Serum lipoprotein ratios as markers of insulin resistance: A study among non-diabetic acute coronary syndrome patients with impaired fasting glucose.

Background & objectives: Recent data suggest that insulin resistance can predict cardiovascular disease independently of the other risk factors, such as hypertension, visceral obesity or dyslipidaemia. However, the majority of available methods to evaluate insulin resistance are complicated to operate, expensive, and time consuming. This study was undertaken to assess whether serum lipoprotein ratios could predict insulin resistance in non-diabetic acute coronary syndrome (ACS) patients. Methods: Ninety non-diabetic patients with impaired fasting glucose admitted with a diagnosis of ACS were included in the study. At the time of admission fasting glucose and insulin concentrations were measured. The homeostatic model assessment-insulin resistance (HOMA-IR) was used for insulin resistance. The fasting serum total cholesterol (TC), triglycerides (TG) and high density lipoprotein cholesterol (HDL-C) levels were checked, and then TC/HDL-C and TG/HDL-C ratios were calculated. The areas under the curves (AUC) of the receiver operating characteristic (ROC) curves were used to compare the power of these serum lipoprotein ratios as markers. Results: Lipoprotein ratios were significantly higher in patients with HOMA-IR index > 2.5 as compared to patients with index <2.5 (P < 0.05). Both TG/HDL-C and TC/HDL-C ratios were significantly correlated with HOMA-IR (P<0.05). The area under the ROC curve of the TG/HDL-C and TC/HDL-C ratio for predicting insulin resistance was 0.80 (95% CI, 0.67 to 0.93), 0.78 (95% CI, 0.65 to 0.91), respectively. Interpretation & conclusions: The findings of this study demonstrate that serum lipoprotein ratios can provide a simple means of identifying insulin resistance and can be used as markers of insulin resistance and cardiovascular diseases risk in adult non-diabetic patients.

A histopathological study of liver and biliary remnants with clinical outcome in cases of extrahepatic biliary atresia.

Context: The indicators of poor prognosis in cases of extrahepatic biliary atresia (EHBA) continue to remain controversial. Aims: To correlate the histopathological findings of wedge biopsy from liver and tissue obtained from the shaving at the porta hepatis, during hepatic portoenterostomy, with the clinical outcome. Materials and Methods: All cases of EHBA surgically treated in our hospital from 1995 to 2006 have been reviewed. Wedge biopsies of the liver and biopsies from the porta hepatis were analyzed with hemotoxylin-eosin stains and immunohistochemistry. The parameters correlated with clinical outcomes were - presence of large bile ducts ( > 150μm diameter) in the portal tissue plaque, degree of fibrosis (semi-quantitative; graded as mild, moderate and severe), presence of ductal plate malformation (DPM) and age at operation. Results: The proportions of patients with small or large ductal diameter who remained clinically controlled (serum bilirubin < 1.5mg/dl with no evidence of end stage liver failure) were 39% and 66.6% respectively (P=0.44). There was a highly significant correlation between the extent of fibrosis and clinical outcome. Mild, moderate and severe fibrosis resulted in clinical control rates of 78.5%, 34.4% and 24% respectively (P=0.001). Ductal plate malformation was seen in 15% of our cases and was uniformly associated with poor outcome. A non-significant trend towards poorer outcome was seen with increasing age at surgery. Conclusions: Histopathological correl ations with clinical outcome in EHBA have been rarely reported from the Indian subcontinent. A greater degree of fibrosis at the time of hepatic portoenterostomy and presence of ductal plate malformation is associated with a significantly poorer clinical outcome.

A study on dyslipidaemia in subclinical hypothyroidism.

Subclinical hypothyroidism is characterised by elevated serum thyroid stimulating hormone (TSH) concentrations in association with normal free thyroid hormones. The aim of the study was to evaluate the prevalence and pattern of serum lipid alterations in patients with stable subclinical hypothyroidism in comparison to age- as well as sex-matched euthyroid group and also subgroup analysis between them in regard to age of presentation, sex, antithyroperoxidase (anti TPO) positivity, and TSH value. In this study, 100 patients of SCH were recruited, age ranged 17-68 years, majority (78%) being females, presenting mainly with non-specific symptoms and compared with 52 euthyroid control regarding lipid parameters. Of the subclinical hypothyroidism patients, only 10% had goitre and anti TPO was positive in 52% cases. Serum lipoprotein (a) above the age of 20 years, and total cholesterol, triglyceride and low density liporpotein cholesterol in the age group of 40-50 years were significantly elevated. In addition, total cholesterol, triglyceride and low density lipoprotein cholesterol levels in anti TPO positive cases and serum triglyceride and low density lipoprotein cholesterol in anti TPO negative patients showed statistically significant higher levels. In males only lipoprotein (a), but in females total cholesterol, triglyceride, low density lipoprotein cholesterol and liproprotein (a)--all were significantly elevated.

Correlation of lipid profile and carotid artery plaque as detected by Doppler ultrasound in ischaemic stroke patients--A hospital-based study.

Stroke is one of the leading causes of morbidity and mortality all over the world. Carotid plaque formation and intima media thickness can be a predictor of ischaemic stroke. In this regard studies from our country, are few and far between. This is a small hospital-based study to look in to this matter. We have assessed the intima media thickness of the common carotid as well as the internal and external carotid arteries by the ultrasound method. The lipid profiles were estimated and correlated with the intima media thickness. Results indicate that in the common as well as in the internal and external carotid arteries, the intima media thickness is a good predictor of ischaemic stroke. This thickness is also well correlated with the lipid levels in blood. Hence this non-invasive method can be used successfully to identify the high risk patients, prone to develop stroke.

Risk factor analysis in ischaemic stroke: a hospital-based study.

Stroke represents a major health burden in our country. Ischaemic stroke has got several risk factors associated with increased chance of atherosclerosis. A small hospital-based study was done to look into the risk factors associated with ischaemic stroke. Forty patients with CT-confirmed cerebral infarction were taken for the study and detailed history and clinical findings were obtained. Investigations like complete haemogram, fasting blood glucose, urea, creatinine, lipid profile, serum Lp(a), homocysteine, fibrinogen, ECG, chest x-ray, echocardiography, MRI/MRA where indicated, were done to identify the risk factors as well. Results indicated that hypertension was the most prevalent (87.5%) risk factor followed by ischaemic heart disease (35%) and diabetes. Dyslipidaemia was also found in a significant number of cases, mostly elevated LDL, low HDL and elevated Lp(a). Fibrinogen and homocysteine were of less significance.

Hepatopulmonory syndrome--an uncommon and severe complication of certain liver diseases.

Hepatopulmonary syndrome (HPS) is charaterised by arterial hypoxaemia found mainly in association with chronic liver disease (most commonly cirrhosis of liver) but also rarely with acute liver diseases like fulminant hepatic failure or Budd-Chiari syndrome. The purpose of this article is to present an uncommon but grave complication mostly associated with cirrhosis of liver and to differentiate this entry from cyanotic heart diseases or certain lung conditions. Investigations include history and physical examination, certain biochemical tests, upper gastro-intestinal (GI) endoscopy, abdominal ultrasonography, liver biopsy and venacavography in appropriate cases. Finally, the suspected cases underwent arterial blood gas (ABG) analysis and contrast enhanced echocardiography (CEE) for confirmation of the diagnosis of HPS. Of the 123 cases of cirrhosis of liver, three cases of HPS (2.4%) were found-all of them being males. Also one male patient with inferior vena cava (IVC) obstruction amongst other causes presenting with HPS was encountered. As of now, no medical treatment has been proved to be useful and liver transplant remains the only hope for this disorder.

Effect of chitosan on lipid levels when administered concurrently with atorvastatin--a placebo controlled study.

In a placebo controlled trialthe lipid lowering effects of chitosan, a unique dietary fibre, was assessed when given along with atorvastatin 10 mg in patients with chronic coronary heart disease. Altogether 100 patients were studied. They were randomly allocated in two groups of 50 patients each. Patients of group A received atorvastatin 10 mg before dinner plus 2 g/day chitosan in two divided doses. The groupB patients received atorvastatin 10 mg plus placebo. Patients were followed up for a period of 6 weeks. There was significant reduction in mean body weight in group A patients (3.14% versus 1,29% of body weight, p<0.05). There was also a significant rise in HDL cholesterol value (3.8% versus 1.07%, p=0.02) in group A patients. However, there was no significant reduction in the mean values of total cholesterol, LDL cholesterol and triglyceride in the two groups, although group A patients showed marginally lower values.

A study on micro-albuminuria--an independent risk factor for vasculopathy in diabetes mellitus.

Diabetes is becoming a serious threat to combat felt among the doctors of the world. India, in partcular is a vulnerable country contributing maximum number of cases to the global diabetic pool. Macro-and microvascular complications are important causes of mortality and morbidity. Micro-albuminuria is a surrogate marker for detetion of vasculopathy for which early detection and aggressive treatment can reduce mortality and morbidity. A small study was conducted to identify the usefulness of this marker in our setting which can be used as a cost-effective tool for detecting the dreadful complication early. This study has demonstrated that in presence of micro-albuminuria the vascular complications of diabetes definitely increase and it is more relevant in cases of type 2 diabetes irrespective of other parameters rendering it to be a independent risk factor. It also indicates that presence of this marker along with vasculopathy is time dependent ie, more the duration of the disease more is the complication.

Carotid intima media thickness: an independent marker for assessment of macrovascular risk in diabetic patients.

In view of the global epidemic of diabetes with India being the hottest reservoir of the disease, it was tried to identify carotid intima media thickness as a surrogate marker for atherosclerosis in diabetic subjects. The study becomes more relevant because diabetes is now considered a disease of the endothelium and a risk equivalent of coronary atherosclerosis (paradigm shift). The study incorporated 41 normotensive patients of diabetes and 31 age and sex matched controls. Plasma glucose and lipid profiles were assessed in all and the carotid intima media thickness was measured. Results were statistically analysed for significance and correlation coefficient between values of plasma glucose and carotid intima media thickness. Results clearly showed that carotid intima media thickness abnormality can pick up atherosclerosis even if the lipid parameters are nearly normal. So it crystallises from this small study that, as a non-invasive test carotid intima media thickness is a better and early predictor of atherosclerosis in diabetic subjects. It also revealed the linear relationship between both fasting and postprandial blood sugar with carotid intima media thickness.

Management of diabetic gastroparesis.

Diabetic gastroparesis is a long term complication of diabetes mellitus which could basically be defined as dysregulated gastric emptying leading to various pathological, biochemical and clinical changes in absence of any structural changes. Symptoms include nausea, vomiting, bloating, epigastric pain, anorexia, weight loss and so on. For symptomatic gastroparesis prokinetic drugs like metoclopramide, domperidone, cisapride, erythromycin and itcopride are used. Itopride is currently emerging as a prokinetic drug of choice. There is also scope of surgery.

Predictive efficacy of Framingham's risk score in Indian scenario--a retrospective case-control study.

To assess the predictive ability of Framingham's risk score in primary prevention in our population, 252 cases and 212 age and sex matched controls were taken up for study. Those patients, who were presenting for the first time with acute coronarysyndrome (ACS) and who did not have any prior manifestations of coronary artery disease (CAD) and whose medical records were available formed the patient group. Framingham's risk score was calculated and the corresponding 10 years risk was assessed in each of them. The patients and controls were divided into two groups--diabetic and non-diabetic. Depending on the 10 years risk, they were further grouped into high risk (10 years risk > 20%), moderately high risk (10 years risk 10 to 20%) and low risk (10 years risk less than 10%). Results were compared and statistically analysed. In the diabetic patients with ACS 14% would have qualified as high risk, 33% as moderately high risk and 53% as low risk whereas in diabetic patients without any manifestation of CAD the distribution was 4% in the high risk, 54% in the moderately high risk and 42% in the low risk. In the non-diabetic subjects, amongst the patients of ACS, 20% would have been in high risk, 39% in moderately high risk and 41% in the low risk. The corresponding figures in the non-diabetic control subjects were 10% in high risk, 22% in the moderately high risk and 68% in the low risk. In the non-diabetic subjects, the mean risk was significantly more in patients than in controls (14.15% versus 8.61%, p <0.01). However, in the diabetic patients there was no significant difference in the mean projected risk between patients with ACS and patients without any manifestation of CAD (11.37% versus 10.41%, p>0.05).

Glycaemic consequences of HIV and highly active antiretroviral therapy: a pilot study and review of literature.

The metabolic consequences of HIV and AIDS are accentuated in the setting of highly active antiretroviral therapy. Peripheral lipodystrophy, central adiposity, hyperlipidaemia, insulin resistance and diabetes mellitus are frequent associations of protease inhibitor containing highly active antiretroviral therapy regimens. Ninety patients aged 25-50 years (males 52, females 38), seropositive for HIV 1 and 2 or both were selected to see the glycaemic profiles in asymptomatic early HIV disease with CD4 counts > 100/microl and to compare this with the glycaemic profile of (a) advanced HIV disease (CD4 counts < 200/microl), not on highly active antiretroviral therapy and (b) advanced HIV disease (CD4 counts < 200/microl), on uninterrupted non-protease inhibitor highly active antiretroviral therapy > 6 months. All the patients were grouped into 3: (1) Group A: CD4 counts > 500/microl (n=37), highly active antiretroviral therapy naive, (2) group B: CD4 counts < 200/microl (n=21), not on highly active antiretroviral therapy, and (3) group C: CD4 counts < 200/microl, receiving uninterrupted non-protease inhibitor based highly active antiretroviral therapy for > 6 months (n=32). The fasting blood glucose, glycosylated Hb (HbA1c) levels, were measured in all the patients in 3 groups and significance of difference between means was calculated among various groups. Body weight and waist-hip ratio were also measured. The results were analysed and compared with other studies.

Insulin in type 2 diabetes: promises to keep.

The concept which has evolved in the management of type 2 diabetes mellitus is early insulin therapy. In type 2 diabetes mellitus first phase insulin response is grossly impaired on eventually absent, overburdening phase 2 responses which obviously fail to compensate in the long run. Perpetuation of the age old practice to continue OHA while almost all beta-cells are exhausted is only buying time for starting insulin. Preservation of beta-cell function by early insulin therapy yields two important benefits: (1) Better glycaemic control at lower medication dose and (2) relative freedom from hypoglycaemia because of well preserved glucagon response. To ensure and to translate the proper action of insulin in the target organs we are now talking about designer insulins which are basically insulin analogues (short and long acting). So type 2 diabetes is a growing menace and is responsible for severe morbidity, mortality and poor quality of life. Good glycaemic control from the very beginning of diabetes has shown to favourably influence all of these and is accepted as a cardinal goal of proper diabetes care.

Efficacy and safety of oral iron chelating agent deferiprone in beta-thalassemia and hemoglobin E-beta thalassemia.

OBJECTIVES: To assess efficacy and safety of oral iron chelating agent deferiprone (DFP) in patients with beta thalassemia and hemoglobin E-beta thalassemia. DESIGN: Non-randomized study. SETTING: Hematology Out-Patient Department. SUBJECTS: Forty-one patients of beta thalassemia and hemoglobin E-beta thalassemia. INTERVENTIONS: DFP was given to 20 patients, 10 patients of beta thalassemia and 10 with hemoglobin E-beta thalassemia; the rest were taken as controls. RESULTS: A significant fall in serum ferritin was observed in the study group along with rise in urinary iron excretion (p < 0.05). Adverse effects of DFP were nausea and vomiting (30%), significant arthropathy requiring stopping of the drug (30%), and reversible neutropenia in one patient. All these complications could be managed easily with medical supervision and no death or permanent disability was seen. CONCLUSIONS: DFP is an effective and fairly well tolerated oral iron chelating agent. The side effects that occur can be tackled easily if monitored properly.