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   Table of Contents - Current issue
Coverpage
January-March 2021
Volume 12 | Issue 1
Page Nos. 1-109

Online since Friday, December 25, 2020

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REVIEW ARTICLES  

Sweetening sixteen: Beyond the ominous octet p. 1
Sanjeev R Phatak, Banshi Saboo, Shivangi Dwivedi, Padmanabh Zinzuwadia, Dharmendra Panchal, Abhilasha Ganguli, Dhruvi Hasnani
DOI:10.4103/jod.jod_9_20  
As the epidemic of type 2 diabetes continues to grow, newer pathophysiologic mechanisms of diabetes are being unraveled in quick succession. From a simplistic model of insulin deficiency and insulin resistance, researchers have moved to a multipronged explanation of the disease. In addition to the ominous octet, eight other players, such as catecholamines, vitamin D deficiency, renin–angiotensin system, testosterone deficiency, melatonin, renal gluconeogenesis, intestinal sodium-glucose cotransporter 1, and gut microbiota, seem to participate in the etiopathogenesis of glucose intolerance and type 2 diabetes. Collectively, these 16 players comprise a cluster of interrelated etiologies implicated in the pathogenesis of diabetes, prompting the authors to address them as the “sweetening sixteen.” While exploring these factors, the authors wish to emphasize that diabetes treatment should focus on the reversal of these proposed pathogenetic defects and not simply reduction of hemoglobin A1C.
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Potential role of yoga in management of the ominous octet: Adding a new facet to type 2 diabetes management and prevention Highly accessed article p. 10
Venugopal Vijayakumar, Ramesh Mavathur, Nagarathna Raguram, Harish Ranjani, Ranjit Mohan Anjana, Viswanathan Mohan
DOI:10.4103/jod.jod_6_18  
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ORIGINAL ARTICLES Top

Use of telemedicine for the management of type 1 diabetes in children and adolescents in Bangladesh during the COVID-19 pandemic p. 18
Bedowra Zabeen, Bishwajit Bhowmik, Kamrul Huda, Farzana Naz, Samin Tayyeb, Kishwar Azad
DOI:10.4103/jod.jod_55_20  
Background: Telemedicine has been an option for healthcare during the COVID-19 pandemic time. According to the COVID-19 forum on the International Society for Pediatric and Adolescent Diabetes, telemedicine is now the reality for all pediatric diabetes centers around the globe. We report here the analysis of telemedicine care provided to children and adolescents with type 1 diabetes by our diabetes team during the first phase of lockdown in Bangladesh. Materials and Methods: The Diabetic Association of Bangladesh (BADAS) is providing a highly structured and organized system of diabetes care as an extended arm of the government. Since the lockdown, diabetes care for children was started through telemedicine by the diabetes team in our center. Results: We analyzed our phone calls, text messages from March 26 to April 30, 2020. During lockdown, more than 645 calls, including text messages and WhatsApp messages, were received. A total of 235 patients were given advice over the phone in 1 month. Fifty-two percent of phone calls were from the capital city Dhaka and rest from other districts of Bangladesh. While analyzing the problems, three of our patients noticed mild fever, but there was no history of contact with infected persons, and they recovered within 2–3 days. No laboratory test was done for the confirmation of COVID-19. Most of the patients developed hyperglycemia during this period. None of them required hospital admission during this month. Free insulin from CDiC (Changing Diabetes in Children) and LFAC (Life for a Child) programs was sent to the BADAS centers in different districts through courier service even during the lockdown. So, there was no patient without access to insulin during pandemic time. Conclusion: Telemedicine service has been found to be a useful medium for the care of children with diabetes in Bangladesh during COVID-19 crisis. In the future, telemedicine service could be a solution for routine care of diabetic children who are unable or unwilling to travel long distances to a clinic.
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Impact of glycemic control in diabetes mellitus on management of COVID-19 infection p. 22
Sudhir Bhandari, Govind Rankawat, Ajeet Singh, Vishal Gupta, Shivankan Kakkar
DOI:10.4103/jod.jod_58_20  
Background: This study was undertaken to evaluate the clinical presentation, laboratory parameters, radiological imaging, management, and outcome of coronavirus disease-2019 (COVID-19) infection in patients of diabetes mellitus and its association with glycemic control. Materials and Methods: This study conducted on 80 admitted COVID-19 patients of known diabetes mellitus, who were categorized into two groups: Group 1 had patients with uncontrolled diabetes as indicated by hemoglobin A1c (HbA1c) > 8 gm% and Group 2 had patients with controlled diabetes as indicated by HbA1c < 8 gm%. Information concerning medical history, clinical manifestations, laboratory findings, radiological imaging, management, and outcome was extracted from medical records for evaluation, interpretation, and association among both the groups. Results: COVID-19 patients with uncontrolled diabetes showed a severe symptomatic presentation, excessive uncontrolled inflammatory responses, and hypercoagulable state. Total leukocyte count, neutrophil–lymphocyte ratio, serum levels of interleukin-6 (IL-6), fibrin degradation product (FDP), and D-dimer were significantly raised (P < 0.05) in case of uncontrolled diabetes as compared to controlled diabetes. Radiological findings detected by chest radiograph and computed tomography chest suggested severe lung involvement in uncontrolled diabetes. COVID-19 patients with uncontrolled diabetes required intensive treatment as compared to controlled diabetes group in terms of insulin therapy (P = 0.0226) and noninvasive ventilation (P = 0.0292). Patients with uncontrolled diabetes had higher mortality (P = 0.0375) and required prolonged hospitalization (P = 0.0479) as compared to controlled diabetes group. Conclusion: From this study, it can be concluded that uncontrolled diabetes mellitus might be responsible for an overall higher susceptibility for COVID-19 infection and severity in terms of symptomatic presentation, inflammatory storm, rapid pulmonary invasion, requirement of more intensive treatment and a poor outcome.
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Quantitative and qualitative assessment of Indian research yield in type 1 diabetes during 1996–2020 p. 28
Devi Dayal, Brij Mohan Gupta, Saniya Gupta
DOI:10.4103/jod.jod_46_20  
Background: Type 1 diabetes (T1D) is a well-researched disease globally. The Indian contribution to global T1D research is unknown. Objective: The aim of this study was to provide a comprehensive assessment of publication output of Indian authors in the field of T1D. Materials and Methods: Scopus database was used to retrieve Indian publications on T1D during 1996–2019. The extracted data included the number of publications, citation metrics, top productive organizations and authors, research collaborations, most cited papers, and active journals, and were analyzed using appropriate bibliometric indicators. Results: Globally, the USA leads the ranking, of about 100 countries which participated in T1D research, with 29.3% of publication share, followed by UK (11.4%), and Germany, Italy, and Australia (6.9%–5.0%). India contributed only 1.7% (513 publications) share of global output, registered annual growth of 26.3% and averaged 9.7 citations per paper (CPP). Only 21.6% of publications involved international collaboration and 15.7% received funding. The two most productive organizations were PGIMER, Chandigarh and AIIMS, New Delhi with 51 and 43 papers, respectively. Indian Journal of Endocrinology and Metabolism (42 papers) and International Journal of Diabetes in Developing Countries (24 papers) were the two leading Indian journals, which published research on this topic.
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Prescription pattern and treatment target in patients with type 2 diabetes attending a tertiary health center in Lagos p. 36
Akinola O Dada, Sunday O Ogundele, Mumuni A Amisu, Adetutu Williams
DOI:10.4103/jod.jod_13_20  
Background: The prevalence of diabetes is on the increase worldwide. Type 2 diabetes is the most common form of diabetes and is characterized by disorders of insulin action and insulin secretion; any of these two abnormalities may be the predominant feature of the disease. The aim of the study was to review the drug treatment of patients with type 2 diabetes attending a follow-up clinic. Materials and Methods: The study took place at the outpatient clinic of a tertiary health center among patients attending a follow-up clinic. The study design was a descriptive cross-sectional review of the use of antidiabetic medications among adult males and females with type 2 diabetes. Results: A total of 235 participants took part in this study. 64.3% were females; the average age of the participants was 60.7 years with an age range of 20–88 years. This study showed metformin as the most commonly prescribed medication among the participants. Almost two-thirds of the participants were diagnosed with diabetes after they had developed symptoms or complications of diabetes. The proportion of participants with fasting blood sugar at the target level was 54.5%. Conclusion: In conclusion, this study revealed that metformin is the most commonly prescribed antidiabetic medication among the participants; almost two-thirds of the participants were detected to be diabetic after they have either developed symptoms or complications of the disease. Fasting blood sugar was at target levels in more than half of the participants.
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Assessment of footwear among patients with diabetes mellitus: A cross-sectional descriptive study from south India p. 41
Anulekha Mary John, Jessilin K Charley, Jibily Joy
DOI:10.4103/jod.jod_16_20  
Background: Diabetic peripheral neuropathy, a well-known complication of diabetes mellitus, leads to insensate foot, prone for ulceration. Inappropriate footwear and walking barefoot increases this risk in a neuropathic foot. A diabetic foot ulcer can be very costly, affecting the quality of life adversely and also result in amputation. A well-fitting, good footwear plays an important role in preventing injury and ulceration. In this study, we aimed to assess the footwear of patients with diabetes. Materials and Methods: This study was conducted during May 2019. Alternate patients among 230 patients were selected, and 112 patients with type 2 diabetes were included. Every patient was educated regarding all aspects of diabetes. Feet of each patient were examined. Biothesiometry, monofilament, and footwear assessments were performed. Results: Among 112 patients enrolled, 69 (61.6%) were males and 43 (38.3%) females. Mean age was 60.2 ± 11.7 years, and age ranged from 21 to 83 years. Duration of diabetes ranged from less than a year to 45 years. Of the total patients, 73 (65.17%) had significant diabetic peripheral neuropathy when assessed objectively, using biothesiometry and 10 g Semmes–Weinstein monofilament. Only 10 (8.9%) patients had footwear made of microcellular rubber. Only 15 (13.3%) wore a footwear with backstrap. Among those with neuropathy, only 4 (3.5%) had microcellular rubber (MCR) footwear with a backstrap. Optimal toe box was seen in 98 (87.5%) patients as most patients wore open footwear. Most of our patients wore footwear that was too hard, with shore value on durometry ranging from 60 to 75. Only 5 (4.46%) patients had desirable soft insole. Conclusion: No patient had an optimal footwear that fulfilled all criteria required for a foot with diabetic peripheral neuropathy. Hence, in addition to screening for neuropathy and regular checking of feet, it is also important to look at patient’s footwear and make necessary amendments periodically.
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Design and methodology of a randomized crossover trial to test the effect of low and high dAGE diets on metabolic risk factors and inflammatory markers among overweight and centrally obese Asian Indian adults p. 46
Mookambika Ramya Bai, Srinivasan Vedantham, Shanmugam Shobana, Lakshmi Priya Nagarajan, Gayathri Rajagopal, Geetha Gunasekaran, Gayathri Nagamuthu, Anitha Chandrashekaran, Kuppan Gokulakrishnan, Narasimhan Sandhya, Bhaskaran Sarojam Regin, Ramajeevan Ganeshjeevan, Balasubramanyam Muthuswamy, Ranjit Mohan Anjana, Ranjit Unnikrishnan, Kamala Krishnaswamy, Viswanathan Mohan, Vasudevan Sudha
DOI:10.4103/jod.jod_22_20  
Background: Heat processing of foods accelerates the formation of advanced glycation end products (AGEs). Dietary AGEs (dAGEs) could exacerbate the risk for diabetes, by adversely affecting glucose metabolism. Asian Indian diets have not been evaluated for AGEs and their effect on metabolic risk factors. Objective: As a proof of concept, we report the dAGE content of Indian foods to further plan the design and methodology of a study that would evaluate the effect of high and low dAGE diets on metabolic risk factors such as insulin resistance, glycemia, lipid profile, and inflammatory markers in overweight and centrally obese Indian adults without diabetes. Materials and Methods: This randomized crossover trial includes 50 overweight and centrally obese adults aged 25–45 years with body mass index (BMI) ≥23 kg/m2 and waist circumference (WC) ≥90cm in men and ≥80cm in women. Participants will be provided 12 weeks each of low and high dAGE diets (with the dAGE content being measured by enzyme-linked immunosorbent assay), matched for calories and macronutrients with a 2-week washout period in between the two diets. Low dAGE diets use steaming, boiling, and pressure cooking compared to deep frying, stir frying, and roasting in high dAGE diets. Biochemical measures will be assessed both at baseline and the end of each diet using standard protocols. The difference in outcome measures will be evaluated (analysis of variance and paired t test) using SAS (version 9.2). Results: The dAGE content was found to be 49709 ± 5239 vs. 26178 ± 4327 mg/day (mean ± standard deviation [SD]) in high and low dAGE diets, respectively (P < 0.001). Baseline demographic and biochemical characteristics did not differ between low and high dAGE diet interventions. Conclusion: The study trial will throw light on the effect of high and low dAGE diets on metabolic risk factors in overweight and centrally obese Indian adults, potentially leading to a novel dietary strategy to prevent diabetes in this population.
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Evaluation of neutrophil–lymphocyte ratio and platelet–lymphocyte ratio as markers of diabetic kidney disease in Bangladeshi patients with type 2 diabetes mellitus p. 58
A BM Kamrul-Hasan, Marufa Mustari, Md Asaduzzaman, Md Abu Jar Gaffar, Palash Kumar Chanda, Mohammad Motiur Rahman, Mohammad Abdul Hannan, Farhana Akter, Mohammad Saifuddin, Shahjada Selim
DOI:10.4103/jod.jod_4_20  
Background: The roles of neutrophil–lymphocyte ratio (NLR) and platelet–lymphocyte ratio (PLR) as novel surrogate markers of diabetic kidney disease (DKD) are promising. Objective: The aim of this study was to evaluate whether NLR and PLR can predict DKD in type 2 diabetes mellitus (T2DM). Subjects and Methods: This cross‑sectional study was conducted from July 2018 to June 2019, among 312 patients with T2DM recruited from eight tertiary hospitals throughout Bangladesh. Complete blood count (CBC) was performed in fully automated hematology analyzers, and NLR and PLR were calculated. The urine albumin-to-creatinine ratio (ACR) was measured in a random single-voided urine sample. The diagnosis of DKD was made based on the presence of albuminuria (ACR ≥30 mg/g) and/or reduced estimated glomerular filtration rate (eGFR <60mL/min/1.73 m2) in the absence of signs or symptoms of other primary causes of kidney damage. Results: Among 312 study subjects, 150 (48.1%) had DKD. The mean age (51.9 ± 11.9 vs. 48.6 ± 9.6 years), fasting plasma glucose (10.3 ± 4.1 vs. 9.2 ± 3.0 mmol/L), 2-h postprandial plasma glucose (14.6 ± 5.6 vs. 12.8 ± 4.5 mmol/L), glycated hemoglobin (HbA1c) (9.2 ± 2.1 vs. 8.4 ± 1.9%), and serum triglyceride (213.6 ± 109.9 vs. 185.5 ± 100.8) were higher (P ≤0.05 in each instance) in subjects with DKD in comparison to those without DKD. DKD group had higher mean absolute neutrophil count (6.0 ± 2.0 vs. 5.4 ± 1.9 ×109/L, P = 0.022), platelet count (310.4 ± 87.3 vs. 287.0 ± 78.7 ×109/L, P = 0.013), NLR (2.16 ± 1.1 vs. 1.92 ± 0.96, P = 0.040), and PLR (115.45 ± 57.07 vs. 101.02 ± 40.06, P = 0.010). The levels of hemoglobin, total leukocyte count, absolute lymphocyte count, mean corpuscular volume, mean corpuscular hemoglobin, mean corpuscular hemoglobin concentration, and red cell distribution width were similar in the two groups. Conclusion: In this study, we found higher NLR and PLR in subjects with DKD than those without DKD. NLR and PLR may be considered as cheap, readily available alternative markers of DKD in resource-poor settings.
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A proposed evaluation plan for the diabetes prevention and control program: A concept paper p. 63
Vinod Ramani Kotreshappa
DOI:10.4103/jod.jod_23_20  
Introduction: India is projected to be the diabetes capital by the next decade, and Asians are predisposed to central obesity and visceral adiposity which puts them at additional risk for diabetes. Materials and Methods: The proposed evaluation plan draws reference from the non-communicable disease prevention and control program, implemented by the Karnataka Health Systems Development & Reforms Project (KHSDRP), Directorate of Health Services, Government of Karnataka (GoK) in collaboration with the World Bank, New Delhi, during the period 2012 to 2016. This evaluation will be conducted by an external agency in consultation with the Medical Officer/Investigator. Results: The relevant reports will officially benefit the District Program Officer and District Health Officer of Davangere and Dakshina kannda districts, Karnataka, India, where the program is being implemented. Conclusion: The results of this plan will benefit health promotion planning by the Health Department including building of community advocacy for the promotional initiatives.
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Relationship between serum sialic acid concentration and diabetic nephropathy in Egyptian patients with type 2 diabetes mellitus p. 70
Ayman M El Badawy, Ahmed E Mansour, Marwa S Elsayed, Rasha O Abdelmoniem
DOI:10.4103/jod.jod_12_20  
Aim: Diabetic nephropathy is a major microvascular complication of diabetes mellitus (DM), and it is the most common cause of end-stage renal disease worldwide. Sialic acid is considered as an acute-phase reactant. Serum sialic acid level was found to be increased in diabetic nephropathy patients. We aimed to measure the serum sialic acid concentration in patients with type 2 DM and to assess if it could be used as an early marker of diabetic nephropathy. Subjects and Methods: This was a cross-sectional study that was carried out on 40 patients subdivided into 3 groups, first group involved 25 patients with diabetic nephropathy, second group involved 15 patients without diabetic nephropathy and the third group involved 10 patients serving as control group. All patients were selected from those attending the outpatient diabetic clinic at Benha University Hospital between July 2017 and July 2018. Mean and standard deviation (±SD) were used for quantitative data, and t test, Fisher extract test, and regression analysis were used for statistical analysis. A P value <0.05 was considered statistically significant, whereas >0.05 statistically insignificant. Results: On comparing patients with diabetic nephropathy with the control group patients we found that serum sialic level is increased and this was statistically significant and also in diabetic patients with nephropathy when compared to diabetic patients without nephropathy. The age of the onset of the discovery of diabetes and the duration of diabetes had no impact on serum sialic acid level. Conclusion: This study showed that serum sialic acid level is significantly increased in patients with diabetic nephropathy, and it is positively correlated with the glycemic control parameters and negatively correlated with estimated glomerular filtration rate, and it could be used as an early predictor of albuminuria and decrease of creatinine clearance.
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Effects of metabolic surgery on energy and nutrient intake in obese asian indians with dysglycemia p. 76
Sundaramoorthy Chandru, Narasimhan Sowmya, Rajendra Pradeepa, Suresh Thangamani, Thyparambil Aravindakshan Pramodkumar, Gopalakrishna Pazhanithampi, Ramesh Aiswarya, Ranjit Mohan Anjana, Viswanathan Mohan
DOI:10.4103/jod.jod_76_20  
Aims and Objectives: The rising prevalence of obesity and consequent metabolic disorders like type 2 diabetes has resulted in an increase in the number of metabolic surgeries. However, the nutrient intake of subjects who have undergone metabolic surgery remains poorly investigated in Asian Indians. The study aimed to assess the nutrient intake of obese Asian Indians who underwent metabolic surgery. Materials and Methods: Thirty obese Asian Indians with dysglycemia who underwent metabolic surgery at a tertiary diabetes center in South India were selected. Anthropometric, clinical, and biochemical measures were collected using standard methods. Using 24-h recalls, data were obtained on the nutrient intakes at baseline and 1, 6, and 12 months after surgery. Results: A significant decline was observed at the end of 6 and 12 months in all anthropometric characteristics such as body mass index, waist circumference, and hip circumference (P < 0.001). The mean daily energy intake at baseline (1371 ± 665 kcal) decreased significantly after 6 months (671 ± 423) and 12 months (847 ± 463). There was a significant decrease after 6 and 12 months in the intake of total carbohydrate, protein, and fat compared to baseline (P < 0.001). At the end of 12 months, energy intake was 70% as compared to baseline (100%), while that of carbohydrate was 62%, protein 75%, and fat 83%. Conclusion: Metabolic surgery resulted in a significant decline in energy intake, which is essential for postoperative weight loss and maintenance. There is also undesirable loss of soft lean mass (SLM); hence, strategies are needed to prevent the muscle loss.
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Guidelines for management of hyperglycemia in pregnancy (HIP) by Society of Obstetricians & Gynaecologists of Pakistan (SOGP)# p. 83
Shabeen Naz Masood, Shehla Baqai, Farrukh Naheed, Yasir Masood, Raheel Sikandar, Rizwana Chaudhri, Haleema Yasmin, Razia Korejo
DOI:10.4103/jod.jod_88_20  
Hyperglycemia in pregnancy (HIP) is an important component of primary prevention of diabetes both globally and in Pakistan. To ensure that the opportunity of primary prevention is not missed it is important to diagnose hyperglycemia early in pregnancy. Universal screening in pregnant women at booking is recommended with its implementation at primary, secondary and tertiary levels of health care settings. These guidelines by Society of Obstetricians and Gynecologists (SOGP) are pragmatic addressing screening methodology, preconception care screening & diagnosis, antenatal care plan, intrapartum and postpartum management & follow up, neonatal care, breastfeeding, contraception, counseling for future pregnancy, lifestyle modification, nutritional recommendations and proper techniques for insulin injection, management of diabetic ketoacidosis (DKA) and recommendations for future research. There are many available guidelines for the screening, diagnosis and management of HIP. The SOGP GDM guidelines recommendations are simple, tailored to the local context especially for the busy health care providers; medical as well as nurse practitioners, for whom it is confusing to choose the recommendations from different available guidelines. These guidelines are meant to standardize clinical practice at all health care levels across the country. In order to ensure its practical utilization, a national GDM registry has been proposed and designed so as to observe its applicability in the clinical practice by health care providers.
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CASE REPORTS Top

Peyroni’s disease maybe initial presentation of diabetes mellitus p. 99
Prabhat Agrawal, Ashish Gautam, Awantika Parihar, Boentika Singh
DOI:10.4103/jod.jod_34_20  
We report a case of a 30-year-old man presenting with complaint of pain during coitus. On history taking and examination, Peyronie’s disease was diagnosed in which the connective tissue of the corpus cavernosum is affected. It is characterized by excessive fibrosis and formation of plaque, causing deformities in the erect state such as curvature, indentation, shortening, and narrowing with a hinge effect, also penile pain with erection. On the basis of deranged blood sugar, he was diagnosed as a case of type 2 diabetes mellitus. We are reporting this case because after control of hyperglycemia, the symptoms and signs of Peyronie’s disease slightly improved.
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A challenge to achieve glycemic control in a patient with diabetes mellitus p. 101
Nisha Batra, Ravi Kant, Prativa Sethi
DOI:10.4103/jod.jod_15_20  
Secondary diabetes mellitus (DM) is a known identity with multiple causes. Acromegaly, a state of growth hormone (GH) excess, is a rare but an established cause of DM. Dysglycemia is present in approximately 50% of patients of acromegaly with impaired glucose tolerance (IGT) or impaired fasting glucose (IFG) ranging from 6% to 45% and from 7% to 22%, respectively, and DM has been reported in 16%–56% of patients (Alexopoulou O, Bex M, Kamenicky P, Mvoula AB, Chanson P, Maiter D. Prevalence and risk factors of IGT and DM at diagnosis of acromegaly: A study in 148 patients. Pituitary 2014;17:81-9; Dal J, Feldt-Rasmussen U, Andersen M, Kristensen LØ, Laurberg P, Pedersen L, et al. Acromegaly incidence, prevalence, complications and long-term prognosis: A nationwide cohort study. Eur J Endocrinol 2016;175:181-90). Diabetes in these patients is usually severe and difficult to treat. Glycemic control in these patients is best achieved by treating the underlying GH excess. We report a 60-year-old female patient, case of somatotropinoma, who was referred to diabetic clinic in view of persistent hyperglycemia despite taking multiple antidiabetic medications along with high-dose basal-bolus insulin regimen. Patient had residual pituitary tumor with GH excess and clinically active disease. She was started with somatostatin analogs for the residual disease. Her blood sugar values improved dramatically with episodes of hypoglycemia in between. Patient was shifted to single oral hypoglycemic (OHA) along with low dose insulin. This case highlights the direct association between GH excess and its hyperglycemic effects. Following successful treatment of acromegaly with surgery, irradiation, or medical management, glucose tolerance improves; although complete resolution is rare, OHA/insulin requirement is dramatically reduced.
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Werner syndrome: A rare cause of young-onset diabetes p. 105
Ana Soraya Palmira Dos Remedios Monteiro, Praveen V Pavithran, Sheela Nampoothiri, Dhanya Yesodharan
DOI:10.4103/jod.jod_35_20  
A 36-year-old male presented with young-onset diabetes and advanced peripheral vascular disease. He had a history of bilateral juvenile cataracts and premature aged appearance. Closer scrutiny unraveled multiple endocrine and nonendocrine abnormalities. Genetic studies revealed a novel pathogenic variant (homozygous c.3233+2T>c) confirming and expanding the mutation spectrum of Werner syndrome. This report highlights the need for precise diagnosis, which has important implications for prognosis and genetic counseling.
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LETTER TO THE EDITOR Top

Recommendations to successfully implement the “National Registry and Surveillance for Children and Adolescents with type 1 diabetes in India” p. 108
Santhosh Olety Sathyanarayana
DOI:10.4103/jod.jod_43_20  
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