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   Table of Contents - Current issue
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September-December 2019
Volume 10 | Issue 3
Page Nos. 89-144

Online since Tuesday, August 27, 2019

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REVIEW ARTICLES  

The economic burden of HIV and type 2 diabetes comorbidity: Implications for care in countries with high burden of HIV p. 89
Sakhile K S Masuku, Joyce M Tsoka-Gwegweni, Ben Sartorius
DOI:10.4103/jod.jod_50_18  
The economic burden of human immunodeficiency virus (HIV) and diabetes shows the need to design interventions to delay the development of type 2 diabetes in HIV-positive population. In 2015 alone, approximately US$19 billion was spent in the HIV/acquired immunodeficiency syndrome response in low- and middle-income countries. Approximately 57% of the total HIV resources in low- and middle-income countries come from the local government budgets. Rising numbers of new HIV infections in many countries mean that US$26.2 billion will be required for the response to the epidemic in 2020. On the other hand, the cost of diabetes mellitus alone is projected to be US$745 billion by 2030 and approximately US$300 billion is estimated to be the cost incurred in low- and middle-income countries. People diagnosed with diabetes at the age of 40 years spent US$124,600 more than those without diabetes over their remaining lifetime. The co-occurrence of type 2 diabetes and HIV increases the economic burden at patient and country level, hence there is a need to identify interventions for preventing diabetes among people living with HIV. This review has shown that both lifestyle and pharmacologic interventions are proven effective and cost-effective. Lifestyle modification, metformin intervention, and diabetes surveillance among people living with HIV are cost-effective strategies that can effectively prevent the development of diabetes in this population. There is also a need for the health policy to support the implementation of these strategies. Health and social policies should support the funding of intensive lifestyle and metformin interventions for diabetes prevention in high-risk groups.
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ORIGINAL ARTICLES Top

Short-term insulin therapy at the time of diagnosis of Type 2 diabetes leads to better glycemic control and improved beta cell function p. 97
Siddharth Madnani, Ranjit Mohan Anjana, Sanjay Baliram Warade, Muthukrishnan Varalakshmi, Brijendra Kumar Srivastava, Prasanna Kumar Gupta, Philips Routray, Chandru Sundaramoorthy, Ranjit Unnikrishnan, Viswanathan Mohan
DOI:10.4103/jod.jod_39_18  
Background: Impaired insulin secretion and insulin resistance are the underlying pathophysiological defects in Type 2 diabetes (T2DM) that lead to hyperglycaemia. The β-cell defect in T2DM is usually progressive, leading to eventual β-cell exhaustion and dependence on insulin. It is known that glucotoxicity and lipotoxicity contribute to the initial decreased insulin secretion at the time of diagnosis of T2DM. Therefore, an aggressive approach early in the course of the disease to correct these defects could possibly alter the natural history of T2DM. Objectives: Our aim was to study the effect of administration of a short course of insulin therapy at the onset of T2DM on glycaemic parameters and pancreatic β-cell function as assessed by C-peptide estimation. Materials and Methods: Treatment-naïve T2DM patients (n = 426) with known duration of diabetes of <3 months were recruited from Dr. Mohan’s Diabetes Specialities Centre at Chennai. All patients were treated initially with short-term insulin therapy (4–6 weeks) along with oral hypoglycaemic agents (OHAs), usually metformin alone or sometimes in combination with sulphonylurea. Subsequently, they were continued on diet, exercise and OHA, wherever required. The baseline characteristics, fasting plasma glucose (FPG) and postprandial plasma glucose (PPG) and glycated haemoglobin (HbA1c), were compared after (an initial) a mean follow-up period of 2.6 months. Patients were then followed up for another 2 years to evaluate their long-term glycaemic control. Fasting and stimulated C-peptide levels were measured in a subset of patients at baseline and at follow-up at 2–3 months, 1 year and 2 years. Results: There was a significant reduction in both FPG and PPG levels. The mean FPG decreased from 214 ± 82 to 111 ± 29mg/dl (P < 0.001), whereas the PPG decreased from 332 ± 120 to 158 ± 54mg/dl (P < 0.001). The HbA1c decreased from 11.8% ± 1.9% to 6.8% ± 1.1% (P < 0.001). There was a significant improvement in the serum C-peptide levels, indicating an improvement in β-cell function. The fasting C-peptide levels improved from a mean of 0.85 ± 0.3 to 1.09 ± 0.4 pmol/ml, whereas the stimulated C-peptide value increased from a mean of 1.63 ± 0.8 to 2.09 ± 1.0 pmol/ml even at the end of 2 years after the insulin was discontinued. There was also a favourable change in lipid profile of the patients. Conclusion: Our study demonstrates that, in newly diagnosed T2DM, a short course of insulin therapy given for 4–6 weeks can lead to long-term good glycaemic control and beneficial effects on pancreatic β-cell function, which is sustained up to 2 years.
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Bacterial causes of community-acquired and nosocomial urinary tract infection in type 2 diabetes: A comparative approach Highly accessed article p. 102
E Premprakash Patra, Sonam Karna, Dayanidhi Meher, Srilekha Mishra
DOI:10.4103/jod.jod_31_18  
Introduction: Urinary tract infection (UTI) in type 2 diabetes (T2D) is one of the most common infectious diseases diagnosed both in community and in hospital. Due to increased prevalence of disease and rising antibiotic resistance among uropathogens, it is important to have local community- and hospital-based knowledge of the organisms causing UTI in T2D and their sensitivity pattern to choose correct treatment regimen. Methodology: Samples were collected from both Outpatient Department (OPD) and Inpatient Department (IPD) of endocrinology, KIMS. The study was selected to compare the prevalence among the bacterial isolates from community-acquired UTI (CUTI) and nosocomial UTI (NUTI) in T2D individuals and compare the antibiogram pattern. Results: Of the total 92 culture-positive samples, 40 were CUTI and 52 were NUTI. Culture positivity was directly proportional to the presence of increased number of pus cell and glycaemic status. The most commonly isolated bacterium was Escherichia coli both in OPD and IPD followed by Enterococcus, Staphylococcus saprophyticus, Staphylococcus aureus, Klebsiella spp., Pseudomonas aeruginosa and Proteus species except the Citrobacter spp. and Candida spp. which were isolated from ward patients. Conclusion: There was no significant difference of resistance pattern between CUTI and NUTI. Inappropriate use of antibiotics results in increase of antibiotic resistance, and hence, proper care should be taken regarding infection treatment guidelines promoting rational antibiotic prescribing in hyperglycaemic UTI cases.
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The influence of one-carbon metabolism gene polymorphisms and gene-environment interactions on homocysteine, Vitamin B12, folate and lipids in a Brazilian adolescent population p. 110
Shelini Surendran, Carla C Morais, Dulcinéia S P Abdalla, Israa A Shatwan, Julie A Lovegrove, Cristiane Cominetti, Vimaleswaran Karani Santhanakrishnan, Maria A Horst
DOI:10.4103/jod.jod_37_18  
Background: Several single-nucleotide polymorphisms (SNPs) have been associated with the metabolism of Vitamin B12, folic acid, homocysteine and lipids. However, the interaction between SNPs involved in the one-carbon metabolism pathway and macronutrient intake on cardiovascular risk factors in the Brazilian population has not yet been investigated. Hence, the present study examined whether the association of ten SNPs involved in the one-carbon metabolism pathway with Vitamin B12, folic acid, homocysteine and lipid levels is modified by dietary factors and physical activity in adolescents with cardiovascular risk. Materials and Methods: A total of 113 adolescents (10–19 years old), from a public school in the city of Goiânia, Goiás, Brazil, underwent anthropometric, biochemical and food consumption evaluations and genetic tests. Results: After adjusting for potential confounders, SNPs rs4633 (catechol-O-methyltransferase, COMT), rs602662 (fucosyltransferase 2, FUT2) and rs1801394 (5-methyltetrahydrofolate-homocysteine methyltransferase reductase) showed significant associations with folic acid (P = 0.042), Vitamin B12 (P = 0.009) and oxidised low-density lipoprotein (ox-LDL) (P = 0.041) concentrations, respectively. The COMT SNP rs4680 showed a significant interaction with carbohydrate intake on ox-LDL concentrations (Pinteraction = 0.005). In addition, the FUT2 SNP rs602662 showed a significant interaction with protein intake on homocysteine concentrations (Pinteraction = 0.007). However, after correction for multiple testing, none of these associations and interactions were statistically significant. Conclusions: For the first time, we provide evidence for the interactions between COMT SNP rs4680 and carbohydrate intake on ox-LDL levels and the FUT2 SNP rs602662 and protein intake on homocysteine concentrations. However, replication of our results in a larger sample size is required to confirm our findings.
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Diabetes mellitus as a risk factor for hepatocellular carcinoma: A single-centre experience from South India p. 123
Mayank Jain, K Baraneedharan, GS Sameer Kumar, Vivek Joshi, Mettu Srinivas Reddy, Mohamed Rela, Jayanthi Venkataraman
DOI:10.4103/jod.jod_40_18  
Aim: Retrospective analysis of medical records to determine whether diabetes mellitus (DM) was a risk factor for hepatocellular carcinoma (HCC) and whether it enhances the neoplastic potential of hepatotropic virus-related chronic liver disease (CLD). Materials and Methods: Patients registered between April 2017 and March 2018 with a clinical diagnosis of HCC in a pre-existing CLD were included. Controls were patients with CLD registered during the same period but with no HCC. Prevalence of DM, hypertension and coronary artery disease (CAD) alone or in combinations was noted in the two groups. The odds ratio (OR) of developing HCC was calculated independently for DM, hepatitis B and hepatitis C infection alone and in combinations. Chi-square test, Mann–Whitney test and OR calculation were done. A P < 0.05 was considered statistically significant. Results: The study population consisted of 150 cases of CLD with HCC and 812 controls (CLD with no HCC). CLD patients with HCC were significantly older (P < 0.0001) with a male preponderance, but no gender predisposition (P = NS). The overall prevalence of DM in patients with CLD was 31.9%, more significant amongst cases than in controls (50.7% vs. 28.7%) (P < 0.0001) and also for a significant duration (10.6 vs. 3.8 years; P < 0.03). Amongst the cases, comorbid conditions such as hypertension and CAD and diabetes in combination with hypertension and CAD was also more frequent among cases (P = 0.0001).The odds of developing HCC in CLD was higher for DM. The OR for HCC was highest for DM with hypertension and/or CAD at 4.69 (3.19–6.88, P < 0.0001). Conclusion: DM and other constituents of metabolic syndrome such as hypertension and CAD are significantly more common in CLD patients with HCC. DM is of prolonged duration and is a risk factor increasing the neoplastic potential of CLD.
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Association of whole grains, dairy and dietary fibre with neonatal outcomes in women with gestational diabetes mellitus: The WINGS project (WINGS – 12) p. 127
Ranjit Mohan Anjana, Parthasarathy Vijayalakshmi, Balaji Bhavadharini, Rajagopal Gayathri, Nagarajan Lakshmipriya, Subashchandrabose Uthra, Ranjit Unnikrishnan, Ram Uma, Viswanathan Mohan, Vasudevan Sudha
DOI:10.4103/jod.jod_2_19  
Background: Dietary modifications have been shown to lower the risk for gestational diabetes mellitus (GDM). However, there is little evidence whether dietary modifications during pregnancy can improve neonatal outcomes in women with GDM, particularly in low-resource settings. Aim: The aim of the study is to assess the effect of a dietary modification delivered through a low-cost model of care (MOC), on neonatal outcomes in women with GDM in India. Methodology: Dietary intake was assessed in 133 women with GDM enrolled under the women in India with GDM strategy-MOC (WINGS-MOC), from six maternity centres in Chennai, in South India. The WINGS-MOC dietary intervention included one-on-one monthly antenatal diet counselling, providing a dietary guideline booklet and healthy recipe demonstrations. Dietary intake was assessed using 24-h dietary recall and an open-ended diet questionnaire. A ‘healthy diet score’ was derived from the reported intake of whole grains, dairy products and dietary fibre. The effect of healthy diet score on neonatal outcomes (macrosomia, hyperbilirubinaemia, congenital anomalies and neonatal intensive care unit admissions) was evaluated. Results: A six-fold increase in the intake of whole grains (30 vs. 5.1g) and 20% increase in consumption of dairy products (265.4 vs. 225g) and dietary fibre (22.3 vs. 18.2g) were observed after the MOC intervention. Higher consumption of whole grain, dairy products and dietary fibre was inversely associated with adverse neonatal outcomes. Those with the highest healthy diet score had lower risk for adverse neonatal outcomes (odds ratio: 0.2, [95% confidence interval: 0.04–0.9]; P = 0.04) even after adjusting for potential confounders. Conclusions: A low-cost dietary intervention helps to improve neonatal outcomes in women with GDM.
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SHORT COMMUNICATION Top

Middle East and North Africa region guidelines for the management of type 2 diabetes p. 134
A Samad Shera, Abdul Basit, Asher Fawwad
DOI:10.4103/jod.jod_43_18  
The International Diabetes Federation is divided into seven regions, Africa (AFR), Europe (EUR), Middle East and North Africa (MENA), North America and Caribbean (NAC), South and Central America (SACA), South East Asia (SEA) and Western Pacific (WP), with the aim of enhancing the work of national diabetes associations and strengthening the collaboration between them. In the MENA region, adult population (aged 20–79 years) was estimated 387 million in 2015 from which 35.4 million were suffering from diabetes and is expected to increase up to 72.1 million in 2040. Of the 35.4 million people affected by diabetes, nearly 40.6% were estimated to be undiagnosed. Therefore, at considerable risk of diabetes complications and poor health outcomes. The importance of glycemic control in preventing and delaying the progression of diabetes complications is well well-known. Diabetes poses extreme financial load to diabetic subjects. Local guidelines help to upgrade management strategies. It provides ideas for health care providers to improve quality of life of patient. Guidelines were prepared reviewing the literature, reviewing the available guidelines, consultative meetings between the experts and country representatives from the region.
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CASE REPORTS Top

Fibrocalculous pancreatic diabetes in a young female: A case report from South Gujarat p. 140
Vineeta Singh, Mohit Singh Tandon
DOI:10.4103/jod.jod_15_18  
Fibrocalculous pancreatic diabetes (FCPD) is a rare form of diabetes secondary to chronic calcific pancreatitis. The patients generally have clinical triad of pain abdomen, steatorrhoea and diabetes. The peculiar features are presence in a tropical country, younger age of onset, presence of pancreatic calculi, ketosis resistance and chances of progression to malignancy. We present a case of a young female presenting with recurrent abdominal pain, diabetes and chronic calcific pancreatitis. She was diagnosed to have FCPD based on the clinical, biochemical and radiological findings. She was managed with insulin, pancreatic enzyme supplementation and analgesics for pain relief. This is the first case reported from south Gujarat as per our knowledge. FCPD is quite rare. This report signifies the importance of keeping high index of suspicion in patients presenting with high sugars and abdominal pain. Early management with sugar control, pain relief and supplementing enzymes may prevent progression to complications.
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LETTER TO EDITOR Top

Shingles near surgical site: A rare complication in a diabetic following hip arthroplasty p. 143
Ganesh Singh Dharmshaktu, Tanuja Pangtey
DOI:10.4103/jod.jod_41_18  
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