Management of diabetic dyslipidemia in Indians: Expert consensus statement from the Lipid Association of India.

In 2021 an estimated 74 million individuals had diabetes in India, almost all type 2 diabetes. More than half of patients with diabetes are estimated to be undiagnosed and more 90% have dyslipidemia that is associated with accelerated development of atherosclerotic cardiovascular disease (ASCVD). Patients of Indian descent with diabetes have multiple features that distinguish them from patients with diabetes in Western populations. These include characteristics such as earlier age of onset, higher frequency of features of the metabolic syndrome, more prevalent risk factors for ASCVD, and more aggressive course of ASCVD complications. In light of the unique features of diabetes and diabetic dyslipidemia in individuals of Indian descent, the Lipid Association of India developed this expert consensus statement to provide guidance for management of diabetic dyslipidemia in this very high risk population. The recommendations contained herein are the outgrowth of a series of 165 webinars conducted by the Lipid Association of India across the country from May 2020 to July 2021, involving 155 experts in endocrinology and cardiology and an additional 2880 physicians.

"Mild'' Hypoxic-Ischaemic Encephalopathy and Therapeutic Hypothermia: A Survey of Clinical Practice and Opinion from 35 Countries.

INTRODUCTION: We aimed to determine global professional opinion and practice for the use of therapeutic hypothermia (TH) for treating infants with mild hypoxic-ischaemic encephalopathy (HIE). METHODS: A web-based survey (REDCap) was distributed via emails, social networking sites, and professional groups from October 2020 to February 2021 to neonatal clinicians in 35 countries. RESULTS: A total of 484 responses were obtained from 35 countries and categorized into low/middle-income (43%, LMIC) or high-income (57%, HIC) countries. Of the 484 respondents, 53% would provide TH in mild HIE on case-to-case basis and only 25% would never cool. Clinicians from LMIC were more likely to routinely offer TH in mild HIE (25% v HIC 16%, p < 0.05), have a unit protocol for providing TH (50% v HIC 26%, p < 0.05), use adjunctive tools, e.g., aEEG (49% v HIC 32%, p < 0.001), conduct an MRI post TH (48% v HIC 40%, p < 0.05) and less likely to use neurological examinations as a HIE severity grading tool (80% v HIC 95%, p < 0.001). The majority of respondents (91%) would support a randomized controlled trial that was sufficiently large to examine neurodevelopmental outcomes in mild HIE after TH. CONCLUSIONS: This is the first survey of global opinion for TH in mild HIE. The overwhelming majority of professionals would consider "cooling" an infant with mild HIE, but LMIC respondents were more likely to routinely cool infants with mild HIE and use adjunctive tools for diagnosis and follow-up. There is wide practice heterogeneity and a sufficiently large RCT designed to examine neurodevelopmental outcomes, is urgently needed and widely supported.

Cooling in mild encephalopathy: Costs and perils of therapeutic creep.

Increasing confidence in therapeutic hypothermia and ambiguity of cooling guidelines has led to many clinicians extending its use to untested populations like mild encephalopathy, or even no encephalopathy. Poor quality clinical neurological examination for encephalopathy staging coupled with a fear of litigation if a baby with mild encephalopathy progress to moderate or severe encephalopathy appears to be the primary driver for this therapeutic creep. Recent data suggesting increased apoptosis with cooling uninjured brains, and lack of hypothermic neuroprotection in partial prolonged hypoxia, implies that such therapeutic creeps may cause more harm than benefit. Currently available preclinical and clinical data do not support the clinical use of therapeutic hypothermia for mild encephalopathy, although phase II clinical trials are ongoing. We recommend that until further evidence from adequately powered randomised controlled trials are available, cooling in mild encephalopathy need to be considered experimental and parental consent should be obtained before providing this therapy.

Resolution of "salt and pepper" appearance of the skull with vitamin D therapy.

Chronic hypovitaminosis D leads to state of decreased mineralization and generalized osteomalacia. It also results in secondary hyperparathyroidism causing increased bone turn over and decreased bone mass, manifested radiologically as a "salt and pepper" appearance in skull, subperiosteal resorption, bone cysts and lytic lesions. In this case, a young male patient with hypovitaminosis D and secondary hyperparathyroidism, radiological features show resolution of "salt and pepper" appearance of the skull with vitamin D in 11 months and regression of other lytic lesions.

A clinical profile of fibrocalculous pancreatic diabetes patients from eastern India with special reference to body fat percentage and insulin resistance.

Fibrocalculous pancreatic diabetes though less commonly seen but is a unique form of diabetes seen mostly in the tropics. Thirty-one (19 males, 12 females) consecutive patients attending the OPD were evaluated for clinical and biochemical profile with special reference to quantifying insulin resistance (by HOMA-IR) and body fat percentage (by bioimpedence). Insulin requirement was found to be 1.15 +/- .33 units/kg. HOMA-IR was abnormal (>2) in 24 (77.42%). Increased body fat percentage (defined as >20% in males and >30% in females) was found in 17 males (89.5%) out of 19 and in 4 females (33.3%) out of 12. There was significant positive correlation between HOMA-IR and body fat (by between feet method p < 0.001) and by between hands method (p = 0.01).

A study of aspirin resistance in type 2 diabetes.

Aspirin is currently known to give inadequate protection against coronary artery disease in diabetes compared to person without it. We evaluated 97 consecutive patients with type 2 diabetes for assessing laboratory aspirin resistance and attempted to assess the impact of various clinical and biochemical parameters on it. Thirty-eight patients (39.1%) were found to be less sensitive to the action of aspirin, 7 persons (7.2%) were found to be resistant and 31 persons (31.9%) were aspirin semi-responders. Only total cholesterol, LDL-cholesterol and triglyceride had statistically significant impact on aspirin resistance (p<0.05). Three persons out of 9 with some form of macrovascular disease had aspirin resistance.