Effect of Overt Diabetes and Gestational Diabetes Mellitus on Pregnancy Outcomes and Progression.

Background/Purpose: To study the clinical characteristics, outcomes, and the incidence of postpartum diabetes in women with overt diabetes and GDM. Methods: This prospective cohort observational study was done on women with GDM diagnosed after the first trimester, attending the tertiary care hospitals for 2.3 years. Comparison of clinical variables and maternal and neonatal outcomes were recorded in women with overt diabetes and GDM. The postpartum glycemic status was determined at 1 and 6 months. Results: There were 32(17.9%) women with overt diabetes and 146(82.1%) women with GDM. Women with overt diabetes were older, had a higher frequency of pre-pregnancy and maternal obesity, family history of diabetes, previous history of GDM, polycystic ovarian syndrome (PCOS), signs of insulin resistance, and need for insulin treatment than women with GDM. The prevalence of gestational hypertension and frequency of spontaneous abortion and large for gestational age (LGA) neonates were significantly higher in women with overt diabetes than in GDM, despite comparable glycemic goals. Postpartum diabetes at 1 and 6 months was significantly higher in women with overt diabetes than in those with GDM. Conclusion: It is critical to identify women with overt diabetes in pregnancy because of increased risk of adverse maternal and neonatal outcomes, and rapid progression to postpartum diabetes, despite achieving optimal glycemic goals.

Maternal and neonatal outcomes in women with recurrent gestational diabetes mellitus.

BACKGROUND AND AIMS: The aim of the study was to evaluate the maternal and neonatal outcomes in women with recurrent gestational diabetes mellitus (GDM), compared to women with GDM. METHODS: This prospective observational cohort study was done on multiparous women with GDM attending the two tertiary care hospitals. Subjects were divided into two groups, recurrent GDM and GDM. Demographics, clinical variables, and maternal and neonatal outcomes were recorded between the two groups. The postpartum glycemic status was determined at six months. RESULTS: There were 36 (20.2%) women with recurrent GDM and 142 (79.8%) women with GDM. Women with recurrent GDM were older (32.4 ± 6.2 versus 29.8 ± 5.6 years), had higher frequency of obesity, and insulin resistance than women with GDM. Women with recurrent GDM had poor glycemia at diagnosis as compared to GDM. Although the glycemic goals achieved were comparable but women with recurrent GDM have increased frequency of gestational hypertension, preeclampsia, and need for cesarean section. Women with recurrent GDM significantly had higher frequency of large for gestational age (LGA) and macrosomic neonates. Postpartum diabetes at six months was significantly higher in women with recurrent GDM. CONCLUSION: Women with recurrent GDM are at increased risk of adverse maternal and perinatal outcomes despite achieving optimal glycemic goals and also at the most significant risk of postpartum diabetes.

A Prospective study of Emphysematous Pyelonephritis in Patients with Type 2 Diabetes.

INTRODUCTION: Emphysematous pyelonephritis (EPN) is a necrotizing infection of the renal parenchyma. There is a lack of studies on follow up of EPN patients. The study aimed to explore the effect of EPN in patients with type 2 diabetes (T2D) on glycemic and renal parameters on follow up, and factors suggesting the failure of medical treatment. METHODS: This was a hospital-based prospective study done over a period of 3 years on newly diagnosed consecutive 20 patients of emphysematous pyelonephritis (EPN) with T2D. Study analyzed the clinical, laboratory, radiological, microbiological findings, complications, treatment modality, and outcome. All patients were followed up for 6 months with respect to the number of urinary tract infections (UTIs), glycemic control, and renal parameters. RESULTS: Most of the patients were postmenopausal females with longer duration of diabetes and complicated by triopathy. Fever and renal angle tenderness were the most common clinical finding. The majority of our patients 12 (60%) had EPN (class 1 and 2). Severe hyperglycemia was present in 19 (95%), hyperosmolar hyperglycemic state (HHS) in 5 (25%), diabetic ketoacidosis (DKA) in 3 (15%), and acute kidney injury (AKI) in 15 (75%). Bacteriuria was present in 90% and bacteremia in 30%. E. coli was the most common organism isolated (80%). The survival rate was 90%, with failure of medical treatment in 30%. Renal obstruction and worsening azotemia predicted the failure of medical management. The significant number (11, 55%) of patients developed recurrent UTI on follow up. Factors that increased the risk of recurrent UTI in EPN were chronic kidney disease, poor glycemia, and renal obstruction. The recurrent UTI patients had significantly higher glycosylated hemoglobin A1c (HbA1c) at follow up than at baseline, but renal parameters did not differ. CONCLUSIONS: We recommend early aggressive medical treatment of EPN. Altered sensorium, renal obstruction, and deteriorating renal function may suggest the failure of medical treatment.

Clinical Characteristics, Outcomes, and Progression to Type 2 Diabetes in Women with Hyperglycemia in Pregnancy.

Context: Women with hyperglycemia in pregnancy (HIP) are at increased risk of developing type 2 diabetes (T2D). Aim: The present study intended to study the incidence of postpartum diabetes among HIP women and predict its risk factors. Settings and Design: This was a prospective observational study done on 178 women with HIP diagnosed after the first trimester, attending the tertiary care hospitals between December 2018 and March 2020. Materials and Methods: Demographics, clinical variables, and feto-maternal outcomes were recorded. The postpartum glycemic status was determined using a 75 g oral glucose tolerance test (OGTT) at 1 and 6 months. Statistical Analysis: All analyses were performed with SPSS software (version 21.0). Results: The mean age of women with HIP was 30.2 ± 6.1 years, with 38% having a family history of diabetes. Eighty percent of the women delivered full-term babies and 71.3% underwent a cesarean section. Gestational hypertension was present in 21.9% of patients. Macrosomia was present in 4.6% of the babies, hypoglycemia in 6.7%, and spontaneous abortion occurred in 7.7%. Postpartum OGTT at 6 months was completed by 76.4% of participants. The incidence of diabetes and glucose intolerance postpartum was 11.7 and 16.2%, respectively at 6 months. Logistic regression analysis showed that maternal obesity, diagnosis of HIP at an earlier trimester (<24 weeks), need for insulin treatment during pregnancy, signs of insulin resistance and fasting and 2-h plasma glucose >100 (>5.6 mmol/L) and >195 mg/dL (>10.9 mmol/L), respectively, and glycated hemoglobin > 6.5% (>48 mmol/mol) increased the risk of having postpartum diabetes significantly. Conclusion: The incidence of postpartum glucose intolerance in women with HIP is high. Prospective diabetes evaluation is required and intervention should be considered in women with HIP who have obesity, diagnosis of HIP at an earlier trimester, signs of insulin resistance, and require insulin treatment during pregnancy.

Factors associated with severity of orbitopathy in patients with Graves' disease.

PURPOSE: Graves' orbitopathy (GO) is one of the most frequent orbital disorders and is the most common cause of proptosis in adults. GO is described as chronic inflammation of orbital and periorbital tissues. This study aimed to evaluate the risk factors for severe GO in patients with Graves' disease (GD). MATERIALS AND METHODS: This was a prospective cross-sectional study done on 52 newly diagnosed patients of GD with GO documented by thyroid 99mTechnetium-pertechnetate scan at our center between May 2016 and May 2019. All patients underwent a comprehensive ophthalmological examination and laboratory and hormonal analysis. Clinical Activity Score (CAS) and severity were estimated as per the European Group on Graves Orbitopathy. Thirty-four patients with mild GO were compared with 18 patients with moderate-to-severe GO (severe) for baseline risk parameters. RESULTS: Majority of the patients had mild orbitopathy (34 [65.4%]) followed by moderate to severe (18 [34.6%]). CAS was active in 13.5% of the study group. There was a statistically significant male preponderance in severe GO. Current smoking increased the risk of severe GO (P = 0.003). Duration of GD symptoms at presentation was statistically significantly longer in severe GO patients than mild GO (P = 0.004). Thyrotropin receptor antibody (TRAb) titer significantly increased in severe GO group (6.2 ± 2.4 IU/L) when compared to mild GO (3.2 ± 1.6 IU/L) (P < 0.001). TRAb positivity was similar between groups. Braley's sign, i.e., the differential intraocular pressure (IOP) of >6 mmHg, was statistically significantly higher in severe GO (P < 0.001). Male gender, current smoking, TRAb >2 upper limit of normal (ULN), and differential IOP >6 mmHg were found to be associated with severe GO. CONCLUSION: Approximately 35% of the patients with GO have severe disease, with a higher risk in men. This study identified male gender, current smoking, TRAb >2 ULN, and differential IOP >6 mmHg to be associated with severe GO.

Comparative study of emphysematous pyelonephritis and pyelonephritis in type 2 diabetes: a single-centre experience.

PURPOSE: Emphysematous pyelonephritis (EPN) patients with type 2 diabetes (T2D) have severe complications and high morbidity with poor prognosis as compared to Pyelonephritis. The aim was to study clinical features, microbiological profile, complications of EPN and pyelonephritis in T2D patients. METHODS: This was a hospital-based prospective study done on 200 T2D patients with upper UTI. Various clinical, biochemical parameters and urine examination and culture were monitored. Patients were followed up for 6 months with respect to number of UTIs, glycemic control and renal parameters. RESULTS: Pyelonephritis was present in 180(90%) and EPN in 20(10%) of upper UTI patients. Longer duration of diabetes, presence of nephropathy, chronic kidney disease (CKD), hypertension (HTN), history of symptomatic UTI in a prior year, renal calculi and obstruction increase the risk of EPN. Patients with EPN commonly present with vomiting, flank pain altered sensorium and renal tenderness. Complications like diabetic ketoacidosis (DKA), hyperglycemic hyperosmolar state (HHS), multiorgan dysfunction syndrome (MODS), acute kidney injury (AKI) and hypotension occur frequently in EPN as compared to pyelonephritis in T2D patients. Patients with EPN had poor glycemia and lower estimated glomerular filtration rate (eGFR) as compared to pyelonephritis. Bacteriuria was present in 90% and 66.7% of EPN and pyelonephritis patients respectively. E. coli was the most common isolate in both UTI groups. A significant number of EPN patients develop recurrent UTI. Patients with EPN have an improvement in glycemia on follow up, but renal parameters do not improve on follow up, while as pyelonephritis patients have an improvement in glycemia and renal parameters with intensive treatment. Recurrent UTI in upper UTI patients leads to worsening of glycemia and renal parameters. CONCLUSION: Complications frequently occur in EPN patients as compared to pyelonephritis.

Role of N-acetylcysteine treatment in non-acetaminophen-induced acute liver failure: A prospective study.

BACKGROUND/AIMS: Acute liver failure (ALF) is a rare but severe medical emergency. To date, there is no established treatment for non-acetaminophen-induced acute liver failure (NAI-ALF) other than liver transplantation, and little is known about the use of N-acetylcysteine (NAC) in NAI-ALF. A randomized case control study was conducted with the aim to determine the effect of NAC on the mortality of NAI-ALF patients, as well as to evaluate the safety and efficacy of NAC use. PATIENTS AND METHODS: A total of 80 patients diagnosed with NAI-ALF were included in the study. Forty patients received NAC infusion for 72 h whereas the control group received placebo. The variables evaluated were demographic characteristics, signs and symptoms, biochemical parameters, and clinical course during hospitalization. RESULTS: The two groups (NAC and control) were comparable for various baseline characteristics (such as etiology of ALF, INR, alanine aminotransferase, creatinine, albumin, and grade of encephalopathy), except for age. Although majority of patients had undetermined etiology (32.5% in NAC group and 42.5% in control group), the second main cause was acute hepatitis E and drug or toxin-induced ALF. The mortality decreased to 28% with the use of NAC versus 53% in the control group (P = 0.023). The use of NAC was associated with shorter length of hospital stay in survived patients (P = 0.002). Moreover, the survival of patients was improved by NAC (P = 0.025). Also, drug-induced ALF showed improved outcome compared to other etiologies. CONCLUSION: The findings of the study recommend the use of NAC along with conventional treatments in patients with NAI-ALF in non-transplant centers while awaiting referrals and conclude the use of NAC as safe.