proteinuria in South Indian type 2 diabetic patients. Our findings are in keeping with several earlier studies showing a strong association of the D allele of the ACE gene with diabetic nephropathy.

Risk variables for coronary artery disease in Asian Indians

No large study from India has addressed the association of risk variables with coronary artery disease (CAD) in angiographically proved cases. In this study, we analyzed the association of anthropometric variables, lipoproteins, and coagulation parameters with CAD in those cases proved by coronary angiography. A cross-sectional study of 447 men > or = 25 years old, classified as with CAD or without CAD, was performed. Men treated with aspirin or lipid-lowering agents, and those with renal, hepatic, or thyroid diseases were excluded. Associations of these variables with CAD were evaluated by univariate and multiple logistic regression analyses. The effect of diabetes on the CAD profile was also analyzed. Prevalences of diabetes and hypertension were significantly higher among those with CAD (p <0.001 for both). Lipid profile abnormalities, except lipoprotein (Lp(a)), were associated with CAD. Antibodies to oxidized low-density lipoprotein was higher in patients with CAD. Fibrinogen levels were higher in CAD, but plasminogen activator inhibitor-1 did not show an association with CAD. In the multiple logistic regression analysis, age, body mass index, very-low-density lipoprotein cholesterol, total to high-density lipoprotein cholesterol ratio, and fibrinogen showed significant independent association with CAD. Several lipid abnormalities were associated with CAD in Asian Indians, but no significant association was seen with Lp(a) levels.