Multiple genetic variants explain measurable variance in type 2 diabetes-related traits in Pakistanis

AIMS/HYPOTHESIS

Multiple genetic variants are associated with type 2 diabetes-related traits in Europeans, but their role in South Asian populations needs further study. We hypothesised that genetic variants associated with diabetes-related traits in Europeans would explain a similar proportion of phenotypic variance in a Pakistani population and could be used in Mendelian randomisation analyses.

METHODS

We used data from 2,131 individuals from the Control of Blood Pressure and Risk Attenuation Trial (COBRA) in Karachi, Pakistan. Individuals were aged 40 years or older.

RESULTS

Combining information from multiple genetic variants showed that fasting glucose, BMI, triacylglycerol, and systolic and diastolic blood pressure variants explained 2.9%, 0.7%, 5.5%, 1.2% and 1.8% of the variance in those traits respectively. Genetic risk scores of fasting glucose, triacylglycerol, BMI, systolic blood pressure and diastolic blood pressure variants were associated with these traits, with per allele SD effects of 0.057 (95% CI 0.041, 0.074), p=3.44 × 10(-12), 0.130 (95% CI 0.105, 0.155), p=2.9 × 10(-21), 0.04 (95% CI 0.014, 0.072), p=0.004, 0.031 (95% CI 0.016, 0.047), p=7.9 × 10(-5), 0.028 (95% CI 0.015, 0.042), p = 5.5 × 10(-5), respectively. These effects are consistent with those observed in Europeans, except that the effect of triacylglycerol variants in South Asians was slightly lower. Mendelian randomisation provided evidence that genetically influenced, raised triacylglycerol levels do not causally affect type 2 diabetes risk to the extent predicted from observational data (p=0.0003 for difference between observed and instrumental variables correlations).

CONCLUSIONS/INTERPRETATION

Genetic variants identified in Europeans are associated with type 2 diabetes-related traits in Pakistanis, with comparable effect sizes. Larger studies are needed to perform adequately powered Mendelian randomisation and help dissect the relationships between type 2 diabetes-related traits in diverse South Asian subgroups.

Virulence markers of Helicobacter pylori in patients with diarrhoea-dominant irritable bowel syndrome

Recent studies suggest that irritable bowel syndrome (IBS) is associated with low-grade inflammation. This study aims to determine the distribution of Helicobacter pylori cytotoxin-associated gene A (cagA) and vacuolating cytotoxin A (vacA) alleles (e.g., s1 and s2) in patients with diarrhoea-dominant IBS (IBS-D) as the latter causes vacuolation in colonic epithelial cells in vitro. One hundred and seventy patients meeting Rome III criteria for IBS-D (mean age: 40 +/- 15 years) were enrolled. Gastric biopsy was assessed histologically and DNA extraction was performed by polymerase chain reaction (PCR) for H. pylori genus 16S ribosomal DNA (16S rDNA), cagA and vacA allele s1 and s2. There was no age- or gender-related difference in H. pylori positivity in IBS-D compared to the control group. H. pylori was positive in 116 (68%) with IBS-D compared to 88 (55%) in the control group (P=0.01). cagA was positive in 73 (63%) with IBS-D compared to 42 (48%) in the control group (P=0.03). vacA s1 was positive in 61 (53%) with IBS-D compared to 32 (36%) in the control group (P=0.02). cagA s1 was positive in 39 (34%) with IBS-D compared to 13 (15%) in the control group (P=0.002).

An FTO variant is associated with Type 2 diabetes in South Asian populations after accounting for body mass index and waist circumference

AIMS

A common variant, rs9939609, in the FTO (fat mass and obesity) gene is associated with adiposity in Europeans, explaining its relationship with diabetes. However, data are inconsistent in South Asians. Our aim was to investigate the association of the FTO rs9939609 variant with obesity, obesity-related traits and Type 2 diabetes in South Asian individuals, and to use meta-analyses to attempt to clarify to what extent BMI influences the association of FTO variants with diabetes in South Asians.

METHODS

We analysed rs9939609 in two studies of Pakistani individuals: 1666 adults aged ≥40 years from the Karachi population-based Control of Blood Pressure and Risk Attenuation (COBRA) study and 2745 individuals of Punjabi ancestry who were part of a Type 2 diabetes case-control study (UK Asian Diabetes Study/Diabetes Genetics in Pakistan; UKADS/DGP). The main outcomes were BMI, waist circumference and diabetes. Regression analyses were performed to determine associations between FTO alleles and outcomes. Summary estimates were combined in a meta-analysis of 8091 South Asian individuals (3919 patients with Type 2 diabetes and 4172 control subjects), including those from two previous studies.

RESULTS

In the 4411 Pakistani individuals from this study, the age-, sex- and diabetes-adjusted association of FTO variant rs9939609 with BMI was 0.45 (95%CI 0.24-0.67) kg/m(2) per A-allele (P=3.0 × 10(-5) ) and with waist circumference was 0.88 (95% CI 0.36-1.41) cm per A-allele (P=0.001). The A-allele (30% frequency) was also significantly associated with Type 2 diabetes [per A-allele odds ratio (95%CI) 1.18 (1.07-1.30); P=0.0009]. A meta-analysis of four South Asian studies with 8091 subjects showed that the FTO A-allele predisposes to Type 2 diabetes [1.22 (95%CI 1.14-1.31); P=1.07 × 10(-8) ] even after adjusting for BMI [1.18 (95%CI 1.10-1.27); P=1.02 × 10(-5) ] or waist circumference [1.18 (95%CI 1.10-1.27); P=3.97 × 10(-5) ].

CONCLUSIONS

The strong association between FTO genotype and BMI and waist circumference in South Asians is similar to that observed in Europeans. In contrast, the strong association of FTO genotype with diabetes is only partly accounted for by BMI.

Respiratory bacterial flora from healthy as well as respiratory symptoms' subjects

Respiratory system is the primary settlement place of opportunistic organisms and considered as chief carrier of common respiratory pathogens. The aim of the study was to know the opportunistic organisms present in the healthy subjects as well as subjects that were suffering from respiratory symptoms. The organisms were identified as per standard bacteriological protocol and pathogenicity tests of the identified organisms were performed in mouse model. Antibiotic sensitivity of the identified organisms was performed. The bacterial flora present in the throat swab of apparently healthy as well as subjects suffering from respiratory symptoms were: Staphylococcus spp. (39.44%) of which Coagulase positive Staphylococcus (21.13%) and Coagulase negative Staphylococcus (18.31%), Klebsiella spp. (19.72%), Pseudomonas spp. (15.49%), Proteus spp. (4.23%), E. coli (9.86%) and Bacillus spp. (11.27%). Among the isolates Staphylococcus, Klebsiella and Pseudomonas were the predominant species. Percentages of identified bacteria were higher in respiratory symptoms exhibiting individuals (53.52%) than apparently healthy individuals (46.48%). All coagulase positive Staphylococcus, Klebsiella spp. and Pseudomonas spp. isolated from respiratory symptoms' subjects were found to be pathogenic. The isolated bacteria were resistant to amoxicillin and ampicillin but sensitive to ciprofloxacin and norfloxacin. Isolated Pseudomonas spp. showed multidrugs resistant properties. The study provided information about the pathogenic organisms' present respiratory systems of apparently healthy as well as subjects suffering from respiratory symptoms. The pathogenic natures of the isolated organisms were determined to make aware of scientists as well as clinicians. Antibiotics sensitivity assays would provide information to the clinicians for the selection of appropriate antibiotics to treat their patients.

Recurrent synovial chondromatosis of the foot

Synovial chondromatosis rarely occurs in the foot. We have diagnosed such a case in National Institute of Cancer Research and Hospital, Mohakhali, Dhaka. The patient came to us with a swelling in the dorsum of left foot. He had a history of operation but one year later swelling reappeared in the same place. Fine Needle Aspiration Cytology (FNAC) of the swelling revealed few atypical cells and diagnosed as a case of malignant neoplasm. Later on surgical intervention was done in the form of wide excision and final histopathology report came as Synovial chondromatosis. No special treatment was given other than periodical follow up. The patient has been responding well. There was no clinical or radiographic evidence of recurrence.

Prevalences of Giardia lamblia and Cryptosporidium parvum infection in adults presenting with chronic diarrhoea

Giardia lamblia and Cryptosporidium parvum are both waterborne pathogens associated with diarrhoea in developing countries. In a recent study based at the Aga Khan University in Karachi, 334 adults aged 16-83 years (178 patients with chronic diarrhoea and 156 diarrhoea-free volunteers who acted as controls) were checked for infection with these parasites, using stool microscopy and/or PCR. Overall, 21 (6.3%) and 29 (8.7%) of the subjects were found positive for G. lamblia by microscopy and PCR, respectively, while the corresponding values for C. parvum were 13 (3.9%) and 14 (4.2%). Although, compared with the diarrhoea-free controls, the patients with diarrhoea were not significantly more likely to be found infected with Giardia, either by microscopy [15 (8.4%) v. six (3.8%); P=0.085] or PCR [19 (10.7%) v. 10 (6.4%); P=0.167], they were significantly more likely to be found infected with C. parvum, both by microscopy [11 (6.2%) v. two (1.3%); P=0.024] and by PCR [12 (6.7%) v. two (1.3%); P=0.014]. The 19 patients found PCR-positive for Giardia comprised 10 (67%) of the 15 found smear-positive for the same parasite but only nine (5%) of the 163 found smear-negative (k=0.545; P<0.001). Similarly, the 12 patients found PCR-positive for Cryptosporidium comprised all 11 (100%) patients found smear-positive for the same parasite but only one (0.6%) of the 167 found smear-negative (k=0.954; P<0.001). Although C. parvum was associated with chronic diarrhoea in the present study, the carriage of G. lamblia often appeared asymptomatic.

Early renal damage assessed by the SLICC/ACR damage index is predictor of severe outcome in lupus patients in Pakistan

We investigated patients with systemic lupus erythematosus with the objective of assessing whether early damage accrued in systemic lupus erythematosus as measured by the SLICC/ ACR Damage Index predicts mortality in lupus patients that have been followed prospectively in a single center. Patients with systemic lupus erythematosus from Aga Khan University hospital presenting between 1992 and 2007 were included. This enabled all patients to be potentially followed for at least 10 years. Yearly SLICC/ACR Damage Index scores were determined for each patient. Early damage was defined as a score ≥1, and no damage as a score of 0 at the initial assessment. Kaplan—Meier and Log rank tests were used to compare the survival experience between those with and without damage, with all patients being assessed at 10 years. In this inception cohort 198 patients were identified and were followed for 10 years. Of these, 47 (23.7%) patients had a SLICC/ACR Damage Index score of 0 (no damage) while 151 patients (76.3%) had at least one SLICC/ACR Damage Index item scored (early damage). Mean renal damage score at 1, 5 and 10 years was 0.16, 0.34 and 0.67, respectively. Of lupus patients who exhibited renal damage at their first SLICC/ACR Damage Index assessment, 31% died within 10 years of their illness as compared with only 13% who had no early renal damage (p < 0.003). Mean renal damage score at 1 year after diagnosis was a significant predictor of death within 10 years of diagnosis (p < 0.002). Lupus (2010) 19, 1573—1578.

Health care risk factors among women and personal behaviours among men explain the high prevalence of hepatitis C virus infection in Karachi, Pakistan

To estimate the prevalence and identify factors associated with hepatitis C virus (HCV) infection among men and women in Karachi, Pakistan. We conducted a cross-sectional study of adult men and women in a peri-urban community of Karachi (Jam Kandah). Households were selected through systematic sampling from within all villages in the study area. All available adults within each household were interviewed about potential HCV risk factors. A blood specimen was collected to test for anti-HCV antibodies by enzyme immunoassay. We used generalized estimating equations while accounting for correlation of responses within villages to identify the factors associated with HCV infection. Of 1997 participants, 476 (23.8%) were anti-HCV positive. Overall, HCV infection was significantly associated with increasing age, ethnicity, and having received > or =2 blood transfusions, > or =3 hospitalizations, dental treatment and >5 injections among women. Among women, > or =2 blood transfusions [adjusted odds ratio (aOR) = 2.32], >5 injections during the past 6 months (aORs = 1.47), dental treatment (aOR = 1.31) and increasing age(aOR = 1.49), while among men, extramarital sexual intercourse (aOR = 2.77), at least once a week shave from barber (aOR = 5.04), > or =3 hospitalizations (aOR = 2.50) and increasing age (aOR = 1.28) were associated with HCV infection. A very high prevalence of HCV was found in the study population. Among women, unsafe health care practices, while among men extramarital sex, shaving from a barber and hospitalizations were associated with HCV infection. Efforts are needed to improve the safety of medical procedures to reduce the transmission of HCV in Pakistan [Corrections made in Summary after initial online publication.].

MDG 5: how close are we to success?

Only 6 years are left until 2015, the target date for achieving the Millennium Development Goals (MDG), yet improving maternal health (MDG 5) continues to lag behind. At the global level, maternal mortality still remains high in sub-Saharan Africa and Southeast Asian countries. Most deaths are preventable and occur due to unavailability of and/or poor quality of service. Skilled care at facilities ensures safety, cleanliness, the availability of supplies and equipment, and it makes management and supervision easier. With the mixture of professionals in a facility, life-saving emergency care can be provided quickly. Wherever childbirth takes place, it is essential that the person who helps has the core competencies for safe delivery, has the necessary equipment and supplies, and has the option to refer to a functioning facility offering emergency obstetric and newborn care. The continuing high incidence of maternal and perinatal mortality and morbidity is unacceptable precisely because it is solvable. We know how to make pregnancy and childbirth safe. The task is enormous but not insurmountable. Our efforts of investment need to be equal to the tasks and must be intensified if maternal and perinatal morbidity and mortality is to be reduced.

Subtypes of dissociative (conversion) disorder in two tertiary hospitals in Bangladesh

Dissociative (conversion) disorders are common among the patients attending in and out patients of Psychiatry Department of tertiary hospitals in Bangladesh. This study was done to see the subtypes of dissociative (conversion) disorder according to International Classification of Diseases, Tenth Revision (ICD-10). This is a descriptive, cross sectional study done on 100 consecutive patients from the Departments of Psychiatry, Bangabandhu Sheikh Mujib Medical University (BSMMU), Dhaka and Dhaka Medical College Hospital (DMCH). Study period was July 2005 to June 2006. Among the patients of dissociative (conversion) disorder, mixed dissociative (conversion) disorder was found highest 34%, followed by dissociative convulsion 33%, dissociative motor disorders 19%, dissociative anaesthesia and sensory loss 5%, dissociative amnesia 4%, dissociative fugue 3%. However, the researcher did not find any multiple personality disorder which is relatively common in North America. This finding reflected that there are differences in prevalence of sub types of dissociative disorders in Bangladesh and Western countries.

Sub arachnoid block for emergency cesarean section in a pituitary dwarf

Anaesthesia for parturient patients with dwarfism is an uncommon problem faced by anaesthesiologists. There is an ongoing debate regarding general versus regional anaesthesia in these cases. In many centers there is lack of facilities for epidural or continuous epidural anaesthesia. A primiparous dwarf woman of 27 years old having 124 cm height and 37 kg weight was admitted in Mymensingh Medical College Hospital for elective cesarean section due to cephalopelvic disproportion. She was diagnosed as a case of pituitary dwarf previously on antenatal checkup depending on both clinical and endocrine ground. After admission she suddenly developed respiratory distress with less foetal movement and presented in our department for emergency cesarean section. We have managed the case by sub-arachnoid block (SAB) using 7.5 mg (1.5 ml) of 0.5% heavy bupivacaine at a level of L3-L4 interspace having adequate level of block and analgesia. The case was managed successfully and uneventfully. In this presentation, the role of SAB and a management guideline has been highlighted.

Survival analysis and prognostic indicators of systemic lupus erythematosus in Pakistani patients

To aim of this study is to analyse the survival rate and prognostic indicators of systemic lupus erythematosus (SLE) in Pakistani population. A total of 198 patients with SLE diagnosed between 1992 and 2005 were reviewed retrospectively. Clinical features at presentation, subsequent evolving features, autoantibody profile, damage scores and mortality data were obtained. Prognostic factors for survival were studied by statistical analysis. Of 198 SLE patients studied, 174 were women and 24 were men. The women to men ratio was 7.2:1. Mean age at presentation was 31 years (range 14-76). Mean duration of symptoms before diagnosis was 2.8 years. Mean duration of follow-up was 34.21 months (+/-33.69). Mean disease duration was 15.6 years. At diagnosis, arthritis, malar rash, oral ulcers and alopecia were the commonest features. During the follow-up, the prevalence of nephritis, arthritis, neurological and hematological disease increased significantly. About 76% (n = 151) of the patients had organ damage at the time of data analysis, and renal disease was the commonest cause. Univariate analysis revealed that renal disease (P = 0.000), seizures (P = 0.048), pleural involvement (P = 0.019), alopecia (P = 0.000) and discoid lesions (P = 0.005) were predictors for damage. Multivariate model, however, revealed that only renal disease was independent risk factor for damage (P = 0.002). During the study period, 47 patients (24%) died (five due to disease-related complications and rest as a result of infections). The 3-, 5-, 10-, 15- and 20-year survival rates of our cohort were 99, 80, 77, 75 and 75%, respectively. Cox regression analysis revealed that renal involvement (P = 0.002) and infections (P = 0.004) were independent risk factors for mortality. The survival of our Pakistani SLE patients was significantly lower compared to that of the Caucasian series reported in last decade. Nephritis not only contributes to organ damage but also acts a major determinant for survival. Infection remains the commonest cause of death. Renal involvement and infections are independent risk factors for mortality. Judicious use of immunosuppressive agents is necessary to improve the short-term survival of lupus patients.