Evaluation of Double M-Band on Serum Protein Electrophoresis Simulating Biclonal Gammopathy: A Case Report.

Multiple myeloma is characterized by the presence of M-protein (monoclonal) in blood or urine. These proteins are immunoglobulins which are produced by a clone of abnormally proliferating B-lymphocytes and/or plasma cells. To evaluate M-protein, serum protein electrophoresis (SPEP) is used where a single band, known as M-band is seen. This band is usually seen in the gamma globulin region. However, in rare entities like biclonal gammopathy, two M-bands appear simultaneously at different positions on SPEP which may be attributed to the clonal expansion of two different neoplastic cell lines. Here, we describe an atypical case of IgA-kappa multiple myeloma, where two M-bands (one in the beta region and one in the gamma globulin region) were found during SPEP. This simulated a picture of biclonal gammopathy. However the monoclonal nature of this M-protein was proved by performing immunofixation electrophoresis (IFE). Further, we put across images to explain how IFE helps in differentiating between apparent and true biclonality.

Establishing evidence-based decision-making mechanism in a health eco-system and its linkages with health service coverage in 25 high-priority districts of Uttar Pradesh, India.

BACKGROUND: Achievement of successful health outcomes depends on evidence-based programming and implementation of effective health interventions. Routine Health Management Information System is one of the most valuable data sets to support evidence-based programming, however, evidence on systemic use of routine monitoring data for problem-solving and improving health outcomes remain negligible. We attempt to understand the effects of systematic evidence-based review mechanism on improving health outcomes in Uttar Pradesh, India. METHODS: Data comes from decision-tracking system and routine health management information system for period Nov-2017 to Mar-2019 covering 6963 health facilities across 25 high-priority districts of the state. Decision-tracking data captured pattern of decisions taken, actions planned and completed, while the latter one provided information on service coverage outcomes over time. Three service coverage indicators, namely, pregnant women receiving 4 or more times ANC and haemoglobin testing during pregnancy, delivered at the health facility, and receive post-partum care within 48 h of delivery were used as outcomes. Univariate and bivariate analyses were conducted. RESULTS: Total 412 decisions were taken during the study reference period and a majority were related to ante-natal care services (31%) followed by delivery (16%) and post-natal services (16%). About 21% decisions-taken were focused on improving data quality. By 1 year, 67% of actions planned based on these decisions were completed, 26% were in progress, and the remaining 7% were not completed. We found that, over a year, districts witnessing > 20 percentage-point increase in outcomes were also the districts with significantly higher action completion rates (> 80%) compared to the districts with < 10 percentage-point increase in outcomes having completion of action plans around 50-70%. CONCLUSIONS: Findings revealed a significantly higher improvement in coverage outcomes among the districts which used routine health management data to conduct monthly review meetings and had high actions completion rates. A data-based review-mechanisms could specifically identify programmatic gaps in service delivery leading to strategic decision making by district authorities to bridge the programmatic gaps. Going forward, establishing systematic evidence-based review platforms can be an important strategy to improve health outcomes and promote the use of routine health monitoring system data in any setting.

Assessment of Mineral Pathophysiology in Patients with Diabetic Foot Ulcer.

Chronic non-healing diabetic foot ulcers (DFU) with a recurrence rate of over 50% in 3 years account for more than 1,08000 non-traumatic lower extremity amputations. Reports of altered mineral status and their role in pathogenesis of diabetes are well documented. However, little is known regarding their status and impact on severity of complications like foot ulcer. A hospital-based case control study was conducted in 64 subjects aged 40-60 years, attending the Podiatric and the Diabetes clinic of the institutional hospitals. Study subjects included were 32 diagnosed cases of type 2 diabetes having foot ulcers along with 32 age-matched diabetics without foot ulcer as controls. Fasting and post-prandial plasma glucose were estimated by glucose oxidase peroxidase method and HbA1c by high-performance liquid chromatography method. Serum zinc, magnesium and copper levels were estimated by colorimetric methods in semi-autoanalyser. Serum levels of zinc, copper and magnesium were significantly decreased in DFU cases as compared with diabetics without ulcers (p < 0.05). Correlation analysis revealed a significant inverse correlation of these minerals with all the glycaemic indices; the association being the strongest in case of zinc in both groups. The higher degree of mineral insufficiencies in the foot ulcer group of this study could be responsible for worsening the glycaemic control in diabetics leading to delayed healing of foot ulcers. The observed decrease of serum copper, magnesium and zinc levels in diabetics with foot ulcers appears to be proportionally related to the length of the diabetic disease. Thus, continuous monitoring and dietary supplementation of minerals in case of severe deficiencies might be beneficial in halting the progression of such complications.

Association of Interleukin-6 and Myeloperoxidase with Insulin Resistance in Impaired Fasting Glucose Subjects.

Impaired fasting glucose (IFG) is a high risk subclinical condition for the progression of type 2 diabetes mellitus and the hyperglycemia seen in this condition is because of the development of insulin resistance (IR). Obesity, inflammation, oxidative stress and many other factors have been implicated in development of IR in type 2 diabetes mellitus and its successive complications. Current study was aimed to ascertain the correlation of inflammation and oxidative stress markers [interleukin-6 (IL-6) and myeloperoxidase (MPO)] with IR in subjects with IFG. In this study, 80 subjects (40 IFG, 40 healthy controls) aged 25-45 years were selected based on their fasting plasma glucose (FPG) values and clinical history. Serum insulin, IL-6 and MPO were estimated by ELISA method and IR was calculated using Homeostatic Model Assessment Index 2 (HOMA 2) calculator. Pearson's correlation coefficient and independent sample 't' test were used for statistical analysis. IL-6 and MPO were found to be significantly elevated in IFG group and both correlates significantly with IR (r 0.413, r 0.645). Only MPO had significant correlation with FPG (r 0.388). In conclusion, the association of altered levels of IL-6 and MPO with IR are suggestive of a role of inflammation and oxidative stress in the initiation and progression of IR in individuals with IFG.

Cross-sectional study of anxiety symptoms in students in preexamination period.

BACKGROUND: Preexamination period is an exceptionally stressful time for schoolgoing children and adolescents, and the propensity of having anxiety symptoms increases. AIM: This study aimed to assess the presence of anxiety symptoms in students in preexamination period. MATERIALS AND METHODS: The study was carried on 619 children from Class VIII to XI. All of them were given a structured questionnaire for sociodemographic profile and Screen for Child Anxiety Related Emotional Disorders questionnaire. Association of various variables with presence of anxiety symptoms was assessed. Statistics was analyzed with SPSS version 17.0 software. RESULTS: Totally 170 children (27.5%) had anxiety symptoms, similarly the various subgroups had increased frequency compared to the known prevalence in this age group. Age, years spent in the current school, living with parents, presence of domestic stressors, and grade deterioration, all were significantly associated with increased frequency of these symptoms. Similarly, association with various subgroups is described. CONCLUSION: This study attempts to give evidence of increased anxiety symptoms, during preexamination phase, compared to the reported prevalence in this age group, and thus to address this becomes imperative which will improve their performance and also the mental health preventing distress along with psychological and behavioral problems.

Association of Serum Selenium, Zinc and Magnesium Levels with Glycaemic Indices and Insulin Resistance in Pre-diabetes: a Cross-Sectional Study from South India.

A growing understanding of antioxidant mechanisms and insulin-like actions of trace elements selenium and zinc has rekindled researchers' interest towards their role in diabetes mellitus, nutritional management of which concentrates predominantly on macronutrient intake. However, selenium studies limiting largely to diabetes have yielded inconsistent results with sparse knowledge in the pre-diabetes population. This hospital-based cross-sectional study screened 300 people who came to the institutional hospital laboratory with fasting plasma glucose and glycosylated haemoglobin requisition over a period of 6 months. Thirty-five pre-diabetes subjects aged 25-45 years and 35 age-matched healthy controls were selected as per inclusion criteria and clinical history. Serum selenium was estimated by inductively coupled plasma-mass spectrometry, zinc and magnesium by colorimetric end-point methods and insulin by enzyme-linked immunosorbent assay, and insulin resistance was calculated using a homeostasis model assessment (HOMA) 2 calculator. Data analysis was done using SPSS ver. 16 employing an independent sample t test for intergroup comparison of means and Pearson's correlation for correlation analysis. Serum mineral levels in the pre-diabetes group (selenium 63.01 ± 17.6 µg/L, zinc 55.78 ± 13.49 µg/dL, magnesium 1.37 ± 0.38 mg/dL) were significantly reduced (p < 0.05) in comparison to the healthy controls (selenium 90.98 ± 15.81 µg/L, zinc 94.53 ± 15.41 µg/dL, magnesium 2.12 ± 0.22 mg/dL). A significant negative correlation was seen with glycaemic indices and insulin resistance. This study conducted in pre-diabetes subjects highlights a considerable deficiency of serum selenium, zinc and magnesium observed at a much earlier pre-clinical phase. This coupled with the evidence of a strong inverse association with glycaemic indices and insulin resistance postulates the role of mineral alterations in the pathophysiology of hyperglycaemia and insulin resistance.

Cord Blood Insulin Levels: It's Correlation with Gender, Birth Weight and Placental Weight in Term Newborns.

The cause of more insulin resistance in female than males are still unknown. To know the cause from early life, normal values of relevant parameters are required. So, aim of this study was to determine the reference levels of glucose and insulin in cord blood of term newborns and to examine their effects on gender, placental and birth weight of term newborns. In cross sectional study 60 consecutive term newborns were included from constituent hospitals. Placental and birth weights were measured and cord blood was collected for estimation of serum insulin and plasma glucose. Plasma glucose estimation was done by auto analyzer (GOD-POD method) and serum insulin analysis was done using Insulin ELISA Kit. After analysis, mean ± 2SD used for estimating cord blood insulin and glucose levels, which were 10.1 ± 7.8 µIU/mL and 67.8 ± 33.8 mg/dL respectively. Correlation of insulin with both birth weight and placental weight were r = 0.359 and 0.41 respectively; p < 0.001. Interestingly we found higher insulin levels in females as compared to male newborns in spite of having lower birth weight in them. In conclusion this study reported the levels of insulin and glucose in cord blood of term newborns. Incidentally, this is the first study as per our knowledge to report significant correlation between cord blood insulin, glucose with birth weight, placental weight and gender in south India. Female newborns had higher insulin levels than males, despite lesser birth weight can be attributed to intrinsic insulin resistance in them.

Metabolic Syndrome in Childhood: Rare Case of Alstrom Syndrome with Blindness.

Alstrom's syndrome (AS) is a rare autosomal recessive ciliopathic condition affecting 1:10,00,000 children. It's a single gene disorder of ALMS1 on chromosome 2 with multisystem involvement with cone-rod retinal dystrophy causing juvenile blindness, obesity, insulin resistance, type 2 Diabetes mellitus, hypogonadism and sensorineural hearing loss. Till now only 800 patients with this disorder has been identified so far. In this report, we describe the case of a 9-year old male boy from south India. He had been initially referred for polyphagia, polyuria, polydipsia, generalized weakness from 1 weeks. On examination he was demonstrated features suggestive of AS, including blindness, obesity, type 2 diabetes, altered lipid profile, hypogonadism, acanthosis nigricans, seborrheic dermatitis, right ear discharge and episodes of respiratory tract infections. So, diagnosis of AS is critical as it can easily be overlooked because of the many features associated with metabolic syndrome starting at age 7, a relatively early age.

Cord Blood Levels of Insulin, Cortisol and HOMA2-IR in Very Preterm, Late Preterm and Term Newborns.

INTRODUCTION: Alteration in the glucose homeostasis is still the major cause of morbidity and mortality in the newborns. Intrauterine undernutrition plays an important role in causing adult insulin resistance and diabetes but the exact cause is still unknown. AIM: To estimate the plasma glucose, serum insulin and cortisol levels at birth in newborns at different gestational age. MATERIALS AND METHODS: The present cross-sectional study conducted from December 2014 to June 2015 included 58 newborns enrolled as per the inclusion criteria and further categorized into Group I (very preterm; n=19; gestational age < 32 weeks), Group II (late preterm; n=20; gestational age between 32-37 weeks) and Group III (full term; n=19; gestational age >37 weeks) newborns. Venous Cord Blood (VCB) was collected and plasma glucose was analysed by GOD-POD (Glucose Oxidase-Peroxidase) method in auto analyser whereas serum insulin and cortisol were analysed by ELISA (Enzyme Linked Immunosorbent Assay). HOMA2-IR (Homeostatic Model Assessment) calculator was used to assess insulin resistance. All parametric data was expressed as mean±SD and analysed using ANOVA with Tukey's as the Post-Hoc test. Correlation analysis was done using Pearson's correlation co-efficient with scatter plot as the graphical representation. RESULTS: Significantly increased insulin and HOMA2-IR levels were found in group I (13.7±4.7µIU/mL and 1.6±0.58 respectively) when compared to group II (8.3±2.9µIU/mL and 0.93±0.2 respectively) and group III (8.3±2.1µIU/mL and 1.03±0.26 respectively). A positive correlation between cortisol levels and gestational age (r = 0.6, n = 58, p < 0.001) and a negative correlation between insulin and gestational age (r = -0.654, n = 58, p < 0.001) was observed in the study population. CONCLUSION: Increased levels of insulin and HOMA2-IR as seen in the very preterm newborns signify the predisposition of these newborns to development of diabetes in later stages of life. The inverse association of cortisol and insulin with gestational age suggests that cortisol could also be responsible for impaired ß cell function and insulin sensitivity.

Evaluation of Ischemia-Modified Albumin, Malondialdehyde, and Advanced Oxidative Protein Products as Markers of Vascular Injury in Diabetic Nephropathy.

AIM: This study aimed at evaluation of ischemia-modified albumin (IMA), malondialdehyde (MDA), and advanced oxidative protein products (AOPP) as markers of vascular injury in diabetic nephropathy (DN) with derivation of cutoff values for the same. MATERIALS AND METHODS: Study population comprised 60 diabetes patients and 30 controls, with diabetes patients further categorized into three groups based on urine albumin/creatinine ratio (UACR) of <30 mg/g (diabetes without microalbuminuria), 30-300 mg/g (early DN), and >300 mg/g of creatinine (overt DN). Serum IMA, MDA, and AOPP were estimated by enzyme-linked immunosorbent assay; HbA1c, serum creatinine, urine albumin, and urine creatinine were estimated using automated analyzers. Statistical analysis was done using analysis of variance, Pearson's correlation coefficient, and receiver-operating characteristic curve. RESULTS: A statistically significant difference was found in the levels of IMA among patients with early DN (154 ng/mL), diabetes without nephropathy (109.4 ng/mL), and healthy controls (45.7 ng/mL), with highest levels in early DN cases. Similar increase was seen in AOPP as well. A significant correlation was observed between IMA and UACR in diabetes without nephropathy (r = 0.448). CONCLUSION: The present study postulates serum IMA as a novel biomarker for the assessment of disease progression in diabetes even before microalbuminuria, and a cutoff point ≥99 ng/mL can be used for detection of early DN.

Serum Lactate Dehydrogenase in Non-Hodgkin's Lymphoma: A Prognostic Indicator.

Non-Hodgkin's lymphoma constitutes a group of disorders originating from the malignant transformation of lymphocytes and involving either the lymph nodes or extranodal sites. NHL commonly presents in the sixth to seventh decade of life with a male preponderance (50-75 %). Recent studies have shown importance of serum LDH in prognosis of NHL. Authors report a case of a 63 year old male presenting with complaints of fever and backache for past 4 months. General and systemic examination revealed bilateral axillary lymphadenopathy and splenomegaly respectively. Serum LDH level was highly elevated (3441 U/l). Excisional axillary and bone marrow biopsy were done before oncology referral. Complete workup revealed diffuse Non-Hodgkin's lymphoma with bone marrow infiltration. Patient died because of acute renal failure due to NHL and DM 2 (Type 2 diabetes mellitus).

Indices of Glucose Homeostasis in Cord Blood in Term and Preterm Newborns.

OBJECTIVE: According to the thrifty phenotype hypothesis, intrauterine malnutrition has a role in the etiology of type 2 diabetes. This study was planned to determine the early alterations in indices of glucose homeostasis (glucose, insulin, and cortisol) in term and preterm newborns and the correlations of glucose, insulin, and cortisol levels with insulin resistance indices. METHODS: A descriptive study comprising 35 term and 35 preterm newborns was carried out from December 2013 to June 2015. Venous cord blood was collected and plasma glucose was analyzed by the glucose oxidase-peroxidase method in an auto analyzer. Serum insulin and cortisol levels were assessed by the enzyme-linked immunosorbent assay. Homeostasis model assessment of insulin resistance (HOMA-IR), quantitative insulin sensitivity check index and glucose insulin ratio were calculated to assess insulin resistance. The data on physical and metabolic parameters were analyzed using standard tests for statistical significance. RESULTS: In term newborns, mean glucose and cortisol levels (83.6±17.4 mg/dL and 11.88±5.78 µg/dL, respectively) were significantly higher than those in preterm infants (70.4±15.8 mg/dL and 8.9±4.6 µg/dL, respectively). Insulin and HOMA-IR levels were found higher in preterm newborns (10.8±4.8 µIU/mL and 1.52±0.66, respectively) than in term newborns (7.9±2.7 µIU/mL and 1.19±0.29, respectively). Insulin was found to positively correlate with HOMA-IR, whereas cortisol was negatively correlated with HOMA-IR in both term and preterm newborns. CONCLUSION: Higher insulin levels and HOMA-IR values in the cord blood of preterm newborns support the theory of intrauterine origin of metabolic diseases.

Assessment of oxidative stress and inflammation in prediabetes-A hospital based cross-sectional study.

BACKGROUND AND AIM: Prediabetes is associated with dysglycemia, obesity, inflammation and endothelial dysfunction, contributing towards the pathogenesis of cardiovascular diseases rendering them vulnerable for the same. The current study intended to explore the risk of cardiovascular disease (CVD) related with prediabetes by assessing oxidative stress and inflammation using serum interleukin-6 (IL-6), myeloperoxidase (MPO) and urine microalbumin (MA) and their correlation with fasting plasma glucose (FPG) and physical measurements. MATERIALS AND METHODS: Based on FPG values, 80 subjects were grouped into prediabetes and healthy controls. IL-6 and MPO were estimated in serum sample whereas MA was estimated in random urine sample. RESULTS: Prediabetes group had significantly increased (p<0.05) mean anthropometric measurements and IL-6, MPO and MA as compared to healthy controls. MPO had significant correlation with FPG (r-0.388) in the prediabetes group. IL-6 and MPO showed a positive correlation with body mass index (BMI (r-0.339, r-0.327)), waist circumference (WC (r-484, r-0.493)) and waist-to-hip ratio (WHR (r-0.430, r-0.493)) while MA did not correlate with FPG and anthropometric measurements. CONCLUSION: This study suggests that prediabetes is associated with central adiposity, inflammation and oxidative stress predisposing them to an increased risk for CVD.

Bronze diabetes.

Thalassemia is a group of disorders characterized by deficient production of the ß-globin sub unit of hemoglobin. The mandatory blood transfusions in patients with thalassemia to maintain adequate erythrocyte levels, leads to iron overload. The prevalence of diabetes in patients with thalassemia varies from 6 to 14%. We here by present a known case of thalassemia major in an 18 year old boy. He was diagnosed with thalassemia before the age of one year and is on regular blood transfusion every two weeks since then. The repeated blood transfusion is one of the common causes for haemochromatosis. Iron overload initially leads to glucose abnormalities such as insulin resistance and hyperinsulinemia, which is followed by impaired secretion of insulin. Diagnosed as a case of bronze diabetes, this patient is on insulin therapy for the last two years. Currently the patient is on iron chelation therapy at Kasturba Medical College Hospital, Mangalore, Karnataka, India.