Jyothi Idiculla

Microalbuminuria and low hemoglobin as risk factors for the occurrence and increasing severity of diabetic retinopathy.

Aim: To assess the influence of urinary microalbuminuria and hemoglobin concentration on the occurrence and severity of diabetic retinopathy (DR), clinically significant macular edema (CSME) and hard exudate formation. Materials and Methods: In this prospective cross-sectional study carried out over a period of 2 years, type 2 diabetic patients seeking ocular evaluation for DR were assessed for presence and severity of DR, presence of hard exudates and CSME. Retinal findings were correlated to severity of microalbuminuria, hemoglobin concentration and other systemic risk factors using linear regression analysis. Results: Three hundred and six patients were included in the study. DR of any grade was seen in 132 (43%) patients, hard exudate formation in 93/306 (30.4%) patients, CSME in 50/306 (16.3%) patients and proliferative DR in 26/306 (8.5%) patients. Duration of diabetes (P <0.001), microalbuminuria (P <0.001) and low hemoglobin (P = 0.001) were found to be highly significant risk factors for the development and increasing severity of DR as well as for CSME and hard exudate formation. Conclusion: Microalbuminuria and low hemoglobin are strong predictors for DR, CSME and hard exudate formation in type 2 diabetics even after correcting for duration of diabetes and other systemic risk factors. Although not directly involved in the pathogenesis, microalbuminuria can help in identifying patients at risk for more severe diabetic eye disease. Microalbuminuria warrants intensive monitoring of both retinal and renal status. The hemoglobin levels should be monitored regularly in diabetic patients to detect and treat anemia, thereby reducing one risk factor for DR.

Autonomic nervous system function in type 2 diabetes using conventional clinical autonomic tests, heart rate and blood pressure variability measures.

Background: There are currently approximately 40.9 million patients with diabetes mellitus in India and this number is expected to rise to about 69.9 million by the year 2025. This high burden of diabetes is likely to be associated with an increase in associated complications. Materials and Methods: A total of 23 (15 male and 8 female) patients with type 2 diabetes of 10-15 years duration and their age and gender matched controls (n=23) were recruited. All subjects underwent detailed clinical proforma, questionnaire related to autonomic symptoms, anthropometry, peripheral neural examination and tests of autonomic nervous system including both conventional and newer methods (heart rate and blood pressure variability). Results: Conventional tests of cardiac parasympathetic and sympathetic activity were significantly lower in patients with diabetes compared to the controls (P<0.05). The diabetic patients group had significantly lower high frequency and low-frequency HRV when expressed in absolute units (P<0.05) and total power (P<0.01) compared to the controls. Conclusion: Data from the current study demonstrated that diabetics had both cardiac sympathetic and cardiac parasympathetic nervous system involvement. The presence of symptoms and involvement of both components of the autonomic nervous system suggest that dysfunction has been present for a while in these diabetics. There is a strong need for earlier and regular evaluation of autonomic nervous system in type 2 diabetics to prevent further complications.

Serum lipids and diabetic retinopathy: A cross-sectional study.

Aim: To evaluate the association of elevated serum lipids with retinal hard exudates formation, the occurrence clinically significant macular edema (CSME), occurrence and severity of diabetic retinopathy (DR) and loss of vision in type 2 diabetics. Materials and Methods: Type 2 diabetic patients seeking ocular evaluation for diabetic retinopathy were included in this cross-sectional study. They were assessed for presence and severity of diabetic retinopathy (DR), presence of hard exudates, clinically significant macular oedema (CSME) and best corrected visual acuity (BCVA). Retinal findings were correlated to serum lipids levels using univariate and multivariate analysis. Results: Totally 330 patients were included, of which 141/330 had diabetic retinopathy of any grade. Retinal hard exudate formation, was found to have statistically significant correlation with the presence of dyslipidemia (p=0.02), increased total cholesterol (p=0.002) and LDL levels (p=0.001). On multivariate analysis, after correcting for duration, glycemic control and albuminuria, increased cholesterol remained significantly associated with increased hard exudate formation (p=0.02). Elevated cholesterol also showed independent association with visual loss (p=0.04). The occurrence CSME showed a statistically significant correlation with dyslipidemia (p=0.04) and increased LDL levels (0.04), which did not persist on multivariate analysis. However the there was no correlation with the occurrence and severity of diabetic retinopathy Conclusion: Elevated serum lipids showed a significant association with retinal hard exudate formation, CSME and loss of vision in type 2 diabetics. Lipid lowering agents may help in reducing the occurrence of these retinal findings and loss of vision in diabetic patients.

Actinomycosis in urachal remnants: A rare cause of pseudotumor.

Actinomycosis is a chronic inflammatory condition caused by Actinomyces israeli, a gram positive anaerobic bacterium. It can have a variety of clinical manifestations and can mimic a malignancy. We present one such case of urachal actinomycosis that mimicked a tumor. A 28-year-old man presented with abdominal pain of 20 days duration. Per abdominal palpation revealed a firm mass with ill-defined borders in the suprapubic region. Computed tomography and magnetic resonance imaging scans of the pelvis showed an irregular lesion in the urinary bladder extending to the umbilicus, giving the impression of urachal remnants with inflammation. Peroperatively, an irregular, hard mass measuring 6 × 5 cm, involving the anterior and posterior bladder walls, the appendix, the terminal ileum and sigmoid colon, was seen, which was suspicious for a malignancy. Frozen sections from the mass showed extensive inflammation and a florid fibroblastic proliferation, giving the impression of an inflammatory pseudotumor. The tissue was extensively sampled for paraffin sections and only one of them revealed a colony of Gram, PAS and GMS- positive organisms, conclusive for Actinomycosis. It is important to be aware of this uncommon, yet significant, presentation of a common infectious disease in order to avoid misdiagnosis and over-treatment as a malignancy.

Exercise in patients with Type 2 diabetes: Facilitators and barriers - A qualitative study

Introduction: Diabetes is a major noncommunicable disease affecting more than 65 million Indians. Although treatment algorithms suggest lifestyle measures (diet and exercise) along with medications data regarding adherence to exercise as well as facilitators and barriers to the practice of physical activity in such patients are limited. Hence, this qualitative study was conducted. Objectives: The objective of this study is to describe the factors which (1) Facilitated and (2) hindered the practice of regular exercise in patients with Type 2 diabetes. Methodology: The study was conducted on 13 diabetic patients admitted to a tertiary care center in Bengaluru - St. Johns Medical College Hospital, to explore factors that acted as facilitators and barriers to physical activity. Data saturation with the coded themes was achieved on interviewing 13 patients, after which, thematic analysis was done, and final themes reported. Results: The age of the study participants (7 males, 6 females) ranged from 40 to 80 years. Among those who did exercise, factors such as awareness regarding the benefits of exercise and complications linked with diabetes, positive family support, and emphasis by nursing staff emerged as facilitators. Lack of time, obligations to others, inability to link exercise with blood sugar control, lack of perception of obesity as a health issue, inadequate emphasis by physicians, social/cultural issues, lack of infrastructure, and physical restriction were the factors that acted as barriers to physical activity. In addition to the above, a clear lack of adherence to standard guidelines, while advising patients by physicians was also noted. Conclusion: A comprehensive approach by both doctors and nurses, based on standard guidelines, could help in implementing adherence to exercise in patients with diabetes.

The Epidemiology of IRIS in Southern India: An Observational Cohort Study

Immune reconstitution inflammatory syndrome (IRIS) is an uncommon but dynamic phenomenon seen among patients initiating antiretroviral therapy (ART). We aimed to describe incidence, risk factors, clinical spectrum, and outcomes among ART-naive patients experiencing IRIS in southern India. Among 599 eligible patients monitored prospectively between 2012 and 2014, there were 59.3% males, with mean age 36.6 ± 7.8 years. Immune reconstitution inflammatory syndrome incidence rate was 51.3 per 100 person-years (95% confidence interval: 44.5-59.2). One-third (31.4%) experienced at least 1 IRIS event, at a median of 27 days since ART initiation. Mucocutaneous infections and candidiasis were common IRIS events, followed by tuberculosis. Significant risk factors included age >40 years, body mass index <18.5 kg/m2, CD4 count <100 cells/mm3, viral load >10 000 copies/mL, hemoglobin <11 g/dL, and erythrocyte sedimentation rate >50 mm/h. Immune reconstitution inflammatory syndrome–related morality was 1.3% (8 of 599); 3 patients died of complicated diarrhea. These findings highlight the current spectrum of IRIS in South India and underscore the importance of heightened vigilance for anemia and treatment of diarrhea and candidiasis during ART initiation.

Tuberculosis and diabetes mellitus, tackling dual maladies: Comment on Bangladeshi tuberculosis-diabetes mellitus guidelines

Sir, The national guidelines issued from Bangladesh on the management of diabetes mellitus (DM) in patients who contract tuberculosis (TB) is a reference document for physicians and would aid in the effective management of these patients.[1] Further, the article touches on the hurdles in diagnosing TB in patients with diabetes due to atypical presentations and on the negative effects of these diseases on each other. While the authors have covered routine management of DM, stressing the importance of glycemic goals, there are few other aspects which need to be highlighted while treating such patients.

Pulmonary hypertension: The thyroid connection

A 52-year-old female presented with exertional dyspnea and swelling of feet for 3 weeks. On examination, she was found to have tachycardia and hypertension, with a small goiter visible on her neck. All routine investigations were normal. Echocardiogram (ECHO) revealed moderate tricuspid regurgitation and severe pulmonary hypertension (PHTN). Pulmonary function tests were normal. There was no evidence of pulmonary embolism on computed tomography pulmonary angiogram. Immunology workup was negative. She was diagnosed to have hyperthyroidism, and a technetium-99 scan of the thyroid was suggestive of Graves′ disease. She was treated with radio-iodine. And is euthyroid and asymptomatic. A repeat ECHO confirmed resolution of PHTN. This case is being reported to highlight the need to detect and treat hyperthyroidism, which can cause resolution of PHTN.

Supplementing Vitamin D: Dangers of too much of a good thing

The practice of checking and supplementing vitamin D even in situations where it is not warranted has become common practice among physicians. While many do not develop ill effects, some patients may suffer from consequent toxicity. This occurs mostly in patients who are vitamin D sufficient or those who have underlying disorders. We report a case of vitamin D supplementation in an elderly lady which resulted in hypercalcemia and pathological calcification.