The increased risk of microvascular complications in South Asians with type 1 diabetes is influenced by migration.

AIM: We aimed to explore the association between South Asian ethnicity and complications of type 1 diabetes, and whether this is affected by migration. METHODS: In this retrospective cohort study, data on diabetes control and complications were obtained for South Asians in India (South AsiansIndia , n = 2592) and the UK (South AsiansUK , n = 221) and white Europeans in the UK (n = 1431). Multivariable logistic regression was used to identify associations between ethnicity and diabetic kidney disease, retinopathy and neuropathy adjusting for age, sex, BMI, disease duration, HbA1c , blood pressure (BP) and cholesterol. RESULTS: South AsiansIndia had significantly greater adjusted odds of diabetic kidney disease [odds ratio (OR) 5.0, 95% confidence intervals (CI) 3.6-7.1] and retinopathy (OR 1.8, 95% CI 1.2-2.5), but lower odds of neuropathy (OR 0.5, 95% CI 0.4-0.6) than white Europeans. South AsiansIndia had significantly greater adjusted odds of diabetic kidney disease (OR 3.0, 95% 1.8-5.3) than South AsiansUK , but there was no significant difference in the odds of other complications. CONCLUSIONS: In this hypothesis-generating study, we report that South Asian ethnicity is associated with greater risk of diabetic kidney disease and retinopathy, and lower risk of neuropathy than white European ethnicity. Part of the excess diabetic kidney disease risk is reduced in South AsiansUK . These associations cannot be accounted for by differences in vascular risk factors. Our findings in South Asians with type 1 diabetes mirror previous findings in type 2 diabetes and now need to be validated in a study of the effect of ethnicity on type 1 diabetes complications where healthcare is provided in the same setting.

Lipid Profile in Childhood-and Youth-Onset Type 2 Diabetes and their Association with Microvascular Complications.

AIM: To assess the lipid profiles in childhood and youth onset type 2 diabetes (T2DM) and study their association with microvascular complications. METHODS: Clinical details of individuals with childhood and youth onset T2DM, age at diagnosis between 10 and 25 yrs (n=1340) were retrieved from electronic medical records. Lipid abnormalities were classified based on the NCEP (ATP III) guidelines and management of dyslipidemia in children and adolescents with diabetes. Retinopathy was assessed by retinal photography; nephropathy, if albumin excretion was ≥300 mg/g of creatinine or if the 24 hour protein excretion was >500 mg and neuropathy by elevated vibration perception threshold (≥20 V) on biothesiometry. RESULTS: Out of 1,340 individuals with childhood and youth with T2DM, 53.3% of them were male. The mean age and duration of diabetes were 28.4 ± 10.4 and 7.4 ± 9.5 years respectively. Overall, the prevalence of dyslipidemia was 82.1%. Prevalence of hypercholesterolemia, hypertriglyceridemia, low HDL-C and high LDL-C were 40.7%, 52.8%, 59.1 % and 64.5% respectively. In logistic regression, both in unadjusted and adjusted model, hypercholesterolemia, and hypertriglyceridemia were associated with diabetic retinopathy [OR:1.8, CI:1.4-2.4, p<0.001 and 1.7, 1.3-2.2, p<0.001] and nephropathy [OR:1.7, CI:1.1-2.5, p=0.015 and 1.8, 1.2-2.8, p=0.007]. Additionally, hypercholesterolemia was associated with neuropathy, even after adjusting for age at diagnosis of diabetes and glycated hemoglobin [OR1.6, 1.0-2.5, p=0.041]. CONCLUSIONS: Lipid abnormalities are common and associated with microvascular complications among these T2DM individuals. This underscores the need for effective control of lipids among childhood and youth onset T2DM.

Obesity, Diabetes and Cardiovascular Diseases in India: Public Health Challenges.

Non-communicable diseases (NCDs; including coronary heart disease and type 2 diabetes) are rapidly increasing in India causing nearly 5.8 million deaths per year. Primary reasons for rise in NCDs in India are nutrition and lifestyle transitions. Further, presence of higher body fat, abdominal fat, liver and pancreatic fat and lower lean mass than whites, contribute to heightened metabolic and cardiovascular risk in Asian Indians. Importantly, conversion from pre-diabetes to diabetes occurs more rapidly, and reversion to normal glucose regulation with appropriate lifestyle measures is more difficult in Asian Indians than white population. Huge number of patients with diabetes and with complications increase morbidity, mortality and pose substantial economic burden. It is difficult, though not impossible, to decrease pace of rapidly expanding juggernaut of NCDs in India. Only concerted efforts from multiple stakeholders, consistently sincere efforts and intensely focused attention from health officialdom and clear political will may help counter this increasingly difficult challenge. Finally, all prevention and management approaches should be cost-effective, pragmatic, and focused on children and underprivileged populations.

Exercise patterns and behaviour in Asian Indians: data from the baseline survey of the Diabetes Community Lifestyle Improvement Program (D-CLIP).

AIMS: This paper attempts to describe the patterns of exercise and the perceived benefits and barriers to exercise in an urban south Indian population. METHODS: Study participants were recruited from the baseline survey of the D-CLIP (Diabetes Community Lifestyle Improvement Program). Frequency, duration, type and location of exercise were assessed using a questionnaire, while a Likert type scale was used to assess perceived benefits of and barriers to exercise. Quality of life was measured using the EQ-5D. RESULTS: Out of 1281 participants (63.7% males), 24.1% reported doing ≥150min of exercise/week ("exercisers") compared to 75.9% "non-exercisers". Exercisers were significantly older (47 vs. 43 years), better educated (68.8% vs. 60%), had a higher monthly income (41% vs. 29.2%), consumed more fruits (38.2% vs. 25.6%) and vegetables (84.1% vs. 77.7%) and had better perceived state of health (81.1% vs. 76.8%), compared to non-exercisers. Exercisers had significantly lower HOMA-IR, higher Matsuda index and lower prevalence of low HDL cholesterol compared to non-exercisers. However, there were no significant differences in cardio-metabolic risk factors like diabetes, hypertension and obesity between the two groups. Walking was the most common type of exercise. Both exercisers and non-exercisers perceived the benefits of exercising, but barriers weighed more heavily on exercise behaviour. CONCLUSIONS: Urgent steps are needed to improve overall exercise levels in India by addressing barriers and improving the quality of exercise performed so as to enhance overall metabolic health.

Prevalence of and risk factors for hypertension in urban and rural India: the ICMR-INDIAB study.

The aim of the study is to determine the prevalence of hypertension (HTN) and its risk factors in urban and rural India. In Phase I of the Indian Council of Medical Research-India Diabetes (ICMR-INDIAB) study, individuals aged ⩾20 years were surveyed using a stratified multistage sampling design, in three states (Tamil Nadu, Maharashtra and Jharkhand) and one union territory (Chandigarh) of India. Blood pressure was measured in all study subjects (n=14 059). HTN was defined as systolic blood pressure ⩾140 mm Hg, and/or DBP ⩾90 mm Hg and/or use of antihypertensive drugs. Overall age-standardized prevalence of HTN was 26.3% (self-reported: 5.5%; newly detected: 20.8%). Urban residents of Tamil Nadu, Jharkhand, Chandigarh and Maharashtra (31.5, 28.9, 30.7 and 28.1%) had significantly higher prevalence of HTN compared with rural residents (26.2, 21.7, 19.8 and 24.0%, respectively). Multivariate regression analysis showed that age, male gender, urban residence, generalized obesity, diabetes, physical inactivity and alcohol consumption were significantly associated with HTN. Salt intake ⩾6.5 g per day, showed significantly higher risk for HTN (odds ratio: 1.4, 95% confidence interval: 1.0-1.9, P=0.042) even after adjusting for confounding variables. In conclusion, prevalence of undiagnosed HTN is high in India and this calls for regular screening.

Knowledge and awareness of diabetes in urban and rural India: The Indian Council of Medical Research India Diabetes Study (Phase I): Indian Council of Medical Research India Diabetes 4.

BACKGROUND: Representative data on knowledge and awareness about diabetes is scarce in India and is extremely important to plan public health policies aimed at preventing and controlling diabetes. AIM: The aim of the following study is to assess awareness and knowledge about diabetes in the general population, as well as in individuals with diabetes in four selected regions of India. MATERIALS AND METHODS: The study subjects were drawn from a representative sample of four geographical regions of India, Chandigarh, Tamil Nadu, Jharkhand and Maharashtra representing North, South, East and West and covering a population of 213 million. A total of 16,607 individuals (5112 urban and 11,495 rural) aged ≥20 years were selected from 188 urban and 175 rural areas. Awareness of diabetes and knowledge of causative factors and complications of diabetes were assessed using an interviewer administered structured questionnaire in 14,274 individuals (response rate, 86.0%), which included 480 self-reported diabetic subjects. RESULTS: Only 43.2% (6160/14,274) of the overall study population had heard about a condition called diabetes. Overall urban residents had higher awareness rates (58.4%) compared to rural residents (36.8%) (P < 0.001). About 46.7% of males and 39.6% of females reported that they knew about a condition called diabetes (P < 0.001). Of the general population, 41.5% (5726/13,794) knew about a condition called diabetes. Among them, 80.7% (4620/5726) knew that the prevalence of diabetes was increasing, whereas among diabetic subjects, it was 93.0% (448/480). Among the general and diabetic population, 56.3% and 63.4% respectively, were aware that diabetes could be prevented. Regarding complications, 51.5% of the general population and 72.7% diabetic population knew that diabetes could affect other organs. Based on a composite knowledge score to assess knowledge among the general population, Tamil Nadu had the highest (31.7) and Jharkhand the lowest score (16.3). However among self-reported diabetic subjects, Maharashtra had the highest (70.1) and Tamil Nadu, the lowest score (56.5). CONCLUSION: Knowledge and awareness about diabetes in India, particularly in rural areas, is poor. This underscores the need for conducting large scale diabetes awareness and education programs.

Clinical and molecular characterization of neonatal diabetes and monogenic syndromic diabetes in Asian Indian children.

Mutations in the pancreatic ATP sensitive K(+) channel proteins [sulfonyluea receptor 1 (SUR1) and inward rectifier K(+) channel Kir6.2 (Kir6.2), encoded by ATP-binding cassette transporter subfamily C member 8 (ABCC8) and potassium channel J11 (KCNJ11), respectively], are the most common cause of neonatal diabetes. We describe the clinical presentation and molecular characterization of Asian Indian children with neonatal diabetes mellitus and monogenic syndromes of diabetes. We sequenced KCNJ11, ABCC8 and insulin (INS) genes in 33 unrelated Indian probands with onset of diabetes below one year of age. A total of 12 mutations were identified which included ABCC8 mutations in seven, KCNJ11 mutations in three and INS mutations in two children. The Asp212Tyr mutation in ABCC8 was novel. We also detected two novel mutations (Val67Met and Leu19Arg) in children with syndromic forms of diabetes like Berardinelli Seip syndrome [1-acyl-sn-glycerol-3-phosphate acyltransferase beta (AGPAT2)] and Fanconi Bickel syndrome [solute carrier family 2A2 (SLC2A2)]. Children carrying the KCNJ11 (Cys42Arg, Arg201Cys) and ABCC8 (Val86Ala, Asp212Tyr) mutations have been successfully switched over from insulin therapy to oral sulfonylurea. Our study is the first large genetic screening study of neonatal diabetes in India.

Tumefactive demyelination-to cracks the nut without cracking the pot.

A 45-year-old female recently detected diabetic, admitted with difficulty in walking, irrelevant talk and urinary incontinence for 3 weeks and deviation of angle of mouth to left. Examination revealed pallor, delusional thoughts, right upper motor neuron facial weakness, ataxia. CT brain revealed bulky hyperdense lesion in corpus callosum and subsequently MRI of the brain revealed T2-hyperintense lesions involving genu and body of corpus callosum with restricted diffusion, and MR spectroscopy revealed reduced uptake of choline. Possibilities considered were infiltrative glioma of corpus callosum, demyelination and central nervous system lymphoma. As the patient and relatives were not willing to allow stereotactic biopsy, she was started on steroids. Her neurological deficits started improving and 1 month later repeat MRI brain showed a drastic reduction in the size of the lesion. Her neurological condition disappeared and is doing well.

Prevalence of diabetes and prediabetes (impaired fasting glucose and/or impaired glucose tolerance) in urban and rural India: phase I results of the Indian Council of Medical Research-INdia DIABetes (ICMR-INDIAB) study.

AIMS/HYPOTHESIS: This study reports the results of the first phase of a national study to determine the prevalence of diabetes and prediabetes (impaired fasting glucose and/or impaired glucose tolerance) in India. METHODS: A total of 363 primary sampling units (188 urban, 175 rural), in three states (Tamilnadu, Maharashtra and Jharkhand) and one union territory (Chandigarh) of India were sampled using a stratified multistage sampling design to survey individuals aged ≥ 20 years. The prevalence rates of diabetes and prediabetes were assessed by measurement of fasting and 2 h post glucose load capillary blood glucose. RESULTS: Of the 16,607 individuals selected for the study, 14,277 (86%) participated, of whom 13,055 gave blood samples. The weighted prevalence of diabetes (both known and newly diagnosed) was 10.4% in Tamilnadu, 8.4% in Maharashtra, 5.3% in Jharkhand, and 13.6% in Chandigarh. The prevalences of prediabetes (impaired fasting glucose and/or impaired glucose tolerance) were 8.3%, 12.8%, 8.1% and 14.6% respectively. Multiple logistic regression analysis showed that age, male sex, family history of diabetes, urban residence, abdominal obesity, generalised obesity, hypertension and income status were significantly associated with diabetes. Significant risk factors for prediabetes were age, family history of diabetes, abdominal obesity, hypertension and income status. CONCLUSIONS/INTERPRETATIONS: We estimate that, in 2011, Maharashtra will have 6 million individuals with diabetes and 9.2 million with prediabetes, Tamilnadu will have 4.8 million with diabetes and 3.9 million with prediabetes, Jharkhand will have 0.96 million with diabetes and 1.5 million with prediabetes, and Chandigarh will have 0.12 million with diabetes and 0.13 million with prediabetes. Projections for the whole of India would be 62.4 million people with diabetes and 77.2 million people with prediabetes.

The need for obtaining accurate nationwide estimates of diabetes prevalence in India - rationale for a national study on diabetes.

According to the World Diabetes Atlas, India is projected to have around 51 million people with diabetes. However, these data are based on small sporadic studies done in some parts of the country. Even a few multi-centre studies that have been done, have several limitations. Also, marked heterogeneity between States limits the generalizability of results. Other studies done at various time periods also lack uniform methodology, do not take into consideration ethnic differences and have inadequate coverage. Thus, till date there has been no national study on the prevalence of diabetes which are truly representative of India as a whole. Moreover, the data on diabetes complications is even more scarce. Therefore, there is an urgent need for a large well-planned national study, which could provide reliable nationwide data, not only on prevalence of diabetes, but also on pre-diabetes, and the complications of diabetes in India. A study of this nature will have enormous public health impact and help policy makers to take action against diabetes in India.

Pneumococcal infections and immunization in diabetic patients.

India is today facing a diabetes epidemic and has the maximum number of patients with diabetes in the world. People with diabetes are more prone to develop all types of infections. Pneumococcal infections are a common cause of morbidity and mortality, and people with diabetes are more prone to develop pneumococcal infections. With the availability of the pneumococcal vaccine, most international organizations now recommend that people with diabetes should be vaccinated against pneumococcal disease. This article tries to provide a balanced review of the place of pneumococcal vaccination in Indian diabetic patients.

Genetic characterization of dengue virus serotypes causing concurrent infection in an outbreak in Ernakulam, Kerala, South India.

Dengue fever, a mosquito-borne viral infection, causes significant morbidity and has become endemic in the Indian subcontinent. Virus strains currently circulating in many parts of the country are not well studied at the molecular level. In the present study, genetic characterization of virus strains from a dengue outbreak that occurred in and around a tertiary care hospital in Ernakulam, Kerala in the year 2008 has been reported. By reverse transcription polymerase chain reaction (RT-PCR), 37 out of 75 (49.3%) clinically suspected cases were positive for dengue viral RNA. Among these, 21 (56.8%) samples showed concurrent infection with multiple serotypes of the virus. Majority of the combined infections were caused by dengue serotype 2 and 3. Co-infections with type 1 and 2 in two patients, and type 1, 2 and 3 in one patient were also observed. The core-pre-Membrane (CprM) junction nucleotide sequencing and phylogenetic analysis revealed that the type 1 strains were related to the viral strains reported from Delhi-2001 and Gwalior-2002 dengue outbreaks, while the type 2 strains were related to the strains from Gwalior-2001 epidemic. Sequences of type 3 strains did not show clear relation to any of the previous Indian isolates, and in the phylogenetic analysis, they formed a distinct lineage within the Indian type 3 strains. This study indicates hyperendemicity of dengue in the region with the presence of multiple serotypes and high rates of co-infection, and local genomic evolution of the viral strains involved in this outbreak.

Repair of spontaneous right ventricular rupture following sternal dehiscence. A novel technique.

Spontaneous rupture of the right ventricle during the early postoperative period is a serious and potentially lethal complication. The inherent friability of the ventricular tissue makes repair difficult since myocardium is frequently weakened by infarction, mediastinitis or trauma caused by an unstable sternum or broken sternal wires. We present a novel yet simple technique for repairing the ruptured anterior wall of the right ventricle in a patient three weeks following coronary artery bypass surgery.

Plasmacytoid lymphoma within a left atrial myxoma: a rare coincidental dual pathology.

Primary malignant cardiac neoplasms are extremely rare. The occurrence of a malignant lymphoid tumour within a left atrial myxoma is highly atypical, with only one such case previously reported. Here, we describe a patient who presented with symptoms and signs of a left atrial myxoma. Subsequent specimen histology demonstrated the presence of lymphoma within the myxoma. We discuss the importance of histological diagnosis in order to best direct treatment and prognosis of such cases.

Unexpected and abnormally low HDL cholesterol levels on combination hypolipidemic therapy.

In general, Indians have low HDL cholesterol levels. Fenofibrate, a drug widely used in the treatment of hypertriglyceridemia, usually also increases HDL cholesterol. There have been a few reports in the literature of a paradoxical decrease in serum HDL-cholesterol in patients treated with fenofibrate, either alone or in combination with a statin. We report three cases of paradoxical decrease in serum HDL-cholesterol in type 2 diabetic patients treated with a statin-fenofibrate combination.

Mortality rates due to diabetes in a selected urban south Indian population--the Chennai Urban Population Study [CUPS--16].

OBJECTIVE: The aim of this study was to determine the mortality rate in diabetic and non-diabetic subjects in urban south India. METHODS: The Chennai Urban Population Study is an ongoing epidemiological study in Chennai [formerly Madras, in south India]. All individuals > or = 20 years of age living in two residential colonies in Chennai were invited to participate in the study. Of the total 1399 eligible subjects, 1262 individuals responded [90.2%] at baseline, and of these, 1140 individuals [90.3%] could be followed annually from 1997 to 2003-04. Mortality rates and causes of death were the main outcome measures. RESULTS: The median follow up period was six years. The overall mortality rate was higher in diabetic compared to non-diabetic subjects [18.9 vs.5.3 per 1000 person-years, p=0.004]. Mortality due to cardiovascular [diabetic subjects, 52.9%; non-diabetic subjects, 24.2%,p=0.042] and renal causes[diabetic subjects, 23.5%; non-diabetic subjects, 6.1%,p=0.072] was higher among diabetic subjects whereas mortality due to gastrointestinal 112.1%], respiratory [9.1%], lifestyle related [6.1%] and unnatural causes [18.2%] were observed only among non-diabetic subjects. Hazards ratio [HR] for all cause mortality for diabetes was 3.6, [95% Confidence Interval [CI]: 2.02-6.53, p<0.001] and this remained significant even after adjusting for age [HR:1.9, 95% CI:1.04-3.45, p=0.038]. Light grade physical activity was associated with higher mortality rate [p=0.008], but the significance disappeared when adjusted for age. Smoking was also associated with increased mortality. CONCLUSIONS: In urban India, mortality rates are two fold higher in people with diabetes compared to nondiabetic subjects. Cardiovascular and renal diseases are the commonest causes of death among diabetic subjects.

Corona-induced photoxidation of alcohols and hydrocarbons over TiO2 in the absence of a UV light source - a novel and environmentally friendly method for oxidation.

Corona-induced photooxidation is a novel oxidation methodology for the efficient oxidation of alcohols and hydrocarbons utilizing the advantage of both the high oxidizing power of ozone formed in the reactor as well as the photooxidation capability of the UV light generated during the corona discharge.

Single stage sternal reconstruction using titanium mesh for dehiscence following open-heart surgery.

Wound complications are a well-recognised entity following median sternotomy. Soft tissue reconstruction in the form of muscle flaps generally provides adequate wound stability; nevertheless, skeletal reconstruction of the anterior chest wall is sometimes necessary. We describe a novel technique applied in three patients for reconstructing fragments of the sternum using a titanium mesh that provides a scaffold for the bony union.

Selective arterialization of the coronary venous system.

The idea of myocardial revascularization by means of grafting the coronary venous system is more than a century old; in cases of diffuse coronary artery disease, this may represent a valid therapeutic option. We present a challenging case in which a patient with an aberrant left coronary system and unstable angina underwent this type of procedure with good clinical results.