The Impact of Kidney/Pancreas Transplantation on Peripheral Arterial Disease.

INTRODUCTION: It is unclear whether kidney/pancreas (KP) transplantation will prevent the progression of peripheral arterial disease (PAD) in patients with insulin dependent diabetes (IDDM) and end-stage renal disease. We sought to determine the pre- and posttransplant prevalence of symptomatic PAD and changes in carotid artery intima-media thickness (IMT) in KP recipients. METHODS: In this single center study, outcomes were compared between KP recipients with and without a history of PAD. A subset of recipients underwent pre- and posttransplant IMT measurements. RESULTS: Among the study group (N = 107), 18 (17%) recipients admitted to a pretransplant history of symptomatic PAD, comprised 11 foot infections and 7 amputations (5 minor and 2 major). Baseline characteristics of age, gender, race, years of diabetes, dialysis history, smoking history, years of hypertension, and history of coronary artery disease (CAD) were equivalent between PAD and non-PAD cohorts. At a median follow-up of 60 months (IQR: 28, 110), 16 (15%) KP recipients had suffered a PAD event. In multivariate analysis, a pretransplant history of PAD (hazard ratio [HR] 9.66, p < 0.001) and CAD (HR 3.33, p = 0.04) were independent predictors of posttransplant PAD events. Among a subset of 20 recipients (3 with PAD), mean IMT measurements pretransplant and at a median of 24 (range 18-24) months posttransplant, showed no evidence of disease progression. CONCLUSION: Based on IMT measurements and clinical results, KP transplantation stabilized PAD in most patients, but did not alter outcomes of symptomatic PAD recipients. A pretransplant history of PAD and CAD was an independent predictor of posttransplant PAD events.

Linear Nevus Sebaceous Syndrome: Clinical Presentation and Management Considerations.

A relatively rare neurocutaneous condition known as linear nevus sebaceous syndrome (LNSS) is marked by a variety of symptoms as well as the unusual characteristics of developing mosaic RASopathies of phacomatoses. Mental retardation, seizures, and midline facial linear nevus sebaceous were the usual diagnostic triad. A hallmark of LNSS is the papillomatous growth of the epidermis, also known as nevus sebaceous. In this case report, we presented a case of a 13-year-old male with LNSS with a vascular conjunctival lesion and a coloboma of the optic disc.

Comparative evaluation of the efficacy of Triphala mouthwash and Curcumin mouthwash in the treatment of gingivitis - A randomized controlled study.

Background: Numerous studies on Triphala and Curcumin mouthwashes were analyzed individually and no study has compared the efficacy of Triphala mouthwash to Curcumin mouthwash in the management of gingivitis. Although various mouthwashes have shown reduction of plaque and gingivitis the search is still on for an ideal mouthwash with minimum side effects and better patient acceptance. Objectives: To access the efficacy of all the mouthwashes in the management of gingivitis. Methods: By purposive sampling, 81 patients of both sexes with gingivitis were randomized by lottery method into 3 groups - A, B and C. Group A received scaling and Triphala mouthwash, Group B received scaling and Curcumin mouthwash and Group C underwent scaling and received Chlorhexidine mouthwash. Oral hygiene was assessed using Plaque, Gingival and Bleeding indices at baseline,7th day and 14th day. The inter-group comparisons were analysed using One-way analysis of variance (ANOVA) and multiple comparisons using Tukey's Honest significant difference test (α = 0.05) and the intra-group comparisons for the indices across various time periods within each group were analysed using Repeated-measures ANOVA and Bonferroni-adjusted pairwise comparisons post hoc test (α = 0.05). The statistical significance was set at p ≤ 0.05. Results: The study has shown that herbal mouthwashes are as effective as chlorhexidine in treating gingivitis although curcumin mouthwash showed a greater potential in reducing gingival inflammation. Conclusion: Both Triphala and Curcumin mouthwashes were proven to be equally effective in reducing plaque, gingival and bleeding scores, although curcumin was better in reducing gingival inflammation. Hence herbal mouthwashes such as Triphala and Curcumin with no side effects can be considered as an alternative mouthwash to chlorhexidine.

Fulminant Eye Infection in a Patient With Nephrotic Syndrome: A Case Report.

This case report presents the clinical course of a 53-year-old male farmer with nephrotic syndrome, specifically focal segmental glomerulosclerosis, who developed a fulminant eye infection. While receiving maintenance hemodialysis and immunosuppressive therapy, the patient presented with sudden onset redness, discharge, and decreased vision in his right eye. Initial management with topical antibiotics and steroids failed to halt the progression of the infection, leading to corneal perforation and iris prolapse within a few days. Despite the discontinuation of immunosuppressive medications and initiation of broad-spectrum antimicrobial therapy, the patient's compromised renal function and anaemia precluded surgical intervention. This case underscores the challenges in managing severe ocular infections in immunocompromised patients. It highlights the importance of early recognition, aggressive antimicrobial therapy, and close ophthalmologic monitoring in preventing sight-threatening complications. Despite intensive management, the prognosis for visual recovery in such cases may be poor, emphasizing the need for preventive strategies and careful surveillance in high-risk patient populations.

Understanding the Clinical Relationship Between Diabetic Retinopathy, Nephropathy, and Neuropathy: A Comprehensive Review.

Diabetic retinopathy, nephropathy, and neuropathy are significant microvascular complications of diabetes mellitus, contributing to substantial morbidity and mortality worldwide. This comprehensive review examines the clinical relationship between these complications, focusing on shared pathophysiological mechanisms, bidirectional relationships, and implications for patient management. The review highlights the importance of understanding the interconnected nature of diabetic complications and adopting a holistic approach to diabetes care. Insights gleaned from this review underscore the necessity for early detection, timely intervention, and integrated care models involving collaboration among healthcare professionals. Furthermore, the review emphasizes the need for continued research to elucidate underlying mechanisms, identify novel therapeutic targets, and assess the efficacy of integrated care strategies in improving patient outcomes. By fostering interdisciplinary collaboration and knowledge exchange, future research endeavors hold the potential to advance our understanding and management of diabetic complications, ultimately enhancing patient care and quality of life.

A Woman with Bilateral Pheochromocytoma and Tuberous Sclerosis Complex.

Background/Objective: Pheochromocytoma and paraganglioma (PPGL) are rare neuroendocrine tumors. Here, we report an unusual case of synchronous PPGL in an asymptomatic patient with tuberous sclerosis complex (TSC). Case Report: A 49-year-old woman with a history of TSC and end-stage renal disease was referred for evaluation of bilateral adrenal and retroperitoneal masses. She denied chest pain, palpitations, headaches, or previous hypertensive crisis. The laboratory test results showed a plasma normetanephrine level of 20.20 nmol/L (normal range, 0.00-0.89 nmol/L) and plasma chromogranin A level Chromogranin A (CgA) levels of 1518 ng/mL (normal range, 0-103 ng/mL). The plasma metanephrine level was normal. After α-blockade, the patient underwent bilateral adrenalectomy and retroperitoneal mass excision. Pathology confirmed these lesions to be pheochromocytoma and composite paraganglioma/ganglioneuroma, respectively. Her plasma normetanephrine level normalized postoperatively, and the chromogranin A levels improved to 431 ng/mL. Discussion: Routine imaging has increased the incidental diagnosis of PPGL. Diagnostic workup includes measurement of the urinary and/or plasma metanephrine and catecholamine levels followed by tumor localization. Patients with young age, syndromic lesions, bilateral PPGL, or unilateral disease with a positive family history should have genetic testing. Definitive treatment is surgical after α-blockade. Conclusion: This case highlights a rare presentation of bilateral PPGL in a patient with TSC.

Regeneration of the Retina Using Pluripotent Stem Cells: A Comprehensive Review.

Retinitis pigmentosa and age-related macular degeneration are the most frequent causes of irreversible visual impairment in the world. Existing therapeutic methods could be more effective, underscoring the necessity of new treatments. Reconstructing the retinal photoreceptors through the transplantation of human pluripotent stem cells, representing an attractive approach for restoring vision, has gained momentum. This paper gives an exhaustive account of what has been known in this field, the discoveries made, and the recent progress. This review paper outlines the retina's organisation, cell types, the pathophysiology of retinal injury/degeneration, and the reasoning behind using pluripotent stem cells in retinal regeneration. This article investigates differentiation strategies, molecular components that dictate cell type specification, and the recreation of retinal development in vitro, genetically engineering and manipulating epigenetic marks using various techniques for driving specific cell fates and improving therapy efficacy. Subretinal injection methods, cell encapsulation techniques, scaffold-based approaches, cell sheet transplantation, and their impact on integrating implanted cells into a functional retina are thoroughly reviewed. Using bioengineering approaches, biomaterials and growth factors form a favourable micro-ambience for grafted cells. Issues around safety and efficacy (tumorigenicity, immunological rejection, and long-term integration/functionality) are explored. Moreover, the paper emphasises the significance of rigorous characterisation, immunomodulatory strategies, and clinical and pre-clinical studies to ensure the safety and effectiveness of retinal regeneration therapy. Future perspectives and challenges are presented, looking at fine-tuning differentiation strategies, improving functional integration and regulatory aspects, and using co-therapy and supportive treatments.

A Narrative Review of Retinopathy in Diabetic Patients.

Patients with diabetes may be at risk of ocular diseases, like retinopathy due to diabetes and oedema of the eye. Patients with retinopathy due to diabetes experience constant injury to the retina and the posterior end of the eye, which is light-sensitive. It is a prominent complication faced by diabetics that threatens a patient's vision. Diabetes can inhibit the body's potential to ingest and maintain blood glycemic levels, resulting in several health problems. Excessive glucose in the blood can affect the eyes and other organs of the body. Diabetes has an effect on the blood supply system of the retina over a prolonged period of time. Diabetes-related retinopathy can lead to blindness as fluid can flow into the macula, which is essential for maintaining a clear visual field. The macula, despite its small size, is the region that enables us to comprehend colours and fine peculiarities well. The fluid swells the macula, leading to an impaired visual field. The weak, irregular blood vessels formed during neovascularization can potentially haemorrhage into the posterior end of the eye, obstructing the visual field. Blood vessels of the eye leak blood and other fluids, causing retinal tissue enlargement and eyesight clouding. Typically, the illness affects both eyes. Diabetes retinopathy is more likely to develop as a person's diabetes progresses. If untreated, retinopathy due to diabetes can result in blindness.

Comparative physicochemical and structural characterisation studies establish high biosimilarity between BGL-ASP and reference insulin aspart.

Biosimilar insulin analogues are increasing market access for diabetic patients globally. Scientific establishment of biosimilarity is cornerstone of this key change in the medical landscape. BGL-ASP is a biosimilar insulin aspart developed by BioGenomics Limited, India. BioGenomics has considered a stepwise approach in generating the totality of evidence required to establish similarity with reference product. Insulin aspart is a recombinant rapid-acting human insulin analogue utilised in the treatment of type-1 and type-2 diabetes mellitus. The single amino acid substitution at position B28 where proline is replaced with aspartic acid results in a decreased propensity to form hexamers, thus increasing the absorption rate on subcutaneous administration compared to native insulin. In order to establish the safety and efficacy of BGL-ASP, the critical quality attributes (CQAs) of BGL-ASP are identified based on the impact created on biological activity, pharmacokinetic/pharmacodynamic (PK/PD), immunogenicity and safety. The CQAs of insulin aspart are related to product structure, purity and functionality and are characterised using a series of state-of-the-art orthogonal analytical tools. The primary protein sequence, the secondary, tertiary and quaternary structure are found to be highly similar for BGL-ASP and reference product. The product related impurities of insulin aspart and the assay content are determined using high performance liquid chromatography (HPLC) based analysis and is similar for BGL-ASP and reference insulin aspart sourced from United States of America (US), Europe Union (EU) and India. The safety, efficacy and immunogenicity of BGL-ASP is also found to be comparable with reference product and is confirmed through the clinical trials conducted as recommended by International Council for Harmonisation of Technical Requirements of Pharmaceuticals for Human Use (ICH) and European Medicines Agency (EMA) guidelines. The data encompassed in this study demonstrates that reference insulin aspart and BGL-ASP are highly similar in terms of structural, physicochemical, and biological properties, thus confirming its safety and efficacy for usage as potential alternative economical medicinal treatment for diabetes mellitus.

Advancement in Understanding Diabetic Retinopathy: A Comprehensive Review.

Diabetic retinopathy (DR) is a significant global health concern, with its prevalence and severity increasing alongside the rising incidence of diabetes. DR is a leading cause of vision impairment among working-age adults, resulting in substantial economic and healthcare burdens. This article explores the epidemiology and pathophysiology of DR, highlighting the global variation in its prevalence and the associated systemic risk factors. It delves into the complex relationship between glycemic control, duration of diabetes, and medication use in the context of DR development and progression. The review also discusses current screening methods and their implications, emphasizing the need for efficient and scalable approaches. Furthermore, it investigates the various treatment strategies available for DR, including laser photocoagulation, vitreous body excision, and anti-vascular endothelial growth factor (VEGF) therapy, while underlining their limitations and potential side effects. In conclusion, this article underscores the urgency of developing novel preventive and therapeutic approaches for DR. It highlights the potential role of cytokines and growth factors as treatment targets and emphasizes the importance of glycemic control and management of systemic risk factors in mitigating the impact of this vision-threatening complication of diabetes. The article serves as a comprehensive resource for understanding the challenges posed by DR and the need for innovative strategies to address this growing public health concern.

Ocular Dominance and Its Association With Central Corneal Thickness: An Observational Study in Central India.

Background The aim of this study is to determine ocular dominance and its association with central corneal thickness (CCT). These two parameters are of great significance in clinical practice; identifying the dominant eye helps in planning cataract surgeries, treatment of presbyopia, monovision correction, etc., and assessing the CCT helps in early diagnosis and management of keratoconus, glaucoma, contact lens-related complications, and dry eye. Methods A cross-sectional study that involves patients and volunteers who have come for a checkup to the ophthalmology department of the college hospital. Ninety patients were examined for this study within two months. The hole-in-card test is performed to determine the ocular dominance in people with normal and healthy eyes without any pathologies except refractive errors. Specular microscopy through a non-contact modality will be done to assess the thickness of the central cornea in both eyes. Statistical analysis was done using the paired t-test to compare the patient's eyes and the chi-square test, which helps us associate ocular dominance and CCT.  Results Right eye dominance was seen in the majority of the participants (72.91%), whereas left eye dominance was seen in comparatively fewer participants (27.08%). The CCT of the dominant eye is found to be 520.40 ± 29.83 µm and that of the non-dominant eye is 524.40 ± 29.37 µm. A lower CCT in the dominant eye was seen in 83.33% of the subjects; 14.58% of them had a higher CCT in the dominant eye and 2.08% had the same CCT in both eyes. Conclusion From the observational study that has been made, the majority of the population shows right eye dominance. The CCT is relatively thinner in the dominant eye. About 80-85% of the examined people showed a thinner cornea in the dominant eye. But we cannot generalize that the eye with a lesser corneal thickness will be the dominant eye in all the cases, as a few cases have shown dominance in the eye with a thicker cornea.

In Vitro Biological Characterization of Recombinant Insulin Aspart from Biogenomics and Originator Insulin Aspart.

BACKGROUND: Bioassays are used to identify the pharmacological activity of new or chemically unknown compounds, as well as their undesirable effect, including toxicity. Biological assays are also required to ensure the quality, safety, and efficacy of recombinant biologics to confirm its biosimilarity to its originator. In the present study, analytical similarity between the biosimilar and its innovator is established by in vitro bioassays. OBJECTIVE: The objective of this study was to show the comparative in vitro characterization of the recombinant insulin aspart from BioGenomics with its originator insulin aspart, using relevant biological assays. METHODS: In vitro assays such as receptor binding, receptor autophosphorylation, glucose uptake, and mitogenic potential were analyzed for biological characterization of BioGenomics recombinant insulin aspart (BGL-ASP) manufactured by BioGenomics Limited and NovoRapid® as the reference medicinal product (RMP) manufactured by Novo Nordisk. Insulin receptor binding was studied by a state-of-the-art method, surface plasmon resonance (SPR) for biomolecular interactions. The receptor autophosphorylation assay measures the phosphorylated insulin receptor in cell lysates. The glucose uptake assay measures the uptake of glucose by 3T3-L1 cells in the presence of insulin. Lipogenesis was studied in treated 3T3-L1 cells by detecting the accumulation of lipid droplets in the cells. Mitogenic effect was studied by cell proliferation assay using MCF-7 cells. A rabbit bioidentity test was performed by measuring the sudden decrease in blood glucose in the presence of insulin. RESULTS: The binding studies showed that the affinity of BGL-ASP was highly comparable to NovoRapid®. Insulin receptor autophosphorylation, glucose uptake, and lipogenesis demonstrated high similarity to the RMP. The mitogenic assay for BGL-ASP did not show any proliferative effect and was comparable to the RMP. The in vivo bioidentity test showed that the BGL-ASP is highly similar to the innovator, NovoRapid®. CONCLUSION: The biological characterization studies of BGL-ASP demonstrated high binding and functional similarity to NovoRapid®.

Study of synthesis and characterization of raw bagasse, its char and activated carbon prepared using chemical additive.

This paper reports the use of naturally available raw material as sugarcane bagasse (SB) to prepare cost-effective activated carbon. Activated carbon preparation from SB by using ZnCl2 was carried out by chemical activation method. The raw bagasse, its char and activated carbon were characterized on the basis of iodine number, carbon, hydrogen, nitrogen analysis, Fourier-transform infrared spectroscopy (FTIR), scanning electron microscopy (SEM), thermogravimetric analysis (TGA) and Brunauer-Emmett-Teller (BET) surface area to check their effectiveness. During activated carbon synthesis, the impregnation ratio of SB and ZnCl2 was maintained at 1:1-1:3 and activation temperature was in the range of 600-900 °C for 1 h. From the characterization study, the highest iodine adsorption of activated carbon was found to be 1140.69 mg/g with a 1:2 ratio at 900 °C whereas char gives an iodine number of 529.63 mg/g at the same temperature. The BET surface area of raw bagasse, its char and activated carbon (SB-Zn2-900) obtained was 4.30, 514.27 and 1386.58 m2/g, respectively, which shows charrification and chemical activation improves surface area. The optimum ratio of impregnation and activation temperature was found to be 1:2 at 900 °C. In this work, activated carbon was successfully prepared and obtained product has better characteristics than previously reported studies.

Digital Health and Shared Decision-Making in Diabetes Care - A Survey Initiative in Patients and Clinicians.

OBJECTIVE: To assess the landscape of digital health resources in the United States, better understand the impact of the digital health on shared decision-making, and identify potential barriers and opportunities for progress in the care of persons with diabetes. METHODS: The study consisted of two phases: A qualitative phase in which one-on-one interviews were conducted virtually with 34 physicians (endocrinologists {Endos}: n = 15; primary care physicians {PCPs}: n = 19) between February 11, 2021 and February 18, 2021, and a quantitative phase in which two online, email-based surveys in the English language were conducted between April 16, 2021 and May 17, 2021: one with healthcare professionals (HCP) (n = 403: n = 200 Endos and n = 203 PCPs), and one with persons with diabetes (n = 517: patients with type 1 diabetes, n = 257; patients with type 2 diabetes, n = 260). RESULTS: Diabetes digital health tools were found to be helpful in shared decision-making, but leading barriers include cost, coverage, and lack of time by healthcare professionals. Among diabetes digital health tools, continuous glucose monitoring (CGM) systems were used most commonly and viewed as most effective in improving quality of life and facilitating shared decision-making. Strategies for increasing use of diabetes digital health resources included lower cost, integration into electronic health records, and increased simplicity of tools. CONCLUSION: This study revealed that both Endos and PCPs feel that diabetes digital health tools have an overall positive impact. Integration with telemedicine and simpler, lower cost tools with increased patient access can further facilitate shared decision-making and improved diabetes care and quality of life.

The Evolution of Diabetes Technology - Options Toward Personalized Care.

OBJECTIVE: Advances in diabetes technology, especially in the last few decades, have transformed our ability to deliver care to persons with diabetes (PWDs). Developments in glucose monitoring, especially continuous glucose monitoring (CGM) systems, have revolutionized diabetes care and empowered our patients to manage their disease. CGM has also played an integral role in advancing automated insulin delivery systems. OBSERVATIONS: Currently available and upcoming advanced hybrid closed-loop systems aim to decrease patient involvement and are approaching the functionality of a fully automated artificial pancreas. Other advances, such as smart insulin pens and daily patch pumps, offer more options for patients and require less complicated and costly technology. Evidence to support the role of diabetes technology is growing, and PWD and clinicians must choose the right type of technology with a personalized strategy to manage diabetes effectively. CONCLUSION AND RELEVANCE: Here, we review currently available diabetes technologies, summarize their individual features, and highlight key patient factors to consider when creating a personalized treatment plan. We also address current challenges and barriers to the adoption of diabetes technologies.

Confounder for Optic Disc Evaluation in Glaucoma.

Congenital disc anomalies like optic disc coloboma or optic disc pit are rare occurrences. Coloboma involving disc or optic disc coloboma occurs due to defective closure of choroidal fissure, which can be unilateral or bilateral. These anomalies are discovered on routine examination or referred to as an open-angle glaucoma suspect. These anomalies can be asymptomatic or may present with visual field defects. Here we report a case of both eyes angle closure glaucoma with incidental finding of unilateral coloboma involving disc in the left eye. Optical coherence tomography of the optic nerve head showed peripapillary nerve fiber loss. Thus assessing such patients for diagnosis and the progression of visual field defects in managing glaucoma is quite challenging.

A Review of Pathogenesis and Risk Factors of Diabetic Retinopathy With Emphasis on Screening Techniques.

Diabetes mellitus (DM) is an important topic for public health in India and globally. The rise in the number of cases of diabetes in India is alarming as it will eventually increase the number of cases of diabetic retinopathy (DR). DM is related to many microangiopathic abnormalities, among which DR has recently emerged as a common cause of vision impairment in middle and low-income countries. If diagnosed on time, we can prevent vision impairment and complete blindness in patients with the help of proper treatment. Life-long retinal check-ups among people who have diabetes are an essential strategy for the early diagnosis of DR. In this article, we have focused mainly on the significance of DR in loss of vision, the risk factors associated with the disease, the proper pathogenesis of the disease, including the involvement of vascular endothelial growth factor (VEGF), the further consequences of the disease, screening techniques that are already available and those that need to be incorporated, and finally the treatment options available for the patients. The knowledge about this disease and various components related to it, be it either risk factors, pathogenesis, or screening techniques and treatment, would surely help clinicians better understand the condition to formulate strategies for its early diagnosis and cost-effective and sustainable treatment, which would ultimately result in providing better care to the patients.

Management of Hyperglycemia in the Noncritical Care Setting: A Real-World Case-Based Approach With Alternative Insulin- and Noninsulin-Based Strategies.

Insulin remains the mainstay of treatment for inpatient hyperglycemia in the United States and Canada. However, some other countries commonly use noninsulin agents such as metformin and sulfonylureas, and several trials have demonstrated the efficacy and safety of incretin-based agents in patients with type 2 diabetes who are admitted to noncritical care medicine and surgery services. There is a high degree of interest in alternative glucose-lowering strategies to achieve favorable glycemic outcomes with lower risks of hypoglycemia. In this case series, we highlight the challenges of inpatient glycemic management and the need for alternatives to the traditional basal-bolus insulin regimen. Additional investigation will be imperative to validate the safety and efficacy of appropriate insulin and noninsulin treatments and to further develop guidelines that are applicable in real-world hospital settings.

Ocular Adverse Effects of Gefitinib: A Case Report.

Gefitinib is a selective epidermal growth factor receptor (EGFR) tyrosine kinase inhibitor. It is used for treating locally advanced or metastatic non-small cell lung carcinoma and is well tolerated systemically. However, sight-threatening ocular adverse effects, like corneal ulcer and perforation, can occur due to the expression of EGFR on limbal and conjunctival epithelia. In this report, we describe a case of a 36-year-old female who presented with loss of eyebrow hair and eyelashes of both eyes and blurring of vision in the right eye. On ocular examination, the patient had anterior blepharitis, madarosis, punctuate epithelial erosions and reduced corneal sensation in both eyes, and corneal thinning in the right eye. On specular microscopy, there was decreased central corneal thickness in both eyes. Treatment with topical antibiotics and lubricating drops led to the resolution of blepharitis and punctate epithelial erosions. This case report aims to create awareness among ophthalmologists and oncologists about the early detection of gefitinib-related ocular adverse effects and timely intervention in patients.