World diabetes day 2018: Battling the Emerging Epidemic of Diabetic Retinopathy

Living with diabetes in Northeast India: An exploration of psychosocial factors in management

Purpose

India is the 'Diabetes Capital of the World' and accounts for one in seven adults living with diabetes worldwide. Psychosocial, economic, and cultural correlates of disease have important implications for disease management but are rarely explored in India. The purpose of this study is to address psychosocial and cultural factors in diabetes management in the northeastern region of India which has a high disease burden.

Methods

This study attempts to explore the psychosocial and lived experience of diabetes in the northeastern state of Meghalaya. The sample was selected from individuals attending an outpatient facility of a multi-speciality clinic. Semi-structured interviews were conducted with 25 individuals (13 women and 12 men), above the age of 40 years, who had been diagnosed with diabetes for at least 6 months. The narratives were analysed using thematic analysis.

Results

Using the social cognitive framework, themes were organized in terms of a thematic map linking knowledge of diabetes to the perception of diabetes as 'a silent killer', to coping, leading to self-efficacy. However high self-efficacy, over time, may lead to complacency, disrupting health behaviours and requiring re-establishment of those behaviours. Adequate knowledge along with cognitive adaptation and self-efficacy were important constructs that contributed to behaviour change and maintenance. Elements of the cultural context were observed in the spiritual aspects of adaptation, the socially isolating consequences of diabetes, as well as gender differences in social support and management.

Conclusion

Understanding the lived experiences of patients contributes to planning more effective interventions keeping the social and cultural context in mind for more effective management of diabetes. Additionally, acknowledging and supporting women's needs in diabetes management is called for.

The effect of socioeconomic status, depression, and diabetes symptoms severity on diabetes patient's life satisfaction in India

Evidence suggests that diabetes is on the rise in India, affecting many people's life satisfaction. Comprehensive estimation of life satisfaction among diabetes patients does not exist in the country. This study examined the effects of socioeconomic status, depression, and diabetes symptoms severity on the life satisfaction of diabetes patients by controlling various demographic variables. It was a cross-sectional study comprising 583 diabetes patients from Punjab, India. Patients were interviewed using a multi-stage purposeful random sampling method. Descriptive analysis and partial least squares structural equation modelling were used in the study to test the hypotheses. Results revealed that socioeconomic status, depression and diabetes symptoms severity significantly influence the life satisfaction of diabetes patients. A 1% drop in diabetes symptoms severity corresponds to a 0.849% increase in life satisfaction, whereas a 1% decrease in depression results in a 0.898% increase in life satisfaction. Patients with higher diabetes symptoms severity were coping with common mental disorders. Women reported higher diabetes symptoms severity and depression than men, resulting in lower life satisfaction. An experimental evaluation of the effects of socioeconomic status, depression and diabetes symptoms severity, and numerous demographic factors on life satisfaction was reported. The findings will help policymakers understand the problem associated with life satisfaction among diabetes patients in the country.

Therapeutic Applications of Plant and Nutraceutical-Based Compounds for the Management of Type 2 Diabetes Mellitus: A Narrative Review

Diabetes mellitus is a condition caused by a deficiency in insulin production or sensitivity that is defined by persistent hyperglycemia as well as disturbances in glucose, lipid, and protein metabolism. Uncurbed diabetes or incessant hyperglycemic condition can lead to severe complications, including renal damage, visual impairment, cardiovascular disease, neuropathy, etc., which promotes diabetes-associated morbidity and mortality rates. The therapeutic management of diabetes includes conventional medications and nutraceuticals as complementary therapies. Nutraceuticals are bioactive compounds derived from food sources that have health-promoting properties and are instrumental in the management and treatment of various maladies. Nutraceuticals are clinically exploited to tackle DM pathogenesis, and the clinical evidence suggests that nutraceuticals can modulate biochemical parameters related to diabetes pathogenesis and comorbidities. Hypoglycemic medicines are designed to mitigate DM in traditional medicinal practice. This review intends to emphasize and comment on the various therapeutic strategies available to manage this chronic condition, conventional drugs, and the potential role of nutraceuticals in managing the complexity of the disease and reducing the risk of complications. In contrast to conventional antihyperglycemic drugs, nutraceutical supplements offer a higher efficacy and lesser adverse effects. To substantiate the efficacy and safety of various functional foods in conjunction with conventional hypoglycemic medicines, additional data from clinical studies are required.

Financial burden of seeking diabetes mellitus care in India: Evidence from a Nationally Representative Sample Survey

Background

Diabetes mellitus (DM) is a major public health concern in India, and entails a severe burden in terms of disability, death, and economic cost. This study examined the out-of-pocket health expenditure (OOPE) and financial burden associated with DM care in India.

Methods

The study used data from the latest round of the National Sample Survey on health, which covered 555,115 individuals from 113,823 households in India. In the present study, data of 1216 individuals who sought inpatient treatment and 6527 individuals who sought outpatient care for DM were analysed.

Results

In India, 10.04 per 1000 persons reported having DM during the last 15 days before the survey date, varying from 6.94/1000 in rural areas to 17.45/1000 in urban areas. Nearly 38% of Indian households with diabetic members experienced catastrophic health expenditure (at the 10% threshold) and approximately 10% of DM-affected households were pushed below the poverty line because of OOPE, irrespective of the type of care sought. 48.5% of households used distressed sources to finance the inpatient costs of DM. Medicines constituted one of the largest proportion of total health expenditure, regardless of the type of care sought or type of healthcare facility visited. The average monthly OOPE was over 4.5-fold and 2.5-fold higher for households who sought inpatient and outpatient care, respectively, from private health facilities, compared with those treated at public facilities. Notably, the financial burden was more severe for households residing in rural areas, those in lower economic quintiles, those belonging to marginalised social groups, and those using private health facilities.

Conclusion

The burden of DM and its associated financial ramifications necessitate policy measures, such as prioritising health promotion and disease prevention strategies, strengthening public healthcare facilities, improved regulation of private healthcare providers, and bringing outpatient services under the purview of health insurance, to manage the diabetes epidemic and mitigate its financial impact.

Is Artificial Intelligence the Cost-Saving Lens to Diabetic Retinopathy Screening in Low- and Middle-Income Countries?

Diabetes is a rapidly growing global health crisis disproportionately affecting low- and middle-income countries (LMICs). The emergence of diabetes as a global pandemic is one of the major challenges to human health, as long-term microvascular complications such as diabetic retinopathy (DR) can lead to irreversible blindness. Leveraging artificial intelligence (AI) technology may improve the diagnostic accuracy, efficiency, and accessibility of DR screenings across LMICs. However, there is a gap between the potential of AI technology and its implementation in clinical practice. The main objective of this systematic review is to summarize the currently available literature on the health economic assessments of AI implementation for DR screening in LMICs. The review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines. We conducted an extensive systematic search of PubMed/MEDLINE, Scopus, and the Web of Science on July 15, 2023. Our review included full-text English-language articles from any publication year. The Joanna Briggs Institute's (JBI) critical appraisal checklist for economic evaluations was used to rate the quality and rigor of the selected articles. The initial search generated 1,423 records and was narrowed to five full-text articles through comprehensive inclusion and exclusion criteria. Of the five articles included in our systematic review, two used a cost-effectiveness analysis, two used a cost-utility analysis, and one used both a cost-effectiveness analysis and a cost-utility analysis. Across the five articles, LMICs such as China, Thailand, and Brazil were represented in the economic evaluations and models. Overall, three out of the five articles concluded that AI-based DR screening was more cost-effective in comparison to standard-of-care screening methods. Our systematic review highlights the need for more primary health economic analyses that carefully evaluate the economic implications of adopting AI technology for DR screening in LMICs. We hope this systematic review will offer valuable guidance to healthcare providers, scientists, and legislators to support appropriate decision-making regarding the implementation of AI algorithms for DR screening in healthcare workflows.

The Economic Cost of Rising Non-communicable Diseases in India: A Systematic Literature Review of Methods and Estimates

BACKGROUND AND OBJECTIVES

India has one of the world's highest proportions of out-of-pocket expenditure (OOPE) payments. The low share of public health expenditure coupled with the double burden of disease (communicable and non-communicable) has a direct financial impact on individual OOPE and an indirect impact in the form of decreasing life expectancy, reduced productivity, and hence a negative impact on economic growth. This systematic review aims to compare and assess the estimated economic cost of non-communicable diseases (NCDs) in India and ascertain the methods used to derive these estimates.

METHODS

This paper reviews the past 12-year (2010-22) literature on the economic impact of health shocks due to NCDs. Three databases were searched for the literature: PubMed, Scopus, and Google Scholar. Thematic analysis has been performed to analyse the findings of the study.

RESULTS

The OOPE was very high for NCDs. The increasing cost was high and unaffordable, pushing many people into financial distress measured by catastrophic payments and rising impoverishment.

CONCLUSION

The results indicate both the direct and indirect impact of NCDs, but the indirect burden of loss of employment and productivity, despite its relevance, has been less studied in the literature. A robust economic analysis will allow an evidence-based policy decision perspective to reduce the rising burden of NCDs.

Capnography as a tool for triaging and diagnosis of diabetic ketoacidosis in the emergency department: A prospective observational study

OBJECTIVES

The cornerstone of management of acidosis in a patient with diabetic ketoacidosis (DKA) has traditionally been carried out by blood gas analysis, which is expensive and associated with significant risk. It is against this background that the correlation between end-tidal carbon dioxide (EtCO₂), blood pH, and EtCO₂ bicarbonate levels was analyzed. The predictive value of EtCO₂ was also analyzed in the diagnosis of DKA. Finally, we aimed to determine the value of EtCO₂ as a screening test for the exclusion of DKA.

MATERIALS AND METHODS

This was a prospective cohort study carried out in the emergency department of a tertiary care teaching hospital from September 2020 to September 2021. Patients with suspected DKA underwent simultaneous blood gas collection and EtCO₂ analysis.

RESULTS

A total of 123 patients with blood sugar levels >250 mg/dl and moderate-to-large (≥2+) urine ketones were studied. A cut-off value of EtCO₂ ≤24 was determined to rule in DKA with a sensitivity of 93.02% and specificity of 91.9%. EtCO₂ >26 could effectively rule out the diagnosis of DKA with sensitivity of 98.8% and specificity of 75.7%. A significant linear correlation between pH and EtCO₂ (P < 0.0001, r = 0.82) and HCO3 and EtCO₂ (r = 0.896, P < 0.0001) was found.

CONCLUSIONS

EtCO₂ values ≤24 can accurately identify patients with DKA in the presence of elevated blood sugar and urinary ketones and must be considered a valuable addition to the diagnostic criteria. EtCO₂ values >26 can be an effective triaging tool for ruling our DKA. A significant linear correlation between pH and EtCO₂ and pH and HCO3 was observed. EtCO₂ can be considered a surrogate marker for the degree of response to the treatment in DKA.

COVID-19 Associated Mucormycosis

Mucormycosis is a life-threatening opportunistic fungal infection seen in immunocompromised states. Rising incidence of mucormycosis among Coronavirus Disease-2019 infected individuals is an increasing concern in India. The disease which was endemic has blown out to become an epidemic. The purpose of this research is to study the epidemiology, management and outcome of Coronavirus Disease-2019 Associated Mucormycosis (CAM) cases. Additionally, the role of diabetes and steroids in the causation of CAM was determined. A hospital-based observational study was conducted at a tertiary care centre involving cases with rhino-orbital mucormycosis with recent history of COVID-19 infection. Out of 205,166(81%) cases had Diabetes Mellitus as a comorbid condition. Among them, 75(36.6%) cases were diagnosed with diabetes during COVID-19 treatment. 161/205(78.5%) cases received corticosteroids during COVID-19 treatment. Corticosteroids were notindicated in 43(26.7%) cases. 177/205(85.4%) cases were alive at the end of 12 weeks. 8 out of 10 deaths were seen in cases having diabetes. As the incidence of mucormycosis is increasing, better awareness among general population about the disease, early diagnosis and multidisciplinary approach is required to improve prognosis.

KADAM topical warm oxygen therapy device for diabetic foot ulcer-a novel approach

Purpose

Diabetic foot ulcer (DFU) is a significant healthcare burden demanding prompt attention. In the past decade, newer technologies such as topical oxygen therapy have grown increasingly popular. The purpose of the study was to determine effect of KADAM-a topical warm oxygen therapy (TWOT) medical device in healing of DFU.

Methods

The KADAM medical device developed by Yostra Labs Pvt Ltd, delivered pure oxygen between 93 ± 3% concentration at an optimal temperature range of 39-42º Celsius to DFU wound site.

Results

A total of 40 diabetic foot ulcer individuals, aged over 18 years were included in the study. Individuals with the Grade 1 DFU were 34 (85%), grade 2 were 5 (12.5%) and grade 3 were 1 (2.5%). The changes in initial area and final area for the various diabetic foot ulcer grades were as follows: 0.32 [0.12, 0.96] (< 0.001) for grade 1 ulcer, 0.76 [0.54, 1.17] (P = 0.013) for grade 2 ulcer and 1.26 for grade 3 ulcer. The percentage reduction in wound size achieved for the grade 1 & 2 DFU were 100%, and grade 3 was 75%.

Conclusion

Topical warm oxygen therapy serves as an adjunctive modality to facilitate diabetic foot ulcer healing in the clinical practice.

India's Opportunity to Address Human Resource Challenges in Healthcare

India's health indicators have improved in recent times but continue to lag behind those of its peer nations. The country with a population of 1.3 billion, has an estimated active health workers density of doctors and nurses/midwives of 5.0 and 6.0 respectively, for 10,000 persons, which is much lower than the WHO threshold of 44.5 doctors, nurses, and midwives per 10,000 population. The issue is compounded by the skewed inter-state, urban-rural, and public-private sector divide. Calls to urgently augment the skilled health workforce reinforce the central role human resources have in healthcare, which has evolved into a complex multifactorial issue. The paucity of skilled personnel must be addressed if India is to accelerate its progress toward achieving universal health coverage and its sustainable development goals (SDGs). The recent increase in the federal health budget offers an unprecedented opportunity to do this. This article utilizes the ready materials, extract and analyze data, distill findings (READ) approach to adding to the authors' experiential learning to analyze the health system in India. The growing divide between the public and the burgeoning private health sector systems, with the latter's booming medical tourism industry and medical schools, are analyzed along with the newly minted National Medical Council, to recommend policies that would help India achieve its SDGs.

A clinicopathological study on management of diabetic foot ulcer in tertiary care centre

INTRODUCTION

Diabetes is a disease in which the body's ability to produce or respond to the hormone insulin is impaired, resulting in abnormal metabolism of carbohydrates and elevated levels of glucose in the blood. India being the Diabetes Capital of the World has a Prevalence of 65.1 million suffering from DM of the Entire Indian Population being 1.33 billion of Worlds 6 billion people. This states that almost half of the Indian Population will sometime in their life be detected with Diabetes Almost 15-20 % of the population suffering from Diabetes are seen to have Diabetic Foot Ulcer at least once in their lifetime. It is also been noted that 10-15 % of patients suffering from Diabetic Foot Ulcer require Expert Management or Multi Disciplinary Approach. Diabetic foot ulcers have many pathogenic mechanisms, These risk factors are as follows: gender (male), duration of diabetes longer than 10 years, advanced age of patients, high Body Mass Index and other co-morbidities such as retinopathy, diabetic peripheral neuropathy, peripheral vascular disease, high glycated haemoglobin level (HbA1C), foot deformity, high plantar pressure, infections and inappropriate foot selfcare habits. Rough estimates are at about 1,00,000 lower limbs are amputated in India every year, of which at least seventy-five percent are neuropathic feet with secondary infections and are potentially preventable.

AIMS AND OBJECTIVES

Deep learning-enhanced diabetic retinopathy image classification

Objective

Diabetic retinopathy (DR) can sometimes be treated and prevented from causing irreversible vision loss if caught and treated properly. In this work, a deep learning (DL) model is employed to accurately identify all five stages of DR.

Methods

The suggested methodology presents two examples, one with and one without picture augmentation. A balanced dataset meeting the same criteria in both cases is then generated using augmentative methods. The DenseNet-121-rendered model on the Asia Pacific Tele-Ophthalmology Society (APTOS) and dataset for diabetic retinopathy (DDR) datasets performed exceptionally well when compared to other methods for identifying the five stages of DR.

Results

Our propose model achieved the highest test accuracy of 98.36%, top-2 accuracy of 100%, and top-3 accuracy of 100% for the APTOS dataset, and the highest test accuracy of 79.67%, top-2 accuracy of 92.%76, and top-3 accuracy of 98.94% for the DDR dataset. Additional criteria (precision, recall, and F1-score) for gauging the efficacy of the proposed model were established with the help of APTOS and DDR.

Conclusions

It was discovered that feeding a model with higher-quality photographs increased its efficiency and ability for learning, as opposed to both state-of-the-art technology and the other, non-enhanced model.

Unlocking India's Potential in Managing Endocrine-Disrupting Chemicals (EDCs): Importance, Challenges, and Opportunities

Endocrine-disrupting chemicals (EDCs) are a prime concern for the environment and health globally. Research shows that in developing countries such as India both the environment and human populations are severely exposed to EDCs and consequently experience rising incidents of adverse health effects such as diabetes and cancers. In this paper, we discuss the current EDC management approach in India, critically assess its limitations, and describe opportunities for potential improvements. Foremost, current EDC management actions and interventions in India are fragmented and outdated, and far behind the modern and comprehensive approaches adopted in the European Union and other developed countries. Strong and well-planned actions are required on various fronts of science, policy, commerce, and public engagement. These actions include the adoption of a dedicated and modern regulatory framework for managing EDCs, enhancing capacity and infrastructure for EDC monitoring in the environment and human population, employing public-private partnership programs for not only managing EDCs but also in the sectors that indirectly contribute toward the mismanagement of EDCs in the country, and raising awareness on EDCs and promoting health-preserving consumption habits among the public. As India hosts a large proportion of the global human population and biodiversity, the success or failure of its actions will substantially affect the direction of global efforts to manage EDCs and set an example for other developing countries.

Mucormycosis and diabetes in the times of COVID-19: A Mumbai-based observational study

Background

There is a significant increase in the number of mucormycosis cases in the setting of the coronavirus disease 2019 (COVID-19) pandemic. This study was undertaken to understand the clinical profile of such patients and the risk factors associated with increased mortality of this already deadly infection.

Materials and Methods

A retrospective observational study was conducted by including microbiologically confirmed cases of mucormycosis with the background of COVID-19 infection (COVID-19-associated mucormycosis [CAM]). Data was segregated into those of survivors versus non-survivors and the two groups were analyzed for various risk factors. Early and late CAM were also compared.

Results

The case fatality rate was 21.73% (5/23 patients). Case fatality in early CAM was 33.3% versus 9.1% in late CAM. Rhino-orbital-cerebral mucormycosis (P = 0.01) and cranial nerve involvement (P = 0.0482) were associated with increased mortality. Diabetes and poor glycemic control were the common factors in all patients. Early CAM patients were more likely to have orbital or cerebral involvement (P = 0.0065). Patients having chronic liver disease had a higher risk of mortality (P = 0.0395). Sequential treatment or concurrent dual drug therapy with a combination of antifungal drugs was independently associated with better survival (P = 0.0395). The average duration of treatment with amphotericin-b required for cure by survivors was 29.05 ± 17.05 days. The average duration of treatment with isavuconazole/posaconazole for survivors was 50.32 ± 25.23 days.

Conclusion

Early CAM had a higher case fatality rate. Patients had better recovery rates with sequential or dual antifungal treatment. The raised incidence and mortality in the COVID-19 pandemic is probably related to the COVID-19-induced immunosuppression with associated diabetes and excessive use of steroids.

Mysterious alarming mucormycosis: Anesthetic challenges in a series of four cases

The sudden epidemic of mucormycosis amid COVID-19 pandemic has significantly challenged our understanding of the disease while affecting the whole medical and surgical management. Overzealous use of steroids in the management of covid-19 and uncontrolled diabetes mellitus has resulted in a tremendous rise in mucormycosis cases further burdening the already strained health care infrastructure and health care workers, especially the anesthesiologists. While working in a tertiary care institute of the country, we have been facing multiple challenges in its anesthetic management on a daily basis. This article is a case series involving four different patients who were operated for rhino-orbito-cerebral mucormycosis with a brief discussion on various aspects of this multisystem epidemic.

Assessment of Bone Mineral Density in Type 2 Diabetes: A Cone Beam Computed Tomography (CBCT) Study

Introduction

The main purpose of the study was to assess and compare bone mineral density (BMD) at prospective implant sites in the mandible in type 2 diabetes mellitus (T2DM) and non-diabetic patients using cone beam computed tomography (CBCT).

Material and methodology

A total of 40 patients were included in this type of cross-sectional study. They were divided into two groups, A and B, according to their haemoglobin A1c values. Group A consisted of patients with HbA1c between the range of 6.1%-8% and group B had patients with no history of T2DM. CBCT scans were made of the mandibular arches of both the patients to evaluate the BMD at lingual and buccal cortical plates and the trabecular regions in two successive slices with the assistance of PlanMeca Romexis software (PlanMeca Romexis®, Helsinki, Finland). The Shapiro-Wilk test was used to determine the normality of continuous data. The Mann-Whitney U test was used to compare the groups.

Results

There were no differences that were statistically significant between the two cohorts according to the Mann-Whitney U test at buccal cortical plate points 1 and 2. However, the diabetes group's mean bone density at implant sites-A, B, C, D, and E at trabeculae points 1 and 2 was considerably (7p>0.001) lower than the non-diabetic groups. The mean bone density of the diabetes group was marginally but significantly (p=0.009) lower than the non-diabetic group at lingual cortical plates.

Conclusion

Individuals with type 2 diabetes mellitus show significantly lower bone mineral density in the lingual cortical plate and trabecular region, however, implant therapy can be performed with certain mentioned guidelines in such regions. In the buccal cortical region, the bone mineral density is seen to be unaffected.

Non-mydriatic fundus photography as an alternative to indirect ophthalmoscopy for screening of diabetic retinopathy in community settings: a comparative pilot study in rural and tribal India

OBJECTIVES

The impending and increasing prevalence of diabetic retinopathy (DR) in India has necessitated a need for affordable and valid community outreach screening programme for DR, especially in rural and far to reach indigenous local communities. The present study is a pilot study aimed to compare non-mydriatic fundus photography with indirect ophthalmoscopy for its utilisation as a feasible and logistically convenient screening modality for DR in an older age, rural, tribal population in Western India.

DESIGN AND SETTING

This community-based, cross-sectional, prospective population study was a part of a module using Rapid Assessment of Avoidable Blindness and DR methodology in 8340 sampled participants with ≥50 years age. In this study, the diabetics identified were screened for DR using two methods: non-mydriatic fundus photography on the field by trained professionals, that were then graded by a retina specialist at the base hospital and indirect ophthalmoscopy by expert ophthalmologists in the field with masking of each other's findings for its utility and comparison.

RESULTS

The prevalence of DR, sight threatening DR and maculopathy using indirect ophthalmoscopy was found to be 12.1%, 2.1% and 6.6%, respectively. A fair agreement (κ=0.48 for DR and 0.59 for maculopathy) was observed between both the detection methods. The sensitivity and specificity of fundus photographic evaluation compared with indirect ophthalmoscopy were found to be 54.8% and 92.1% (for DR), 60.7% and 90.8% (for any DR) and 84.2% and 94.8% (for only maculopathy), respectively.

CONCLUSION

Non-mydriatic fundus photography has the potential to identify DR (any retinopathy or maculopathy) in community settings in Indian population. Its utility as an affordable and logistically convenient cum practical modality is demonstrable. The sensitivity of this screening modality can be further increased by investing in better resolution cameras, capturing quality images and training and validation of imagers.

TRIAL REGISTRATION NUMBER

CTRI/2020/01/023025; Clinical Trial Registry, India (CTRI).

The Role of Nutraceutical Containing Polyphenols in Diabetes Prevention

Research in pharmacological therapy has led to the availability of many antidiabetic agents. New recommendations for precision medicine and particularly precision nutrition may greatly contribute to the control and especially to the prevention of diabetes. This scenario greatly encourages the search for novel non-pharmaceutical molecules. In line with this, the daily and long-term consumption of diets rich in phenolic compounds, together with a healthy lifestyle, may have a protective role against the development of type 2 diabetes. In the framework of the described studies, there is clear evidence that the bio accessibility, bioavailability, and the gut microbiota are indeed affected by: the way phenolic compounds are consumed (acutely or chronically; as pure compounds, extracts, or in-side a whole meal) and the amount and the type of phenolic compounds (ex-tractable or non-extractable/macromolecular antioxidants, including non-bioavailable polyphenols and plant matrix complexed structures). In this review, we report possible effects of important, commonly consumed, phenolic-based nutraceuticals in pre-clinical and clinical diabetes studies. We highlight their mechanisms of action and their potential effects in health promotion. Translation of this nutraceutical-based approach still requires more and larger clinical trials for better elucidation of the mechanism of action toward clinical applications.

Quantification of chronic diseases presenting in the Emergency Department and their disposition outcomes: A hospital-based cross-sectional study in north India

A knowledge of the extent and distribution of chronic comorbidity plays an essential role in providing appropriate care, and allocating health resources to the patients admitted to the emergency department. We performed a cross-sectional study to quantify the chronic diseases presenting in the Emergency Department of PGIMER, Chandigarh (India). Out of 205 patients, 133 (64.9%) had pre-existing comorbidity. Common were chronic kidney disease (29, 14.1%), chronic liver disease (23, 11.2%), diabetes mellitus (21, 10.2%), malignancy (20, 9.8%), cardiac diseases (17, 8.3%), and chronic obstructive pulmonary disease (9, 4.4%). The median Charlson comorbidity index score was 2 (range, 0-9). In-hospital mortality was 43 (21%) and was predicted by older age (median, 60 v. 50 years; p-value, 0.017). Deaths with previous stroke (66.6%), chronic obstructive pulmonary disease (55.6%), and diabetes (28.6%) were higher than cardiac (2.3%) and renal (6.9%) comorbidity. Increasing comorbidity requires a shift in existing models of emergency care.

Challenges in managing glaucoma-related morbidity due to lockdown in a developing country

Objective:

The aim of this study was to assess the ocular morbidity due to delayed presentation in glaucoma patients because of COVID lockdown.

Methodology:

This was a retrospective study of 15 cases presented to us between October 2020 and February 2021. Cause of glaucoma in our study group was either primary angle closure, pseudoexfoliation, lens-induced glaucoma, or neovascular glaucoma. The cause of delayed presentation was identified and patients were treated with antiglaucoma medications, Nd-Yag laser, and surgery as per the standard treatment protocol.

Results:

With both medical and surgical intervention, some useful vision was restored in five cases while in rest it was not salvageable. The vision in the affected eye ranged from 6/60 in Snellen’s chart to perception of light and projection of rays positive. Better results were achieved in angle, closure, and lens-induced glaucoma cases as compared to neovascular glaucoma cases.

Conclusion:

The time of presentation in such cases is as important as the etiopathogenesis. We are left with limited treatment options if the presentation is late. The lockdown ended but it unraveled quite a few instances of disease presentation which were totally preventable under normal circumstances. Introspection on finding out newer and proactive methods to reach people suffering from such irreversible but preventable diseases is the need of the day especially when preventable but irreversible diseases like glaucoma are considered.

COVID-19 associated mucormycosis: evolving technologies for early and rapid diagnosis

The post-coronavirus disease (COVID-19) mucormycosis is a deadly addition to the pandemic spectrum. Although it’s a rare, aggressive, and opportunistic disease, the associated morbidity and mortality are significant. The complex interplay of factors aggravating CAM is uncontrolled diabetes, irrational and excessive use of antibiotics, steroids, and an impaired immune system. Recently, India has been witnessing a rapid surge in the cases of coronavirus disease-associated mucormycosis (CAM), since the second wave of COVID-19. The devastating and lethal implications of CAM had now become a matter of global attention. A delayed diagnosis is often associated with a poor prognosis. Therefore, the rapid and early diagnosis of infection would be life-saving. Prevention and effective management of mucormycosis depend upon its early and accurate diagnosis followed by a multimodal therapeutic approach. The current review summarizes an array of detection methods and highlights certain evolving technologies for early and rapid diagnosis of CAM. Furthermore, several potential management strategies have also been discussed, which would aid in tackling the neglected yet fatal crisis of mucormycosis associated with COVID-19.

Evaluation of Antidiabetic Activity of Sargassum tenerrimum in Streptozotocin-Induced Diabetic Mice

Diabetes mellitus has become the most predominant disease in most of the developing and developed countries. Diabetes could occur at any stage of life for which a change in sedentary life style is the possible solution. Despite the introduction of several medications, to curtail the side effects associated with diabetes mellitus, there is no medication or treatment for complete cure. Existing medications and treatments are targeted to mitigate the intensity of the disease which abruptly could result in organ failure. Rather than the available types of treatments, natural medication is reported to produce commendable results. Extracts of many medicinal plants and seaweeds have been documented to possess anti-diabetic properties. A brown alga, S. tenerrimum, found on the west coast of India, is chosen in this study to analyse the anti-diabetic property of its methanolic extract. This extract was used to treat streptozotocin-induced diabetic mice. An experimental design was framed based on acute toxicity studies to determine the change in blood glucose level, body weight, lipid profile, liver enzymes (SGPT and SGOT) and the renal function markers (urea and creatinine). After 15 days of treatment, an increase in body weight and HDL cholesterol was observed while the total cholesterol, VLDL, LDL, serum triglyceride, SGOT, SGPT, creatinine and urea decreased with 250 mg/Kg.bw of S. tenerrimum methanolic extract in Streptozotocin-induced diabetic mice group. This difference is significant (p<0.05) when compared with a healthy non-diabetic mice group and a treated diabetic mice group. This proves that the methanolic extract of S. tenerrimum possess anti-diabetic property. Further research could explore the active compounds that can be used in the formulation of herbal medicine for diabetes mellitus.

Social factors in understanding illness behaviour of women with Type 2 diabetes mellitus in Jammu, North India

AIMS

Females in the South Asian region form a deprived community in diabetes management, and if we narrow it down to the Indian context, the situation is even grimmer. This necessitates an exploration of the socio-cultural factors, in the form of personal perception of the respondents, responsible for diabetes management among women.

METHODS

Data for the present study were collected at Government Medical College (GMC) Hospital, Jammu (India). In total 41 female respondents suffering from diabetes, for more than two years, were interviewed by using an unstructured interview schedule. Field research consisted of purposive sampling method and observation which took place in the out-patient department and in-patient department of the Department of Medicine, GMC.

RESULTS

Results show that the biggest challenge posed by diabetes management for women is to take care of household expenses amid treatment demanded by this disease. Results were looked at from social constructivist point of view which revealed that socially constructed notions about disease have a major role to play in its management.

CONCLUSION

These women opt for different mechanisms for diabetes management which may or may not be recommended by their diabetologist; however, their personal beliefs have maximum role to play in disease management.

Significance of monitoring vascular endothelial growth factor, monocyte chemoattractant protein-1 and Interleukin-8 in diabetic macular edema towards early identification of nonresponders to ranibizumab therapy

Purpose:

Identification of nonresponders prior to anti-vascular endothelial growth factor (anti-VEGF) therapy would help in the judicious clinical management of diabetic macular edema (DME) patients. Thus, a systematic study was initiated to identify nonresponding DME patient population undergoing ranibizumab treatment to figure out additional inflammatory components that may contribute to their nonresponsiveness to anti-VEGF therapy.

Methods:

A total of 40 patients recruited to this investigator-initiated trial received intravitreal ranibizumab monthly for 3 months. The fourth- and fifth-month injections were according to PRN protocol and the sixth-month injection was mandatory. Best-corrected visual acuity (BCVA), central macular thickness (CMT), and VEGF in aqueous humor were measured for all the patients. Patients were grouped into responders/nonresponders on the formulated criteria and the levels of key pro-inflammatory cytokines were also measured between the two groups at baseline, 2 month and 5 months using cytometric bead array (CBA).

Results:

Eleven patients were categorized (29.72%) as responders and 10 patients (27.02%) as nonresponders. Nonresponders showed poorer BCVA (P = 0.024, 0.045, and 0.048 for 4, 5, and 6 months) and higher CMT (P = 0.021, 0.0008 and <0.0001 for baseline, 1, 2, 3, 4, 5, and 6 months) compared to responders. The cytokines IL-8, MCP-1 were significantly up regulated (P = 0.0048 and 0.029 for MCP-1 and IL-8) in nonresponders.

Conclusion:

Elevated MCP-1 and IL-8 levels found in the nonresponders could be used as a prognostic marker to identify these groups of patients and can help in developing alternative treatment options along with anti-VEGF therapy.

Evaluation of retrobulbar circulation in type 2 diabetic patients using color Doppler imaging

Purpose:

To investigate the retrobulbar circulatory parameters in type 2 diabetes mellitus patients with color Doppler imaging (CDI) and compare the results with nondiabetic controls.

Methods:

This prospective study included 50 type 2 diabetic patients and 50 age-matched controls. Seven field stereo fundus photography was used to diagnose and classify diabetic retinopathy (DR). Diabetic patients were further divided into two: Group 1, consisted of patients with no DR, mild and moderate non-proliferative DR (n = 36); Group 2, severe nonproliferative and proliferative DR (n = 14). CDI was performed using Philips iU22 xMATRIX ultrasound. The peak systolic velocity (PSV), end-diastolic velocity (EDV), resistivity index (RI) and pulsatile index (PI) of ophthalmic (OA), posterior ciliary artery (PCA), and central retinal artery (CRA) along with central retinal vein (CRV) were recorded.

Results:

RI in the ophthalmic artery was significantly higher in both DR groups than the control group (P = 0.000). Diabetic Group 1 had decreased blood flow velocity (PSV and EDV) in PCA compared to controls (P = 0.046 and P = 0.010, respectively). Group 2 DR had significantly reduced EDV and increased RI in CRA compared to Group 1 (P = 0.015). Binary logistic regression analysis revealed glycosylated hemoglobin and RI of OA to be independent risk factors of DR.

Conclusion:

Significant changes in resistivity index and flow velocities were observed in the retrobulbar vessels, especially in ophthalmic artery in diabetics compared to controls. CDI with results of increased resistance or decreased flow could be useful to predict individuals at higher risk for developing severe DR.

Decreased expression of TIPE2 in the eye under high-glucose conditions tested in vivo and in vitro

AIMS

Inflammation is important in the development of angiogenesis diabetic retinopathy (DR). Anti-inflammation is promising strategy in early DR management. This study aimed to evaluate the level of tumour necrosis factor (TNF)-α-induced protein-8 like-2 (TIPE2), a formerly anti-inflammatory factor, under high-glucose conditions.

METHODS

TIPE2 was detected in the ① retina from db/db and streptozotocin-induced diabetic mice; ② vitreous fluid of patients with proliferative diabetic retinopathy (PDR) and ③ mouse retinal microendothelial cells (RMEC) cultured in glucose of varying concentrations. In situ expression was evaluated by immunohistochemistry and immunofluorescence assay. The expression of protein was analysed by Western blot or ELISA and mRNA by qRT-PCR.

RESULTS

TIPE2 was down-regulated in the retina of the mice with diabetes. TIPE2 was present in the cytoplasm of RMEC and down-regulated in high-glucose conditions in line with concentration and time. The expression of TIPE2 in the vitreous fluid of patients with PDR was significantly lower than that without diabetes. Silencing TIPE2 by an siRNA resulted in increased expression of vascular endothelial growth factor (a vital factor in the development of DR), TNF-α and IL-1β.

CONCLUSIONS

TIPE2 down-expressed and exerted anti-VEGF and anti-inflammatory function in the high-glucose environment. TIPE2 was verified to be involved in the process of DR and might be a potential regulator for DR development.

Delivering High-Quality, Equitable Care in India: An Ethically-Resilient Framework for Healthcare Innovation After COVID-19

Developing countries struggle to provide high-quality, equitable care to all. Challenges of resource allocation frequently lead to ethical concerns of healthcare inequity. To tackle this, such developing nations continually need to implement healthcare innovation, coupled with capacity building to ensure new strategies continue to be developed and executed. The COVID-19 pandemic has made significant demands of healthcare systems across the world-to provide equitable healthcare to all, to ensure public health principles are followed, to find novel solutions for previously unencountered healthcare challenges, and to rapidly develop new therapeutics and vaccines for COVID-19. Countries worldwide have struggled to accomplish these demands, especially the latter two, considering that few nations had long-standing systems in place to ensure processes for innovation were on-going before the pandemic struck. The crisis represents a critical juncture to plan for a future. This future needs to incorporate a vision for the implementation of healthcare innovation, coupled with capacity building to ensure new strategies continue to be developed and executed. In this paper, the case of the massive Indian healthcare system is utilized to describe how it could implement this vision. An inclusive, ethically-resilient framework has been broadly laid out for healthcare innovation in the future, thereby ensuring success in both the short- and the long-term.

Therapeutic application of Carica papaya leaf extract in the management of human diseases

INTRODUCTION

Papaya (Carica papaya Linn.) belongs to the family Caricaceae and is well known for its therapeutic and nutritional properties all over the world. The different parts of the papaya plant have been used since ancient times for its therapeutic applications. Herein, we aimed to review the anticancer, anti-inflammatory, antidiabetic and antiviral activities of papaya leaf.

METHODS

All information presented in this review article regarding the therapeutic application of Carica papaya leaf extract has been acquired by approaching various electronic databases, including Scopus, Google scholar, Web of science, and PubMed. The keywords Carica papaya, anticancer, anti-inflammatory, immunomodulatory, and phytochemicals were explored until December 2019.

RESULTS

The papaya plant, including fruit, leaf, seed, bark, latex, and their ingredients play a major role in the management of disease progression. Carica papaya leaf contains active components such as alkaloids, glycosides, tannins, saponins, and flavonoids, which are responsible for its medicinal activity. Additionally, the leaf juice of papaya increases the platelet counts in people suffering from dengue fever.

CONCLUSION

The major findings revealed that papaya leaf extract has strong medicinal properties such as antibacterial, antiviral, antitumor, hypoglycaemic and anti-inflammatory activity. Furthermore, clinical trials are needed to explore the medicative potential of papaya leaf. Graphical abstract Graphical abstract showing the medicinal properties of Carica papaya leaf.

Teneligliptin Real-World Effectiveness Assessment in Patients with Type 2 Diabetes Mellitus in India: A Retrospective Analysis (TREAT-INDIA 2)

INTRODUCTION

Teneligliptin is an antidiabetic medication that has been approved for the management of type 2 diabetes mellitus (T2DM) in Japan, South Korea and India. It is one of the most commonly prescribed antihyperglycaemic agents. The aim of this study was to assess the effectiveness of teneligliptin in improving glycemic control amongst Indian patients with T2DM in a real-world setting.

METHODS

This was a retrospective observational study in which a predesigned structured proforma was used to collect information from hospital records of 18 medical centres across India. All participating centres were established primary care hospitals with adequate record keeping, a pre-determined condition in the study design. Data were collected during the period of January 2019 to June 2019. Data extracted from patient records, including glycaemic parameters, concomitant drugs, drug dosage and duration, were collated. The effectiveness of teneligliptin was assessed by analyzing the mean change in glycosylated haemoglobin (HbA1c), fasting plasma glucose (FPG) and post-prandial plasma glucose (PPG) at 12 weeks after initiation of teneligliptin.

RESULTS

Data from 10,623 patients were available for analysis. The mean age of the enrolled patients was 51.86 ± 11.76 years. At 12 weeks after initiation of teneligliptin as monotherapy or add-on to other medications (combination therapy), the patients showed a signficant decrease from baseline in mean HbA1c, FPG and PPG. Mean HbA1c dropped from 8.66 ± 1.15% at baseline to 7.67 ± 1.28% at 12 weeks (71 ± 12.6 to 60 ± 14 mmol/mol), with a difference of - 0.99% (95% confidence interval [CI] 0.96-1.02) or - 10.8 (95% CI 10.5-11.1) mmol/mol (p < 0.0001). The mean reductions in FPG and PPG were 43.12 mg/dL (2.39 mmol/L) and 87.73 mg/dL (4.87 mmol/L) (both p < 0.0001) respectively. HbA1c (%) reductions with teneligliptin when used as add-on to metformin, add-on to metformin + sulfonylurea combination and add-on to metformin + sulfonylurea + alpha glucosidase inhibitor combination were 0.76% (8.3 mmol/mol), 1.24% (13.6 mmol/mol) and 1.04% (11.4 mmol/mol), respectively. Teneligliptin also significantly reduced HbA1c (1.13% or 12.4 mmol/mol, p < 0.0001) in patients with impaired renal function, without worsening the estimated glomerular filtration rate. Teneligliptin consistently reduced HbA1c across all three age categories tested-by 1% (10.9 mmol/mol) in patients aged < 60 years, by 1.15% (12.6 mmol/mol) in patients aged 60-75 years and by 0.88% (9.6 mmol/mol) in patients aged > 75 years.

CONCLUSION

Teneligliptin significantly improved glycaemic parameters in Indian patients with T2DM when prescribed either as monotherapy or as an add-on to one or more other commonly prescribed antihyperglycaemic agents.

Transcriptional Profiling and Biological Pathway(s) Analysis of Type 2 Diabetes Mellitus in a Pakistani Population

The epidemic of type 2 diabetes mellitus (T2DM) is an important global health concern. Our earlier epidemiological investigation in Pakistan prompted us to conduct a molecular investigation to decipher the differential genetic pathways of this health condition in relation to non-diabetic controls. Our microarray studies of global gene expression were conducted on the Affymetrix platform using Human Genome U133 Plus 2.0 Array along with Ingenuity Pathway Analysis (IPA) to associate the affected genes with their canonical pathways. High-throughput qRT-PCR TaqMan Low Density Array (TLDA) was performed to validate the selected differentially expressed genes of our interest, viz., ARNT, LEPR, MYC, RRAD, CYP2D6, TP53, APOC1, APOC2, CYP1B1, SLC2A13, and SLC33A1 using a small population validation sample (n = 15 cases and their corresponding matched controls). Overall, our small pilot study revealed a discrete gene expression profile in cases compared to controls. The disease pathways included: Insulin Receptor Signaling, Type II Diabetes Mellitus Signaling, Apoptosis Signaling, Aryl Hydrocarbon Receptor Signaling, p53 Signaling, Mitochondrial Dysfunction, Chronic Myeloid Leukemia Signaling, Parkinson's Signaling, Molecular Mechanism of Cancer, and Cell Cycle G1/S Checkpoint Regulation, GABA Receptor Signaling, Neuroinflammation Signaling Pathway, Dopamine Receptor Signaling, Sirtuin Signaling Pathway, Oxidative Phosphorylation, LXR/RXR Activation, and Mitochondrial Dysfunction, strongly consistent with the evidence from epidemiological studies. These gene fingerprints could lead to the development of biomarkers for the identification of subgroups at high risk for future disease well ahead of time, before the actual disease becomes visible.

Distribution of peripheral lesions identified by mydriatic ultra-wide field fundus imaging in diabetic retinopathy

PURPOSE

To analyze the distribution of diabetic retinopathy (DR) lesions in an Indian population using ultra-wide field (UWF) fundus imaging.

METHODS

Seven hundred fifteen subjects (1406 eyes) with diabetic retinopathy in India were enrolled in this multicenter, prospective, observational study using UWF pseudocolor imaging with Optos Daytona Plus (Optos plc, Dunfermline, Scotland, UK). Images were transmitted to Doheny Image Reading Center, Los Angeles, CA, for grading. The ETDRS grid was overlaid on stereographic projections of UWF images, and images were graded independently by 2 masked graders. Lesion distribution was graded as predominantly central (PCL) or predominantly peripheral (PPL) according to previous criteria, considering both lesion number and area. An image was graded as PPL if > 50% of the lesion area was seen in at least one peripheral field as compared with the corresponding ETDRS field. Diabetic retinopathy severity was also assessed based on the International Classification of Diabetic Retinopathy (ICDR) grading scale. The main outcome measures were lesion distribution (PPL versus PCL): overall and within specific fields in eyes with various grades of DR.

RESULTS

Lesion distribution was rated to be PPL in 37% of eyes and PCL in 63% of eyes (P < 0.003). The frequency of a PPL distribution varied significantly across all ICDR severity levels, with frequencies of mild non-proliferative DR (NPDR) (30.9%), moderate NPDR (40.3%), severe NPDR (38.5%) and PDR (34.9%), P = 0.005. When assessing which individual fields were rated to show a PPL distribution, the frequency was greatest in field 4 and least in field 7. For any grade of DR, temporal fields showed the greatest PPL frequency, followed in order by the superior, inferior, and nasal fields (P < 0.001). Only 3.5% of eyes showed PPL distribution in all five peripheral fields.

CONCLUSIONS

One-third of the UWF images showed a PPL distribution in this cohort with the temporal quadrant having the widest distribution of PPL. As the PPL distribution varied significantly between various grades of DR, UWF imaging may prove to be important for screening of referral warranted retinopathy.

Distribution of glycated haemoglobin and its determinants in Indian young adults

AIM

The aim of the present study is to understand the distribution of A1c in four different age groups in young adults and its relation to other co-variants.

METHODS

The countrywide data was collected in 2017 in Individuals with high risk analysed by Indian Diabetes Risk Score (IDRS) and self-declared diabetics were identified after screening a sample of 240,968 individuals from rural (4 villages of about 500 adults each) and urban (4 census enumeration blocks of about 500 adults each) population spanning 65 districts of 29 states/UTs of Indian subcontinent. Blood tests and other detailed assessments were carried out on this selected group. This study presents the analysis of the A1c values of 2862 young adults (<35 years).

RESULTS

In the age group of 31-34 years, the proportion of Diabetes (22.36%) and Prediabetes (9.86%) was higher in comparison with younger age groups. Also, Diabetes (7.3%) and Prediabetes (22%) were highest among those who had parental history of DM in both parents as compared to those with Diabetes history in one parent [Diabetes (7.1%) or Prediabetes (19.0%)] and no Diabetes Parental History (Diabetes (7.3%) and Prediabetes (18.3%) cases. BMI was found to play a significant positive correlation with Diabetes and Prediabetes (p < 0.001) with range of A1c.

CONCLUSION

Age, BMI and parental history were found to be correlated with A1c levels in IDRS screened high-risk population. With increasing age, the proportion of Diabetics and Prediabetics also increased with positive correlation of age with A1c levels.

Effect of deep tissue laser therapy treatment on peripheral neuropathic pain in older adults with type 2 diabetes: a pilot randomized clinical trial

Background

This study assessed the safety and efficacy of deep tissue laser therapy on the management of pain, functionality, systemic inflammation, and overall quality of life of older adults with painful diabetic peripheral neuropathy.

Methods

The effects of deep tissue laser therapy (DTLT) were assessed in a randomized, double-masked, sham-controlled, interventional trial. Forty participants were randomized (1:1) to receive either DTLT or sham laser therapy (SLT). In addition to the standard-of-care treatment, participants received either DTLT or SLT twice weekly for 4 weeks and then once weekly for 8 weeks (a 12-week intervention period). The two treatments were identical, except that laser emission was disabled during SLT. Assessments for pain, functionality, serum levels of inflammatory biomarkers, and quality of life (QOL) were performed at baseline and after the 12-week intervention period. The results from the two treatments were compared using ANOVA in a pre-test-post-test design.

Results

All participants randomized to the DTLT group and 85% (17 of 20) of participants randomized to the SLT group completed the trial. No significant differences in baseline characteristics between the groups were observed. After the 12-week intervention period, pain levels significantly decreased in both groups and were significantly lower in the DTLT group than in the SLT group. The Timed Up and Go test times (assessing functionality) were significantly improved in both groups and were 16% shorter in the DTLT group than in the SLT group. Serum levels of IL-6 decreased significantly in both groups. Additionally, serum levels of MCP-1 decreased significantly in the DTLT group but not in the SLT group. Patients’ quality of life improved significantly in the DTLT group but not in the SLT group.

Conclusions

Deep tissue laser therapy significantly reduced pain and improved the quality of life of older patients with painful diabetic peripheral neuropathy.

Trial registration

Clinical Trial Registry-India CTRI/2017/06/008739. [Registered on: 02/06/2017]. The trial was registered retrospectively.