Evaluation of Madras Diabetes Research Foundation-Indian Diabetes Risk Score in detecting undiagnosed diabetes in the Indian population: Results from the Indian Council of Medical Research-INdia DIABetes population-based study (INDIAB-15)

Background & objectives: Screening of individuals for early detection and identification of undiagnosed diabetes can help in reducing the burden of diabetic complications. This study aimed to evaluate the performance of Madras Diabetes Research Foundation (MDRF)-Indian Diabetes Risk Score (IDRS) to screen for undiagnosed type 2 diabetes in a large representative population in India. Methods: Data were acquired from the Indian Council of Medical Research–INdia DIABetes (ICMR–INDIAB) study, a large national survey that included both urban and rural populations from 30 states/union territories in India. Stratified multistage design was followed to obtain a sample of 113,043 individuals (94.2% response rate). MDRF-IDRS used four simple parameters, viz. age, waist circumference, family history of diabetes and physical activity to detect undiagnosed diabetes. Receiver operating characteristic (ROC) with area under the curve (AUC) was used to assess the performance of MDRF-IDRS. Results: We identified that 32.4, 52.7 and 14.9 per cent of the general population were under high-, moderate- and low-risk category of diabetes. Among the newly diagnosed individuals with diabetes [diagnosed by oral glucose tolerance test (OGTT)], 60.2, 35.9 and 3.9 per cent were identified under

Correlation of estimated glomerular filtration rate with ejection fraction among type 2 diabetes mellitus patients: results of a cross sectional study from Southern India

Background: There is paucity of data regarding the relationship between the severity of left ventricular dysfunction and renal function impairment in diabetic patients. Aims and objectives was to study the relation between eGFR and ejection fraction in type 2 diabetes mellitus of more than 5 years duration.Methods: This cross sectional was carried out from May 2017 to May 2018 at Yenepoya Medical college a tertiary care center in the southern Indian state of Karnataka. The data on 220 diabetic patients were studied. A detailed clinical history physical examination was carried out on the study population as per the approved proforma. Apart from base line investigations, eGFR was calculated using serum creatinine levels. 2D echocardiography was done for the assessment of ventricular function.Results: Out of 220 patients, 138 were men (63%) and 82 were women (37%) and the mean age of the patients was 59.60±11.145 years. The mean duration of diabetes was 10.08±5.28 years. We found a progressive reduction in ejection fraction from 57.74±9.97% to 50.64±14.7 as the eGFR declined from <90 mL/min/1.73m2 to 30 mL/min/1.73m2. There was significant correlation between eGFR and RWMA (p value 0.001) and LVDD (p value 0.029) in this study cohort. Micro/macroalbuminuria was found to be in 55% of patients. Proteinuria had significant correlation with longer duration of diabetes, blood urea, serum creatinine and eGFR.Conclusions: This study found positive clinical correlation between LVEF and eGFR. However, it did not reach significant levels statistically. Further studies may be carried out to confirm the association.

Virulence factor profiles, phylogenetic background, and antimicrobial resistance pattern of lactose fermenting and nonlactose fermenting Escherichia coli from extraintestinal sources.

Context: In recent years, nonlactose fermenting (NLF) Escherichia coli have been increasingly isolated in the microbiology laboratory, but their clinical significance has not yet been clearly elucidated. Aims: To characterize the lactose fermenting (LF) and NLF isolates on the basis of their virulence factors, phylogenetic background, and drug resistance property. Settings and Design: This descriptive study was carried out in a multi‑specialty tertiary care hospital. Subjects and Methods: Three hundred nonrepeat E. coli isolates from inpatients were studied. Isolates were differentiated as LF and NLF on the basis of colony characteristics on MacConkey’s agar. Possession of virulence and drug resistance genes was determined by multiplex polymerase chain reaction (PCR). Phylogenetic analysis was performed by triplex PCR methods. Antibiotic sensitivity testing was performed by disk diffusion method. Results: Of 300 isolates 39 (13%) were NLF isolates. Maximum number of NLF isolates belonged to phylogroups B2 and D when compared with LF isolates. The incidence of iutA, hlyA, and neuC genes were significantly higher in NLF isolates. The presence of drug resistance genes such as AmpC gene, SHV, and CTXM were higher in LF isolates. Conclusions: LF isolates demonstrated a higher antimicrobial resistance and NLF isolates possessed higher virulence properties. The microbiology laboratory should report lactose fermentation profile as it may help the physician to initiate appropriate treatment.

Cost and Antibiotic Utilization of Pneumonia Patients in Intensive Care Unit.

Objective of this study is to evaluate the cost and antibiotic utilization of pneumonia patients admitted in intensive care unit. It was a retrospective study. Details required for antibiotic utilization and cost analysis were acquired from hospital files. Out of 320 cases evaluated 110 cases were of pneumonia.28.2% of people had pneumonia as their primary diagnosis and 71.8% had hospital acquired/aspiration pneumonia. The mean length of ICU stay was 3.30± 1.91 days. 21.8% patients were put on ventilator. The mortality rate was 34.5%. Betalactum along with betalactamase inhibitor antibiotics were prescribed for 91% patients, Carbapenams for 20%, anti-staphylococcal antibiotic for 51% of patients and macrolides and miscellaneous antibiotics were prescribed in 25.5% and 36.4% patients respectively. Betalactum antibiotic along with betalactamase inhibitor and clindamycin combination was most commonly prescribed antibiotic. Average cost per patient who was not put on ventilator was Rs 27,123 where as ventilated patient per cost was Rs44, 812. This study showed that one third of ICU admissions was due to pneumonia. Highest numbers of pneumonia were hospital acquired/aspiration pneumonia. Cost of ventilator supported pneumonia was two times more than non-ventilated pneumonia. Ventilator support was the most expensive intervention adding to the cost of care followed by cost of antibiotics and investigations.

Mid Arm Circumference: An Alternate Anthropometric Index of Obesity in Type 2 Diabetes and Metabolic Syndrome.

Aim: To evaluate alternate anthropometric index for obesity in type 2 diabetes and metabolic syndrome. Study Design: This is a cross sectional study. Place and Duration of the Study: Department of Medicine, Kasturba medical college-hospital, Mangalore, Manipal university, between January 2012 - July 2015. Methodology: We recruited 207 type 2 diabetic and 101 metabolic syndrome subjects with their age and sex matched controls. Anthropometric parameters like BMI, Waist circumference and mid arm circumference (MAC) were measured. Biochemical details were collected from case record. Results: The mean differences in anthropometric and biochemical parameters were compared between cases and controls by independent T test. MAC was correlated with clinical parameters in control subjects by Karl pearson’s correlation and multiple linear regression analysis. There was significant difference in MAC between metS and their control subjects (31.35±4.21 vs 28.04±2.86, P<.001). There was significant positive linear correlation of MAC with BMI (P<.001), WC (P<.05), post prandial blood sugar (P<.05) and HbA1c (P<.05) in controls. Further multivariate analysis after adjusting for conventional risk factors showed a significant association of MAC with BMI (β=0.611, P<.001). Conclusion: These findings show that MAC can be useful as an alternate index for obesity in South Indians.

Asymptomatic Bacteriuria with Escherichia coli in Type 2 Diabetic Patients: An Unresolved Riddle.

Asymptomatic bacteriuria (ASB) is a common finding, but there is a considerable controversy about the appropriate management of bacteriuria. ASB was found to be three times higher in patients with diabetes, especially in women when compared to non-diabetic counterpart. Asymptomatic bacteriuria is the presence of bacteria in the urine presenting without any clinical symptoms of UTI. The objective of this review is to highlight the studies done on ASB in diabetes patients with special reference to Escherichia coli (E. coli), risk factors and its management. The review showed that increasing age, females, post-menopausal status, poor glycaemic control, long duration of diabetes, microalbuminuria, leukocyturia ,poor hygiene were associated with ASB. Available literature does not support the use of antibiotics, however short term trials have shown benefit with topical esteriol. Further clinical trials are needed.

Molecular characterization and clinical significance of New Delhi metallo-beta-lactamases-1 producing Escherichia coli recovered from a South Indian tertiary care hospital.

Context: The increased rate of infection by New Delhi metallo-beta-lactamases-1 (NDM1) producing Escherichia coli is a major concern since they show a high rate of drug resistance and are responsible for mortality and morbidity. Aims: To characterize the NDM1 producing E. coli isolates and their impact on patients’ clinical outcome. Settings and Design: This descriptive study was carried out in a multi-specialty tertiary care hospital. Materials and Methods: Three hundred nonrepeat strains of E. coli from inpatients were included in the study. Modifi ed Hodge test and metallo-beta-lactamases (MBL) e-test were performed to detect carbapenemase and MBL activity. Polymerase chain reaction (PCR) technique was performed to detect NDM1. NDM1 positive isolates were further tested for plasmid mediated AmpC, blaCTX, blaSHV, blaTEM genes and also for phylogrouping by PCR methods. Treatment and patients’ clinical outcome were also analyzed. Results: Out of 300 isolates, 21 (7%) were MBL producers by phenotypic methods. Of this, 17 (81%) were NDM1 positives, among the NDM1 producers 6 (35%) isolates were belongs to phylogroups D followed by A 5 (29%), B1 4 (24%) and B2 2 (12%), 15 (88%) isolates were blaCTX-M positive suggestive of extended-spectrum beta lactamase producing strain and 7 (47%) were positive with CIT type of AmpC. With the follow-up of the patients, it was found that 12 (71%) recovered and 3 (18%) developed relapses, and mortality was seen in 2 (12%) patients. Conclusions: NDM1 producing isolates showed a high degree of drug resistance but can be treated with suitable antimicrobials, in the majority. Early detection and choice of appropriate antibiotics may help in reducing mortality and morbidity.

Genomic analysis and clinical importance of Escherichia coli isolate from patients with sepsis.

Context: Escherichia coli is a major cause of bloodstream infections and death due to sepsis. Bacteremic isolates harbor a signifi cantly greater repertoire of virulence factors (VFs) in contrast with commensal E. coli isolates. Aims: The aim was to determine the relationships between E. coli VFs, phylogenetic groups, and their clinical importance. Settings and Design: This descriptive study was carried out in a multi-specialty tertiary care hospital. Materials and Methods: Escherichia coli isolates from consecutive episodes of bacteremia in 100 patients were screened for their VFs, phylogenetic group, and their effect on patient’s clinical outcome. Virulence genes of all isolates were determined by multiplex polymerase chain reaction (PCR). Phylogenetic analysis was performed by triplex PCR methods. Estimation of risk of death was calculated using APACHE score II calculator. Results: Of the 100 patients, the most common predisposing factors were diabetes (42%), followed by carcinoma (23%). On analysis of the VF genes of the isolates, a majority of strains (88%) were possessing the fi mH gene followed by iutA (76%), papC (44%), cnf1 (16%), hlyA (16%) and neuC (5%) respectively. Phylogenetic analysis revealed that 25 (25%) isolates belonged to phylogroup A, 8(8%) strains to group B1, 30 (30%) were from group B2 and 37 (37%) were from group D. The incidence of iutA gene was signifi cant in higher APACHE II score group. Conclusions: Our fi ndings indicate that virulent as well as commensal strains are capable of causing sepsis. Host related predisposing factors, adherence factors, and iron uptake are essential for the survival of the sepsis inducing strains.

A study on the Pattern of Genetic Inheritance of Polycystic Ovarian Syndrome.

Aims: Inheritance of polycystic ovary syndrome (PCOS) is still a controversy. Our study aims to analyze the family history of PCOS features and related metabolic disturbances including the male members to determine the mode of their inheritance. Study Design: A cross sectional study with convenient sampling. Place and Duration of Study: Department of Medicine, Kasturba Medical College, Mangalore between 2009 and 2012. Methodology: Demographic data such as body weight and age was recorded. Menstrual, obstetric and medical history of 85 PCOS females was collected. Presence of metabolic syndrome (MetS) was confirmed. Blood pressure and waist circumference were measured. Biochemical and hormonal estimations were done. Relevant information required for the study of 604 members of first and second generation relatives was collected. SPSS (version 17.0) was used to analyze the data. Results: Seventy eight percent of the PCOS patients were either overweight or obese and 98% of them had hirsutism. Approximately, 33% of them had MetS which was higher in the first generation (62%) of PCOS relatives. An equal transmission of MetS characteristics from the paternal and maternal side indicated that it was not X- linked inheritance. Segregation analysis of nine families PCOS of patients suggested that MetS inheritance was autosomal dominant although PCOS inheritance was not. Conclusion: PCOS daughters come from families of MetS suggesting that parental MetS features may be related to the occurrence of PCOS in their off-springs.

Characterization of plasmid mediated AmpC producing Escherichia coli clinical isolates from a tertiary care hospital in South India.

Context: Plasmid mediated AmpC (pAmpC) β-lactamase producing Escherichia coli are an emerging problem worldwide as they are now exhibiting resistance to multiple classes of antibiotics and are a major cause of therapeutic failure. Aims: The aim of this study was to characterize pAmpC β-lactamase producing extraintestinal E. coli, their phylogenetic distribution, resistance pattern, treatment options, and impact on patient’s clinical outcome. Settings and Design: This descriptive study was carried out in a multi-specialty tertiary care hospital. Materials and Methods: A total of 300 clinically signifi cant, non-repeat isolates were studied. AmpC disk test was used for phenotypic AmpC-β- lactamase detection. Molecular types of pAmpC were determined by a multiplex polymerase chain reaction (PCR). Phylogenetic analysis was performed by triplex PCR methods. Metallo-beta-lactamase (MBL) detection was done by E test. Antibiogram, treatment, and clinical outcome were collected in a structured proforma. Results: Although 95 isolates (32%) were phenotypically positive for AmpC, PCR detected CIT type of AmpC gene in only 37 isolates. Majority of strains were from phylogroup A (85%) and B1 (58%) which are considered as commensal groups. Co-production of ESBL’s was observed in 33 strains and 5 strains were found to be MBL producers. Most widely prescribed antibiotics were 3rd generation cephalosporins (30%), carbapenems (19%) and aminoglycosides (16%). Conclusions: Plasmid mediated AmpC producing isolates were found to exhibit a high degree of drug resistance, and they mainly belonged to commensal strains possibly due to misuse of antibiotics. Proper antibiotic policy is required to limit the spread of pAmpC producers or else it will lead to a therapeutic dead end in the near future.

Oral health status in geriatric diabetics / Condições de saúde bucal em pacientes diabéticos geriátricos

OBJECTIVE: To determine if any difference exists in the oral health status between geriatric patients with diabetes mellitus and the normal population. SUBJECTS AND METHODS: The oral health status of 100 metabolically controlled geriatric diabetic patients attending the Diabetes Clinic of the Manipal Hospital, were prospectively assessed over six months and compared with that of 50 non-diabetic acting as controls. RESULTS: The mean duration of diabetes was 100.5±85.1 months. The degree of hyposalivation between the two groups was statistically significant (p < 0.05). No significant difference was observed in the taste, burning mouth sensation, angular cheilitis, glossitis, and stomatitis status of the two groups and no pathgnomonic lesions or alterations could be observed in relation to the disease. CONCLUSION: It was concluded that, with adequate metabolic control, the oral health status of a diabetic may not be significantly different from that of a non-diabetic except for xerostomia.

OBJETIVO: Avaliar possíveis diferenças na saúde bucal de pacientes geriátricos com diabetes mellitus em comparação a uma população normal. CASUÍSTICA E MÉTODO: A condição de saúde bucal de 100 pacientes geriátricos diabéticos, metabolicamente controlados, atendidos na Clínica de Diabetes do Hospital Manipal foram avaliados prospectivamente durante seis meses e comparados com 50 pacientes geriátricos não diabéticos (grupo controle). RESULTADOS: A duração média do diabetes foi 100 m5 +- 85,1 meses. O grau de hiposalivação entre os dois grupos foi estatisticamente significante (p < 0,05). Não foram encontradas diferenças significativas no paladar, sensação de queimação bucal, queilite angular, glossite e estomatites entre os dois grupos. Não foram observadas lesões patognômicas ou alterações relacionadas ao diabetes. CONCLUSÃO: Concluiu-se que, com controle metabólico adequado, as condições bucais de pacientes diabéticos geriátricos pode não ser significativamente diferente das de um não diabético, com exceção da xerostomia.

Painless pancreatitis: a rare manifestation of leptospirosis.

A rare case of painless pancreatitis caused by Leptospira is reported. The patient presented clinically with features of paralytic ileus and renal failure. Hyperamylasemia was persistent inspite of recovery of renal function. The patient recovered on treatment with penicillin and serum amylase returned to normal in three months.

Clinical study of 100 cases of Kyasanur Forest disease with clinicopathological correlation.

100 cases of Kyasanur Forest Disease were studied clinically and autopsy or postmortem biopsies of various organs were done in 8 cases. 1. Our study showed that KFD passes through 4 stages each lasting for about a week. i.e. a prodromal stage with fever, hypotension hepatomegaly, a stage of complication characterized by haemorrhage, neurological manifestation or bronchopneumonia, a stage of recovery followed by a li stage of fever in some cases. 2. The exact of cause of haemorrhage could not be identified though Disseminated Intravascular Coagulation was suspected. 3. Hypotension in KFD could be of Myocardial origin. 4. Encephalopathy in KFD could be due to a metabolic cause probably of hepatic origin. 5. Lung signs could be due to intraalveolar haemorrhage and secondary infection.