Association between serum osteocalcin and atherosclerosis in Type-2 diabetes mellitus: a cross-sectional study.

BACKGROUND: The past few decades have seen a marked increase in the macrovascular complications of Type-2 diabetes mellitus (T2DM) such as coronary heart disease, peripheral arterial disease, and cerebrovascular disease. This has been predominantly attributed to the increased atherosclerosis in these patients. Atherosclerosis usually remains an asymptomatic condition and this poses a significant challenge in its early diagnosis and timely intervention. Hence, there is an immediate need for exploring novel tools to aid in the early detection of atherosclerosis, especially in T2DM patients. Osteocalcin (OC), synthesized by osteoblasts, is a protein hormone found in the skeletal system. This protein is considered as a marker for bone density and in recent times has been gaining interest due to its protective role in cerebrovascular diseases(CVD). METHODS: We conducted a cross-sectional study and evaluated the association between serum OC levels and atherosclerosis in 113 T2DM patients. Carotid intima-media thickness (CC-IMT) was used as an estimate of atherosclerosis and patients were divided into two groups (CC-IMT < 0.9 and ≥ 0.9). Correlation of serum OC levels and glycemic parameters and lipid profiles were studied and compared between both groups. RESULTS: There is a significant negative correlation between the CC-IMT estimates and serum OC levels. CC-IMT also has a significant association with other biochemical parameters such as fasting blood sugar, glycated hemoglobin and high-density lipoprotein. CONCLUSION: Although the independent association of serum OC could not be established in the T2DM patient population, overall, the results favor low serum OC as a prognostic marker for atherosclerosis.

Osteocalcin and Metabolic Syndrome.

Introduction: Metabolic syndrome which is a syndrome complex that is associated with insulin resistance. Osteocalcin (OC), a bone derived protein has been found to decrease insulin resistance and stimulate production of insulin from the pancreas. Serum osteocalcin levels correlate with body mass index (BMI) and waist circumference. Thus, serum osteocalcin levels in metabolic syndrome could potentially be a new area to explore therapeutically. However, its role in clinical practice needs to be established. Methods: We conducted a cross-sectional study on patients, who visited Kasturba Hospital, Manipal between September 2018 and September 2020, to study the relationship between Serum Osteocalcin and the parameters of metabolic syndrome. All patients above the age of 18 years who satisfied the NCEP-ATP III guidelines (Asian adaptation) for metabolic syndrome were considered for the study. Patients who had thyroid and parathyroid disorders, bone malignancies, osteoporosis, liver failure and renal dysfunction were excluded. Results: A total of 115 subjects were analyzed. As serum osteoclacin increased, there was a significant decrease in fasting blood glucose levels (r = -.748, P < .05) and a significant increase in serum HDL levels (r = .617, P < .01). There was no correlation found between serum osteocalcin and BMI/waist circumference in this study. Finally, it was observed that individuals with fewer components of metabolic syndrome had a significantly higher serum osteocalcin when compared with individuals with a higher number of components of metabolic syndrome (P < .01). Conclusion: This data further confirmed the association between serum OC and parameters of metabolic syndrome such as FBS and serum HDL. It also found that increased serum OC was associated with fewer components of the metabolic syndrome indicating that OC could have a positive metabolic impact and may prevent atherosclerotic risk.

Unveiling the masked native blood group following thalidomide therapy in a thalassemia patient: A 5 WHY analysis approach.

Blood grouping discrepancy in patients with hematological disorders can occur due to red cell sensitization following transfusion, transplantation, and pregnancy or pre-analytical errors. Prompt initiation of root cause analysis is vital to avoid complications of wrong blood transfusion. We present an unusual case of Rh mismatched grouping report of 24 year old female thalassemia patient being managed in our hospital since 2015. Her current type and screen were observed as O Rh D negative with negative antibody screen while the historical blood group was O Rh D positive. The pre-analytical errors were ruled out and blood grouping performed from fresh sample also demonstrated as O Rh D negative despite antigen enhancement techniques and had no recent transfusion history. We sought to reason out the possibilities for discordant Rh grouping report, historical and present group through "Funnel based problem solving 5 WHY analysis" approach. The review of the past clinical history revealed that the patient had undergone Rh mismatch bone marrow transplant (Rh D positive donor and Rh D negative recipient) at 5 years of age which soon resulted in graft failure. Yet, she continued to receive Rh D positive blood thereafter with no development of anti-D which explains the historical blood group. Recently the patient was started on thalidomide, the Hb F inducer drug, which helped in maintaining her hemoglobin level between 9 and 10 g/dl without transfusion support for two months. This allowed unmasking of native Rh D negative blood and the review of clinical history played a significant role in resolution of grouping discrepancy.

Oral melatonin improves the detection of parasitemia in malaria.

INTRODUCTION: Malaria is a growing global threat and a major cause of mortality in the tropics. The gold standard diagnosis is peripheral blood smear examination. It has been demonstrated that melatonin acts as messenger molecule in malaria pathophysiology. This concept was used to evolve a clinical study wherein use of exogenous melatonin could improve the chance of detection of the parasite. METHODOLOGY: In a prospective study, 80 consecutive patients seen in the Department of Medicine at Kasturba Hospital, Manipal, suspected to have malarial fever were enrolled with proper informed consent, and randomly assigned to the groups given oral melatonin 3mg (melatonin group, n = 40) or placebo (control group, n = 40). Blood samples were collected for peripheral smear examination at baseline and then at two, three, four and five hours after drug administration. The primary end point was the parasite detection index. RESULTS: Baseline characteristics of patients were comparable. In the melatonin group, there was a significant increase of 0.0943 ± 0.22 in the mean parasite index from 0.217 ± 0.42 pre-melatonin to 0.3114 ± 0.5 post-melatonin (p = 0.001), compared to a difference of 0.0025 ± 0.22 in mean parasite index before and after placebo in the control group (p = 0.95). The maximum rise in parasite detection was seen at five hours after melatonin. CONCLUSIONS: In a single centre study, for the first time, it has been shown that a significantly higher proportion of patients was diagnosed with malaria on peripheral smear after oral melatonin administration, maximal at five hours after administration of melatonin.

Design of dual hormone blood glucose therapy and comparison with single hormone using MPC algorithm.

The complete automated control and delivery of insulin and glucagon in type 1 diabetes is the developing technology for artificial pancreas. This improves the quality of life of a diabetic patient with the precise infusion. The amount of infusion of these hormones is controlled using a control algorithm, which has the prediction property. The control algorithm model predictive control (MPC) predicts one step ahead and infuses the hormones continuously according to the necessity for the regulation of blood glucose. In this research, the authors propose a MPC control algorithm, which is novel for a dual hormone infusion, for a mathematical model such as Sorenson model, and compare it with the insulin alone or single hormone infusion developed with MPC. Since they aim for complete automatic control and regulation, unmeasured disturbances at a random time are integrated and the performance evaluation is projected through statistical analysis. The blood glucose risk index (BGRI) and control variability grid analysis (CVGA) plot gives the additional evaluation for the comparative results of the two controllers claiming 88% performance by dual hormone evaluated through CVGA plot and 2.05 mg/dl average tracking error, 2.20 BGRI. The MPC developed for dual hormone significantly performs better and the time spent in normal glycaemia is longer while eliminating the risk of hyperglycaemia and hypoglycaemia.

Syndrome of inappropriate antidiuretic hormone release as the initial presentation of adenocarcinoma of the colon.

Syndrome of inappropriate antidiuretic hormone release (SIADH) is a condition defined by the unsuppressed release of antidiuretic hormone (ADH) from the pituitary gland or nonpituitary sources or its continued action on vasopressin receptors. Of the many causes of SIADH, an important one includes tumours that secrete ADH. We describe a rare case of a patient with colonic adenocarcinoma presenting initially as SIADH. A 60-year-old man presented with confusion and vomiting. Over the previous month he had fatigue and loss of weight. Baseline investigations showed a low serum sodium level of 108mmol/l. He was euvolaemic on examination and fulfilled the criteria for SIADH. Further evaluation and imaging tests revealed that the patient had adenocarcinoma of the colon. It is remarkable that our patient did not present with any of the cardinal symptoms/signs suggestive of colorectal carcinoma including haematochezia, change in bowel habits or iron-deficiency anaemia. Initial therapy with hypertonic saline, fluid restriction and salt diet for management of SIADH was unsuccessful. Tolvaptan was added to the treatment regimen and the patient improved dramatically. Oncology consultation was initiated, and chemotherapy for the carcinoma was planned.

Factors associated with outcomes in organophosphate and carbamate poisoning: a retrospective study.

Organophosphate and carbamate (OPC) poisoning is a major global health hazard requiring immediate medical intervention. Atropine (ATR) is an essential antidote in organophosphate and carbamate poisoning, with the inclusion of cholinesterase reactivators and other anticholinergics, namely pralidoxime (PAM) and glycopyrrolate (GPR). This study aimed to compare the efficacy of various treatment regimens and identify the factors affecting mortality. The data of patients presented at the emergency unit with the consumption of OPC compounds between the years 2013 and 2017 were retrospectively reviewed. The study population was then categorized into four treatment patterns (1) ATR alone, (2) ATR and PAM, (3) ATR and GPR, (4) ATR, PAM and GPR. The outcome of the patients was assessed in terms of survival, intubation, ICU days, and days of ventilation and hospitalization. Univariate and multivariate analyses were performed to investigate the risk factors associated with mortality and odds ratio (OR). A total of 441 patients were included in the study, of which 69.16% were males, and 375 patients survived. Consumption of poison with a suicidal intention was reported in 98.19% of the patients, and the treatment with ATR and PAM (42.86%) was observed to have lower days of ventilation in comparison to the treatment with ATR and GPR (p = 0.003). Patients requiring intubation were also lowest in the group treated with ATR and PAM (27.51%). The age group of > 50 years (OR 4.275 [CI 2.179-8.387]), male gender (OR 2.608 [CI 1.258-5.406]), and the treatment pattern with ATR, PAM and GPR (OR 2.233 [CI 1.002-4.040]) were independently associated with mortality. In summary, male gender, elderly population, and treatment patterns followed adversely affected the outcome in patients with OPC poisoning.

Predictive performance of traditional and novel lipid combined anthropometric indices to identify prediabetes.

BACKGROUND AND AIMS: Diabetes mellitus is one of the critical public health challenges in the Indian healthcare scenario. Novel anthropometric indices are promising surrogate markers to detect prediabetes compared to the traditional anthropometric indices that only reflect gross obesity. Thus, the authors aim to analyse the potential of three novel lipid combined anthropometric indices in predicting prediabetes in the Asian Indian population. METHODS: We conducted an age and gender-matched case-control study to identify the predictors of prediabetes. Prediabetes was diagnosed as per the American Diabetes Association (ADA) guidelines 2010. The traditional anthropometric measurements including waist circumference (WC), waist to hip ratio (WHR) and body mass index (BMI) were executed using standardised methods. Fasting lipid profile was obtained and using standardised formulas, the novel lipid combined anthropometric indices such as lipid accumulation product (LAP), visceral adiposity index (VAI) and triglyceride glucose index (TyG index) were derived. TyG related indices such as triglyceride glucose-waist circumference (TyG-WC) and triglyceride glucose-body mass index (TyG-BMI) were also calculated. RESULTS: The novel lipid combined anthropometric indices LAP, VAI, TyG index, TyG-WC and TyG-BMI were significantly higher in subjects with prediabetes of both the genders (p < 0.05). During receiver operating characteristic (ROC) curve evaluation, TyG index (AUC = 0.802) was the superior predictive measure in males, while in females, TyG-WC (AUC = 0.767) was the best among all the markers. CONCLUSION: TyG index and TyG-WC seem to be a superior indicator of prediabetes in the Asian Indian population in comparison with other anthropometric indices to screen prediabetes.

Blood glucose regulation and control of insulin and glucagon infusion using single model predictive control for type 1 diabetes mellitus.

This study elaborates on the design of artificial pancreas using model predictive control algorithm for a comprehensive physiological model such as the Sorensen model, which regulates the blood glucose and can have a longer control time in normal glycaemic region. The main objective of the proposed algorithm is to eliminate the risk of hyper and hypoglycaemia and have a precise infusion of hormones: insulin and glucagon. A single model predictive controller is developed to control the bihormones, insulin, and glucagon for such a development unmeasured disturbance is considered for a random time. The simulation result for the proposed algorithm performed good regulation lowering the hypoglycaemia risk and maintaining the glucose level within the normal glycaemic range. To validate the performance of the tracking of output and setpoint, average tracking error is used and 4.4 mg/dl results are obtained while compared with standard value (14.3 mg/dl).

Acute tension hydrothorax in chronic liver disease secondary to spontaneous diaphragmatic rupture.

Pleural effusion in liver cirrhotics is more commonly transudative. A transudative pleural effusion secondary to ascites in decompensated cirrhosis is also known as hepatic hydrothorax and is usually due to fluid seepage through congenital pores in the diaphragm. The patient, a known case of decompensated chronic liver disease, presented with a massive, left-sided, rapidly accumulating and transudative pleural effusion secondary to spontaneous diaphragmatic rupture. Clinically, he developed sudden onset shortness of breath and became hypotensive. This is a rare entity, and was confirmed on CT thorax revealing a focal segment defect ~1.6 cm over the left hemidiaphragm. Ascites treatment consisting of diuretics with salt restriction and repeated thoracentesis with albumin replacement improved his symptoms and lead to a complete resolution of the effusion.

Posterior reversible encephalopathy syndrome due to hypercalcaemia: a rare cause.

Posterior reversible encephalopathy syndrome (PRES) is a clinico-radiological entity described by Hinchey et al in late 90's, characterised by variable associations of seizure activity, consciousness impairment ranging from confusion to coma, headaches, visual abnormalities, nausea/vomiting and focal neurological signs. Common causes are accelerated hypertension, eclampsia, preeclampsia, cytotoxic drug use and autoimmune diseases like systemic lupus erythematosus.We report a case of PRES in a 62-year-old female patient due to hypercalcemia secondary to vitamin D toxicity on treatment with calcium supplements and vitamin D for secondary hypoparathyroidism. She had seizures and visual defects on presentation which recovered completely with treatment of hypercalcemia.

Body composition analysis, anthropometric indices and lipid profile markers as predictors for prediabetes.

OBJECTIVES: To compare different anthropometric indices, Body composition analysis and lipid profile markers in terms of their ability to predict prediabetes (PD). METHODS: We enrolled 83 subjects with PD and 84 normoglycemic subjects who were matched for age and gender. The diagnosis of prediabetes was done according to the American Diabetes Association (ADA) criteria. All subjects were aged between 30-55 years of age and visited the outpatient department of tertiary care hospital. Anthropometric and lipid profile measurements were obtained. Analysis of body composition was done using Bodystat 1500MDD Instrument. Backward logistic regression was performed for detecting the predictors of PD. A receiver operator characteristic curve (ROC) with area under curve (AUC) was utilized for the accuracy of the predictors of PD. RESULTS: Comparison of anthropometric measurement and body composition analysis parameters between the two groups showed that Waist circumference (WC), Body mass index, Body Fat% were significantly higher whereas Extracellular water and Dry lean weight in percentage (ECW% and DLW%) were found to be lower in PD (p< 0.05). Higher triglyceride (TG) levels and lower high-density cholesterol (HDL-C) with high TG/HDL-C were seen in subjects with PD. Backward logistic regression analysis found the combination of Body Fat % with WC, TG, ECW% and DLW% as strong predictors of PD. In ROC analysis, ECW% (AUC = 0.703) was the most predictive measure, followed by WC (AUC = 0.702). CONCLUSION: This study demonstrated that estimation of Body Fat % combined with waist circumference, Extracellular water and Dry lean weight in percentage are valuable in screening and diagnosis of prediabetes. Plasma levels of TG in lipid profile measurements can also serve as an additional marker for prediction of prediabetes.

A case of H3N2 complicated by acute kidney injury secondary to rhabdomyolysis.

H3N2 was first detected in July 2011 in the USA. It is responsible for sporadic cases of influenza and localised outbreaks and has not yet taken over on an epidemic or pandemic scale. An 84-year-old man presented with a dry cough, fever and myalgia for 3 days. On examination, he had a pulse of 98 bpm and blood pressure of 124/88 mm Hg. The patient was tachypnoeic, SpO2 was 90%. Auscultation revealed bilateral diffuse wheeze and crackles. He had generalised muscle tenderness on examination. On admission, creatinine was 1.9 mg/dL and CK(creatine kinase) was 44 000 U/L. Chest X-ray was suggestive of ARDS (acute respiratory distress syndrome). Throat swab was positive for H3N2. The patient was given intravenous fluids, oral sodium bicarbonate, oxygen and oseltamivir tablet. In view of ARDS, he was given intravenous methylprednisolone and bronchodilators for bronchospasm. The patient improved symptomatically; vitals and lab reports were normal at the time of discharge.

Escitalopram Induced SIADH in an Elderly Female: A Case Study.

Hyponatraemia is a well-established and potentially, a life-threatening adverse effect of selective serotonin receptor uptake inhibitors (SSRI). However, its occurrence secondary to syndrome of inappropriate antidiuretic hormone secretion (SIADH) with escitalopram, has been reported extremely sporadically. The reporting of such rare, but life-threatening adverse effects of escitalopram assumes immense significance in light of the fact that SSRIs presently form the mainstay of treatment of depressive disorders. Here, we report a case where a 58 year old diabetic lady, when initiated on escitalopram for dysthymia developed severe hyponatraemia within 2 weeks. Further, we discuss other relevant cases that have been reported in the past with an eye on the management of SIADH and hyponatraemia.

Recognition of possible risk factors for clinically significant drug-drug interactions among Indian people living with HIV receiving highly active antiretroviral therapy and concomitant medications.

BACKGROUND: Greatest challenges for clinician is to recognize risk factors for clinically significant drug interactions (CSDIs). There is a lack of awareness about CSDIs among healthcare professionals in India. OBJECTIVE: To recognize all possible risk factors for drug-drug interactions (DDIs) and to identify clinically significant drug interactions (CSDIs), the prevalence, pattern of occurrence of DDIs in People Living with HIV (PLW-HIV) receiving highly active antiretroviral therapy (HAART) and concomitant medications. METHODS: A retrospective medical record review was carried out by clinical pharmacist with ethics committee approval. Case files of HIV patients receiving HAART with concomitant medications were analyzed for CSDIs using University of Liverpool drug interaction database and CSDIs were classified based on red flag indication (RFI) or contraindicated drug-drug interaction (XDDIs) and orange flag indication (OFI) or DDIs that needs close monitoring. Patients with DDIs (cases) and patients without DDIs (controls) were compared with Chi-square tests. P value <0.05 was considered as statistically significant. RESULTS: A total of 240 HIV patients' cases were screened. Out of which 267 DDIs were reported in 107 patients. Prevalence of DDIs was higher in male 71 (66.4%) compared to female 36 (33.6%). On zero-inflated poisson regression analysis, factors of polypharmacy, opportunistic infections, comorbid condition like Ischemic heart disease, respiratory tract infections, and psychiatric disorder were found to be predictors of high risk factors for DDIs to HAART. Fourteen XDDIs with RFI and two hundred fifty three DDIs with OFI were reported. XDDIs were atazanavir with fluconazole 4 (28.6%), ritonavir with fluconazole 4 (28.6%), nevirapine with rifampicin 2 (14.4%), ritonavir with quetiapine, atazanavir with pantoprazole. Pharmacokinetic DDIs were highest 238 (89.1%). Sixteen DDIs were reported in a single patient. The majority 97 (90.6%) patients had developed ≤5 DDIs, 8 (7.5%) developed six to eleven DDIs. The highest DDIs were reported with efavirenz 49 (18.4%) and zidovudine 44 (16.5%) based HAART regimen. CONCLUSION: In India, with the increasing access to HAART usage, Clinician must focus to pay attention to recognize possible risk factors for CSDIs associated with HAART regimen and strictly to avoid "Red Flag Indication combinations" while prescribing so as to prevent CSDIs.

Effectiveness of self-management programmes in diabetes management: A systematic review.

BACKGROUND: Diabetes is a major noncommunicable disease, which is increasing, and approximately 415 million people are affected around the globe. Since diabetes is a lifelong disease, patients require better understanding and knowledge of the condition to become self-reliant in making diabetes-related decisions. AIMS: This systematic review was performed to assess the effectiveness of diabetes self-management programs in people with type 2 diabetes. METHODS: A comprehensive literature search was undertaken to identify all published English language articles through EBSCO discovery services in the following electronic database: Science Direct, CINAHL Plus with Full Text, MEDLINE, and Access Medicine. Studies were published from January 2000 to October 2015. The initial search retrieved 37 566 studies and based on the inclusion criteria, 14 studies were selected for review. RESULTS: Of 14 studies, most findings favoured diabetes self-management. But the overall effectiveness of individual interventions was not conclusive. A wide variety of interventions was used including diabetes education as a major component in self-management programs. CONCLUSION: Interventions used varied strategies in differing composition, and further work is needed to find out the effectiveness of individual interventions.

Hemi-Chorea in a Patient with Ketotic Hyperglycemia: An Unusual Presentation.

Chorea has often been associated with lesions in the basal ganglia and in the sub thalamic nucleus. It is possible for a patient with chorea-ballismus to have hyperglycemia at the initial presentation. We hereby present a case of an 81-year-old female, who was on treatment for type 2 diabetes mellitus and presented to us with sub acute onset of abnormal movements of right side of the body. She had semi purposeful, rapid and jerky movements of right upper limb and lower limb along with abnormal tongue movements. Laboratory data showed very high blood glucose levels, urine ketones were positive and pH of arterial blood was normal. MRI brain showed hyperintensities in right basal ganglia. So, hyperglycemia induced hemichorea was considered as a possibility and she was treated with insulin. These abnormal movements decreased subsequently with treatment and patient is doing better in the follow-up visits. This presentation is extremely rare, as review of literature showed similar presentations in patients with non ketotic hyperglycemia but not reported so far in diabetic ketosis.