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   2020| September-December  | Volume 11 | Issue 3  
    Online since September 1, 2020

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Indian reality of managing type 2 diabetes: an expert review of global and national guidelines for optimum insulin use
Ajay Kumar, Surendra Kumar Sharma, Arvind Gupta, Arundhati Dasgupta, Arthur J Asirvatham, Pradeep G Talwalkar, Ashok Kumar Das, Viswanathan Mohan
September-December 2020, 11(3):148-157
Several guidelines provide recommendations on insulin therapy in people with type 2 diabetes mellitus (T2DM). Major global guidelines have been adapted in multiple countries, and local consensus recommendations have been published giving guidance on insulin therapy considering local realities. This expert review focuses on the recommendations from global and Indian guidelines on insulin therapy in people with T2DM. It emphasizes on a patient-centric approach, including the glycemic parameters, psychosocial aspects, phase of life, and the Indian realities of T2DM management in guiding optimum insulin therapy for initiation and intensification. Therapeutic inertia towards timely insulin initiation needs to be bridged. Owing to the high carbohydrate diet and high postprandial glucose (PPG) excursions, insulin co-formulation and premix insulins offering total glycemic control can be preferred for a timely insulin initiation in Indians with T2DM that is uncontrolled despite multiple oral antidiabetic drugs. They also provide simplicity and convenience for insulin initiation and intensification. Among basal insulins, insulin degludec and glargine U300 are found to be safer, and offer more dosing flexibility than the first-generation basal insulin analogs. Faster-acting insulin aspart has been shown to provide better PPG control and dosing flexibility compared to a rapid-acting insulin analog with a lower risk of hypoglycemia. Thus, based on available evidences, a preferred use of insulin analog over conventional human insulins is suggested, keeping cost considerations in mind. The review also discusses optimum use of concomitant medications with insulin therapy for T2DM management.
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Dipeptidyl-peptidase-4 inhibitors in type 2 diabetes and COVID-19: From a potential repurposed agent to a useful treatment option
Awadhesh Kumar Singh, Ritu Singh
September-December 2020, 11(3):131-136
Dipeptidyl-peptidase-4 inhibitors (DPP-4Is) are very commonly prescribed antidiabetic agents in the treatment of type 2 diabetes owing to its modest ability to reduce blood glucose without ensuing any hypoglycemia and weight gain. Many experts have advised continuing DPP-4Is in patient with type 2 diabetes with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and coronavirus disease 2019 (COVID-19). In addition, several researchers have proposed DPP-4Is to be used as a repurposed agent for COVID-19 not only for the patients with diabetes but also for those without diabetes. We aimed to review as to what could be the reason behind this approach and how does the use of DPP-4Is alter the outcome in patients with type 2 diabetes and COVID-19.
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COVID-19: Considerations for children and adolescents with diabetes
Devi Dayal, Arti Yadav
September-December 2020, 11(3):126-130
Recent reports suggest that the clinical course of coronavirus disease 2019 (COVID-19) in previously healthy children is usually milder as compared to adults. However, children with comorbid conditions such as diabetes are at increased risk of infection with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) as well as morbidity and mortality due to COVID-19. Experience in adults with diabetes shows that they are prone to faster metabolic decompensation, develop diabetes-related complications, and have a poor prognosis when hospitalized with COVID-19. Data on children are limited. The aim of this mini review was to discuss the possible risks to children and adolescents with diabetes during the current pandemic and the special considerations in management in those affected with COVID-19. The challenges for children who develop new-onset type 1 diabetes during the COVID-19 lockdown, especially in accessing health care, are also discussed.
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Guide on diabetes and COVID-19 for healthcare professionals in Bangladesh
Bishwajit Bhowmik, Tareen Ahmed, Faria Afsana, Nazmul Kabir Qureshi, Tasnima Siddiquee, Faruque Pathan, Firoz Amin, Nayla Cristina do Vale Moreira, MA Samad, SM Ashrafuzzaman, Tofail Ahmed, Zafar Ahmed Latif, Abul Majid Bhuiyan, Abdul Alim, Sanjida Binte Munir, Rajat Kanti Karmokar, Kaiser Alam Choudhury, Bedowra Zabeen, Khaleda Islam, Mohammad Mahbubur Rahman, Mofizur Rahman, Sarowar Uddin Milon, Rie Ozaki, Md. Abdur Razzaqul Alam, Tabassum Huda, Md. Habibur Rahman, AHM Enayet Hossain, Hajera Mahtab, Akhtar Hussain, AK Azad Khan
September-December 2020, 11(3):137-143
The world is suffering from a pandemic of coronavirus disease-2019 (COVID-19), and people with diabetes mellitus (DM) are more vulnerable to the serious effects of the COVID-19. This interaction is alarming, considering the high transmission rate of COVID-19 and the global prevalence of DM. Considering the importance of the link between COVID-19 and DM, Bangladesh Diabetic Association has formed a panel of national and international experts in the field of public health, diabetes, and endocrinology to provide some evidence-based guidance for the prevention and care of people with DM during the COVID-19 pandemic.
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Management of coronavirus disease-2019 (COVID-19) in patients with diabetes
Dhanasekaran Bodhini, Viswanathan Mohan
September-December 2020, 11(3):125-125
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Telemedicine for the initial management of newly diagnosed gestational diabetes in the pandemic period: A report of three case studies
Monie Riju Simon, Nikita Sarkar, Suganthi Kumaran, Anil Chittake, Vedavati Purandare, Ambika Gopalakrishnan Unnikrishnan
September-December 2020, 11(3):144-147
Amidst the coronavirus disease of 2019 (COVID-19) pandemic and the subsequent guidance regarding movement restrictions, people may not be able to or willing to visit hospitals for a diabetes consultation. This especially applies to women with gestational diabetes mellitus (GDM) who are worried about getting infected during their visit to hospital. National telemedicine guidelines have now paved the way for using telemedicine for clinical care in India. We describe a series of three cases, where telemedicine aided the management of GDM. Aided by the use of digital technology, along with glucometers which synchronize with mobile phones and store data in the cloud for clinicians to access, we suggest that telemedicine could be considered in management of hyperglycemia in pregnancy in the current scenario.
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Evaluation of type 2 diabetes treatment with gliclazide modified release in Azerbaijan (the EdiAzer study): Results from a 16-week observational clinical study
Valeh A Mirzazada, Ramila A Huseynova, Sevil A Mustafayeva, Fidan N Gasimova, Ulviyya Ahmadova, Narmin Ismayilova, Vafa Kerimova, Hagigat Mehdiyeva, Rana Suleymanova, Zahrakhanim Maharramova, Gulnara Iskandarli, Ofeliya Gurbanova, Sariyya Aghayeva, Sabina Malikova, Konul Ismayilova, Khanim Salimkhanova
September-December 2020, 11(3):175-182
Introduction: Type 2 diabetes is a major public health problem across all economic regions. This open-label study collected real-world data on patients presenting with type 2 diabetes in Azerbaijan treated with gliclazide modified release (MR). Materials and Methods: Newly-diagnosed patients uncontrolled by diet, and patients uncontrolled by metformin were prescribed gliclazide MR 60mg (30–120mg/day) for 16 weeks. Primary study endpoints were changes in mean glycated hemoglobin A1c (HbA1c) and percentage of participants achieving HbA1c ≤7.0% and/or an HbA1c improvement ≥1.0%. Secondary endpoints included changes in mean fasting plasma glucose (FPG) and weight. Serious adverse events were monitored throughout the study. Results: Data from 105 patients were available for analysis. Mean age was 55.1 ± 10.4 years, 53.3% were female and 82.9% were overweight or obese. Mean duration of diabetes was 2.3 ± 2.6 years. A total of 44 patients were receiving metformin before study entry. At W0, 61 patients (58.1%) were prescribed gliclazide MR monotherapy, and 44 (41.9%) were prescribed gliclazide MR in combination with the metformin. At the end of the study, a statistically significant decrease was observed in mean HbA1c levels from 8.8% ± 1.4% to 7.6% ± 1.0% (P < 0.001). In addition, 30 (28.6%) patients achieved an HbA1c <7.0% (P < 0.0001), and 61 (58.1%) an HbA1c reduction of ≥1.0%. Reductions in FPG levels were statistically significant compared with baseline from week 2 onward. No weight gain was observed, and there were no serious adverse events, including no reports of severe hypoglycemia. Conclusion: Gliclazide MR is an effective and well-tolerated first- or second-line agent in type 2 diabetes and may be particularly valuable in low-to-middle income countries where therapeutic options are limited by accessibility and cost.
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Predisposing factors of hypoglycemia in patients with type 2 diabetes mellitus presented with symptomatic hypoglycemia in a tertiary hospital of Bangladesh
Ajit K Paul, A. B.M. Kamrul-Hasan
September-December 2020, 11(3):163-168
Background: Hypoglycemia is almost inevitable complication of diabetes treatment and the most important barrier in achieving tight glycemic control in diabetes patients. Objective: To describe characteristics of the patients with T2DM presenting with hypoglycemia and identify the predisposing factors of hypoglycemia in them. Materials and Methods: This cross-sectional study was conducted in a tertiary hospital of Bangladesh from January 2017 to March 2018. Venous plasma glucose was measured in all patients with T2DM presented with signs-symptoms of hypoglycemia, patients having biochemically confirmed hypoglycemia (venous plasma glucose <3.9 mmol/L) were finally selected for the study. A semi-structured data collection sheet was used to obtain the demographic and clinical data including hypoglycemic symptoms. Results: One hundred patients with T2DM were included in the study among whom 59% were female, 53% aged ≥60 years, 90% lived in rural and sub-urban areas, 60% had diabetes for ≥10 years, and 88% took insulin. Hypertension was the most common (45%) co-morbid condition followed by ischemic heart disease (28%). Adrenergic symptoms were present in the majority of the subjects and 62% lost consciousness before reaching the hospital. Their mean plasma glucose at presentation was 2.41 mmol/L (±0.48); mean HbA1c was 7.5% (±1.7) and 86% of them had eGFR <60 mL/min/1.73m2. Most of them (92%) received no education on hypoglycemia management and did not perform (95%) self-monitoring of blood glucose (SMBG). More than half had (51%) hypoglycemic episodes in the preceding 6 months and 28% were hospitalized for that. The meal-related factors (missed, inadequate or delayed meals) were the most common precipitating factors followed by drug overdose and excess exercise before hypoglycemia. Conclusion: Diabetes education emphasizing on appropriate lifestyle and dietary habit, and SMBG at recommended frequency are of utmost importance to prevent hypoglycemia.
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Foot self-care knowledge and practice evaluation among patients with diabetes
Liaqat A Khan, Awaji Q Al-Nami, Husain Al-Gaseer, Ibrahim A Al-Neami
September-December 2020, 11(3):169-174
Background: Diabetes mellitus is a common major health problem and diabetic foot problems are important complications of diabetes. Patient’s awareness about proper foot care is important in preventing foot problems and amputations. Objective: This study aimed to assess the knowledge and practices of foot self-care in people with diabetes attending diabetic clinic of secondary care hospital in Jazan region, southwest of Saudi Arabia. Design: This was a hospital-based descriptive, cross-sectional study. Setting: This study was conducted in diabetic clinic of secondary care hospital. Materials and Methods: In this cross-sectional study, using non-probability convenience sampling, 132 respondents with diabetes fulfilling the inclusion criteria were assessed by a modified pretest two questionnaires that consisted of 11 questions, each were adopted to assess the foot-care knowledge and practices. Knowledge and practices regarding foot-care were classified as good, satisfactory, and poor depending upon the score.Each question was assigned 1 mark. A score ≥70% (8–11) was regarded as good, 50–69% (6–7) as satisfactory, and ≤50% (5 or less) as poor both for knowledge and practice of foot-care. Results: There were 103 (78.0%) male and 29 (22.0%) female patients with the mean age of 51.97 years ± 9.2195 standard deviation (SD). Mean score of knowledge about foot care was 8.37 ± 3.106 SD and median score was 10.0, whereas the mean score of practices about foot care was 8.14 ± 2.518 SD with median score of 8.0. A positive correlation was observed between the knowledge scores and the practice score (P < 0.001). Education has statistically significant impact on the knowledge (P = 0.001) and practices (P = 0.001) regarding foot care. Socioeconomic status had significant impact on knowledge and practices regarding foot care with P value of <0.05. Conclusion: This observational study revealed that many people with diabetes had negative behaviors toward foot -care. This simple quality initiative concludes the notion that people with diabetes should receive ongoing foot-specific education to prevent foot problems and complications.
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The relationship between serum triglyceride level and heart rate variability in type 2 diabetes mellitus patients of North Karnataka
Fareedabanu A Balikai, Neeta Deshpande, Shivalingappa Javali, Darshit P Shetty, Jyoti M Benni, Varsha Shindhe, Kamaruddin Jaalam, Nitin Kapoor
September-December 2020, 11(3):191-197
Context: Diabetes mellitus is associated with an increased risk of mortality and morbidity from cardiovascular disease (CVD), which is mainly because of dyslipidemias. Several researchers have suggested that increased serum lipid fractions such as low-density lipoprotein cholesterol (LDL-C) and total cholesterol (TC) were linked to decreased heart rate variability (HRV). Until now no papers have studied the association between serum triglyceride (TG) values and HRV. Aims: The objective of this study was to evaluate the relationship between serum TG levels and HRV in patients with type 2 diabetes mellitus. Materials and Methods: The study included 120 patients with type 2 diabetes mellitus (both male and female) of the age group 35–65 years, who visited Belgaum Diabetes Centre. They were selected by simple random sampling and recruited into the study. The patients were divided into three groups depending on the duration of diabetes. The study duration was 6 months. One-minute HRV was analyzed during deep breathing and defined as the difference between the shortest and the longest heart rate interval measured by Lead II electrocardiographic recording during six cycles of deep breathing using an electrocardiograph (BPL Cardiart 6208 BPL Medical Technologies Pvt Ltd, Bannerghatta Road, Bangalore, India). Kubios HRV Standard (version 3.0, Department of Applied Physics, University of Eastern Finland, Kuopio, Finland) software tool was used to analyze HRV. Fasting serum TG of all the patients (5mL of venous blood) was analyzed using semiautomatic analyzer (Transasia Erba Chem –5 Plu, Transasia Bio-Medicals, Andheri east, Mumbai, Maharashtra, India). Data were analyzed by using Statistical Package for the Social Sciences (SPSS 20.0 version, IBM Bangalore, Karnataka, India) software program, version 20.0. One-way analysis of variance (ANOVA) followed by Tukey’s multiple post hoc tests was used for comparison and Karl Pearson’s correlation coefficient was used to test the correlation between serum TG values and HRV in the three groups. The statistical significance was set at 5% level (P < 0.05). Results: No significant difference was observed in the TG levels (P > 0.05) between the three groups of patients with type 2 diabetes mellitus. The TG levels were significant and negative correlation was observed with HRV (r = 0.6141, P = <0.001) at 5% level of significance in all the three groups. Conclusion: From this study, we conclude that the hypertriglyceridemia in patients with type 2 diabetes mellitus could affect HRV. Further studies are needed to prospectively validate the impact of this novel finding.
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Management of diabetic ketoacidosis after the introduction of local hospital protocol in the secondary care hospital
Salim S Qassabi, Shiju Ramanunni, Melba S D’Souza, Jeffrey Singh, Padma M J Kurup
September-December 2020, 11(3):183-190
Background: Diabetic ketoacidosis (DKA) is an acute, severe and life-threatening metabolic complication of diabetes. Objective: The objective of this study was to conduct a clinical audit of the management of DKA based on the hospital protocol in the selected secondary care hospital. Design: An observational retrospective longitudinal study design was used to review the data of the patients admitted with DKA. Settings: The study was conducted in a secondary care government hospital, which has 200 beds, including 48 beds in medical ward and 6 beds in the high dependency unit. Materials and Methods: A survey questionnaire was used based on local hospital protocol, and the data was collected from patients admission notes between January 2010 and December 2014, using electronic patients records. Outcome Measures: The study looked at outcomes such as how DKA protocol was followed, complications, adherence, causes, investigations carried out or not, severity, readmissions, and duration of the stay. Sample Size: The audit selected 49 patients from a total of 83 admission notes with DKA who fits the sampling criteria. Results: Of 49 patients, 38 patients were having type 1 diabetes mellitus and 11 patients having type 2 diabetes mellitus. The most common cause in both groups is omission of insulin. Intravenous 0.9% sodium chloride was initiated in the early first hour of diagnosis of DKA for most patients. Readmission rate was 25%. Insulin was commenced in less than 1h for two-thirds of the total patients. Poor adherence to the protocol such as monitoring serum sodium bicarbonate, serum potassium levels and replacement of potassium levels in the early period of management were observed. Conclusion: Continued evidence-based practice and education for medical and paramedical staffs is needed to reduce the complications of DKA and efficiently resolve DKA, improve patient outcomes, and reduce the length of hospital stay. New DKA protocol has been introduced in the hospital as the result of this audit.
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Correlation between cortical renal thickness and estimated glomerular filtration rate in diabetic nephropathy patients
Rajeev Chawla, Shakti Zala, Hitesh Punyani, Jatin Dhingra
September-December 2020, 11(3):158-162
Background and Objectives: Conventionally urine creatinine test and renal ultrasound are used in clinical practice for staging and progression of diabetic nephropathy. The objectives of this study were (1) to determine the correlation between cortical renal thickness and eGFR (estimated glomerular filtration rate) in diabetic nephropathy, and (2) to further assess if the cortical renal thickness is a better predictor of eGFR than the linear bipolar length in diabetic nephropathy. Materials and Methods: A total of 163 patients were recruited between April 2017 and March 2018 (86 men and 77 women) who had diabetic nephropathy with eGFR <90mL/min/1.73 m2 according to Cockcroft–Gault formulation. Results: The mean age (mean ± standard deviation [SD]) of the patients was 59.5 ± 7.2 years with range 39 –78 years and the median age was 59 years. The mean level of creatinine (mean ± SD) of the patients was 1.4 ± 0.4 mg/dL with range 0.6–3.2 mg/dL and the median was 1.4 mg/dL. Mean eGFR (in mL/min/1.73 m2) being 49.8 ± 13.4 (range 41.2–62.5). Cortical renal thickness right upper part, right middle part, left upper part, and left middle part (in mm) were found to be 5.5 ± 1.04, 5.6 ± 1.05, 5.5 ± 1, and 5.6 ± 1.02, respectively. Mean values of renal length of right- and left-sided kidney were 9.2 ± 0.4 and 9.5 ± 0.4, respectively. Pearson’s coefficient of correlation showed a moderately significant correlation between eGFR and cortical renal thickness in diabetic nephropathy patients. Correlation coefficient of the cortical renal thicknesses correlated better with eGFR than cortical renal length. Summary and Conclusion: This cross-sectional study in diabetic nephropathy patients showed a positive correlation between eGFR and cortical renal thickness. Cortical renal thickness was found to be a better predictor of renal function than bipolar renal length.
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Plantar pressure analysis and customized insoles in diabetic foot ulcer management: Case series
Avijan Sinha, Durga Kulkarni, Priyanka Mehendale
September-December 2020, 11(3):204-208
Nonhealing diabetic foot ulcers are a major health concern, reducing the quality of life of individuals and families. It is well-known that reduction and redistribution of plantar pressure prevents ulceration or its recurrence. However, studies regarding the use of customized insoles to off-load existing ulcers are limited. This case series highlights the potential of customized insoles in improving outcomes of diabetic plantar foot ulcers in three patients. Functional Ambulation Performance Score (FAPS) and plantar pressure readings obtained from barefooted gait analysis were noted. Customized insoles were crafted using fully customized insole (Boyner insole) technology at Advanced Wound Care Department, Deenanath Mangeshkar Hospital, Maharashtra, India for every subject as necessary. Gait analysis, wearing footwear with customized insoles, was performed immediately and repeated after 2 months for comparison. All three cases presented with improved FAPS, reduced plantar pressure at wound site, and accelerated healing after 4 months.
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Muscle biopsies differ in relation to expression of fiber-type specific genes
Rakesh Kumar, Krishna Kumar Ojha, Pooja Kushwaha, Vijay Kumar Singh
September-December 2020, 11(3):198-203
Background: Skeletal muscle transcriptome has been analyzed to report muscle-specific biomarkers, but muscle heterogeneity has largely been overlooked in pursuit of formulating a balanced design. Given the heterogeneity of muscle tissue in terms of both function and fiber-type composition, there could be several unaccounted sources of variation affecting the gene expression profile of skeletal muscles. Categorization of muscle transcriptome according to the source of variation will not only improve the power of transcriptome comparison tests but also will help to identify unaccounted biological sources of variation. Materials and Methods: Gene expression profile of normal skeletal muscle subjects (GSE18732) were analyzed with R-statistical software and Bioconductor packages. Gene-sets were prepared by grouping Affymetrix probes according to biological processes they were annotated. Coherence score and associated P values were calculated for each gene-set. All gene-sets having P < 0.05 were selected as coherent gene-set. Results: We have analyzed gene-sets and used coherence scores to measure the degree of coregulation between genes of a gene-set. We have shown that coherent gene-sets have a better chance to classify samples into biologically relevant subgroups as compared to noncoherent gene-sets. Further, we have applied the developed method to the muscle gene expression profiles and found that muscle fiber-type proportion in collected biopsies is one of the most prominent unaccounted “source of variations” affecting gene expression measurements. Conclusion: The sample classification produced based on the expression profile of genes belonging to coherent gene-sets has a better chance to result in biologically meaningful clusters.
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H syndrome presenting as juvenile diabetes: an underdiagnosed entity
Kingini Bhadran, Manjunath P. Ramakrishna, Nisha Bhavani, Praveen V Pavithran
September-December 2020, 11(3):214-217
H syndrome is a rare recessively inherited histiocytosis resulting from mutations in the SLC29A3 gene which encodes the human equilibrative nucleoside transporter 3 (hENT3).This multisystem disorder can have myriad of presentations ,with skin lesions ,sensory hearing loss and insulin dependent diabetes being the most characteristic.The most important step in the correct diagnosis involves awareness about the entity and careful physical examination. Genetic analysis is essential to confirm the diagnosis as it has many shared clinical features with other histiocytosis, with systemic manifestations which may confuse the physician. Management is symptomatic depending on the clinical presentation.Here we describe two genetically proven patients with H syndrome in whom diagnosis was missed for several years.Both patients presented in their second decade with clinical features suggestive of H syndrome. Increasing awareness is contributing to more reporting and helps in avoiding unnecessary evaluation.
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Non-islet cell tumor hypoglycemia in a patient with pleural tumor and hypoinsulinemic hypoglycemia: A case report
Hariharasudan Natarajan, Muthukrishnan Varalakshmi, Viswanathan Mohan
September-December 2020, 11(3):209-213
Non-islet cell tumor hypoglycemia (NICTH) is a relatively rare paraneoplastic syndrome associated with tumors of mesenchymal and epithelial cell origin. Hypoglycemia can be the presenting symptom of NICTH or can appear later in the disease course. The cause of NICTH is stated to be due to secretion of poorly processed insulin-like growth factor (IGF)-2 and in most previous reported cases, the diagnosis of NICTH is made based on the identification of this fraction of IGF-2 or an increased ratio between total IGF-2 and IGF-1. However, in clinical setting, especially in developing countries, such tests cannot be readily available and a diagnosis of NICTH should not be delayed in a patient with a combination of solid tumor, recurrent fasting hypoglycemia, and a low serum insulin and C-peptide level. We describe in our report an 87-year-old man with a history of a pleural tumor presenting with recurrent episode of hypoglycemia. Although surgical removal of the tumor is the ideal management, it is often not feasible as exemplified in our report. In such cases, treatment with glucocorticoid is effective in alleviating the symptoms of hypoglycemia.
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Medial arterial calcification of dorsalis pedis artery in a diabetic foot: A poor prognostic feature
Ganesh S Dharmshaktu
September-December 2020, 11(3):218-219
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