The increased risk of microvascular complications in South Asians with type 1 diabetes is influenced by migration

AIM

We aimed to explore the association between South Asian ethnicity and complications of type 1 diabetes, and whether this is affected by migration.

METHODS

In this retrospective cohort study, data on diabetes control and complications were obtained for South Asians in India (South Asians_India , n = 2592) and the UK (South Asians_UK , n = 221) and white Europeans in the UK (n = 1431). Multivariable logistic regression was used to identify associations between ethnicity and diabetic kidney disease, retinopathy and neuropathy adjusting for age, sex, BMI, disease duration, HbA_1c , blood pressure (BP) and cholesterol.

RESULTS

South Asians_India had significantly greater adjusted odds of diabetic kidney disease [odds ratio (OR) 5.0, 95% confidence intervals (CI) 3.6-7.1] and retinopathy (OR 1.8, 95% CI 1.2-2.5), but lower odds of neuropathy (OR 0.5, 95% CI 0.4-0.6) than white Europeans. South Asians_India had significantly greater adjusted odds of diabetic kidney disease (OR 3.0, 95% 1.8-5.3) than South Asians_UK , but there was no significant difference in the odds of other complications.

CONCLUSIONS

In this hypothesis-generating study, we report that South Asian ethnicity is associated with greater risk of diabetic kidney disease and retinopathy, and lower risk of neuropathy than white European ethnicity. Part of the excess diabetic kidney disease risk is reduced in South Asians_UK . These associations cannot be accounted for by differences in vascular risk factors. Our findings in South Asians with type 1 diabetes mirror previous findings in type 2 diabetes and now need to be validated in a study of the effect of ethnicity on type 1 diabetes complications where healthcare is provided in the same setting.

Seminal vesicle schwannoma presenting as rectal pain: successful robotic-assisted excision

Schwannomas, not uncommon in the head and neck, rarely occur in the pelvis. Here we describe a seminal vesicle schwannoma, the first of its kind successfully excised via robotic surgery. An otherwise well 62 year−old male presented with a complaint of rectal pain. Colonoscopy identified a mass effect on the rectum, suggesting an external lesion. A computed tomography scan revealed a right seminal vesicle mass. Transrectal ultrasound guided biopsy returned a tissue diagnosis of schwannoma. To aid in operative planning, magnetic resonance imaging of the prostate and pelvis was obtained with and without contrast. This defined a 5 × 4 × 4 cm³ mass abutting the right seminal vesicle without evidence of invasion into adjacent structures. The patient underwent an elective robotic−assisted laparoscopic resection of the mass. Final pathology demonstrated a completely excised schwannoma arising from the soft tissue adherent to the right seminal vesicle.

Lipid Profile in Childhood-and Youth-Onset Type 2 Diabetes and their Association with Microvascular Complications

AIM

To assess the lipid profiles in childhood and youth onset type 2 diabetes (T2DM) and study their association with microvascular complications.

METHODS

Clinical details of individuals with childhood and youth onset T2DM, age at diagnosis between 10 and 25 yrs (n=1340) were retrieved from electronic medical records. Lipid abnormalities were classified based on the NCEP (ATP III) guidelines and management of dyslipidemia in children and adolescents with diabetes. Retinopathy was assessed by retinal photography; nephropathy, if albumin excretion was ≥300 mg/g of creatinine or if the 24 hour protein excretion was >500 mg and neuropathy by elevated vibration perception threshold (≥20 V) on biothesiometry.

RESULTS

Out of 1,340 individuals with childhood and youth with T2DM, 53.3% of them were male. The mean age and duration of diabetes were 28.4 ± 10.4 and 7.4 ± 9.5 years respectively. Overall, the prevalence of dyslipidemia was 82.1%. Prevalence of hypercholesterolemia, hypertriglyceridemia, low HDL-C and high LDL-C were 40.7%, 52.8%, 59.1 % and 64.5% respectively. In logistic regression, both in unadjusted and adjusted model, hypercholesterolemia, and hypertriglyceridemia were associated with diabetic retinopathy [OR:1.8, CI:1.4-2.4, p<0.001 and 1.7, 1.3-2.2, p<0.001] and nephropathy [OR:1.7, CI:1.1-2.5, p=0.015 and 1.8, 1.2-2.8, p=0.007]. Additionally, hypercholesterolemia was associated with neuropathy, even after adjusting for age at diagnosis of diabetes and glycated hemoglobin [OR1.6, 1.0-2.5, p=0.041].

CONCLUSIONS

Lipid abnormalities are common and associated with microvascular complications among these T2DM individuals. This underscores the need for effective control of lipids among childhood and youth onset T2DM.

Obesity, Diabetes and Cardiovascular Diseases in India: Public Health Challenges

Non-communicable diseases (NCDs; including coronary heart disease and type 2 diabetes) are rapidly increasing in India causing nearly 5.8 million deaths per year. Primary reasons for rise in NCDs in India are nutrition and lifestyle transitions. Further, presence of higher body fat, abdominal fat, liver and pancreatic fat and lower lean mass than whites, contribute to heightened metabolic and cardiovascular risk in Asian Indians. Importantly, conversion from pre-diabetes to diabetes occurs more rapidly, and reversion to normal glucose regulation with appropriate lifestyle measures is more difficult in Asian Indians than white population. Huge number of patients with diabetes and with complications increase morbidity, mortality and pose substantial economic burden. It is difficult, though not impossible, to decrease pace of rapidly expanding juggernaut of NCDs in India. Only concerted efforts from multiple stakeholders, consistently sincere efforts and intensely focused attention from health officialdom and clear political will may help counter this increasingly difficult challenge. Finally, all prevention and management approaches should be cost-effective, pragmatic, and focused on children and underprivileged populations.

Acute Urinary Tract Disorders

Acute urinary tract disorders often manifest as flank pain and are a common complaint of patients who present to the emergency department. The pain is often a vague, poorly localized sensation that may have a variety of causes. Laboratory and clinical findings, such as hematuria, are neither sensitive nor specific for determining the cause of the flank pain. Accordingly, imaging is an important tool in determining a diagnosis and management plan. Patients with acute urinary tract disorders who present with pain include those with calculi as well as renal infection, vascular disorders, and hemorrhage.

Exercise patterns and behaviour in Asian Indians: data from the baseline survey of the Diabetes Community Lifestyle Improvement Program (D-CLIP)

AIMS

This paper attempts to describe the patterns of exercise and the perceived benefits and barriers to exercise in an urban south Indian population.

METHODS

Study participants were recruited from the baseline survey of the D-CLIP (Diabetes Community Lifestyle Improvement Program). Frequency, duration, type and location of exercise were assessed using a questionnaire, while a Likert type scale was used to assess perceived benefits of and barriers to exercise. Quality of life was measured using the EQ-5D.

RESULTS

Out of 1281 participants (63.7% males), 24.1% reported doing ≥150min of exercise/week ("exercisers") compared to 75.9% "non-exercisers". Exercisers were significantly older (47 vs. 43 years), better educated (68.8% vs. 60%), had a higher monthly income (41% vs. 29.2%), consumed more fruits (38.2% vs. 25.6%) and vegetables (84.1% vs. 77.7%) and had better perceived state of health (81.1% vs. 76.8%), compared to non-exercisers. Exercisers had significantly lower HOMA-IR, higher Matsuda index and lower prevalence of low HDL cholesterol compared to non-exercisers. However, there were no significant differences in cardio-metabolic risk factors like diabetes, hypertension and obesity between the two groups. Walking was the most common type of exercise. Both exercisers and non-exercisers perceived the benefits of exercising, but barriers weighed more heavily on exercise behaviour.

CONCLUSIONS

Urgent steps are needed to improve overall exercise levels in India by addressing barriers and improving the quality of exercise performed so as to enhance overall metabolic health.

Knowledge and awareness of diabetes in urban and rural India: The Indian Council of Medical Research India Diabetes Study (Phase I): Indian Council of Medical Research India Diabetes 4

BACKGROUND

Representative data on knowledge and awareness about diabetes is scarce in India and is extremely important to plan public health policies aimed at preventing and controlling diabetes.

AIM

The aim of the following study is to assess awareness and knowledge about diabetes in the general population, as well as in individuals with diabetes in four selected regions of India.

MATERIALS AND METHODS

The study subjects were drawn from a representative sample of four geographical regions of India, Chandigarh, Tamil Nadu, Jharkhand and Maharashtra representing North, South, East and West and covering a population of 213 million. A total of 16,607 individuals (5112 urban and 11,495 rural) aged ≥20 years were selected from 188 urban and 175 rural areas. Awareness of diabetes and knowledge of causative factors and complications of diabetes were assessed using an interviewer administered structured questionnaire in 14,274 individuals (response rate, 86.0%), which included 480 self-reported diabetic subjects.

RESULTS

Only 43.2% (6160/14,274) of the overall study population had heard about a condition called diabetes. Overall urban residents had higher awareness rates (58.4%) compared to rural residents (36.8%) (P < 0.001). About 46.7% of males and 39.6% of females reported that they knew about a condition called diabetes (P < 0.001). Of the general population, 41.5% (5726/13,794) knew about a condition called diabetes. Among them, 80.7% (4620/5726) knew that the prevalence of diabetes was increasing, whereas among diabetic subjects, it was 93.0% (448/480). Among the general and diabetic population, 56.3% and 63.4% respectively, were aware that diabetes could be prevented. Regarding complications, 51.5% of the general population and 72.7% diabetic population knew that diabetes could affect other organs. Based on a composite knowledge score to assess knowledge among the general population, Tamil Nadu had the highest (31.7) and Jharkhand the lowest score (16.3). However among self-reported diabetic subjects, Maharashtra had the highest (70.1) and Tamil Nadu, the lowest score (56.5).

CONCLUSION

Knowledge and awareness about diabetes in India, particularly in rural areas, is poor. This underscores the need for conducting large scale diabetes awareness and education programs.

Microvascular reconstruction after intra-arterial chemotherapy with concomitant radiation

OBJECTIVE

While the success of microvascular reconstruction is well established, even in the setting of prior radiotherapy, the outcomes in the setting of prior chemoradiation are less well documented. We present our experience with microvascular reconstruction in a unique cohort of patients previously treated with concomitant hyperfractionated radiation and intra-arterial chemotherapy (HYPERRADPLAT). Despite the observation in prior studies of minimal vessel damage in this setting, the hypothesis of this study is that in the late setting of most salvage surgical therapy, either for recurrence or osteoradionecrosis, a different, progressive level of vessel injury may be encountered.

STUDY DESIGN

Case series with chart review.

SETTING

Tertiary referral academic medical center practice.

SUBJECTS AND METHODS

Eighty-four patients received primary treatment for advanced head and neck squamous cell carcinoma with HYPERRADPLAT. Of these, 8 patients (10%) underwent free tissue transfer reconstruction and a total of 11 free flaps.

RESULTS

Wound breakdown, fistula, or both occurred postoperatively in 50% (4/8) of these patients. No complications of the venous anastomoses occurred. Fifty percent (4/8) of patients required return to surgery for arterial failure due to thrombosis of the anastomosis. Two cases of these flaps could not be salvaged.

CONCLUSION

Microvascular reconstruction following HYPERRADPLAT appears to result in a high number of arterial related complications. This experience implies an important delayed treatment effect of HYPERRADPLAT occurs upon recipient arteries. The manner in which this effect may occur in recipient arteries in the setting of more conventional chemoradiation requires further study.

Clinical and molecular characterization of neonatal diabetes and monogenic syndromic diabetes in Asian Indian children

Mutations in the pancreatic ATP sensitive K(+) channel proteins [sulfonyluea receptor 1 (SUR1) and inward rectifier K(+) channel Kir6.2 (Kir6.2), encoded by ATP-binding cassette transporter subfamily C member 8 (ABCC8) and potassium channel J11 (KCNJ11), respectively], are the most common cause of neonatal diabetes. We describe the clinical presentation and molecular characterization of Asian Indian children with neonatal diabetes mellitus and monogenic syndromes of diabetes. We sequenced KCNJ11, ABCC8 and insulin (INS) genes in 33 unrelated Indian probands with onset of diabetes below one year of age. A total of 12 mutations were identified which included ABCC8 mutations in seven, KCNJ11 mutations in three and INS mutations in two children. The Asp212Tyr mutation in ABCC8 was novel. We also detected two novel mutations (Val67Met and Leu19Arg) in children with syndromic forms of diabetes like Berardinelli Seip syndrome [1-acyl-sn-glycerol-3-phosphate acyltransferase beta (AGPAT2)] and Fanconi Bickel syndrome [solute carrier family 2A2 (SLC2A2)]. Children carrying the KCNJ11 (Cys42Arg, Arg201Cys) and ABCC8 (Val86Ala, Asp212Tyr) mutations have been successfully switched over from insulin therapy to oral sulfonylurea. Our study is the first large genetic screening study of neonatal diabetes in India.

Tumefactive demyelination-to cracks the nut without cracking the pot

A 45-year-old female recently detected diabetic, admitted with difficulty in walking, irrelevant talk and urinary incontinence for 3 weeks and deviation of angle of mouth to left. Examination revealed pallor, delusional thoughts, right upper motor neuron facial weakness, ataxia. CT brain revealed bulky hyperdense lesion in corpus callosum and subsequently MRI of the brain revealed T2-hyperintense lesions involving genu and body of corpus callosum with restricted diffusion, and MR spectroscopy revealed reduced uptake of choline. Possibilities considered were infiltrative glioma of corpus callosum, demyelination and central nervous system lymphoma. As the patient and relatives were not willing to allow stereotactic biopsy, she was started on steroids. Her neurological deficits started improving and 1 month later repeat MRI brain showed a drastic reduction in the size of the lesion. Her neurological condition disappeared and is doing well.

Prevalence of diabetes and prediabetes (impaired fasting glucose and/or impaired glucose tolerance) in urban and rural India: phase I results of the Indian Council of Medical Research-INdia DIABetes (ICMR-INDIAB) study

AIMS/HYPOTHESIS

This study reports the results of the first phase of a national study to determine the prevalence of diabetes and prediabetes (impaired fasting glucose and/or impaired glucose tolerance) in India.

METHODS

A total of 363 primary sampling units (188 urban, 175 rural), in three states (Tamilnadu, Maharashtra and Jharkhand) and one union territory (Chandigarh) of India were sampled using a stratified multistage sampling design to survey individuals aged ≥ 20 years. The prevalence rates of diabetes and prediabetes were assessed by measurement of fasting and 2 h post glucose load capillary blood glucose.

RESULTS

Of the 16,607 individuals selected for the study, 14,277 (86%) participated, of whom 13,055 gave blood samples. The weighted prevalence of diabetes (both known and newly diagnosed) was 10.4% in Tamilnadu, 8.4% in Maharashtra, 5.3% in Jharkhand, and 13.6% in Chandigarh. The prevalences of prediabetes (impaired fasting glucose and/or impaired glucose tolerance) were 8.3%, 12.8%, 8.1% and 14.6% respectively. Multiple logistic regression analysis showed that age, male sex, family history of diabetes, urban residence, abdominal obesity, generalised obesity, hypertension and income status were significantly associated with diabetes. Significant risk factors for prediabetes were age, family history of diabetes, abdominal obesity, hypertension and income status.

CONCLUSIONS/INTERPRETATIONS

We estimate that, in 2011, Maharashtra will have 6 million individuals with diabetes and 9.2 million with prediabetes, Tamilnadu will have 4.8 million with diabetes and 3.9 million with prediabetes, Jharkhand will have 0.96 million with diabetes and 1.5 million with prediabetes, and Chandigarh will have 0.12 million with diabetes and 0.13 million with prediabetes. Projections for the whole of India would be 62.4 million people with diabetes and 77.2 million people with prediabetes.

Cervical esophageal perforation and cricopharyngeal dysfunction

Spontaneous perforation of the esophagus is an uncommon event; when it does occur, it usually affects the thoracic esophagus. We present a rare and fatal case of spontaneous perforation of the cervical esophagus in a 68-year-old woman. We believe this rupture was related to a proximal outlet obstruction secondary to cricopharyngeal muscle dysfunction.

Pneumococcal infections and immunization in diabetic patients

India is today facing a diabetes epidemic and has the maximum number of patients with diabetes in the world. People with diabetes are more prone to develop all types of infections. Pneumococcal infections are a common cause of morbidity and mortality, and people with diabetes are more prone to develop pneumococcal infections. With the availability of the pneumococcal vaccine, most international organizations now recommend that people with diabetes should be vaccinated against pneumococcal disease. This article tries to provide a balanced review of the place of pneumococcal vaccination in Indian diabetic patients.

The need for obtaining accurate nationwide estimates of diabetes prevalence in India - rationale for a national study on diabetes

According to the World Diabetes Atlas, India is projected to have around 51 million people with diabetes. However, these data are based on small sporadic studies done in some parts of the country. Even a few multi-centre studies that have been done, have several limitations. Also, marked heterogeneity between States limits the generalizability of results. Other studies done at various time periods also lack uniform methodology, do not take into consideration ethnic differences and have inadequate coverage. Thus, till date there has been no national study on the prevalence of diabetes which are truly representative of India as a whole. Moreover, the data on diabetes complications is even more scarce. Therefore, there is an urgent need for a large well-planned national study, which could provide reliable nationwide data, not only on prevalence of diabetes, but also on pre-diabetes, and the complications of diabetes in India. A study of this nature will have enormous public health impact and help policy makers to take action against diabetes in India.

Partial nephrectomy does not compromise survival in patients with pathologic upstaging to pT2/pT3 or high-grade renal tumors compared with radical nephrectomy

OBJECTIVE

To compare survival in patients with clinical T1b renal tumors that are pathologically upstaged, or high-grade tumors, treated by either partial nephrectomy (PN) or radical nephrectomy (RN). The American Urological Association Guidelines recently advocated increasing use of PN in all patients with cT1 renal masses, but urologists are often hesitant to perform PN for larger more aggressive appearing cT1 renal tumors for fear of pathologic upstaging and a perceived compromise in cancer control.

METHODS

From a single institutional kidney cancer registry, 2511 consecutive patients with presumed cT1 renal cell cancer underwent extirpative surgery; 1981 (79%) were found to have renal cell cancer (RCC) and 213 (10.7%) were upstaged on final pathology. In addition, 95 (5%) were found to have grade 4 cancer. Cancer-specific survival (CS) and overall survival (OS) were compared between the groups.

RESULTS

In the upstaged cohort, patients treated by PN (n = 96, 45%) had comparable OS and CS when studied stage for stage with those treated by RN (n = 117, 55%). Multivariate cox-proportional hazards analysis of OS in the upstaged subset demonstrated that only age, grade, and Charlson score predicted OS, whereas PN vs RN and stage did not. PN did not compromise survival in patients with grade 4 RCC compared with RN.

CONCLUSIONS

PN does not appear to compromise the chance for cancer cure in patients with cT1 tumors that are upstaged pathologically to pT2 or pT3 or high-grade renal masses when compared with RN. These concerns should not deter a surgeon from attempting PN when otherwise technically feasible.

Genetic characterization of dengue virus serotypes causing concurrent infection in an outbreak in Ernakulam, Kerala, South India

Dengue fever, a mosquito-borne viral infection, causes significant morbidity and has become endemic in the Indian subcontinent. Virus strains currently circulating in many parts of the country are not well studied at the molecular level. In the present study, genetic characterization of virus strains from a dengue outbreak that occurred in and around a tertiary care hospital in Ernakulam, Kerala in the year 2008 has been reported. By reverse transcription polymerase chain reaction (RT-PCR), 37 out of 75 (49.3%) clinically suspected cases were positive for dengue viral RNA. Among these, 21 (56.8%) samples showed concurrent infection with multiple serotypes of the virus. Majority of the combined infections were caused by dengue serotype 2 and 3. Co-infections with type 1 and 2 in two patients, and type 1, 2 and 3 in one patient were also observed. The core-pre-Membrane (CprM) junction nucleotide sequencing and phylogenetic analysis revealed that the type 1 strains were related to the viral strains reported from Delhi-2001 and Gwalior-2002 dengue outbreaks, while the type 2 strains were related to the strains from Gwalior-2001 epidemic. Sequences of type 3 strains did not show clear relation to any of the previous Indian isolates, and in the phylogenetic analysis, they formed a distinct lineage within the Indian type 3 strains. This study indicates hyperendemicity of dengue in the region with the presence of multiple serotypes and high rates of co-infection, and local genomic evolution of the viral strains involved in this outbreak.

Unexpected and abnormally low HDL cholesterol levels on combination hypolipidemic therapy

In general, Indians have low HDL cholesterol levels. Fenofibrate, a drug widely used in the treatment of hypertriglyceridemia, usually also increases HDL cholesterol. There have been a few reports in the literature of a paradoxical decrease in serum HDL-cholesterol in patients treated with fenofibrate, either alone or in combination with a statin. We report three cases of paradoxical decrease in serum HDL-cholesterol in type 2 diabetic patients treated with a statin-fenofibrate combination.

Measurements of acceleration during videofluorographic evaluation of dysphagic patients

Accelerometry represents a noninvasive technique for the assessment of the swallowing mechanism. However, the underlying physiological events that give rise to the acceleration signal are poorly understood. In the present study, the acceleration signal was measured simultaneously during videofluorography examination. Preliminary results revealed that the signal occurred during laryngeal elevation and the magnitude of acceleration correlated well with the laryngeal displacement. Acceleration measurements present a potentially useful noninvasive tool.

Charge-Transfer Complexation of C(60) with Diphenyltetrathiafulvalene (DPTTF) Capped Gold Clusters

4,4'-Diphenyltetrathiafulvalene (DPTTF) capped gold nanoparticles of 3- to 5-nm diameter have been prepared and their thermal stability has been investigated by variable temperature FT-IR spectroscopy. The DPTTF molecules at the cluster surface undergo charge-transfer complexation with C(60) to form Au/DPTTF.C(60). Direct evidence of complexation is observed in the x-ray photoelectron and infrared spectra of the clusters. The orientational ordering transition of C(60) in Au/DPTTF.C(60) clusters occur at a higher temperature than pure C(60) indicating increased resistance to orientational disorder due to charge transfer. Variable-temperature infrared spectroscopic studies yield complementary information. Both FT-IR and mass spectra show that some of the sites on the gold surface are occupied by the phase-transfer reagent used in the cluster preparation. Copyright 1999 Academic Press.