Jaundice and anaemia as presenting features of an incomplete autoimmune polyglandular syndrome type II.

The coexistence of adrenal failure with either autoimmune thyroid disease and/or type 1 diabetes is defined as autoimmune polyglandular syndrome (APS) type 2 or Schmidt's syndrome. Vitiligo, hypergonadotropic hypogonadism, chronic autoimmune hepatitis, alopecia, pernicious anaemia and seronegative arthritis may also be present. We present a case of 45-year-old Indian man with progressive jaundice and asthenia for 3 months. He was also found to have pallor, icterus, dry coarse skin and delayed relaxation of ankle jerk. Investigations showed pancytopaenia with megaloblastic changes due to pernicious anaemia, autoimmune hypothyroidism and autoimmune adrenalitis with evolving adrenal insufficiency. Upper gastrointestinal endoscopy guided biopsy showed evidence of gastric mucosal atrophy. Patient responded well to hydroxocobalamin and thyroxine replacement. Detailed workup to check for evolving APS II is prudent in a hypothyroid patient presenting with pallor and jaundice. It may alert physicians to possible adrenal crisis in the future, especially after starting levothyroxine replacement in these patients.

A case of adult onset Still's disease with flare of arthritis.

Adult onset Still's disease is a febrile illness of unknown aetiology, accounting for about 6% cases of fever of unknown origin. It was first described by Eric GL Bywater in 1971, and since then few case series have been reported from India and other parts of the globe. A case of adult onset Still's disease who presented with fever and polyarthralgia of 18 months duration with flare of joint symptoms during fever spikes has been reported.

Quality of life as a key indicator of patient satisfaction and treatment compliance in people with type 2 diabetes mellitus in the IMPROVE study: a multicentre, open label, non-randomised, observational trial.

Diabetes is a debilitating chronic illness having multiple impacts on physical and mental well-being of patients. When treating chronic conditions like diabetes, psychosocial aspects and quality of life (QoL) have to be considered; however, these receive less attention due to various reasons. Patients with diabetic complications have increased levels of depression and decreased QoL This necessitates evaluating QoL of patient which now is used as a primary or secondary end point in clinical trials eg, Diab-MedSat QoL questionnaire used in diabetes. At some point all diabetic patients may require insulin to control hyperglycaemia and disease progression. The traditional insulin syringe and needle delivery system has been the principal barrier in the treatment of diabetes as it was not well accepted among the patients due to various reasons. A success over this approach has been pen like devices like FlexPen and Novopen3 which are becoming more popular than the conventional syringe-and-needles as they have several advantages like, easy to carry, use, maintain and also reduces administrative errors ensuring accurate doses are delivered. The objective of IMPROVE study is to evaluate the safety and effectiveness of biphasic insulin aspart (NovoMix 30) in normal clinical practice conditions, in India. This is an open label, non-randomised, non-interventional, observational, safety and effectiveness study in approximately 17,995 patients with type 2 diabetes mellitus. A cohort of Indian patients (n = 349) from all 4 geographical locations (North, West, East and South of India) were administered QoL instrument Diab-MedSat at baseline and 346 patients at final visit (n = 346) to assess their satisfaction with the treatment they received. The results were included in the final statistical analysis as additional outcome variables. The Diab-MedSat Novo Nordisk June 2004 English (UK) version is used. The Diab-MedSat has 21 items that need to be answered and it is scored as an overall score (all 21 items) as well as three subscale scores regarding burden (11 items), symptoms (5 items), efficacy (5 items). The complete analysis took into account all 21 items of Diab-MedSat questionnaire with their subscales. Analyses of the cohort showed higher patient satisfaction among the patients administered Diab-MedSat questionnaire from baseline (n = 349) to final visit (n = 346). The mean of overall score was 52.33 (baseline visit) versus 79.03 (final visit). The difference in the overall score and sub parameters like burden, symptoms and efficacy between the baseline and final visits were statistically significant (p-value < 0.001). The mean value of difference in overall score between the baseline visit and final visit was 26.73 +/- 20.83; while the difference for burden, symptoms and efficacy were respectively 27.86 +/- 20.81, 19.75 +/- 20.94 and 32.87 +/- 28.08. A fairly clear picture emerged that the use of biphasic insulin aspart resulted in improved QoL of the patients substantially. This is demonstrated in the results for all the parameters that were used like symptoms, efficacy and burden. The overall number of extremely satisfied patients had increased from 5.4% in the baseline visit to 91% in the final visit. This unambiguously proves that the satisfaction of patients on biphasic insulin aspart (NovoMix 30) is beyond question.

A study to find out the proportion of prediabetes in patients with acute coronary syndrome in a medical college of Kolkata.

Prediabetes is now considered as a definite entity for increased incidence of cardiovascular disease and a potent risk for progression to type 2 diabetes mellitus. As macrovascular disease is the commonest cause of increased mortality in dysglycaemic individuals (prediabetes and diabetes) by 2-4 times as opposed to normal individuals, clinicians do encounter patients with cardiovascular disease of varying severity regularly. There are increased constellation of other cardiovascular risk factors (hypertension, dyslipidaemia, etc), in prediabetes as compared to normal population. Here a study was carried out among 62 acute coronary syndrome patients who were admitted in a tertiary care hospital in Kolkata to find out the proportion of prediabetes in them. Majority of the patients (54.8%) were in the age group of 45-64 years and were males (77.4%). The study showed 48.4% of all acute coronary syndrome patients were prediabetic and 25% were diabetic. The proportion of impaired fasting glucose and impaired glucose tolerance were 19.4% and 22.6% respectively. So, altogether 72.4% patients were dysglycaemic. Out of all acute coronary syndrome patients, non-ST elevated myocardial infarction group had 50% prediabetic patients, ST elevated myocardial infarction group had 50% prediabetic patients and unstable angina group have 45.8% prediabetic patients. So, all patients of acute coronary syndrome should be screened to detect hyperglycaemia in early stage to prevent further development of diabetes mellitus and also further cardiovascular events.

Metabolic emergencies in diabetes.

Hypoglycaemia is the commonest metabolic abnormality faced by diabetic patients on hypoglycaemic therapy including insulin. Diabetic keto-acidosis (DKA) requires prompt diagnosis and all patients arriving emergency with dehydration, shock, coma, severe respiratory difficulty and evidence of any major illness should be tested for capillary blood glucose (CBG) and urinary ketones urgently not to miss DKA. Hyperosmolar non-ketotic state complicates elderly type 2 diabetes with intercurrent infections (respiratory tract infection is commonest) characterised by severe dehydration, severe hyperglycaemia and absence of acidosis and vomiting. Lactic acidosis is extremely rare; may be compounded with comorbidities like tissue hypoxia, septic shock, heart failure--metformin usage inadvertently may precipitate the condition.