Nithyananda K Chowta

Serum C peptide level and renal function in diabetes mellitus.

C peptide is an active peptide hormone with potentially important physiological effects. C peptide has the capacity to diminish glomerular hyperfiltration and reduce urinary albumin excretion in both experimental and human type 1 diabetes. The present study is aimed at correlating the serum C peptide level with that of renal clearance, urinary albumin excretion and duration of diabetes. This is a prospective cross sectional study. Patients with diagnosis of type 2 diabetes mellitus were evaluated for their baseline clinical and laboratory profile. Both males and females above the age of 18 years were included in the study. The laboratory investigations include fasting serum C peptide, HbA1C, serum creatinine, blood urea nitrogen, urine albumin and creatinine. Creatinine clearance was calculated using modification of diet in renal disease formula from serum creatinine value. A total of 168 patients were included in the study, among them 90 were females (53.57%) and 78 males (46.43%). Mean age of the patients was 57.64 years. Pearson correlation test showed negative correlation of serum C peptide level with creatinine clearance, though statistically not significant. Negative correlation was also seen between serum C peptide, and urine albumin, urine albumin creatinine ratio, HbA1C and duration of diabetes. Mean urine albumin was higher in patients with subnormal C peptide level. Duration of disease was more in patients with lower serum C peptide level. The study has shown weak association of serum C peptide level with microalbuminuria and creatinine clearance. Risk of albuminuria is more in patients with low serum C peptide level.

Caregiver Burden among Adults Caring for People Living with HIV/AIDS (PLWHA) in Southern India.

INTRODUCTION In India, family caregivers provide bulk of care to People Living With HIV/AIDS (PLWHA). Caregiver burden refers to the physical, emotional and financial hardships associated with providing care to a diseased individual. Attending to the needs of PLWHA can place a significant burden on family members. This may adversely affect their Quality of Life (QOL). AIM The main aim of our study was to assess the caregiver burden and QOL among the family members of PLWHA in Southern India. We also determined the impact of caregiver burden on QOL. MATERIALS AND METHODS This facility based cross-sectional study was carried out at Kasturba Medical College (KMC) Mangalore. The study was conducted over a period of 18 months starting from October 2013. A total of 360 caregivers participated in our study. The data were collected by face-to-face interview. Caregiver burden was assessed using the Zarit Burden scale & WHOQOL-BREF scale was used to assess the QOL of caregivers. The collected data was entered and analysed using SPSS version 11.5. A p-value of less than 0.05 was considered statistically significant. RESULTS The mean age of caregivers was 36.09± 10.18 years. Most of the caregivers were females 279 (77.5%). Majority of caregivers 184 (51.1%) belonged to Middle/Lower Middle socioeconomic class (Kuppuswamy class III). Majority of PLWHA 155 (43.1%) had Stage 2 disease. Mean CD4 count of the patients was 405.2± 240 cells/μL. In our study 88(24.4%) caregivers had moderate to severe burden and 36(10%) had very severe burden. Physical domain of QOL showed maximum score of 60.28±13.08, while a minimum score of 51.88 ± 14.20 was seen in social domain. With increase in caregiver burden, the mean QOL scores decreased which was statistically significant. CONCLUSION Our study highlights the need to counsel the caregivers on how to deal with PLWHA in the family. Family care plays a major role in the general wellbeing of PLWHA. Majority of national HIV programmes all over the world focus mainly on PLWHA. National programmes should immediately address the mental health issues of caregivers thereby reducing caregiver burden. More studies on this topic have to be conducted in developing countries.

Mastication Frequency and Postprandial Blood Sugar Levels in Normoglycaemic and Dysglycaemic Individuals: A Cross- Sectional Comparative Study

INTRODUCTION Mastication has potential to affect postprandial blood glucose levels by affecting cephalic phase of insulin release. However, limited number of studies done in this regard has yielded conflicting results. AIM To evaluate effects of mastication on postprandial blood glucose levels. MATERIALS AND METHODS We compared routine and thorough mastication in 2 separate groups: dysglycaemic (prediabetics and diabetics) and normoglycaemic in prospective interventional study. Blood glucose levels were measured pre-prandial and postprandial (after 2 hours) on separate days after routine and thorough mastication in both groups. RESULTS In normoglycaemic group, thorough mastication significantly reduced postprandial blood glucose levels at 2 hours (128.25± 7.82 mg/dl on routine mastication vs 119.74±9.08 mg/dl on thorough mastication, p<0.05). Comparatively, in dysglycaemic group, thorough mastication had little effect on postprandial blood glucose levels at 2 hours (244.07±22.37 mg/dl vs. 243.55±22.87 mg/dl). CONCLUSION In normoglycaemic group, postprandial blood glucose concentration upon thorough mastication was significantly lower, due to early-phase insulin secretion. This simple lifestyle modification of thorough mastication can be a useful preventive measure against diabetes in people with a strong family history and other risk factors for diabetes who have not yet developed diabetes or prediabetes.

Gitelman's syndrome

Classic Bartter’s syndrome is primary renal tubular hypokalemic metabolic alkalosis with normocalciuria or hypercalciuria, a severe disorder and Gitelman’s syndrome is primary renal tubular hypokalemic metabolic alkalosis with hypocalciuria and magnesium deficiency, a benign disorder. It has been suggested that the antenatal and classic Bartter’s syndrome and Gitelman’s syndrome represent distinct variants of primary renal tubular hypokalemic metabolic alkalosis and are easily distinguished on the basis of urinary calcium levels. The Gitelman’s syndrome present during adolescence or adulthood, inherited as autosomal recessive traits. The dominant features are fatigue, weakness, hypocalciuria, hypomagnesemia with hypermagnesuria and normal prostaglandin production. We report here a patient who presented with features of Gitelman’s syndrome.

Fertility Desires and Intentions among People Living with HIV/AIDS (PLWHA) in Southern India.

INTRODUCTION The desire of people living with HIV/AIDS (PLWHA) to have children can have significant public health implications. Combination Antiretroviral Therapy (cART) has increased the life expectancy of PLWHA as a result of which they may consider child bearing. There are hardly any studies from India addressing the fertility desires among PLWHA. AIM This study was done to assess the fertility desires of PLWHA in Southern India. MATERIALS AND METHODS It was a cross-sectional study conducted among 230 HIV-positive men and women who presented to Kasturba Medical College (KMC), Mangalore, India. Study was conducted between October 2012 and October 2014. Statistical analysis was performed using SPSS software version 11.5. Chi-square test, Fishers exact test and student t-test was used to find out the association of various factors affecting fertility desire. A p-value of less than 0.05 was considered statistically significant. RESULTS The mean age of our study population was 36.3±5.5 years. The mean age of males was 37.3±6 years and for female 34.9±5 years. In our study 132 (57.4%) were males. Majority were literate 229 (99%). Majority of patients were employed 166 (72%). In our study 195 (84.7%) were on cART. Out of 230 PLWHA 39 (16.95%) were unmarried and 151(65.5%) married PLHIV were living with partners at the time of study. In our study 77 (33.5%) patients had fertility desire. Age, gender, marital status, number of children, partners fertility desire and HIV status of partner had an association with fertility desire. CONCLUSION Providing universal access to cART is the main aim of national programs. It is high time that these programs focus on fertility issues of PLWHA. Reproductive rights of PLWHA need to be respected. Physicians and HIV counselors should proactively discuss and address reproductive issues of PLWHA.

Carbamzepine-induced toxic epidermal necrolysis.

Toxic epidermal necrolysis (TEN), also known as Lyells syndrome, is a widespread life-threatening mucocutaneous disease where there is extensive detachment of the skin and mucous membrane. Many factors involved in the etiology of TEN including adverse drug reactions. Here we are reporting a case of toxic epidermal necrolysis in an adult male patient after receiving carbamazepine in a 38 year old male. On the 18th day of carbamazepine, patient developed blisters which first appeared on the trunk, chest and arms. The erythematous rash was covering almost all over the body with epidermal detachment of 70% body surface area. There was loss of eye lashes, congestion of conjunctiva with mucopurulent discharge and exposure keratitis. The clinical impression was TEN induced by carbamazepine. Carbamazepine was stopped immediately. He was treated with high dose intravenous betamethasone and systemic and topical antibiotics. After one month, the progression of the skin lesions halted and he was discharged.

Association of serum uric acid level with estimated glomerular filtration rate in diabetic patients

Background and Objective: Uric acid may be a novel and important player in the pathogenesis of microvascular complications in diabetes mellitus. The objective of this study was to investigate the association between eGFR and uric acid in patients with type 2 diabetes mellitus. Materials and Methods: A cross-sectional study was done in type 2 diabetic patients of both genders above the age of 18 years. Demographic characteristics collected include age, gender, body weight, height, and duration of diabetes. Laboratory investigations data collected included serum creatinine, blood urea nitrogen, serum uric acid, urine albumin, urine creatinine, urine albumin creatinine ratio, HbA1c, and blood glucose. GFR was calculated using the Modification of Diet in Renal Disease formula (4 variable formula). Results: A total of 63 patients were included in the study. Among them, 35 (55.6%) were males and 28 were females (44.4%). Mean age of the patients was 61.63 ± 10.37 years. Out of 63 patients, 52 had normal uric acid level and 11 patients had elevated uric acid level. eGFR was 81.32 ± 17.53 ml/min in patients with normal uric acid level, whereas it was 61.63 ± 26.18 ml/min in patients with elevated uric acid level. The difference is statistically significant (P = 0.03). Urine albumin creatinine ratio was 12.2 ± 40.92 μg/mg in patients with normal uric acid level and was 47.04 ± 76.58 μg/mg in patients with elevated uric acid level, the difference being statistically significant (P = 0.035). There was a significant negative correlation between uric acid and eGFR (r = -31, P = 0.014), whereas statistically significant correlation was not seen between uric acid level and urine albumin creatinine ratio. Uric acid level was 0.312 ± 0.072 mmol/L in normoalbuminuric patients (55 patients), whereas it was 0.343 ± 0.092 mmol/L in patients with microalbuminuria (8 patients). Conclusion: Serum uric acid is independently and negatively associated with GFR in patients with type 2 diabetes mellitus and thus supporting the concept that uric acid may be involved in the pathogenesis of diabetic nephropathy.

An Interesting Case of Dysphagia in a HIV Patient.

Oesophageal tuberculosis is a rare disease. Tuberculosis (TB) can cause dysphagia due to oesophageal ulcers, Tracheo-Oesophageal Fistulas (TOFs) and an extrinsic compression which is caused by the mediastinal lymph nodes. A 33-year-old gentleman was admitted to our hospital for the evaluation of fever, dysphagia and cough. His chest X-ray was suggestive of miliary tuberculosis. A CT scan of his chest revealed miliary tuberculosis, mediastinal lymphadenopathy and pneumomediastinum. His sputum AFB (acid-fast bacilli) test was positive. An upper gastrointestinal endoscopy revealed a large ulcer in the oesophagus with a fistulous opening which was suggestive of a tracheo-oesophageal fistula. A biopsy from the ulcer was positive for AFB. The test for HIV-1 was positive. A nasogastric feeding tube was placed and the Anti Tubercular Therapy ( ATT) was started. The main aim of this case report is to sensitize the clinicians about the fact that Tuberculosis can present with dysphagia, especially in HIV patients.

Analysis of hemogram profile of elderly diabetics in a tertiary care hospital

Background: Anemia is a common concern in geriatric health, but its exact incidence and prevalence are unclear. Several studies have addressed this issue with discrepant results. Recent findings have shown that anemia can lead to cardiovascular and neurological complications, such as congestive heart failure and impaired cognitive function. Objective: To evaluate the hemogram profi le in elderly diabetic patients and compare the same with younger diabetic patients. Materials and Methods: A retrospective chart review of type 2 diabetic patients who participated in clinical trials on diabetes mellitus was carried out. The clinical trials have been approved by the institutional ethics committee. Patient population included both males and females. Patients who underwent baseline hemogram profi le were included for the study. Laboratory parameters collected include hemoglobin, hematocrit value, mean corpuscular volume (MCV), mean corpuscular hemoglobin (MCH), mean corpuscular hemoglobin concentration (MCHC), red cell distribution width (RDW), glycosylated hemoglobin, serum creatinine, and urine albumin. Results: A total of 127 elderly patients with age60 years and 122 patients with age below 60 years were included in the study. Mean hemoglobin concentration in elderly was 13.1 g/dL and in younger patients was 14.8 g/dL. The differences in the hemogram values among the two populations showed statistical signifi cance only for hematocrit (P0.03) and RDW (P  0.002). There was signifi cant positive correlation between hemoglobin level and creatinine clearance (P0.019) and between hemoglobin and urine albumin concentration (P0.035) among elderly patients. Among the elderly patients 25 (19.7%) had anemia (hemoglobin below 12 g/dL), and 18 (14.8%) younger patients had anemia. Chi-square analysis did not show signifi cance for distribution of anemia among the two populations. Conclusion: There was signifi cant difference in the hemogram profi le of elder and younger diabetics; levels were much less in elderly patients.

Effect of participation in a clinical trial on glycemic control in type 2 diabetic patients..

Sir, Improved self-management following participation in a clinical trial with better glycemic control has been recently reported in the literature.[1,2] Participation in a clinical trial encourages a greater involvement of patient in self-care. It also results in more equal partnership between patients and health care professionals. The present retrospective analyses aims at examining the influence of study participation on glycemic control in type 2 diabetic patients. Retrospective analysis of glycemic control in type 2 diabetic patients who participated in clinical trials was done by comparing the fasting glucose and HbA1C values at screening and randomization visits. We selected the patients who participated in a randomized controlled clinical trial on new therapy for type 2 diabetes mellitus. A total of three such studies were selected. All these studies were approved by the Institutional Ethics Committee. Eligible patients for the evaluation were those who undertook both the screening as well as randomization visits. Those who had undergone only screening were excluded. The interval between the two visits varied between studies depending upon the study design. Antidiabetic medication remained unchanged between the two visits. Fasting glucose, HbA1C, and body weight were measured at both the visits. All these trials included adult, males or females. Trial 1 included obese patients with features of metabolic syndrome (body mass index above 25 kg/m2) who were inadequately controlled with insulin alone or in combination with oral hypoglycemic agents. Patients were screened at visit 1 and those found eligible continued with stable dose of insulin and oral hypoglycemic agents along with placebo medication for 2 months. At the end of 2 months patients were randomized to receive active study medication. Trial 2 included type 2 diabetic patients with inadequate glycemic control. Patients were drug naive at the time of inclusion. Patients were screened at visit 1 and received placebo for 1 month after which the eligible patients were randomized. Trial 3 included patients with history of type 2 diabetes mellitus and body mass index between 23 and 45 kg/m2. These were inadequately controlled (HbA1C above 8.0%) and received a combination therapy including metformin and another oral hypoglycemic agent. After screening, all eligible patients were put on maximum tolerated dose of metformin along with pioglitazone for 3 months after which the eligible patients were randomized to receive the study medication. Fasting glucose and HbA1C were measured at screening as well as randomization visit in all the three studies. Glucometer was dispensed to all patients for self-monitoring of blood glucose. Patients were given adequate education and were taught to use the glucometer. They were also advised to maintain a diary for daily record of glucometer readings. Data from all three studies were combined as well as analyzed individually. The Student ‘t’-test was used for statistical analysis and a P < 0.05 was considered significant. The main outcome was short-term glycemic control measured by glycated hemoglobin (%) and fasting glucose level. A total of 61 patients (32 males and 29 females) were studied (trial l: 17, trial 2: 25 and trial 3: 19). Patients in trial 3 had maximum duration of diabetes (17.65±8.02 years) and trial 2 patients had shortest. The median interval between screening (visit 1) and randomization (visit 2) was 60 days in trial 1, 30 days in trial 2, and 90 days in trial 3. Baseline HbA1C was highest in trial 1 patients. It increased further in trial 1 patients from baseline to randomization visit, whereas it decreased in trial 2 and 3 patients. Drop in HbA1C was much more in trial 3 patients though statistically insignificant (P=0.074). Overall analysis has shown a decrease in HbA1C between the two visits. Baseline fasting blood glucose was also highest in trial 1 patients and was lowest in trial 2 patients. Fasting blood glucose increased from visit 1 to visit 2 in trial 1 patients and decreased in trial 2 and 3 patients. The drop in fasting glucose level in trial 3 patients was statistically significant (P=0.01). Overall analysis also showed a decrease in fasting glucose level between the two visits [Table 1]. Body weight increased from screening to randomization visit in all the trials except trial 2 where a small decrease was noted. Overall analysis showed an increase in body weight between the two visits. A mean increase in body weight in trial 3 patients was statistically significant. Table 1 Fasting blood glucose (mmol/L) and Hba1C (%) at screening and randomization visits The present analysis has shown that study participation itself causes sufficient changes in the glycemic control. Combined analysis of all the three studies has shown that there was sufficient reduction in blood glucose and HbA1c level in patients who participated in clinical trials. Similar observations have also been made before.[2,3] In the present study, patients who were in trial 1 have shown poorer glycemic control when compared to other two trials. Poor baseline glycemic control as well as long duration of diabetes could be the reason for this observation. In contrast, Gale et al.[3] have reported that reduction in blood sugar concentration is proportional to initial HbA1C with large decreases in those with the poor initial control but no overall change in those at or below the 10th percentile of HbA1C. Improved glycemic control following participation in a clinical trial can be best understood as a result of enhanced awareness in patients, increased care given by health professionals, frequent monitoring and motivation of patients for better adherence to therapy and lifestyle modification.[4,5] It is observed that people tend to alter their behavior when they know that they are being studied.[3] Our results also imply that the benefits seen in uncontrolled trials should be interpreted with extreme caution. It is advisable to have a run-in or lead-in phase of adequate length before randomization in a clinical trial to achieve a stable baseline value of HbA1c.