Profile of diabetic foot complications and its associated complications--a multicentric study from India

AIM

The aims of this study were to determine. The prevalence of foot complications such as neuropathy, peripheral vascular disease (PVD), amputations and infections and the associated diabetic complications and practice of foot care among these subjects.

METHODS

A total of 1319 type 2 diabetic patients, were selected from four different centres across India. The centres were Diabetes Research Centre (DRC), Chennai, Government Rajaji Hospital (GRH), Madurai, Christian Medical College (CMC), Vellore and All India Institute of Medical Science (AIIMS), Delhi. Details were collected regarding foot problems and associated complications.

RESULTS

The prevalence of neuropathy was 15% (n=193) and PVD was 5% (n=64). Infections were present in 7.6% (n=100) of patients. The infection rate varied from 6-11% in the different centres. Nearly 3% of subjects had undergone a minor or major amputation.

DISCUSSION

This study found that the prevalence of infection was 6-11% and prevalence of amputation was 3% in type 2 diabetic patients. Neuropathy (15%) was found to be an important risk factor for diabetic foot infections. Effective foot care advice should be propagated to reduce the burden imposed by diabetic foot complication particularly in developing countries like India.

The first successful simultaneous pancreas-kidney transplant in India

Insulin-dependent diabetes mellitus is associated with renal failure, diabetic retinopathy, neuropathy and vasculopathy. We report the first successful simultaneous pancreas-kidney transplant in India in a young diabetic with renal failure. The dual transplant has cured his diabetes and renal failure and has had a beneficial effect on his neuropathy, retinopathy and quality of life. Obstacles to dual transplant in India include a lack of suitable recipients and a cadaver donor programme that is still in its infancy.

Bone mineral parameters in healthy young Indian adults with optimal vitamin D availability

BACKGROUND

Several recent studies indicate a marked prevalence of vitamin D deficiency in asymptomatic, apparently healthy urban subjects from different socioeconomic groups in north India.

METHODS

To further examine this trend, we studied 40 men and 50 women, 20-30 years of age, from the Indian paramilitary forces. These individuals consume a nutritious, high-protein diet, have optimal exposure to sunlight and undertake strenuous outdoor physical exercise.

RESULTS

The mean serum calcium, phosphorus and alkaline phosphatase levels were normal in both men and women. The mean (SD) serum intact parathyroid hormone and 25-hydroxyvitamin D3 levels were 19.3 (8.2) pg/ml and 18.4 (5.3) ng/ml in men, and 11.9 (6.6) pg/ml and 25.3 (7.4) ng/ml in women. Bone mineral density estimated in 20 men and 22 women revealed that in comparison with white Caucasians, 35%-50% of men and 14%-32% of women were osteopenic at different sites, while an additional 10% of men had osteoporosis of the lumbar spine.

CONCLUSION

We found that with optimal nutrition, good sunlight exposure and regular physical exercise, healthy young individuals have normal bone and mineral biochemical values. The reasons for the abnormalities detected in bone mineral density in them needs further study. The impact of childhood nutrition on accumulation of peak bone mass may contribute to our findings. There is a need for establishing normative bone mineral density data for Indians.

Angiolymphoid Hyperplasia with Eosionophilia-Scalp

abstract

High seroprevalence and clinical significance of hepatitis B and C infection in hospitalized patients with alcoholic cirrhosis

OBJECTIVES

Patients with alcoholic cirrhosis (AC) are frequently infected with hepatotropic viruses which could alter the clinical spectrum of the disease. We studied the seroprevalence of hepatitis B (HBV) and hepatitis C virus (HCV) and their impact on the clinical profile of patients with AC.

METHODS

Two hundred and ten hospitalized patients of AC were studied and screened for markers of HBV and HCV infection. Clinical, biochemical and virological correlation was done.

RESULTS

One hundred and forty (66.6%) patients had no viral infection Group I, 50 (23.8%) were positive for HBsAg Group II and 20 (9.5%) for anti-HCV Group III. All patients were males with comparable ages (43.9 years, 44 years and 45.9 years respectively). The amount of alcohol consumed by patients in Group III (130 +/- 115 g/d) was significantly less than Group II (204 +/- 130 g/d, P < 0.05) and Group I (281 +/- 188 g/d, p < 0.001). The duration of alcohol abuse was shorter in Group II and III, although not statistically significant. Presentation as jaundice was common in Group II and III (p < 0.05). The AST and ALT values (IU/L) were significantly higher in Group II (239 +/- 351, 197 +/- 266) and III (157 +/- 170, 86 +/- 52) than Group I (89 +/- 78, 66 +/- 54) (P < 0.05). The serum alkaline phosphatase (IU/L) was higher in Group III (349 +/- 223) as compared to Group II (263 +/- 186) and Group I (162 +/- 62) (P < 0.05). There was however, no difference in Child's grade or the discriminant function between the three groups of patients.

CONCLUSIONS

(i) One-third of the hospitalized patients with AC are infected with HBV or HCV infection, (ii) these infections hasten clinical presentation of patients with alcoholic liver disease, with lesser amount of alcohol consumption and (iii) jaundice, raised ALT/AST and alkaline phosphatase are more common with superadded viral infection.

Prevalence of ICA-12 and other autoantibodies in north Indian patients with early-onset diabetes

This study attempts to assess the prevalence of various autoantibodies in early-onset diabetics in northern India, with emphasis on antibodies against glutamic acid decarboxylase (GAD65), IA-2, ICA-12, 21-hydroxylase (21-OH), and tissue transglutaminase (TTG). GAD65 and IA-2 antibodies were found to be present in approximately 26% of cases of type 1 diabetes. A subset of patients clinically diagnosed to have MMDM appears to have an autoimmune etiology, with more than 20% showing serpositivity for IA-2 antibodies. Antibodies against ICA-12 were prevalent in both type 1 diabetes and MMDM. Approximately one of seven patients with type 1 diabetes showed erological evidence of celiac disease.

ICA12 autoantibodies are associated with non-DR3/non-DR4 in patients with latent autoimmune diabetes in adults from northern India

Associations of HLA-DR3/DQ2 with GAD65 and DR4 with IA-2 antibodies in insulin-dependent diabetes mellitus (IDDM) and DR3/DQ2 with GAD65 antibodies in latent autoimmune diabetes in adult (LADA) patients are known. The aim of the present study was to look for association of HLA DR and DQ with GAD65, IA2 and ICA12 antibodies in IDDM (n = 97), LADA (n = 32), and malnutrition-modulated diabetes mellitus (MMDM) (n = 22) patients from northern India. HLA genotyping was done by the PCR-SSO method. Antibodies to GAD65, IA-2, and ICA-12 were assayed by radioimmunoassay using (35)S-labeled recombinant human GAD65, IA2, and ICA12 using the in vitro transcription-translation method. We found DR3 (29% vs. 11%) and DQ2 (36% vs. 14%) were increased in GAD65 antibody-positive compared to GAD65 antibody-negative IDDM patients (P > 0.05). ICA 12 antibodies were increased in either DR3 or DR4 (84% vs. 69%) positives compared to non-DR3/DR4 IDDM patients (P > 0.05). However in LADA patients, ICA12 was increased in non-DR3/DR4 patients compared to DR3- or DR4-positive patients (P < 0.05). In conclusion, in LADA patients, ICA 12 is associated with non-DR3/DR4 patients. No association between HLA and autoantibodies was seen in MMDM patients.

Neuropsychiatric manifestations in patients of primary hyperparathyroidism and outcome following surgery

BACKGROUND

A wide variety of psychiatric symptoms ranging from mild personality changes to severe depression and psychosis have been described in patients of PHPT. However, the psychiatric profile in Indian patients remains a mystery. It remains to be seen if surgery can alleviate the psychiatric morbidity and improve the quality of life of patients. Although, the pathophysiology remains largely unknown, we attempted to see if psychiatric morbidity correlated with serum calcium values.

OBJECTIVE

a) To study the nature and severity of neuropsychiatric manifestations in patients of hyperparathyroidism before surgery and their outcome after surgery b) To study their correlation with levels of serum calcium.

MATERIAL AND METHODS

This prospective study documented the occurrence of psychiatric symptoms among 14 patients of primary hyperparathyroidism (group I). 13 patients of gall stone disease (group II) and 12 patients of thyromegaly, undergoing total thyroidectomy (Group III) constituted the control groups. The relationship between such symptoms and degree of hypercalcemia was also studied. Assessment of psychologic symptoms, using the CPRS scale (validated in Hindi) and the scale for Memory and Intelligence for use in Hindi speaking population was carried out preoperatively and at 1 wk, 6 wk, 3, and 6 months postoperatively.

OBSERVATIONS

The hyperaparathyroid group had significantly higher levels of total serum calcium and PTH preoperatively, with biochemical normalization postoperatively. The preoperative CPRS rating of the 14 patients with primary hyperparathyroidism revealed pronounced psychiatric symptoms, with a mean total CPRS score of 20 +/- 8.7, compared with 10.5 +/- 6.9(II) and 12.7 +/- 5.6 (III) in the control groups. Statistically significant improvement was seen in the CPRS score, maximally at 6 weeks post operatively for the following symptoms: Sadness, lassitude, ache and pains, and fatigability. There was no memory and intelligence impairment in any of the groups pre or post operatively. No correlation was found between the serum calcium levels and the psychiatric morbidity.

CONCLUSIONS

The psychologic symptom distress is multidimensional and symptoms significantly improved by 6 weeks post parathyroidectomy. There was no memory and intelligence impairment in any of the groups pre or post operatively. No correlation was found between serum calcium levels and psychiatric morbidity.

Fulminant radiation-induced necrosis after stereotactic radiation therapy to the posterior fossa. Case report and review of the literature

The problem of radiation-induced necrosis of normal brain surrounding the target area has been a major catalyst for the development of stereotactically focused radiation therapy. According to current opinion, the effects of stereotactic irradiation are confined to the region targeted. The authors present a case in which the administration of a conventional dose of stereotactically focused irradiation for treatment of a pilocytic astrocytoma produced fulminant necrosis that necessitated a combination of intensive surgical and medical management, after which the patient improved over the course of 1 year. Concomitant with his improvement, the initially remarkable findings on magnetic resonance imaging gradually resolved. In this presentation the authors emphasize the need to evaluate alternatives carefully before a decision is made to administer therapeutic irradiation. Furthermore, they explore the roles that target, host, and dosage factors play in hypersensitivity to radiation injury, the detection of these factors before treatment, and the administration of radioprotective agents. With the growing use of stereotactically focused irradiation as a primary treatment modality for a variety of neurosurgical conditions, it is important to be cognizant of its uncommon but potentially lethal side effects. A cooperative multicenter database in which the outcomes and morbidity following stereotactic irradiation are recorded is essential to the detection of relatively uncommon but severe complications such as those observed in this case.

Treatment with extracts of Momordica charantia and Eugenia jambolana prevents hyperglycemia and hyperinsulinemia in fructose fed rats

Insulin resistance has been implicated as a major contributor to the development of hyperglycemia in NIIDM patients. Herbal extracts of Momordica charantia (MC) and Eugenia jambolana (EJ) have been shown to reduce hyperglycemia in diabetic animal models and human patients. However, no work has been done so far to assess their effect on insulin resistance. This study was undertaken to study the effects of different doses (100,200 and 400 mg per day) of alcoholic and aqueous extracts of MC and EJ on the metabolic parameters (body weight and serum glucose, insulin and triglycerides levels) of fructose fed rats. Fructose feeding for 15 days increased serum glucose and insulin levels markedly and triglycerides levels marginally vs. control (75.46+/-2.41 vs. 55.59+/-2.89 mg/dl, 6.26+/-1.27 vs. 15.04+/-2.43 mg/dl and 50.93+/-3.30 vs.41.1+/-3.33 mg/dl, respectively). Treatment with 400 mg per day of aqueous extracts of MC and EJ for 15 days substantially prevented hyperglycemia and hyperinsulinemia induced by a diet high in fructose (63.52+/-2.9 and 66.46+/-2.2 vs. 75.46+/-2.4, respectively).

Interventional therapy for acute myocardial infarction

Percutaneous transluminal coronary angioplasty has proven to be more effective and safer than thrombolytic therapy for the treatment of acute ST elevation myocardial infarction. Coronary intervention decreases early mortality and the incidence of intracerebral hemorrhage when performed by an experienced interventional team in a timely fashion. After failed fibrinolytic therapy for myocardial infarction, percutaneous transluminal coronary angioplasty is indicated for signs of ischemia and is very effective in restoring vessel patency and reducing mortality when used as a rescue procedure. The glycoprotein IIb-IIIa inhibitors improve outcomes in percutaneous transluminal coronary angioplasty, particularly in patients undergoing stent placement. Percutaneous interventional therapy in acute myocardial infarction is particularly beneficial in patients with cardiogenic shock and effective for saphenous vein graft occlusions, patients with diabetes mellitus, and in the elderly. New devices and drugs are currently being tested for acute myocardial infarction and provide hope for even better interventional therapies in the near future.

Target gland functional status in patients with non-Cushing's pituitary macroadenomas undergoing transsphenoidal microsurgery

OBJECTIVES

Hypopituitarism occurring in patients with pituitary macroadenoma may be reversible after pituitary microsurgery, and surgery itself can lead to hypopituitarism. This study was undertaken to evaluate target gland function prospectively in patients of non-Cushing's pituitary macroadenoma undergoing trans-sphenoidal microsurgery.

MATERIAL AND METHODS

A prospective study of fifty patients of non-Cushing's pituitary adenoma was carried out to evaluate target gland (thyroid, adrenal and gonadal) undergoing trans-sphenoidal microsurgery. Thirty-two patients completed postoperative evaluation before radiotherapy. Target gland functions were assessed by measurement of T3, T4, TSH, basal and stimulated cortisol, LH, FSH, testosterone and estradiol. GH and PRL were also measured. Tumor size was assessed on CT/MRI scan.

RESULTS

Hypothyroidism, hypoadrenalism and hypogonadism were present in 24%, 54% and 52% of patients. Preoperative hypopituitarism correlated with tumour size. Thyroid, adrenal and gonadal function improved in 87%, 50% and 31%; deteriorated in 4%, 29%, and 37%, respectively after trans-sphenoidal microsurgery.

CONCLUSIONS

A subset of patients with non-Cushing's pituitary macroadenoma suffers from hypopituitarism, which reverses after surgery. Failure of recovery correlates with preoperative lower serum prolactin levels.

Hashimoto's thyroiditis: countrywide screening of goitrous healthy young girls in postiodization phase in India

Countrywide salt iodization, to prevent nutritional iodine deficiency, has been achieved in India recently. The current study was planned to evaluate the prevalence of goiter and thyroid autoimmunity and assess thyroid functional status in a cohort of 6283 healthy schoolgirls from different parts of the country in the postiodization phase. Goitrous girls (n = 1810; 28% of subjects) were investigated for serum T4 and TSH, antithyroid microsomal antibody (TMA) and antithyroglobulin antibody (TGA), urinary iodine excretion, and cytomorphology by fine-needle aspiration cytology (FNAC). FNAC carried out successfully in 764 goitrous girls revealed juvenile autoimmune thyroiditis (JAT) in 58 (7.5%), which included Hashimoto's thyroiditis in 43 (5.6%) and focal lymphocytic thyroiditis in 15 (1.9%). TMA and TGA estimated in 722 goitrous girls detected significantly positive titers of TMA (> or =1:1600) and TGA (> or =1:160) in 52 (7.2%) and 4 (0.55%) girls, respectively. Only 29 (67.4%) girls with Hashimoto's thyroiditis were TMA positive. In patients with FNAC-proven JAT, overt clinical and biochemical hypothyroidism was seen in three (6.5%) and subclinical hypothyroidism in seven (15%). Subclinical hyperthyroidism was detected in 5.1% cases of JAT, and none had overt hyperthyroidism. No definite correlation was seen between urinary iodine excretion and thyroid autoimmunity.

Breeding habitats and larval indices of Aedes aegypti and Ae. albopictus in the residential areas of Calcutta City

Aedes aegypti and Ae. albopictus larvae were found breeding in almost all indoor and outdoor, temporary and/or permanent collections of water, either alone or in association with each other in residential areas of the city, the former throughout the year (June'97-May'98) and the latter during monsoons and post-monsoons only. Ae. aegypti showed preference for breeding in chowbachhas, indoors and Ae. albopictus for collections of water in flower pots and discarded containers and outdoors. The larval indices of both the species were highest during monsoons and post-monsoons.

Tissue gene expression analysis using arrayed normalized cDNA libraries

We have used oligonucleotide-fingerprinting data on 60,000 cDNA clones from two different mouse embryonic stages to establish a normalized cDNA clone set. The normalized set of 5,376 clones represents different clusters and therefore, in almost all cases, different genes. The inserts of the cDNA clones were amplified by PCR and spotted on glass slides. The resulting arrays were hybridized with mRNA probes prepared from six different adult mouse tissues. Expression profiles were analyzed by hierarchical clustering techniques. We have chosen radioactive detection because it combines robustness with sensitivity and allows the comparison of multiple normalized experiments. Sensitive detection combined with highly effective clustering algorithms allowed the identification of tissue-specific expression profiles and the detection of genes specifically expressed in the tissues investigated. The obtained results are publicly available (http://www.rzpd.de) and can be used by other researchers as a digital expression reference.

Prevalence and significance of low 25-hydroxyvitamin D concentrations in healthy subjects in Delhi

BACKGROUND

Despite abundant sunlight, rickets and osteomalacia are prevalent in South Asian countries. The cause of this paradox is not clear.

OBJECTIVE

The objective was to assess 25-hydroxyvitamin D [25(OH)D] status and its functional significance in apparently healthy subjects residing in Delhi, a city in the northern part of India.

DESIGN

Serum 25(OH)D, total calcium, inorganic phosphate, alkaline phosphatase, intact parathyroid hormone, and 1, 25-dihydroxyvitamin D [1,25(OH)(2)D] were measured in groups of healthy subjects who differed with respect to variables relevant to vitamin D and bone mineral metabolic status, such as direct sunlight exposure, season of measurement, skin pigmentation, dietary calcium and phytate contents, and altered physiologic states such as pregnancy and neonatal age.

RESULTS

All groups except one with maximum direct sunlight exposure had subnormal concentrations of 25(OH)D. The 25(OH)D-deficient groups tended to have an imbalance in bone mineral metabolic homeostasis when exposed to winter weather and low dietary calcium and high dietary phytate, with significantly low calcium and elevated intact parathyroid hormone concentrations, chemical osteomalacia, or both. Increased values of 1,25(OH)(2)D during pregnancy did not help correct the imbalance in bone mineral metabolic homeostasis.

CONCLUSION

Healthy subjects with low 25(OH)D concentrations are at risk of bone mineral metabolic imbalance when exposed to factors that strain bone mineral homeostasis.

Role of the catheter in the treatment of cardiac arrhythmias

During the last decade, there has been a remarkable shift away from drug therapy toward catheter-based treatment of many tachyarrhythmias. Catheter ablation using radiofrequency energy has been shown to provide a cure for many supraventricular and ventricular tachycardias with excellent safety and has now become the first line of treatment. A review of biophysics and biology of radiofrequency energy, the technique of catheter ablation, and its application in the treatment of specific tachycardias encountered in clinical practice is presented.

Beneficial influence of an indigenous low-iron diet on serum indicators of iron status in patients with chronic liver disease

The main Fe storage organ in the body is the liver. In patients with chronic liver disease, secondary Fe overload is common. Phlebotomy, often used in the West to reduce Fe overload to improve the efficacy of interferon therapy, is not socially acceptable in India. We assessed the efficacy of a low-Fe diet in reducing serum Fe levels. Nineteen patients with hepatitis B- and C-related chronic liver disease, ten with normal (< 25 mumol/l) baseline serum Fe levels (group A) and nine with high (> 25 mumol/l) serum Fe levels (group B) were included. All the subjects were advised to eat a low-Fe diet. The daily Fe intake was reduced approximately 50% by consumption of the rice-based diet. Haemoglobin, serum Fe, transferrin saturation index (TSI), ferritin and alanine transaminase (EC 2.6.1.2) levels were studied at 1 and 4 months. Dietary Fe intake and body weight were closely monitored. All patients complied with the dietary regimen and at 4 months significant (P < 0.001) reductions from baseline were seen in serum Fe (20 (SD 3) v. 12 (SD 4) mumol/l group A; 30 (SD 3) v. 19 (SD 7) mumol/l group B) and TSI (38 (SD 8) v. 23 (SD 9)% group A; 53 (SD 15) v. 34 (SD 13)%, group B) in both the groups, albeit earlier in group B subjects. Serum ferritin levels, however, reduced only in group A (112 (SD 62) v. 43 (SD 25) ng/ml, P < 0.05) and not in group B. Non-significant reductions in haemoglobin levels were seen in both groups. Alanine transaminase levels reduced significantly (P < 0.05) in both the groups (95 (SD 49) v. 44 (SD 25) IU/l, group A; 82 (SD 16) v. 51 (SD 14) IU/l group B). Thus, a low-Fe diet results in significant reductions in serum Fe and TSI levels, irrespective of baseline Fe levels. This diet should be evaluated to improve the efficacy of interferon therapy in patients with hepatitis B- and C-related chronic liver disease.