Effect of Preoperative Oral Carbohydrate Intake on Perioperative Hyperglycemia in Indian Patients Undergoing Hip Fracture Fixation

Objective

Preoperative fasting leads to a catabolic state aggravated by surgical stress. This leads to poor patient outcomes. This study aimed to determine the effect of preoperative oral carbohydrate administration on perioperative hyperglycemia and patient comfort.

Methods

This prospective, randomized study was conducted on 60 adult American Society of Anesthesiologist I/II patients undergoing hip fracture fixation after obtaining institutional ethical committee clearance. Patients were randomly kept conventionally fasted before surgery (group F, n = 30) or were given oral carbohydrate 2 h before surgery (group C, n = 30). Under all aseptic precautions, a combined spinal epidural block was administered, and surgery was allowed. The primary outcome was blood glucose, and secondary outcomes included incidence of postoperative hyperglycemia, insulin level, blood urea, hunger, thirst, and anxiety.

Results

Blood glucose levels were not statistically different between the two groups at baseline (T0; P=0.400), immediately after surgery (T1; P=0.399) and 24h after surgery (T2; P=0.619). The incidence of postoperative hyperglycemia was significantly higher in group F than in group C (P=0.045) at T2. Insulin levels, blood urea levels, and hunger scores were also not statistically different between the groups. The thirst and anxiety scores were lower at T0 and T1 in group C.

Conclusion

Preoperative oral carbohydrate administration does not prevent perioperative increases in blood glucose levels. However, it reduces the incidence of perioperative hyperglycemia and decreases perioperative thirst and anxiety, thereby improving the quality of perioperative patient care.

Effect of Antenatal Oral Vitamin D Supplementation on Serum 25(OH)D Concentration in Exclusively Breastfed Infants at 6 Months of age - A Randomized Double-Blind Placebo-Controlled Trial

OBJECTIVE

To compare the proportion of exclusively breastfed (EBF) infants having severe vitamin D deficiency (25(OH)D concentration <11 ng/mL) at 6 months of age when mothers were supplemented with 300,000 IU Vitamin D3 or placebo during the third trimester of pregnancy.

METHODS

In this randomized double-blind placebo-controlled trial, we recruited 100 pregnant women who were willing to exclusively breastfeed their babies for 6 months at 30-32 weeks gestation and the infants born to them. Pregnant women were randomized to receive either oral vitamin D3 60,000 IU or placebo, given weekly for 5 weeks during the third trimester. Serum 25(OH)D, calcium, phosphorus and alkaline phosphatase concentration were measured in all participants at recruitment, in the cord blood at delivery, and in infants at 6 months of age. The proportion of infants developing severe vitamin D deficiency and rickets at 6 months was assessed.

RESULTS

A total 72 mother-infant dyads followed till 6 months. At enrolment, the mean (SD) serum 25(OH)D concentration were comparable in mothers in the intervention and control groups (12.90 (5.84) vs 12.84 (5.88), P = 0.96). The mean (SD) 25(OH)D concentration (ng/mL) in the cord blood was significantly higher in the intervention group compared to the control group [42.14 (17.08) vs 12.74 (6.28); P = 0.002]. The mean (SD) serum 25(OH)D levels (ng/mL) in the infants at 6 months' age were higher in the intervention group compared to the control group [31.82 (10.89) vs 12.46 (5.68); P < 0.001]. No infant in the intervention group had severe vitamin D deficiency at 6 months' age compared to 54.3% infants in the control group (P < 0.001). No infant in the intervention group developed rickets.

CONCLUSIONS

Oral supplementation of vitamin D3 to pregnant women in the third trimester prevents severe hypovitaminosis D in the EBF infants at 6-months of age.

Evaluation of CRP/Albumin Ratio in Polycystic Ovarian Syndrome

Background

Polycystic ovarian syndrome is a common endocrine disorder among women of reproductive age. It is characterized by menstrual abnormalities, hyperandrogenism and polycystic ovaries and can lead to many complications. Studies have postulated the role of inflammation in the pathophysiology of PCOS. As acute phase reactants often serve as markers of inflammation, this study aimed to evaluate the role of inflammatory markers in women with PCOS and healthy controls.

Material and Methods

A total of 60 participants were enrolled; 30 cases of PCOS and 30 age matched healthy controls. Peripheral venous blood was collected for assessment of CRP, serum albumin, serum total testosterone, serum fasting insulin and fasting blood glucose, following which statistical analysis was done.

Results

The CRP/albumin ratio was found to be significantly higher in women with PCOS as compared to healthy controls along with serum total testosterone and HOMA-IR. Correlation between CRP/albumin ratio and the levels of serum total testosterone and insulin resistance was found to be non-significant.

Conclusion

An elevated CRP/albumin ratio in cases of PCOS compared to healthy controls supports the hypothesis of inflammation playing a key role in the pathophysiology of PCOS. CRP/albumin ratio can serve as a cheaper biochemical marker of the disease subject to further validation studies to establish its use in Indian population.

Long-Term Persistence of COVID-Induced Hyperglycemia: A Cohort Study

Although the short-term mortality of patients with COVID-19 infection and hyperglycemia has been well documented, there is little available data regarding longer-term prognosis. The presence of diabetes has not only influenced disease severity but has also impacted its transmission dynamics. In this study, we followed a historical cohort of patients without previous history of diabetes who presented with moderate to severe COVID-19 and were found to have hyperglycemia (random blood glucose > 140 mg/dL) at the time of admission. We evaluated the need for antidiabetic therapy in these patients at the end of 6 months and the risk factors associated with persistent hyperglycemia determined by monthly values of self-monitored blood glucose. Of the seventy participants who were followed telephonically, 54 (77%) continued to receive antidiabetic therapy or have persistent hyperglycemia (> 140 mg/dL) at the end of 6 months. Persistent hyperglycemia at the end of follow-up, was found to be associated with a higher blood glucose at presentation.

Clinico-Mycological Study of Onychomycosis in Indian Diabetic Patients

Background

Onychomycosis (OM) is the most common nail disorder accounting for 40-50% of all onychopathies. Onychomycosis is caused by dermatophytes in majority, mostly Trichophyton (T.) rubrum followed by T. mentragrophytes var. interdigitale. However, there is a variation in the etiological profile with the subset of population, time, and geographical location. In immunocompromised hosts, non-dermatophytic molds (NDMs) and yeasts like Candida albicans and Candida parapsilosis are the main causative agents. Diabetes mellitus (DM) is a well-established risk factor for OM.

Aim and Objectives

This study was conducted to determine the clinical and mycological characteristics of OM in diabetic patients and to evaluate the clinico-etiological correlation, if any.

Materials and Methods

Three hundred consecutive diabetic patients were screened, of whom 102 (34%) patients were diagnosed with OM based on clinical, mycological, dermoscopic, and histological criteria.

Results

Distal lateral subungual onychomycosis was the most common clinical variant seen in 80 (78.43%) patients. Fungal culture was positive in 57 (55.88%) of which NDMs constituted approximately half (47.61%) of the isolates, followed by Candida species (30.15%) and dermatophytes (22.22%). The clinico-mycological correlation was performed to look for the association of various fungi with the clinical type of OM. Distal lateral subungual onychomycosis was majorly caused by NDMs (51.02%), followed by Candida species (28.57%), and dermatophytes (20.40%).

Conclusion

Non-dermatophytic molds are increasingly incriminated as the causative organisms for OM in DM and must be considered as potential pathogens in the present scenario, thus necessitating the change in the treatment options accordingly.

Prevalence of onychomycosis in patients with diabetes mellitus: A cross-sectional study from a tertiary care hospital in North India

Background Though diabetes mellitus (DM) is a well-recognised risk factor for onychomycosis (OM), the epidemiology of OM in diabetic patients remains largely unexplored, especially from the Indian subcontinent. Aims and objectives To estimate the prevalence of OM in diabetic patients, to identify and analyse risk factors, and correlate the severity of nail changes with glycemic control (HBA1c). Methods This cross-sectional, analytical study involved 300 diabetic patients. Patients with the clinical diagnosis of OM, supplanted by at least two of the four tests (KOH, culture, onychoscopy and nail histopathology) were considered cases of OM. Demographic and haematological profile was analysed using chi-square test/ Fischer's exact test. Logistic regression was applied to assess the independent risk factors. Results The prevalence of OM in DM patients was 34% (102/300) and significant risk factors included; age >60 years, male gender, closed shoes, disease duration >5 years, high BMI (>25) and lack of awareness about nail changes. Distal and lateral subungual OM (78%) was the commonest presentation followed by proximal subungual OM, superficial OM and total dystrophic OM. Correlation between HbA1c and the number of nails involved was found to be significant. Limitation As cases were recruited from a hospital setting, there could be chances of Berksonian bias. Conclusion The prevalence of OM in diabetic patients is high and the severity of nail changes correlates with HbA1C levels. It is important to diagnose OM early in order to treat and prevent complications.

Assessing Pulmonary Tuberculosis Using Bandim Tuberculosis and Karnofsky Performance Scale Scores with Serum Adenosine Deaminase Levels

BACKGROUND

Elevated pulmonary serum adenosine deaminase (ADA) levels signify lung tissue damage and severe tuberculosis (TB). Serum ADA assays can be used as an additional criterion for assessing TB treatment response and as a prognostic marker in patients with pulmonary TB. The Bandim TB and Karnofsky Performance Scale (KPS) scores were developed based on available clinical data and investigations to allow physicians to evaluate disease treatment and response. This study examined the use of a clinical scoring system (Bandim TB and KPS scores) in the context of serum ADA activity.

METHODS

Forty adults (aged >18 years) diagnosed with pulmonary TB by Ziehl-Neelsen staining for acid-fast bacilli and/or cartridge-based nucleic acid amplification test were recruited. Standardized questionnaires were used to record Bandim TB and KPS scores. Serum ADA levels were estimated using a commercial kit.

RESULTS

The Bandim TB score was positively associated (ρ=0.74, P≤0.001) and the KPS score was negatively associated (ρ=-0.69, P≤0.001) with serum ADA levels.

CONCLUSION

Subjective and objective clinical scores of pulmonary TB were strongly correlated with serum ADA levels. Knowledge of clinical scores corresponding to serum ADA levels could help physicians understand stage and progression of the disease which may aid in early detection and better management, and reduce disease transmission in a TB-endemic country.

An Evaluation of the Second Trimester Thyroid Function Test in Gestational Diabetes Mellitus: A Case-Control Study

INTRODUCTION

Gestational diabetes mellitus (GDM) is defined as glucose intolerance in a female with its onset or first recognition during pregnancy. Females with GDM are at higher risk of developing antenatal complications like preeclampsia during pregnancy and increased risk of type 2 diabetes as well as cardiovascular disorders later in their life. Maternal thyroid changes in the first and second trimesters of pregnancy have been widely related to the risk of GDM. Hypothyroidism during pregnancy is associated with early and late complications like abortions, anaemia, gestational hypertension, placental abruption and postpartum haemorrhage, impaired infant neurodevelopment, and low birth weight.

OBJECTIVES

This study aims to compare the thyroid function test (TFT) (serum fT3, fT4, TSH) and thyroid peroxidase antibody (anti TPO) between GDM and non GDM pregnant women in the second trimester and to correlate the adverse pregnancy outcomes with TFT in GDM and non GDM women.

METHODS

A nested case-control study was done in the Department of Obstetrics and Gynaecology, Department of Endocrinology, Department of Paediatrics, University College of Medical Sciences, and Guru Teg Bahadur (GTB) Hospital, Delhi. About 350 pregnant women from 13 weeks till 28 weeks period of gestation were screened out of which 40 GDM and 40 non GDM women were selected after performing an oral glucose tolerance test (OGTT). A TFT and anti TPO test were compared between GDM and non GDM participants. Furthermore, various parameters like sociodemographic profile, mode of delivery, pregnancy outcomes, and adverse maternal and adverse neonatal outcomes were compared.

CONCLUSION

The mean age of GDM women is found to be more than non GDM women. The mean TFT values are significantly lower in women with GDM as compared to non GDM women. In addition, higher values of anti TPO antibody (thyroid autoantibody) were found in the GDM group which aids in insulin resistance. Maternal complications like polyhydramnios, preterm labour, and pregnancy-induced hypertension were found to be more frequent in the GDM group compared to the non GDM group, but the results were statistically not significant. There was a higher incidence of caesarean delivery in the GDM group. Thus, we recommend the implementation of routine thyroid function profile testing in all antenatal females especially those who are at risk of developing GDM. Our study is one of the few Indian studies to evaluate the association of TFT in GDM, and we recommend similar research with a larger sample size and postnatal follow-up.

PINK1 and oxidative stress in lean and obese patients with type 2 diabetes mellitus

AIM

To compare mRNA [messenger RNA] expression of PINK1 in whole blood and the levels of biomarkers of Oxidative Stress (mitochondrial DNA [mtDNA] content & Total Antioxidant status [TAS]) in newly diagnosed lean and obese patients with T2DM.

METHODS

Newly diagnosed patients of T2DM were enrolled in this study. The patients were divided into two groups of 30 patients each, lean (BMI < 18.5 kg/m²) and obese (BMI > 25 kg/m²). mRNA expression of PINK1 & mtDNA content was measured by real time PCR. Serum TAS was measured using a commercially available kit.

RESULTS

There was a 1.78-fold decrease in mRNA expression of PINK1 in obese group compared to the lean group. Mean mtDNA content was 300.82 ± 169.66 in the obese group and 332.78 ± 147.07 in the lean group (p = 0.06). Mean levels of TAS was 5.39 ± 2.28 μM Trolox Equivalents in the obese group and 3.85 ± 3.33 μM Trolox Equivalents in the lean group (p = 0.001).

CONCLUSION

The T2DM patient with obesity had greater OS than the lean patients. Thus, there is a compensatory increase in antioxidants in obese patients with T2DM. Our findings also suggest that decreased levels of PINK1 in obese group are unable to protect the mitochondria against OS leading to decreased mtDNA content. Does it also result in beta cell dysfunction or contribute to insulin resistance in obese patients with T2DM needs to be explored.

Can Bone-Specific Alkaline Phosphatase be a Marker of Vascular Calcification in Type 2 Diabetes Mellitus?

Background and Aims

Alkaline phosphatase (ALP) enzyme has been linked to vascular calcification. Unexplained elevations in serum ALP levels have been reported in patients with type 2 diabetes mellitus (T2DM). We assessed bone-specific alkaline phosphatase (BAP) levels in patients with T2DM who had unexplained ALP elevations and studied the association between BAP and other markers of vascular calcification.

Methods

Patients with T2DM who had high serum ALP in the absence of known causes of ALP elevation were studied. The control group was T2DM patients with normal ALP. We measured the serum levels of BAP along with the leptin, fetuin-A, and vitamin K2 levels. Ankle-brachial index (ABI) was also measured in both groups.

Results

Serum BAP levels were significantly higher in the group with high ALP when compared with the normal ALP group. A significant positive correlation was present between BAP and serum fetuin-A as well as between BAP and Vit K2 levels. There was no correlation between BAP and serum leptin. ABI was comparable between the two groups.

Conclusions

Patients with T2DM may have unexplained elevation in ALP due to an increase in BAP. Elevation in BAP may be associated with other markers of vascular calcification suggesting an increased risk of vascular calcification.

Sunlight Exposure vs Oral Vitamin D Supplementation for Prevention of Vitamin D Deficiency in Infancy: A Randomized Controlled Trial

OBJECTIVE

To compare the efficacy of sunlight exposure and oral vitamin D3 supplementation to achieve vitamin D sufficiency in infants at 6 months of age.

DESIGN

Open-label randomized controlled trial.

SETTING

Public hospital in Northern India (28.7°N).

PARTICIPANT

Breastfed infants at 6-8 weeks of age.

INTERVENTION

Randomized to receive sunlight exposure (40% body surface area for a minimum of 30 minutes/week) or oral vitamin D3 supplementation (400 IU/day) till 6 months of age.

OUTCOME

Primary - proportion of infants having vitamin D sufficiency (>20 ng/mL). Secondary - proportion of infants developing vitamin D deficiency (<12ng/mL) and rickets in both the groups at 6 months of age.

RESULTS

Eighty (40 in each group) infants with mean (SD) age 47.8 (4.5) days were enrolled. The proportion of infants with vitamin D sufficiency increased after intervention in the vitamin D group from 10.8% to 35.1% (P=0.01) but remained the same in sunlight group (13.9%) and was significant on comparison between both groups (P=0.037). The mean (SD) compliance rate was 72.9 (3.4) % and 59.7 (23.6) % in the vitamin D and sunlight group, respectively (P=0.01). The geometric mean (95% CI) serum 25(OH) D levels in the vitamin D and sunlight group were 16.23 (13.58-19.40) and 11.89 (9.93-14.23) ng/mL, respectively; (P=0.02), after adjusting baseline serum 25(OH)D with a geometric mean ratio of 1.36 (1.06-1.76). Two infants in sunlight group developed rickets.

CONCLUSION

Oral vitamin D3 supplementation is more efficacious than sunlight in achieving vitamin D sufficiency in breastfed infants during the first 6 months of life due to better compliance.

Association of 25 (OH) Vitamin D and Leptin in Individuals with Insulin Resistance

Introduction

Asian-Indian individuals with diabetes have been shown to have low vitamin D levels. Whether this hypovitamonisis D is associated with hyperleptinaemia is unclear. Also, whether this association is different in those with and without insulin resistance has not been ascertained. The present study aimed to investigate the association of 25-hydroxy vitamin D [25(OH) vitamin D] and leptin in individuals with and without insulin resistance.

Methods

Ninety two individuals were recruited in two study groups (n = 46 each group). First group included individuals with insulin resistance (homeostasis model assessment of insulin resistance [HOMA-IR] ≥2.0). Second group included those without insulin resistance (HOMA-IR <2.0). Comparison of 25(OH) vitamin D, leptin, anthropometry, and biochemical parameters was done between two groups and correlations between 25(OH) vitamin D, leptin, and HOMA-IR were studied.

Results

Individuals with insulin resistance were of simiar age (39.6 ± 5.3 years) and body mass index (24.4 ± 3.2 kg/m2) as those without (39.5 ± 5.2 years and 23.6 ± 3.2 kg/m2). Individuals with insulin resistance showed significantly lower 25(OH) vitamin D (17.8 ± 7.1 vs. 22.3 ± 11.6 ng/mL, P = .03) and significantly higher leptin levels (16.9 ± 15.8 vs. 9.6 ± 9.3 ng/mL, P = .09) compared to those without. Significant negative correlation was observed between 25(OH) vitamin D and leptin levels overall (r = -0.3, P = .008). HOMA-IR showed significantly negative correlation with 25(OH) vitamin D levels in individuals with insulin resistance (r = -0.33, P = .027).

Conclusion

The present study found higher circulating leptin levels and lower 25(OH) vitamin D levels in individuals with insulin resistance. 25(OH) vitamin D levels were inversely associated with leptin levels particularly in women.

Development and implementation of a sustainable COVID-19 training package for healthcare workers: Experience from a teaching hospital of North India

Background

With the impending threat of future COVID-19 waves, it is imperative that teaching hospitals develop, implement, and evaluate a systematic training program to render HCW elastic in delivering COVID-19 related services. We present our experience in developing, implementing, and evaluating a sustainable and scalable COVID-19 patient management training package for healthcare workers.

Materials and Methods

A mixed-methods study design was used. Rapid assessment to understand the need of the trainees and identify the available resources was done followed by planning of the training module and its implementation. The program was evaluated for effectiveness and sustainability. Data analysis was done using descriptive statistics and qualitative data generated from open-ended questions in the feedback forms and the discussions were analyzed using rapid content analysis.

Results

A total of 66.8% of the doctors and 18.9% of the nurses were trained by online synchronous mode while 55.0% of the nursing officers and 47.1% of the nursing orderlies and paramedical staff were trained in onsite skill development sessions. Need assessment identified that healthcare workers were ill-prepared to use medical devices such as Bipap machines, ventilators, and oxygen delivery devices. The participants mentioned that the multidisciplinary approach and video-based demonstrations facilitated their online learning while the incremental learning approach, easy-to-understand terminology and hands-on experience facilitated their onsite skill development sessions.

Conclusion

The COVID-19 training package developed was multidisciplinary, effective, sustainable, and scalable in a resource-limited setting. We suggest that this model can be adapted by healthcare organizations to develop and implement such training packages for their healthcare workers.

Differential Expression of Suppressor of Cytokine Signaling and Interferon Gamma in Lean and Obese Patients with Type 2 Diabetes Mellitus

BACKGROUND

The model of obesity-induced insulin resistance has long been used to explain the development of type 2 diabetes mellitus (T2DM) in obese individuals (body mass index (BMI) > 25 kg/m²), but this model failed to explain the development of the disease in lean individuals (BMI < 18.5 kg/m²). Defects in the insulin signaling pathway have been postulated to play a role in these patients, particularly in suppressors of cytokine signaling (SOCS) proteins, which are involved in the downregulation of insulin transduction. The expression of SOCS is also known to be induced by cytokines such as interferon gamma (IFN-γ). It is still not clear whether these pathways operate differently in lean versus obese patients with T2DM. Therefore, this pilot study was designed to study the expression of SOCS1, SOCS3, and IFN-γ in lean and obese patients with T2DM.

OBJECTIVES

The levels of IFN-γ in serum and the messenger RNA (mRNA) expression of SOCS (SOCS1 and SOCS3) and IFN-γ genes in whole blood in lean and obese patients with T2DM.

METHODS

Sixty newly diagnosed T2DM patients (not on any pharmacotherapy) were enrolled and divided into 2 groups of lean (BMI < 18.5 kg/m²) and obese (BMI > 25 kg/m²) patients (n = 30 per group). Serum IFN-γ was measured by enzyme-linked immunosorbent assay (ELISA), and mRNA expression of IFN-γ, SOCS1, and SOCS3 was measured by real-time polymerase chain reaction (PCR) using the ∆∆ Ct method.

RESULTS

Serum IFN-γ levels were 10.83 ± 5.81 pg/mL in the lean group and 9.35 ± 5.14 pg/mL in the obese group (P = 0.02). Fasting serum insulin levels were 16.07 ± 8.39 µIU/mL in the lean group and 27.11 ± 4 .91 µIU/mL in the obese group (P = 0.001). There was a 3.16-fold increase in mRNA expression of IFN-γ and a 1.3-fold increase in mRNA expression of SOCS1 in the lean group compared to the obese group. mRNA expression of SOCS3 was similar in both groups.

CONCLUSIONS

The level of IFN-γ increased at both transcriptional and translational levels, and mRNA expression of SOCS1 was higher in the lean group than in the obese group. The SOCS protein is a known negative regulator in insulin signaling pathways. Thus, our findings and available scientific literature suggest that IFN-γ might impair the insulin signaling pathway to a greater extent in lean patients than in obese patients via induction of SOCS1. This signaling pathway could be a major contributing factor to hyperglycemia in lean patients with T2DM compared with obese counterparts. This suggests that different therapeutic approaches to these groups might be of greater benefit in the treatment of T2DM.

Adipose tissue expression of UCP1 and PRDM16 genes and their association with postprandial triglyceride metabolism and glucose intolerance

AIMS

UCP1 and PRDM16 genes, primarily involved in browning of adipose tissue that can affect lipid metabolism are also associated with diabetes risk. Therefore, we planned to study the adipose tissue expression of UCP1 and PRDM 16 genes in subjects with glucose intolerance to find out its association with postprandial triglyceride (PPTg) measures and T2DM.

METHODS

A total of 30 subjects were recruited in three groups i.e., NGT, prediabetes and T2DM (NDDM + known T2DM) who were matched for age, sex and BMI. An 8-hour standardized fat challenge test was performed to study lipemic responses. UCP1 and PRDM16 genes quantification in adipose tissue was performed by real-time PCR followed by SDS PAGE.

RESULTS

UCP1 gene expression in SAT was significantly lower in T2DM and prediabetes as compared to NGT group while PRDM16 gene expression was significantly lower in T2DM group as compared to NGT group. UCP1 gene expression correlated with PPTg measures as well as with glycaemic measures while PRDM16 gene expression correlated with glycaemic measures only.

CONCLUSION

This study found downregulation of PRDM16 and UCP1 gene expression in SAT in subjects with glucose intolerance. The association of UCP1 gene expression with PPTg dysmetabolism may contribute to greater predisposition to T2DM.

Postprandial endothelial dysfunction and CIMT after oral fat challenge in patients with type 2 diabetes mellitus with and without macrovascular disease - A preliminary study

BACKGROUND

Very few studies have reported on association of postprandial lipids and endothelial dysfunction among patients with diabetes. Whether endothelial dysfunction particularly postprandial FMD is worse in patients with T2DM with macrovascular disease compared to those without and whether this difference is related to postprandial hypertriglyceridemia (PPHTg) is unclear. Therefore, present study was aimed to assess the relationship between PPHTg and endothelial function in patients with T2DM with and without macrovascular disease.

METHOD

Endothelial dysfunction by FMD and CIMT were compared in patients with T2DM with and without macrovascular disease (n = 13 each group) and 13 age, sex and BMI matched healthy individuals after an oral fat challenge.

RESULTS

There was significant postprandial deterioration of FMD 4-hr after fat challenge in patients with diabetes (P < 0.001) as well as healthy individuals (P = 0.004). Patients with diabetes with macrovascular disease had significantly lower fasting (5.7 ± 6.1% vs. 22.7 ± 10.0% and vs. 24.7 ± 5.3%) as well as postprandial (4-hr) (3.1 ± 5.0% vs. 15.3 ± 8.1% and vs. 15.4 ± 5.7%) FMD compared to other two groups. Fasting, postprandial as well as change in FMD and CIMT in patients with diabetes correlated significantly with fasting as well as postprandial triglycerides with stronger correlation in those with macrovascular disease.

CONCLUSION

Study found significant endothelial dysfunction by FMD that shows substantial further deterioration postprandially following high fat meal in patients with diabetes with macrovascular disease compared to patients with diabetes without macrovascular disease and healthy individuals. Study also indicates that PPHTg is a contributor to endothelial dysfunction. However, more studies are required to corroborate these findings.

Prevalence of diabetes related vascular complications in subjects with normal glucose tolerance, prediabetes, newly detected diabetes and known diabetes

AIMS

Varying prevalence of individual diabetes related vascular complications in prediabetes has been reported. However, very few studies have looked at both macrovascular and microvascular complications in prediabetes.

METHODS

Study subjects without any history of diabetes underwent oral glucose tolerance test (OGTT) and were classified as either normal glucose tolerance (NGT), prediabetes (PD), newly detected diabetes mellitus (NDDM) on the basis of American Diabetes Association (ADA) criteria. Age and sex matched known diabetes mellitus (KDM) patients were also recruited. All the participants were subsequently screened for both macrovascular (CAD, CVA,PVD) and microvascular (retinopathy, nephropathy and neuropathy)complications of diabetes.

RESULTS

Prevalence of vascular complications among prediabetes subjects was 11.1% as compared to 1.4% among NGT subjects, 13.9% among NDDM subjects and 23.8% among KDM subjects. There was no significant between complication rates in prediabetes and NDDM group (p = 0.060). The prevalence of macrovascular and microvascular complications among prediabetes subjects was 4.2% and 6.9% while the same in NDDM was 4.2% and 9.7%.

CONCLUSIONS

The proportion of subjects with prediabetes and vascular complications was about half of those with known diabetes and almost similar to those with newly detected diabetes mellitus.

Hyperleptinaemia and its Association with Postprandial Hypertriglyceridemia and Glucose Intolerance

INTRODUCTION

Leptin resistance is believed to cause insulin resistance though the exact mechanism is not fully understood. The present study aims to investigate the temporal profile of postprandial triglyceride (PPTG) and leptin levels, and their association with each other as well as with markers of metabolic syndrome.

MATERIALS AND METHODS

Serum leptin and PPTG levels were measured longitudinally till 26 weeks in Wistar rats fed on controlled diet (group 1) and high sucrose diet (HSD) (group 2). Two additional groups fed on HSD were taken and treated with pioglitazone (group 3) and atorvastatin (group 4). Body weight, homeostasis model assessment of insulin resistance (HOMA-IR), and glucose intolerance were also measured during this period. Comparison of the groups were done and Pearson's correlation coefficient was used to ascertain the association.

RESULTS

Leptin levels were significantly higher in all three groups receiving HSD compared to controlled diet group from week 2 to week 26 (P < 0.01). The postprandial triglyceride area under the curve (PPTG AUCs) were significantly higher in group 2 than controls during this period (P < 0.001). Body weight, HOMA-IR and glucose AUC were found to be significantly higher in group 2 rats than controls only from week 6, 8, and 12 respectively. In HSD-fed rats, but not in control, mean serum leptin levels from 2-26 weeks as well as peak (10^th week) and 26^th week were strongly associated with corresponding as well as preceding PPTG levels. Leptin levels significantly predicted HOMA-IR and prediabetes in group 2.

CONCLUSION

This study found significant hyperleptinemia associated with postprandial hypertriglyceridemia that predicted insulin resistance and prediabetes in high sucrose diet-fed rats.

Longterm effects of rotational night shift work on expression of circadian genes and its association with postprandial triglyceride levels - A pilot study

Abnormalities of lipid metabolism in the form of high fasting as well as postprandial triglyceride levels immediately after night shift work and under simulated night shift conditions have been reported in the literature. Whether dysregulation of circadian genes in the long term is associated with abnormal triglyceride metabolism has not been previously investigated. This pilot study aimed to investigate the long-term effect of rotational night shift work on the expression of circadian genes among healthcare workers and to ascertain the association between the expression of circadian genes and postprandial triglyceride and insulin resistance parameters. The study was conducted on two groups of healthcare workers (n = 20/group). Group 1 included day shift workers who had not done night shift duty during the past one year or ever. Group 2 included healthcare workers doing rotational night shift duties (≥4 night shift duties/month). Fasting blood samples were collected at 08:00 h to study the expression of circadian genes CLOCK, NPAS2, BMAL1, CRY1, CRY2, PER1, PER2, PER3, REVERBα, and biochemical parameters after which a standardized fat challenge test was done to measure postprandial triglyceride levels. Study of Group 2 individuals was conducted after a minimum of one week after the last night shift duty. Expression of CLOCK, NPAS2, PER1, PER3, and REV-ERBα genes was higher in Group 2 compared to Group 1 subjects, and expression of BMAL1 and CRY1 genes were lower in Group 2 compared to Group 1. Several of these genes showed significant correlations with postprandial triglyceride and insulin resistance parameters in Group 2 but not in Group 1 subjects. The present study showed altered expression of several circadian genes in healthcare workers involved in rotational night shift duties associated with postprandial triglyceride and insulin resistance parameters. This study therefore suggests that long term circadian gene dysregulation could have serious metabolic consequences in individuals engaged in rotational night shift duties.

Effect of postprandial triglycerides on DDT/ppDDE levels in subjects with varying degree of glucose intolerance

BACKGROUND

Organochlorine pesticides such as DDT as well as postprandial hypertriglyceridemia have been linked with insulin resistance and diabetes mellitus. The cardiometabolic risk of PPhTg could also be due to its potential to increase the serum levels of this highly lipophilic pesticide. We studied the effect of postprandial triglyceride responses to a standard oral fat challenge on the levels of DDT and its metabolites in subjects with varying degree of glucose intolerance METHODS: A standard fat challenge was performed in 60 subjects who were categorized as NGT, prediabetes, and NDDM based on an earlier OGTT. Fasting and postprandial levels of serum triglycerides, plasma DDT and its metabolites were estimated and compared in the 3 groups and their association with each other, and measures of glycemia and insulin resistance were also determined.

RESULTS

Peak Tg and TgAUC levels were significantly higher in NDDM group as compared to NGT and PD groups. TgAUC showed positive correlation with fasting plasma glucose (r=0.33, p=0.01), postprandial plasma glucose (r=0.39, p=0.002) and HOMA IR(r=0.63, p=0.001). ppDDE levels were found to be significantly higher in NDDM subjects compared with NGT group. ppDDE-AUC was significantly higher in the NDDM group compared with the other two study groups. Mean ppDDE levels also showed strong positive correlation with peak Tg (r=0.295 p=0.022), TgAUC (r=0.303 p=0.018), iPPTgAUC(r=0.57 p≤0.001) and iPPpeakTg(r=0.51 p≤0.001) as well as with FPG (r=0.269 p=0.038) PPPG (r=0.424 p=0.001) and HbA1c (r=0.321 p=0.012).

CONCLUSION

The findings of this study support the concept that the cardiometabolic risk associated with PPhTg may at least in part be related to the associated increase in serum levels of lipophilic OCPs like DDT.

Comparison of the incidence of diabetes in United States and Indian youth: An international harmonization of youth diabetes registries

OBJECTIVE

Incidence of youth-onset diabetes in India has not been well described. Comparison of incidence, across diabetes registries, has the potential to inform hypotheses for risk factors. We sought to compare the incidence of diabetes in the U.S.-based registry of youth onset diabetes (SEARCH) to the Registry of Diabetes with Young Age at Onset (YDR-Chennai and New Delhi regions) in India.

METHODS

We harmonized data from both SEARCH and YDR to the Observational Medical Outcomes Partnership (OMOP) Common Data Model. Data were from youth registered with incident diabetes (2006-2012). Denominators were from census and membership data. We calculated diabetes incidence by averaging the total cases across the entire follow-up period and dividing this by the estimated census population corresponding to the source population for case ascertainment. Incidence was calculated for each of the registries and compared by type and within age and sex categories using a 2-sided, skew-corrected inverted score test.

RESULTS

Incidence of type 1 was higher in SEARCH (21.2 cases/100 000 [95% CI: 19.9, 22.5]) than YDR (4.9 cases/100 000 [95% CI: 4.3, 5.6]). Incidence of type 2 diabetes was also higher in SEARCH (5.9 cases/100 000 [95% CI: 5.3, 6.6] in SEARCH vs 0.5/cases/100 000 [95% CI: 0.3, 0.7] in YDR). The age distribution of incident type 1 diabetes cases was similar across registries, whereas type 2 diabetes incidence was higher at an earlier age in SEARCH. Sex differences existed in SEARCH only, with a higher rate of type 2 diabetes among females.

CONCLUSION

The incidence of youth-onset type 1 and 2 diabetes was significantly different between registries. Additional data are needed to elucidate whether the differences observed represent diagnostic delay, differences in genetic susceptibility, or differences in distribution of risk factors.

Diabetic ketoacidosis at diagnosis among youth with type 1 and type 2 diabetes: Results from SEARCH (United States) and YDR (India) registries

BACKGROUND

There is significant global variation in the prevalence of diabetic ketoacidosis (DKA) at diagnosis among youth with type 1 diabetes (T1D). However, data for youth with type 2 diabetes (T2D) are limited, even in developed countries. We compared the prevalence of DKA at diagnosis among individuals with T1D and T2D from the SEARCH for Diabetes in Youth (SEARCH) and the Registry of Youth Onset Diabetes in India (YDR) registries.

METHODS

We harmonized the SEARCH and YDR registries to the structure and terminology in the Observational Medical Outcome Partnership Common Data Model. Data used were from youth with T1D and T2D diagnosed before 20 years and newly diagnosed between 2006 and 2012 in YDR and 2009 and 2012 in SEARCH.

RESULTS

There were 5366 US youth (4078 with T1D, 1288 with T2D) and 2335 Indian youth (2108 with T1D, 227 with T2D). More than one third of T1D youth enrolled in SEARCH had DKA at diagnosis which was significantly higher than in YDR (35.3% vs 28.7%, P < .0001). The burden of DKA in youth with T1D was significantly higher among younger age groups; this relationship was similar across registries (P = .4). The prevalence of DKA among T2D in SEARCH and YDR were 5.5% and 6.6% respectively (P = .4).

CONCLUSIONS

There is significant burden of DKA at diagnosis with T1D among youth from United States and India, especially among the younger age groups. The reasons for this high prevalence are largely unknown but are critical to developing interventions to prevent DKA at diagnosis.

Diagnosis and Management Considerations in Steroid-Related Hyperglycemia in COVID-19: A Position Statement from the Endocrine Society of India

The current coronavirus disease (COVID-19) pandemic is showing no signs of abatement and result in significant morbidity and mortality in the infected patients. Many therapeutic agents ranging widely between antivirals and anti-inflammatory drugs have been used to mitigate the disease burden. In the deluge of the drugs being used for COVID-19 infection, glucocorticoids (GCs) stand out by reducing mortality amongst in-hospital severe-to-critically ill patients. Health-care practitioners have seen this as a glimmer of hope and started using these drugs more frequently than ever in clinical practice. The fear of mortality in the short term has overridden the concern of adverse long-term consequences with steroid use. The ease of availability, low cost, and apparent clinical improvement in the short term have led to the unscrupulous use of the steroids even in mild COVID-19 patients including self-medication with steroids. The use of GCs has led to the increasing incidence of hyperglycemia and consequent acute complications of diabetic ketoacidosis and mucormycosis in COVID-19 patients. There is an urgent need to dissipate information about optimum management of hyperglycemia during steroid use. In view of this, the Endocrine Society of India has formulated this position statement about the diagnosis and management of hyperglycemia due to the use of GCs in patients with COVID-19 infection.

Basal Insulin Titration: Moving Towards a More Patient-Centric Approach with Gla-100 in India

Owing to the progressive nature of the disease, patients with type 2 diabetes mellitus (T2DM) eventually require adjustment or titration of insulin doses to achieve the desired glycemic control. Titration inertia, or the inability to dose-titrate, is one of the key barriers to optimized insulin therapy and is common in Asian countries such as India. Simple and effective titration algorithms involving the use of basal insulin, which has the lowest hypoglycemia risk, that can be individualized by physicians and easily followed by patients aid in tackling titration inertia. In this context, insulin glargine 100 U/mL (Gla-100) appears to be the ideal insulin to overcome titration inertia, owing to its low risk of hypoglycemia and effective glycemic control. Different guidelines recommend the use of basal insulin, such as Gla-100, and encourage a patient-centric approach for dose titration. Although the effective implementation of the patient-centric approach in India is challenging, it is nevertheless achievable.

Anaemia in patients with type 2 diabetes mellitus without nephropathy is related to iron deficiency

BACKGROUND AND AIMS

Iron deficiency anaemia, although well reported in diabetic nephropathy, has not been well studied in type 2 diabetes patients in the absence of nephropathy. We studied the prevalence of anaemia and iron deficiency in type 2 diabetes patients without nephropathy.

MATERIAL AND METHODS

A total of 89 patients were selected for this study. 24 h urine protein less than 500 mg was used as the criteria to rule out diabetic nephropathy. Complete hemogram, iron profile and high sensitivity C reactive protein (hs CRP) levels were performed in each patient.Functional iron deficiency (FID) was defined as serum ferritin more than 100 μg/l with serum transferrin less than 20% and total iron deficiency state was defined as serum ferritin less than 100 μg/l.

RESULTS

Fifteen patients (16.8%)had anaemia out of which 13 had total iron deficiency and one each had functional iron deficiency and normal iron status respectively. Assessment of the iron status overall showed that 49 patients had TID (55.05%), 16 had FID (17.9%)and 24 (27.05%) had normal iron status. The hs-CRP was significantly higher in those with iron deficiency.

CONCLUSIONS

The present study found a high prevalence of iron deficiency anaemia in type 2 diabetic patients even in the absence of nephropathy. Most of the diabetic subjects also displayed an iron deficiency state the cause of which needs further investigation.

Association of PPARγ gene expression with postprandial hypertriglyceridaemia and risk of type 2 diabetes mellitus

PURPOSE

Peroxisome proliferator-activated receptor γ (PPARγ) gene is strongly associated with type 2 diabetes mellitus, as well as postprandial lipemia, and plays an important role in Wnt dependent adipogenesis in subcutaneous adipose tissue (SAT) and visceral adipose tissue (VAT). We aimed to study the expression of PPARγ gene in SAT and VAT to find out its correlation with postprandial hypertriglyceredemia and glucose intolerance.

METHODS

Thirty subjects who were scheduled to undergo abdominal surgery were recruited in three groups (n = 10 in NGT, n = 10 in prediabetes, and n = 10 in T2DM). A standardized oral fat challenge was performed. Anthropometry, plasma glucose, HbA1c, and fasting serum insulin were also measured. SAT and VATs were collected during surgery for PPARγ gene expression studies by real-time PCR.

RESULTS

PPARγ gene expression was 5.5-fold lower in T2DM and 1.7-fold lower in prediabetes as compared with NGT subjects in VAT. There was a significant negative correlation of expression of PPARγ gene in VAT {Tgauc (r = -0.57, p < 0.007), Peak Tg (r = -0.51, p < 0.01)} as well as in subcutaneous adipose tissue {Tgauc (r = -0.45, p < 0.02)} with PPTg responses measures.

CONCLUSION

Reduced adipocyte expression of PPARγ gene and the resultant postprandial hypertriglyceredemia is associated with greater risk of diabetes and prediabetes.

Monocyte CD36 expression associates with atherosclerotic burden in diabetes mellitus

BACKGROUND

By virtue of its role in oxidized low-density lipoprotein uptake and foam cell transformation, monocyte CD36 (mCD36) is a potential non-invasive tool to detect atherosclerosis (ATH) in patients of type 2 diabetes mellitus (DM).

METHODS

Flowcytometric expression of mCD36 was evaluated with reference to ankle brachial index (ABI) in 70 patients of type 2 DM [40 with and 30 without coronary artery disease (CAD) respectively] and 30 age and gender matched normoglycemic controls (NGCs).

RESULTS

DM patients had significantly higher mCD36 indices than NGCs (p < 0.001). The mCD36 expression was significantly higher in DM persons with CAD and those with poor glycemia control (glycosylated haemoglobin, HbA1c ≥ 7%) than their respective counterparts (p < 0.001 for both). Thirty subjects had compromised ABI (≤0.9); all were DM persons with CAD. ABI compromised subjects had consistently higher mCD36 indices than all other sub-groups (p < 0.001 for all comparisons). Notably, within the ABI-uncompromised group, mCD36 indices differed significantly and showed progressive increase from NGCs to diabetics without and with CAD respectively.

CONCLUSIONS

mCD36 plays an important role in atherogenesis. With reference to ABI, mCD36 performed robustly as a marker of ATH. Furthermore, it could stratify subjects within the 'ABI-uncompromised group' commensurate with their conventional clinico-pathological ATH risk predisposition.