Mortality in diabetes mellitus--data from a developing region of the world

Emphysematous Pyelonephritis in a Diabetic Patient with Remarkable Radiological Findings and Excellent Outcome without Surgical Intervention or Drainage

BACKGROUND Emphysematous pyelonephritis (EPN) is a life-threatening infection of the renal parenchyma. The purpose of this report is to present a case of EPN with distinctive imaging. CASE REPORT An 87-year-old man with a history of type 2 diabetes mellitus presented to the ER with fever and shivering, hypotension, and anuria, which is a clinical presentation of septic shock. He had recently been hospitalized at another hospital due to myocardial infarction and ischemic stroke, where a temporary urinary catheter was placed. Upon physical examination, he had right lateral abdominal pain with extension to the right renal region. Laboratory studies showed leucocytosis (WBC: 24 320/μl with 94.4% polymorphonuclear), elevated C-reactive protein 340 mg/l (NV <3.45), and acute renal failure (urea 155mg/dl NV <50 mg/dl, creatinine 4.4 mg/dl NV <1.2 mg/dl). A plain X-ray showed air was present peripheral to the right kidney, while the abdominal CT revealed air inside the right kidney and bilateral nephrolithiasis. The patient was initially put on aggressive hydration, vasoconstrictors, and hydrocortisone to treat the septic shock, and an advanced antibiotic treatment (meropenem) was initiated immediately. Blood culture grew Escherichia coli. After 3 days of treatment, he showed significant improvement in diuresis and renal function (urea 90 mg/dl, creatinine 1.0 mg/dl), with a concomitant decrease in inflammatory markers (CRP 36.7 mg/l). The antibiotic treatment was tapered to cefuroxime and metronidazole. The patient's condition improved, and he was discharged with per os antibiotic treatment. Subsequently, surgical assessment for the nephrolithiasis was suggested. CONCLUSIONS Emphysematous pyelonephritis, although rare, should be included in the differential diagnosis of fever in a diabetic patient with renal pain.

Clinical spectrum, etiology and outcome of infectious disease emergencies in adult diabetic patients in northern India

BACKGROUND AND AIMS

The patients with diabetes mellitus (DM) have an increased incidence of both common and unusual infections. Despite an increasing prevalence of DM in India, local data on the epidemiology and clinical spectrum of associated infections are lacking. We aimed to investigate the spectrum, etiology, and outcome of infectious disorders in adult patients with DM admitted in a medical emergency.

METHODS

A single-center retrospective observational study conducted between January 2018 to June 2019 in a tertiary care hospital in north India. Based on clinical presentation, radiological features, and microbiological or pathological evidence, 152 diabetic patients aged 12 years and above were diagnosed with the infectious syndrome.

RESULTS

Urinary tract infection was the most prevalent infectious syndrome (32.2%), followed by pneumonia and empyema (26.3%), skin and soft tissue infections (6.6%), sepsis of unknown primary source (6.6%), pulmonary tuberculosis (4.6%), rhinocerebral infections (4.6%), infectious diarrhea (3.9%), and viral encephalitis (2.6%). The majority of the infections were community-acquired (94.7%). 80.3% of study cases had type 2 DM. The common presenting symptoms were fever (46.1%), dyspnea (27.6%), and altered sensorium (25.7%). Shock and diabetic ketoacidosis were frequent, and each was seen in 27.6% of cases. The mortality rate was 27.6% and was higher with sepsis of unrecognized source (50.0%) and lung infections (30.0%). The presence of shock was the independent predictor of mortality on a multivariant analysis (p-value 0.000).

CONCLUSIONS

Urinary tract and lung infections remain common in DM. Establishing a microbiological etiology and identification of the source are necessary steps to reduce mortality.

Association of Diabetes With All-Cause and Cause-Specific Mortality in Asia: A Pooled Analysis of More Than 1 Million Participants

IMPORTANCE

Asia is home to the largest diabetic populations in the world. However, limited studies have quantified the association of diabetes with all-cause and cause-specific mortality in Asian populations.

OBJECTIVES

To evaluate the association of diabetes with all-cause and cause-specific mortality in Asia and to investigate potential effect modifications of the diabetes-mortality associations by participants' age, sex, education level, body mass index, and smoking status.

DESIGN, SETTING, AND PARTICIPANTS

This pooled analysis incorporated individual participant data from 22 prospective cohort studies of the Asia Cohort Consortium conducted between 1963 and 2006. A total of 1 002 551 Asian individuals (from mainland China, Japan, South Korea, Singapore, Taiwan, India, and Bangladesh) were followed up for more than 3 years. Cohort-specific hazard ratios and 95% confidence intervals for all-cause and cause-specific mortality were estimated using Cox regression models and then pooled using random-effects meta-analysis. Analysis was conducted between January 10, 2018, and August 31, 2018.

EXPOSURES

Doctor-diagnosed diabetes, age, sex, education level, body mass index, and smoking status.

MAIN OUTCOMES AND MEASURES

All-cause and cause-specific mortality.

RESULTS

Of 1 002 551 participants (518 537 [51.7%] female; median [range] age, 54.0 [30.0-98.0] years), 148 868 deaths were ascertained during a median (range) follow-up of 12.6 (3.0-38.9) years. The overall prevalence of diabetes reported at baseline was 4.8% for men and 3.6% for women. Patients with diabetes had a 1.89-fold risk of all-cause death compared with patients without diabetes (hazard ratio [HR], 1.89; 95% CI, 1.74-2.04), with the highest relative risk of death due to diabetes itself (HR, 22.8; 95% CI, 18.5-28.1), followed by renal disease (HR, 3.08; 95% CI, 2.50-3.78), coronary heart disease (HR, 2.57; 95% CI, 2.19-3.02), and ischemic stroke (HR, 2.15; 95% CI, 1.85-2.51). The adverse diabetes-mortality associations were more evident among women (HR, 2.09; 95% CI, 1.89-2.32) than among men (HR, 1.74; 95% CI, 1.62-1.88) (P for interaction < .001) and more evident among adults aged 30 to 49 years (HR, 2.43; 95% CI, 2.08-2.84) than among adults aged 70 years and older (HR, 1.51; 95% CI, 1.40-1.62) (P for interaction < .001). A similar pattern of association was found between diabetes and cause-specific mortality, with significant variations noted by sex and age.

CONCLUSIONS AND RELEVANCE

This study found that diabetes was associated with increased risk of death from several diseases among Asian populations. Development and implementation of diabetes management programs are urgently needed to reduce the burden of diabetes in Asia.

Causes and predictors of mortality in Asian Indians with and without diabetes-10 year follow-up of the Chennai Urban Rural Epidemiology Study (CURES - 150)

Background

The incidence and prevalence of diabetes is increasing worldwide and it is the fifth leading cause of mortality accounting for over 3.8 million deaths annually. Despite the enormity of the diabetes-related health burdens, very few studies have evaluated the factors associated with mortality among people with diabetes in India. We sought to study the causes and predictors of mortality among urban Asian Indians with and without diabetes.

Methods and findings

Of 2273 adults (27,850 person-years of follow-up) from the 10-year follow-up of the Chennai Urban Rural Epidemiology Study (CURES), the cause of death could be ascertained in 552 individuals out of the 671 who had died (response rate 82.3%). Verbal autopsy was obtained from the family members of the deceased and this was adjudicated by trained physicians. The age-standardized mortality rate was 28.2 (95%CI 25.9–30.6) per 100,000 population. Mortality rates were significantly higher in individuals with diabetes compared to those without [27.9(95% CI 25.5–30.6) vs. 8.0 (6.6–9.9) per 1000 person years]. Compared to individuals of normal body mass index, underweight individuals had higher risk of mortality (Hazard ratio 1.49; 95% CI 1.11–2.0), whereas overweight and obese individuals did not show a higher risk. The population-attributable risk for all-cause mortality in the entire study cohort was highest for ischemic heart disease and diabetes. The excess mortality attributable to diabetes was highest in the age group of 51 to 70 years, and was mostly accounted for by renal disease (Rate ratio 5.68, 95%CI 2.43–6.23), ischemic heart disease (4.23,2.78–6.67), and cerebrovascular disease (4.00,1.87–9.81).

Conclusion

Underweight (but not overweight or obesity) was strongly associated with mortality in this Asian Indian population. Ischemic heart disease and diabetes contributed the most to risk for all cause mortality. Excess mortality due to diabetes was higher in relatively younger individuals and was mostly accounted for by renal disease.

Diabetes Care in India

BACKGROUND

Diabetes has become a major health care problem in India with an estimated 66.8 million people suffering from the condition, representing the largest number of any country in the world.

OBJECTIVE

The rising burden of diabetes has greatly affected the health care sector and economy in India. The goal of health care experts in India is to transform India into a diabetes care capital in the world.

METHODS

An expert detailed review of the medical literature with an Asian Indian context was performed.

FINDINGS

Recent epidemiologic studies from India point to a great burden from diabetes. Diabetes control in India is far from ideal with a mean hemoglobin A1c of 9.0%-at least 2.0% higher than suggested by international bodies. Nearly half of people with diabetes remain undetected, accounting for complications at the time of diagnosis. Screening can differentiate an asymptomatic individual at high risk from one at low risk for diabetes. Despite the large number of people with diabetes in India, awareness is low and needs to be addressed. Other challenges include balancing the need for glycemic control with risk reduction due to overly tight control, especially in high-risk groups and taking into account health care professional expertise, attitudes, and perceptions. Pharmacologic care should be individualized with early consideration of combination therapy. Regular exercise, yoga, mindful eating, and stress management form a cornerstone in the management of diabetes.

CONCLUSIONS

Considering the high cost incurred at various steps of screening, diagnosis, monitoring, and management, it is important to realize the cost-effective measures of diabetes care that are necessary to implement. Result-oriented organized programs involving patient education, as well as updating the medical fraternity on various developments in the management of diabetes, are required to combat the current diabetes epidemic in India.

Emphysematous pyelonephritis: A 10-year experience with 26 cases

BACKGROUND

Emphysematous pyelonephritis (EPN) is a necrotizing infection which results in gas within the renal parenchyma, collecting system, or perinephric tissue. A majority of cases occur in patients with diabetes mellitus (DM). In EPN, early aggressive medical treatment may avoid nephrectomy.

AIMS

The aim of this study was to analyze the characteristics of patients with EPN with respect to patient demographics, clinical presentation, diagnostic investigations, microbiological findings, treatment modality and outcome, and the influence of prognostic factors on the outcome.

MATERIALS AND METHODS

We reviewed the hospital records of 26 patients with EPN for clinical, laboratory, radiological, and microbiological findings, treatments given, and outcome. The severity of EPN was graded as per the Huang classification. We applied the reported prognostic factors to our patients to find out whether these factors correlated with failure of conservative treatment.

RESULTS

All the study subjects had DM and all but two of them were females. The majority of our patients (61.5%) had extensive EPN (class 3 or 4) and majority (76.9%) had two or more bad prognostic factors. Escherichia coli was the most common causative organism involved in 50% of our cases. Twenty-three (88.5%) of our patients responded to conservative treatment, two required nephrectomy, and one expired on conservative treatment.

CONCLUSIONS

In this series of patients with EPN, all had DM, nearly all were women, and E. coli was the most frequently isolated pathogen. Nearly a third of our patients had bilateral disease. Despite the presence of two or more bad prognostic factors and extensive EPN (class 3 or 4) in a majority of our patients, conservative treatment afforded a striking success rate of 88.5%. We recommend early aggressive medical treatment and suggest that nephrectomy should be considered only if patients deteriorate or do not improve on conservative treatment.

Pattern of anti-diabetic drugs prescribed in a tertiary care hospital of Bangladesh

Background

Globally, diabetes mellitus is a common endocrine disorder. This study was conducted for collecting the demographic details of diabetic patients and determining the pattern of drugs prescribed among them in outpatient department of a tertiary healthcare center.

Methods

A descriptive type of cross-sectional study was carried out at the outpatient department of Endocrinology, Dhaka Medical College Hospital, Bangladesh from 1 May to 31 July, 2015. Diabetic patients receiving the management for at least 6 months were enrolled and interviewed by the researchers after getting informed written consent. Structured case record form was used for demographic data & prescription details. Data were analysed using computer in SPSS 22 and Microsoft Excel 2010.

Results

Altogether 105 patients, 40 males (38.1%) and 65 females (61.9%) were enrolled with urban predominance (69.5%) where 51 (48.6%) were in the age group 47-61 years with a mean of 53.4 (SD±10.6) years. 70 (66.7%) had diabetic history of less than 5 years and 66 (62.9%) had at least one concurrent illness. Hypertension accounted for majority (34.3%) of complications. On an average, 5.62 (SD±3.16) drugs were advised per prescription for diabetes as well as associated co-morbidities and majority (23.8%) had 4 drugs. The majority of drugs (74.3%) were from local manufacturers. Most patients (62.9%) were prescribed with oral drugs singly. Metformin alone predominated in 41% prescriptions followed by the combination of Metformin and Sitagliptin (31.4%).

Conclusions

The findings can serve as a guide to choose the formulation and combination of anti-diabetic drugs in this part of the world before developing & marketing any new drug.

ASSOSIATION ANALYSYS OF 11 POLYMORPHISMS OF SNPS WITH ENDOTHELIUM DEPENDENT VASODILATATION IN CHILDREN WITH DIABETES MELLITUS TYPE 1

We have studied the association with the level of the endothelium dependent vasodilatation (EDVD) among 11 single nucleotide polymorphisms (SNPs) of 10 genes in 45 children suffering from diabetes mellitus type 1. Following polymorphisms have been studied: G894→T of the eNOS exon 7 and Т-786→С of the eNOS promotor, А1266→G of the Eln exon 16, Т-381→C of the NPPB promotor, І\D of the ACE, Arg60→His of the LMP2, Met235→Thr of the AGT, A1166→C of the ATR1, C-1562→T of the MMP9, C-1306→T of the MMP2, and С-8→G of the PSMA6. It was shown that children with genotypes G/T by eNOS (G894→T), G/G by Eln (А1266→G), C/C by NPPB (Т-381→C) and І/D by ACE genes have lower EDVD (Р<0,05) than patients with others allelic variants of these genes, and this does not depend on duration of the disease, level of glicated hemoglobin and initial diameter of a humeral (brachial) artery. The combination of the above-stated genotypes influences most significantly on EDVD decrease (r=0,61; Р<0,01), comparing to each genotype separately.

Type 1 diabetes guidelines: Are they enough?

The discovery of insulin by Banting and Best in 1922 changed the landscape of type 1 diabetes mellitus (T1DM). Guidelines on T1DM should be evidence based and should emphasize comprehensive risk management. Guidelines would improve awareness amongst governments, state health care providers and the general public about the serious long-term implications of poorly managed diabetes and of the essential resources needed for optimal care. T1DM requires lifelong daily medication, regular control as well as access to facilities to manage acute and chronic complications. American Diabetes Association 2014 guidelines recommends annual nephropathy screening for albumin levels; random spot urine sample for albumin-to-creatinine ratio at start of puberty or age ≥10 years, whichever is earlier, once the child has had diabetes for 5 years. Hypertension should be screened for in T1DM patients by measuring blood pressure at each routine visit. Dyslipidemia in T1DM patients is important and patients should be screened if there is a family history of hypercholesterolemia or a cardiovascular event before the age of 55 years exists or if family history is unknown. Retinopathy is another important complication of diabetes and patients should be subjected to an initial dilated and comprehensive eye examination. Basic diabetes training should be provided for school staff, and they should be assigned with responsibilities for the care of diabetic children. Self-management should be allowed at all school settings for students.

Clinical profile of long-term survivors and nonsurvivors with type 2 diabetes

OBJECTIVE

To compare clinical profile of long-term survivors and nonsurvivors with type 2 diabetes (T2DM).

RESEARCH DESIGN AND METHODS

After conducting a retrospective survey of >200,000 case records, we identified T2DM survivors (>40 years of duration) and age at diagnosis and sex-matched T2DM nonsurvivors. Prevalence of complications and causes of death were analyzed. Retinopathy was diagnosed by retinal photography. Microalbuminuria and macroalbuminuria, peripheral vascular disease based on ankle-brachial index <0.9, coronary artery disease based on history of myocardial infarction or coronary revascularization, and neuropathy based on vibration perception threshold >20 V were compared in both groups.

RESULTS

The mean duration of diabetes of survivors (n = 238) was 43.7 ± 3.9 years, and that of the nonsurvivors (n = 307), at time of death, was 22.4 ± 11.0 years (P < 0.001). Nonsurvivors had significantly higher systolic and diastolic blood pressures, plasma glucose, HbA1c, serum cholesterol, LDL cholesterol, and triglycerides and lower HDL cholesterol compared with long-term survivors (P < 0.001 for all parameters except systolic blood pressure, which was P = 0.027). Myocardial infarction (46.4%) and renal failure (16.6%) were the most common causes of death. Prevalence of most complications was higher among survivors because of longer duration and older age, as follows, for survivors versus nonsurvivors: retinopathy, 76 vs. 62%; microalbuminuria, 39.1 vs. 27.3%; macroalbuminuria, 8.4 vs. 23.7%; neuropathy, 86.5 vs. 63.5%; peripheral vascular disease, 23.1 vs. 11.4%; and coronary artery disease, 44.5 vs. 40.7%.

CONCLUSIONS

Long-term survivors with T2DM had better glycemic and blood pressure control and more favorable lipid profiles.

Diabetic population mortality and cardiovascular risk attributable to hypertension: a decade follow-up from the Tehran Lipid and Glucose Study

To determine the extent to which burden of cardiovascular disease (CVD) outcomes among diabetic population is attributable to hypertension. Nine-year follow-up data were secured for 7068 participants aged ≥ 20 years old, free from CVD at baseline. Cox proportional hazards regression was implemented to estimate hazard ratios (HRs) of hypertension. Population-attributable hazard fraction (PAHF) was used to assess proportion of diabetic population hazard of CVD events and mortality attributable to hypertension. In the whole population, irrespective of diabetes or hypertension status, incidence rate (95% CI) of CVD, coronary heart disease (CHD), as well as CVD and all-cause mortality per 1000 person-year were 8.3 (7.6-9.0), 7.1 (6.5-7.8), 1.8 (1.5-2.1) and 3.9 (3.5-4.5), respectively. Among diabetes participants, hypertension was a risk factor for CHD (HR = 1.63, 95% CI 1.15-2.03), CVD (HR = 1.74, 95% CI 1.50-2.41), CVD mortality (HR = 1.65, 95% CI 0.87-3.12) and all-cause mortality (HR = 1.53, 95% CI 0.97-2.42). HRs, however, were not statistically significant for all-cause or CVD mortality. PAHFs (%) of hypertension was 27.5 (95% CI 8.3-42.6) for CHD, 29.6 (95% CI 10.6-44.4) for CVD, 27.9 (95% CI - 17.2 to 55.7) for CVD mortality and 22.6 (95% CI - 5.9 to 43.4) for all-cause mortality. Our study shows that there is an excess risk of CVD in hypertensive patients with diabetes related to inadequate control of blood pressure.

Prevention of diabetes in rural India with a telemedicine intervention

BACKGROUND

Diabetes care is not presently available, accessible, or affordable to people living in rural areas in developing countries, such as India. The Chunampet Rural Diabetes Prevention Project (CRDPP) was conceived with the aim of implementing comprehensive diabetes screening, prevention, and treatment using a combination of telemedicine and personalized care in rural India.

METHODS

This project was undertaken in a cluster of 42 villages in and around the Chunampet village in the state of Tamil Nadu in southern India. A telemedicine van was used to screen for diabetes and its complications using retinal photography, Doppler imaging, biothesiometry, and electrocardiography using standardized techniques. A rural diabetes center was set up to provide basic diabetes care.

RESULTS

Of the total 27,014 adult population living in 42 villages, 23,380 (86.5%) were screened for diabetes, of which 1138 (4.9%) had diabetes and 3410 (14.6%) had prediabetes. A total of 1001 diabetes subjects were screened for complications (response rate of 88.0%). Diabetic retinopathy was detected in 18.2%, neuropathy in 30.9%, microalbuminuria in 24.3%, peripheral vascular disease in 7.3%, and coronary artery disease in 10.8%. The mean hemoglobin A1c levels among the diabetes subjects in the whole community decreased from 9.3 ± 2.6% to 8.5 ± 2.4% within 1 year. Less than 5% of patients needed referral for further management to the tertiary diabetes hospital in Chennai.

CONCLUSIONS

The Chunampet Rural Diabetes Prevention Project is a successful model for screening and for delivery of diabetes health care and prevention to underserved rural areas in developing countries such as India.

Cause-specific mortality in diabetes: retrospective hospital based data from south India

BACKGROUND

India lacks comprehensive mortality data in individuals with diabetes. The present retrospective case-control study compared the causes of death in diabetic and non-diabetic inpatients in a tertiary care hospital in 2007.

METHODS

Deaths in diabetic patients (n = 315) were compared with 307 randomly selected controls. Medical chart review established the primary cause of death, demographics, and clinical data. Data were summarized using descriptive statistics and comparative analyses were performed.

RESULTS

Of the 79 067 inpatient admissions during 2007, diabetes of any type was recorded for 6517 (8.2%). There were 2017 inpatient deaths registered, 315 (15.6%) in diabetic patients and 1702 (84.4%) in non-diabetic patients, corresponding to mortality rates of 48.3/1000 admissions for diabetic patients and 23.4/1000 admissions for non-diabetic patients. The mean duration of hospitalization prior to death in diabetic versus non-diabetic patients was 6.4 vs 7.7 days (P = 0.015). Causes of death in diabetic patients were vascular disease (38.4%), infection (34.3%), renal failure (8.9%), and malignancy (8.9%); diabetic patients had significantly higher odds of death from vascular disease (odds ratio [OR] 4.05, 95% confidence interval [CI] 2.67-6.16; P ≤ 0.0001), renal causes (OR 7.39, 95%CI 2.53-29.27; P ≤ 0.001) and infection (OR 1.61, 95% CI 1.12-2.32; P ≤ 0.0001). Comparing cases and controls after stratifying by age (<56 and ≥56 years), the greater odds of vascular death among diabetics remained significant in both age categories.

CONCLUSIONS

We report vascular disease as the leading cause of death among diabetic hospital inpatients in one tertiary care center in India, in contrast with previous hospital-based studies from India.

Hyperglycemic emergencies in Indian patients with diabetes mellitus on pilgrimage to Amarnathji yatra

BACKGROUND

Diabetic ketoacidosis (DKA) and hyperosmolar hyperglycemic state (HHS) represent two distinct metabolic derangements manifested by insulin deficiency and severe hyperglycemia, with estimated mortality rates of 2.5-9%. In patients with type 2 diabetes mellitus (DM) controlled by diet or oral agents, DKA does not occur unless there is significant severe stress such as severe sepsis, major surgery, trauma, etc. We observed many such emergencies occurring in pilgrims.

OBJECTIVE

We analyzed the data of 13 patients with DM admitted in our endocrine department with hyperglycemic emergencies during 2 years of the annual pilgrimage (yatra) to Amarnathji.

MATERIALS AND METHODS

We reviewed and analyzed the case records of 13 yatris with DM who were referred and admitted in our hospital with hyperglycemic emergencies during the yatra season (July-August) of 2006 and 2007.

RESULTS

Eleven of 13 had DKA and 1 each had HHS and hypoglycemia. After initial clinical assessment and blood sampling for blood counts, electrolytes, blood gases, urinalysis, chest radiography, and electrocardiography, these cases were managed with standard protocol published by American Diabetes Association (ADA) for the management of DKA and HHS. Average blood glucose was 466 mg/dl and nine subjects had moderate to severe ketonuria. All the cases, except one, were in stable condition at the time of discharge.

CONCLUSION

High altitude, strenuous exertion of going uphill, withdrawal of insulin or oral hypoglycemic drugs, starvation, sepsis, and alcohol intake were recorded as predisposing factors. Therefore, there is an immense need for institution of a special health education program to all the yatris before taking the endeavor.

The role of oxidative stress and antioxidants in diabetic complications

Diabetes is considered to be one of the most common chronic diseases worldwide. There is a growing scientific and public interest in connecting oxidative stress with a variety of pathological conditions including diabetes mellitus (DM) as well as other human diseases. Previous experimental and clinical studies report that oxidative stress plays a major role in the pathogenesis and development of complications of both types of DM. However, the exact mechanism by which oxidative stress could contribute to and accelerate the development of complications in diabetic mellitus is only partly known and remains to be clarified. On the one hand, hyperglycemia induces free radicals; on the other hand, it impairs the endogenous antioxidant defense system in patients with diabetes. Endogenous antioxidant defense mechanisms include both enzymatic and non-enzymatic pathways. Their functions in human cells are to counterbalance toxic reactive oxygen species (ROS). Common antioxidants include the vitamins A, C, and E, glutathione (GSH), and the enzymes superoxide dismutase (SOD), catalase (CAT), glutathione peroxidase (GPx), and glutathione reductase (GRx). This review describes the importance of endogenous antioxidant defense systems, their relationship to several pathophysiological processes and their possible therapeutic implications in vivo.

Infected foot ulcers in male and female diabetic patients: a clinico-bioinformative study

BACKGROUND

The study aimed at (i) characterizing the mode of transmission of bla(CTX-M) and bla(TEM-1) among extended-spectrum-beta-lactamase (ESBL)-producing Escherichia coli strains isolated from infected diabetic foot ulcers, and (ii) identifying the risk factors for "sex-associated multidrug resistant Gram-negative bacterial (MDRGNB)-infection status" of the ulcers.

METHODS

Seventy-seven diabetic patients having clinically infected foot ulcers were studied in a consecutive series. The E. coli strains isolated from the ulcers were screened for bla(CTX-M), bla(TEM-1), armA, rmtA and rmtB during the 2-year study-period. PCR amplified bla(CTX-M) genes were cloned and sequenced. Enterobacterial repetitive intergenic consensus (ERIC)-PCR was used for the analysis of genetic relatedness of the ESBL-producers. Risk factors for "sex-associated MDRGNB-infection status" of ulcers were assessed. Modeling was performed using Swiss-Model-Server and verified by Procheck and verify3D programmes. Discovery Studio2.0 (Accelrys) was used to prepare Ramachandran plots. Z-scores were calculated using 'WHAT IF'-package. Docking of cefotaxime with modeled CTX-M-15 enzyme was performed using Hex5.1.

RESULTS

Among 51 E. coli isolates, 14 (27.5%) ESBL-producers were identified. Only 7 Class1 integrons, 2 bla(CTX-M-15), and 1 bla(TEM-1) were detected. Ceftazidime and cefotaxime resistance markers were present on the plasmidic DNA of both the bla(CTX-M-15) positive strains and were transmissible through conjugation. The residues Asn132, Glu166, Pro167, Val172, Lys234 and Thr235 of CTX-M-15 were found to make important contacts with cefotaxime in the docked-complex. Multivariate analysis proved 'Glycemic control at discharge' as the single independent risk factor.

CONCLUSIONS

Male diabetic patients with MDRGNB-infected foot ulcers have poor glycemic control and hence they might have higher mortality rates compared to their female counterparts. Plasmid-mediated conjugal transfer, albeit at a low frequency might be the possible mechanism of transfer of bla(CTX-M-15) resistance marker in the present setting. Since the docking results proved that the amino acid residues Asn132, Glu166, Pro167, Val172, Lys234 and Thr235 of CTX-M-15 (enzyme) make important contacts with cefotaxime (drug) in the 'enzyme-drug complex', researchers are expected to duly utilize this information for designing more potent and versatile CTX-M-inhibitors.

Instant 99mTc-ciprofloxacin scintigraphy for the diagnosis of osteomyelitis in the diabetic foot

BACKGROUND

The diagnosis of osteomyelitis of the foot in patients with diabetes mellitus remains a challenge. This study was conducted to evaluate bone infections using scintigraphy with instantly prepared single-vial kit, radio-labeled ciprofloxacin (Diagnobact TM) in comparison to a bacterial culture taken from the involved site.

METHODS

Twenty-five patients with type 2 diabetes mellitus having foot ulcers, including six with superficial ulcers and positive 99mTc-methylene diphosphonate (MDP) bone scan as a control, were subjected to 99mTc-ciprofloxacin scan and subsequent bacteriological culture.

RESULTS

99mTc-ciprofloxacin scan was positive in 13 patients and negative in 12 patients, including the six with superficial ulcers. Bacterial culture was positive in 18 patients and negative in seven, including one with osteomyelitis on bone biopsy only. 99mTc-ciprofloxacin scan showed "true positive" results in 12, "true negative" in six, "false positive" in one, and "false negative" in six. The specificity and sensitivity of the test were 66.7% and 85.7%, respectively. The positive and negative predictive values and an accuracy of 92.8%, 50% and 72%, respectively. Staphylococcus aureus and Escherichia coli were the most frequently isolated organisms.

CONCLUSION

99mTc-ciprofloxacin is a sensitive and specific marker to diagnose bone infection in patients with diabetes mellitus, but care must be taken in case of fastidious organisms and ciprofloxacin-resistant bacterial flora in which false results may be obtained.

Phenotypes of Isolates of Pseudomonas aeruginosa in a Diabetes Care Center

BACKGROUND

Pseudomonas aeruginosa is an invasive organism that frequently causes severe tissue damage in diabetic foot ulcers. A major problem in P. aeruginosa infection may be that this pathogen exhibits a high degree of resistance to a broad spectrum of antibiotics. Some researchers feel that P. aeruginosa is a homogeneous species, whereas others have suggested that they are panmictic. Here we characterized P. aeruginosa populations isolated from diabetic foot ulcer and from hospital environment specimens, both from a tertiary diabetes care center in Chennai, India.

METHODS

Phenotypic methods like antibiotic susceptibility determinations using Kirby-Bauer's disc diffusion test and minimum inhibitory concentration (MIC) as well as outer membrane protein SDS-PAGE analysis of P. aeruginosa were performed.

RESULTS

Twenty three isolates (29.8%) of P. aeruginosa from 77 diabetic foot ulcers and two environmental isolates (13.3%) from 15 different hospital fomites were detected. Both environmental isolates were sensitive to antibiotics than those isolated from clinical specimens by Kirby-Bauer's disk-diffusion method, which correlated the resistance levels by MIC determination. Outer membrane proteins (OMP) corresponding to 21, 23, 43, 46, 50, and 70 kDa were detected.

CONCLUSIONS

The study is captivative as the resistance in P. aeruginosa from diabetic foot ulcers seems very common and because all the isolates were resistant to at least one or more antibiotics tested. Disk-diffusion and MIC results shows that piperacillin, amikacin and imipenem retain high levels of antipseudomonal activities and amikacin two times more active than the aforementioned antibiotics to enable itself as a potent antipseudomonal agent in diabetic foot infections. The OMP profile has revealed that clinical isolates were different from hospital environment isolates, which suggests that the origin of infections by P. aeruginosa is mainly due to growth of bacterial strains acquired by patients prior to hospital admission.

Bacterial etiology of diabetic foot infections in South India

BACKGROUND

Foot infections are a frequent complication of patients with diabetes mellitus, accounting for up to 20% of diabetes-related hospital admissions. Infectious agents are associated with the worst outcomes, which may ultimately lead to amputation of the infected foot unless prompt treatment strategies are ensued. The present study sought to reveal the bacterial etiology of diabetic foot ulcers in South India, the diabetic capital of India.

METHODS

A 10-month-long descriptive study was carried out to analyse the aerobic and anaerobic bacterial isolates of all patients admitted with diabetic foot infections presenting with Wagner grade 2-5 ulcers. Bacteriological diagnosis and antibiotic sensitivity profiles were carried out and analysed using standard procedures.

RESULTS

Diabetic polyneuropathy was found to be common (56.8%) and gram-negative bacteria (57.6%) were isolated more often than gram-positive ones (42.3%) in the patients screened. The most frequent bacterial isolates were Pseudomonas aeruginosa, Staphylococcus aureus, coagulase-negative staphylococci (CONS), and Enterobacteriaceaes. Forty-nine cultures (68%) showed polymicrobial involvement. About 44% of P. aeruginosa were multi-drug-resistant, and MRSA was recovered on eight occasions (10.3%). Bacteroides spp. and Peptostreptococcus spp. were the major anaerobic isolates.

CONCLUSIONS

Our study supports the viewpoint put forth by previous South Indian authors that the distribution of gram-negative bacteria (57.6%) is more common than that of gram-positive ones (42.3%) and it is contrary to the viewpoint that diabetic foot infections are frequently monomicrobial. Furthermore, recovery of multi-drug-resistant P. aeruginosa isolates is of serious concern, as almost no one has reported the same from the South Indian milieu.

Postprandial hypertriglyceridemia and oxidative stress in patients of type 2 diabetes mellitus with macrovascular complications

BACKGROUND

Oxidative stress has been implicated in vascular complications of diabetes mellitus (DM). This study aims to evaluate the relationship between postprandial hypertriglyceridemia (PP-HTG) and oxidative stress in Indian patients of type 2 DM with macrovascular complications.

METHODS

Plasma triglycerides (TG), thiobarbituric acid reactive substances (TBARS), erythrocyte reduced glutathione (GSH) and superoxide dismutase (SOD) were measured in fasting and postprandial (PP) state at 2, 4, 6 and 8 h after a high fat meal challenge in controls (Group I) and patients of type 2 DM without (Group II) and with macrovascular complications (Group III).

RESULTS

Postprandial TGs increased significantly in patients with type 2 DM, which showed an exaggerated response to high fat meal challenge in Group III as compared to Group II. Highest PP-TBARS were also observed in Group III which correlated positively with TG. However, GSH and SOD were lower in both groups of diabetics as compared to controls.

CONCLUSIONS

The magnitude of PP-HTG appears to be the major determinant of oxidative stress in type 2 DM, which along with a compromised antioxidant status may lead to endothelial dysfunction and macrovascular complications.

Mortality in diabetes: a retrospective analysis from a tertiary care hospital in North India

Cause(s) of death in patients with diabetes mellitus (DM) admitted to a tertiary care hospital in North India was analysed from classified information in patients' death records and case file. Of the 306652 total admissions from 1991 to 1999, 21584 patients died (7.04%), 592 of whom (355 men and 237 women) had DM (2.7%). Information from 92 patients with diabetes could not be retrieved and six patients with hyperglycemia of short duration (two with gestational DM, three with post-transplant diabetes and one with stress hyperglycemia) were excluded. Of the 494 patients, 456 (92.3%) had T2DM and 38 (7.7%) had T1DM. Four hundred and forty patients had diabetes related mortality: infections (230, 46.5%), cardiovascular events (86, 17.4%), chronic renal failure (CRF) (48, 9.7%), stroke (30, 6%), diabetic ketoacidosis (DKA) (15, 3%), hyperosmolar coma (11, 2.2%), and hypoglycemia (5, 1%), while others (54 patients) had diabetes unrelated deaths. Cause of death could not be ascertained in six patients (1.2%). Death was attributed to a single cause in 301 (60.9%), to two causes in 175 (35.4%) and to three or more causes in 12 (2.4%) patients. Analysis of the cause of death in DM versus hospital in-patients in general, showed infection (P<0.02), coronary artery disease (CAD) (P<0.001), and CRF (P<0.001) to be more frequent in diabetes.

The effects of diabetes on the risks of major cardiovascular diseases and death in the Asia-Pacific region

OBJECTIVE

To provide reliable age- and region-specific estimates of the associations between diabetes and major cardiovascular diseases and death in populations from the Asia-Pacific region.

RESEARCH DESIGN AND METHODS

Twenty-four cohort studies from Asia, Australia, and New Zealand (median follow-up, 5.4 years) provided individual participant data from 161,214 people (58% from Asia) of whom 4,873 had a history of diabetes at baseline. The associations of diabetes with the risks of coronary heart disease, stroke, and cause-specific mortality during follow-up were estimated using time-dependent Cox models, stratified by study cohort and sex and adjusted for age at risk.

RESULTS

In all, 9,277 deaths occurred (3,635 from cardiovascular disease). The hazard ratio (95% CI) associated with diabetes was 1.97 (1.72-2.25) for fatal cardiovascular disease; there were similar hazard ratios for fatal coronary heart disease, fatal stroke, and composites of fatal and nonfatal outcomes. For all cardiovascular outcomes, hazard ratios were similar in Asian and non-Asian populations and in men and women, but were greater in younger than older individuals. For noncardiovascular death, the hazard ratio was 1.56 (1.38-1.77), with separately significant increases in the risks of death from renal disease, cancer, respiratory infections, and other infective causes. The hazard ratio for all-causes mortality was 1.68 (1.55-1.84), with similar ratios in Asian and non-Asian populations, but with significantly higher ratios in younger than older individuals.

CONCLUSIONS

The relative effect of diabetes on the risks of cardiovascular disease and death in Asian populations is much the same as that in the largely Caucasian populations of Australia and New Zealand. Hazard ratios were severalfold greater in younger people than older people. The rapidly growing prevalence of diabetes in Asia heralds a large increase in the incidence of diabetes-related death in the coming decades.

Looking at the future of geriatric care in developing countries

During the next 20 years, many less developed countries (LDC) will have age structures approaching those of the present time in more developed countries (MDC). This is occurring more rapidly in the LDC of Asia and Latin America. The future of aging populations in LDC is dependent on the degree of poverty in these countries. Poverty is a major determinant of disability and mortality in older persons. With the march of globalization, diseases in LDC are changing from infectious to noncommunicable diseases, such as diabetes. Nevertheless, infections such as tuberculosis still take a major toll on the elderly. The epidemiological transition in LDC has created a need for health care transitions from systems based on cure to ones that highlight prevention and long-term care. LDC have the opportunity to develop systems that differ from those in MDC by capitalizing on the lack of infrastructure to produce more home-based rather than institution-based long-term care systems. Involvement of the elderly in the planning of their own futures is of paramount importance. Appropriate planning now will decide the future of the elderly in LDC during the next 20 to 40 years.

Prevalence of urinary tract infection and renal scars in patients with diabetes mellitus

In a case control study, we assessed the prevalence of bacterial urinary tract infections (UTI) and renal scarring in 155 consecutive type 1 (n=102) and type 2 (n=53) diabetic individuals and 128 healthy controls. Subjects who received antibiotics during the past 6 months, pregnant women and those with overt renal failure were excluded. In all subjects, urine culture and 99m Technetium (Tc) dimercapto-succinic acid renal scan was performed. UTI was diagnosed if two consecutive urine cultures grew the same organism with at least 10(5) colony forming unit (cfu)/ml in asymptomatic and at least 10(4) cfu/ml in symptomatic subjects, respectively. Renal scan was considered abnormal if focal or multiple tracer uptake defects and/or break in cortical outline were observed. The prevalence of UTI in diabetes mellitus was higher, when compared to that in controls (9% vs. 0.78%, P=0.005). Escherichia coli was the most commonly grown organism (64.3%), followed by Staphyloccocus aureus (21.4%) and Klebsiella pneumoniae (14.3%). Prevalence of renal scarring was higher in patients with diabetes (28/155, 18.0%), when compared to that of controls (7/128, 5.4%, P=0.002). Fifty percent of patients with diabetes and UTI had renal scarring. The prevalence in diabetics with no UTI was also higher, when compared to controls (14.8 vs. 5.5%, P<0.01). The prevalence of UTI as well as renal scarring was significantly higher in females, when compared to male diabetics. No significant difference in vascular events, hypertension, proteinuria, renal function tests and HbA1 was observed in patients with and without renal scar. Thus, patients with diabetes mellitus have 10- and 3-folds increased risk of UTI and renal scarring, respectively. The results could help prioritize protocols for management of UTI among patients with diabetes mellitus.

Non-industrialised countries and affluence

The prevalence of type 2 diabetes is rising rapidly in all non-industrialised populations. By 2025, three-quarters of the world's 300 million adults with diabetes will be in non-industrialised countries, and almost a third in India and China alone. There is strong evidence that this epidemic has been triggered by social and economic development and urbanisation, which are associated with general improvements in nutrition and longevity, but also with obesity, reduced physical exercise and other diabetogenic factors. There is evidence too that fetal growth retardation and growth failure in infancy, both still widespread in non-industrialised populations, increase susceptibility to diabetes. An additional factor may be intergenerational effects of gestational diabetes occurring in mothers who grew poorly in early life and become obese as adults. Prevention of type 2 diabetes will require measures to promote exercise and reduce obesity in adults and children, alongside programmes to achieve healthy fetal and infant growth.