Empathy amongst doctors: an observational study.

INTRODUCTION: Empathy is the ability to put oneself in another's emotional space and experience what they feel. Either due to lack of experience or mundaness of practice, a state of empathy can become premised, and individuals become indifferent or detached. We aimed to explore the level of empathy among doctors at different levels of practice, age, gender, academics, non-academics and discipline. MATERIALS AND METHODS: This was a cross-sectional, observational study on empathy among doctors practicing in the private, public hospital sector and faculty at a medical university in Negeri Sembilan, Malaysia that utilised convenience sampling for data collection. The Toronto Empathy Questionnaire (TEQ) a validated tool was used to measure empathy. RESULTS: The questionnaire was completed by 127 doctors, 52% (n= 66) were males and 48% (n=61) females. There was no significant difference in empathy between male (M=46.44; SD=6.01) and female (M=45.05, SD=5.69) doctors; t (123) = 1.326, p=0.187. Pearson correlation coefficient was computed to assess the linear relationship between age and empathy and revealed no correlation between the two variables: r (125) =0.15, p=0.099. Medical-based doctors (M= 47.47, SD=5.98) demonstrated more empathy than surgicalbased (M=44.32, SD=5.41); t (123) =-3.09, p=0.002. Those already specialised in their fields (M=47.38, SD=4.57) had more empathy than those who had not (M= 44.36, SD=6.52); t (123) =-2.96, p = 0.004. Doctors in the university (M=47.97, SD=4.31) tended to have more empathy than those in the public hospitals (M= 44.63, SD=6.27); t (117) =-2.91, p=0.004. Academicians had more empathy than non-academicians but there was no difference between those who were in clinical practice and not. CONCLUSION: Our findings indicate that medical-based doctors demonstrate more empathy than surgical-based doctors, and there appeared to be no correlation between age and empathy. However, clinical experience and growth within the specialty seem to improve empathy. Doctors teaching in the university setting demonstrated more empathy than those practicing in the hospital setting. Inclusion of empathy-related sessions in the undergraduate and post-graduate curriculum could bridge the gap in empathy noted with age, discipline, and experience in practice. Further research on empathy among doctors using a wider population in Malaysia and a TEQ questionnaire validated to the Asian population would provide better insight regarding this area of medical practice. Future research on outcomes of inclusion of programmes targeted at improving empathy to create awareness during practice would support patient satisfaction and safety.

Factors influencing nodal yield in neck dissections for head and neck malignancies.

OBJECTIVE: A standard lateral neck dissection should yield at least 18 lymph nodes. The goal of the present study was to examine what factors might influence the number of lymph nodes retrieved during a neck dissection. METHODS: This was a retrospective cohort study in a tertiary academic referral centre for head and neck oncology. Two hundred and nineteen consecutive neck dissections were examined. Age of the patient and primary site were recorded, along with tumour histology, previous radiotherapy and final nodal count. RESULTS: The mean age was 62.2 ± 13.0 years. The most common primary site was the oral cavity (38.8 per cent). The mean number of lymph nodes was 30.63 ± 13.9. In total, 17.8 per cent had undergone previous radiotherapy. The mean number of lymph nodes was 33.26 ± 13.27 in patients with no previous radiation exposure and 18.47 ± 9.46 in those with previous radiation treatment. CONCLUSION: Lymph node yield from a neck dissection is likely multi-factorial in nature. Previous radiotherapy, the only significant contributor, led to a mean reduction of lymph node yield from 33.3 to 18.5.

Temperature measurement: Must it be the forehead? A prospective cross-sectional study.

BACKGROUND: The aim of this study was to compare temperature readings measured at the forehead and wrist against the tympanic temperature which is generally accepted as the standard. METHOD: This is a cross-sectional study carried out on 325 people from the general population entering a private hospital for consultation or work. Forehead and wrist temperature was taken using the CEFC RoHS K3 model (China) and tympanic temperature using the Braun Thermoscan 7 Thermometer Irt6520 by the same investigator on consenting individuals. RESULTS: There was no significant difference between the forehead (mean =36.6, standard deviation, SD=0.30) and tympanic (mean=36.6, SD=0.41), Z= -1.609, p=0.108. However, there was significant difference between the wrist (mean=36.4, SD= 0.28) and tympanic (mean=36.6, SD=0.41) temperature values, Z= -8.749, p<0.001, the former being lower. Temperature measured at forehead (mean=36.6, SD=0.30) was also significantly higher than the wrist (mean=36.4, SD=0.28), Z= -9.381, p<0.001. The wrist temperature values were lower than forehead and tympanic. CONCLUSION: Forehead temperature values are better representatives of the core temperature (tympanic) and be the preferred site of measurement compared to the wrist.

Zinc-α2-glycoprotein is associated with non-albuminuric chronic kidney disease progression in type 2 diabetes: a retrospective study with 4-year follow-up.

AIM: To investigate the association between baseline plasma zinc-α2-glycoprotein and non-albuminuric chronic kidney disease progression in type 2 diabetes. METHODS: Adults with normoalbuminuria at entry (n=341; age 57±10 years, 52% men) were analysed. Chronic kidney disease progression was defined as a decrease in chronic kidney disease stage and a decline of ≥25% in estimated GFR from baseline. Baseline plasma zinc-α2-glycoprotein levels were quantified by immunoassay, and analysed either as a continuous variable or by tertiles in Cox proportional hazards models. Model discrimination was assessed using Harrell's C-index. A sensitivity analysis was performed on a subset of individuals who maintained normoalbuminuria during follow-up. RESULTS: Chronic kidney disease progression occurred in 54 participants (16%). Zinc-α2-glycoprotein levels were elevated in chronic kidney disease progressors (P = 0.011), and more progressors were assigned to the higher zinc-α2-glycoprotein tertile than non-progressors. In the unadjusted Cox model, zinc-α2-glycoprotein, both as a continuous variable (hazard ratio 1.72, 95% CI 1.08-2.75) and tertile 3 (vs tertile 1; hazard ratio 2.14, 95% CI 1.10-4.17), predicted chronic kidney disease progression. The association persisted after multivariable adjustment. The C-index of the Cox model increased significantly after incorporation of zinc-α2-glycoprotein into a base model comprising renin-angiotensin system antagonist usage. Sensitivity analysis showed that zinc-α2-glycoprotein independently predicted chronic kidney disease progression among individuals who maintained normoalbuminuria during follow-up. CONCLUSIONS: Plasma zinc-α2-glycoprotein is associated with chronic kidney disease progression, and may serve as a useful early biomarker for predicting non-albuminuric chronic kidney disease progression in type 2 diabetes.

Laryngeal Chondrosarcoma: A rare cause of critical upper airway obstruction.

Laryngeal cancers are rare, encompassing around one percent of all cancers. Suspicion should be raised if a patient presents with classical signs and symptoms; i.e. dysphonia, inspiratory stridor, dysphagia, odynophagia, neck mass, or persistent cough. Laryngeal chondrosarcoma is a rare form of laryngeal cancer, the diagnosis of which can be difficult. The case in question describes an unusual presentation of one such case, and its subsequent investigation, management and outcome.

Knowledge and Risk Perceptions of Occupational Infections Among Health-care Workers in Malaysia.

Health-care workers are at risk of exposure to occupational infections with subsequent risk of contracting diseases, disability, and even death. A systematic collection of occupational disease data is useful for monitoring current trends in work situations and disease exposures; however, these data are usually limited due to under-reporting. The objective of this study was to review literature related to knowledge, risk perceptions, and practices regarding occupational exposures to infectious diseases in Malaysian health-care settings, in particular regarding blood-borne infections, universal precautions, use of personal protective equipment, and clinical waste management. The data are useful for determining improvements in knowledge and risk perceptions among health-care workers with developments of health policies and essential interventions for prevention and control of occupational diseases.

Management of Epistaxis - A Single Centre Experience and Economic Considerations.

Epistaxis represents the most common ENT emergency and its management has been a focus of audit recently, with consideration given to the associated economic burden. The aim of our study is to evaluate the management of epistaxis in terms of treatments used, duration of stay, recurrence and cost. A retrospective review of hospital inpatient enquiry (HIPE) data from a single secondary referral centre was undertaken during a four year period. Four hundrefd and thirty-four patients were identified. The majority (n= 262, 60.3%) were male and the average age was 64.2 years. The vast majority (n=362, 83.4%) were managed non-operatively. Only 15 patients (3.4%) were managed surgically. The average length of stay was 2.5 days and did not vary greatly between the treatment groups. The recurrence rate was 8.2% (n=36). Approximate costs of packing vs EUA and cautery suggest that packing alone is more economical but more data is needed to fully compare the options.

Sharing experiences from a reference laboratory in the public health response for Ebola viral disease, MERS-CoV and H7N9 influenza virus investigations.

An efficient public health preparedness and response plan for infectious disease management is important in recent times when emerging and exotic diseases that hitherto were not common have surfaced in countries with potential to spread outside borders. Stewardship from a reference laboratory is important to take the lead for the laboratory network, to proactively set up disease surveillance, provide referral diagnostic services, on-going training and mentorship and to ensure coordination of an effective laboratory response. In Malaysia, the Institute for Medical Research has provided the stewardship for the Ministry of Health's laboratory network that comprises of hospital pathology, public health and university laboratories. In this paper we share our experiences in recent infectious disease outbreak investigations as a reference laboratory within the Ministry of Health infectious disease surveillance network.

The teaching of trauma management in undergraduate medical education.

BACKGROUND: The teaching of trauma in medical schools faces many educational and logistic challenges. Issues on what to teach, how to teach, when to teach, who will teach and whether medical students with insufficient exposure to clinical medicine can benefit from a trauma course are unclear. MATERIALS AND METHODS: A well-designed one day intensive trauma course concentrating on the primary survey was taught to semester seven and semester eight students by a multi-disciplinary team comprising of surgeons, anaesthetists, emergency physicians and trained medical officers. The course comprised of a pre-test of 30 multiple choice questions followed by three hours of lectures, three hours of skill stations and a post-test. The pre-test and posttest scores were analysed using the paired sample t-test and the independent t-test. RESULTS: The pre- and post-test scores showed significant improvement for both semester seven and semester eight students. Semester seven students, who only had a sevenweek posting in Surgery had pre-test and post-test scores of only 4% less than semester eight students who had an additional six weeks in Orthopaedics and two weeks in Accident and Emergency postings. The use of a multidisciplinary team reduced the logistic burden of finding sufficient surgeons to teach trauma management. CONCLUSION: Trauma education can be taught to undergraduates by a multidisciplinary team as early as year three, in semester seven. However, the mean score of semester eight students is only at 66%, suggesting that a refresher course prior to graduation at semester ten will be useful. KEY WORDS.

Total rhinectomy, a clinical review of nine cases.

INTRODUCTION: A large proportion of malignancies involving the external nose can be managed with limited resection and local autologous reconstruction or, in some cases, radiotherapy as primary or adjuvant treatment. We highlight a small cohort of patients undergoing total rhinectomy for advanced nasal malignancies. METHODS: A retrospective review of all patients undergoing total rhinectomy in our institution from 2006 to 2014 was undertaken. We reviewed patient demographics, surgical management, adjuvant treatment, histology, reconstruction and outcomes. RESULTS: Nine patients underwent total rhinectomy over an 8-year period, three of whom were being treated for recurrent disease. Eight patients had squamous cell carcinoma (SCC) and a single patient had an angiosarcoma. Two patients completed adjuvant radiotherapy. Seven patients underwent nasal prosthetic rehabilitation. All nine patients are alive and disease free at latest follow-up. CONCLUSION: Total rhinectomy is an uncommon procedure usually undertaken for extensive nasal malignancy. Nasal prosthetic rehabilitation is a viable method of reconstruction.

Validation and evaluation of new assessments for the otolaryngology undergraduate medical clerkship.

OBJECTIVES: To validate and evaluate a short answer question paper and objective structured clinical examination. Validity and effect on overall performance were considered. METHODS: Students completed a voluntary short answer question paper during their otolaryngology attachment. Short answer question paper results were collated and compared to the essay examination and new end of year objective structured clinical examination. RESULTS: The study comprised 160 students. Questions were validated for internal consistency (Cronbach's alpha = 0.76). Correlations were determined for: short answer question paper and essay results (r = 0.477), short answer question paper and objective structured clinical examination results (r = 0.355), and objective structured clinical examination and essay results (r = 0.292). On unpaired t-tests comparing the short answer question paper group and non-short answer question paper group, essay results were 1.2 marks higher (p = 0.45) and the objective structured clinical examination results were 0.09 marks lower (p = 0.74) in the short answer question paper group. CONCLUSION: Two new valid summative assessments of student ability have been introduced, which contribute to an enhanced programme of assessment to drive student learning.

Ongoing challenges in the treatment of adenoid cystic carcinoma of the head and neck.

BACKGROUND: Adenoid cystic carcinoma is a malignant tumour of major and minor salivary glands. Distant metastasis and poor survival are persistent in the literature, with recent publications aimed at understanding molecular pathogenesis and development of pharmaceutical therapeutic options. AIM: Provide an update of recent studies in the management of adenoid cystic carcinoma of the head and neck. METHODS: Literature search using Medline, Scopus, Google Scholar, the Cochrane Database of Systematic Reviews and the Cochrane central register of controlled trials for articles on adenoid cystic carcinoma from January 2005 to January 2015. CONCLUSION: Adenoid cystic carcinoma is characterized by a slow growing mass, with distant metastasis independent of local or regional control. Primary tumour resection remains the preferred option with radiotherapy having an adjuvant role. Recent advances have been made with novel targeted therapies however, limited to clinical trials and advanced disease.

Viral Aetiology of Acute Flaccid Paralysis Surveillance Cases, before and after Vaccine Policy Change from Oral Polio Vaccine to Inactivated Polio Vaccine.

Since 1992, surveillance for acute flaccid paralysis (AFP) cases was introduced in Malaysia along with the establishment of the National Poliovirus Laboratory at the Institute for Medical Research. In 2008, the Ministry of Health, Malaysia, approved a vaccine policy change from oral polio vaccine to inactivated polio vaccine (IPV). Eight states started using IPV in the Expanded Immunization Programme, followed by the remaining states in January 2010. The objective of this study was to determine the viral aetiology of AFP cases below 15 years of age, before and after vaccine policy change from oral polio vaccine to inactivated polio vaccine. One hundred and seventy-nine enteroviruses were isolated from the 3394 stool specimens investigated between 1992 and December 2012. Fifty-six out of 107 virus isolates were polioviruses and the remaining were non-polio enteroviruses. Since 2009 after the sequential introduction of IPV in the childhood immunization programme, no Sabin polioviruses were isolated from AFP cases. In 2012, the laboratory AFP surveillance was supplemented with environmental surveillance with sewage sampling. Thirteen Sabin polioviruses were also isolated from sewage in the same year, but no vaccine-derived poliovirus was detected during this period.

Genetically modified mosquito: the Malaysian public engagement experience.

On December 21, 2010, 6000 genetically modified (GM) mosquitoes were released in an uninhabited forest in Malaysia. The purpose of the deliberate release was a limited "marked release and recapture" (MRR) experiment, a standard ecological method in entomology, to evaluate under field conditions, the flight distance and longevity of the sterile male Aedes aegypti strain OX513A(My1), a GM strain. As with any other GM technologies, the release was received with mixed responses. As the scientific community debate over the public engagement strategies for similar GM releases, dengue incidence continues to rise with a heavy toll on morbidity, mortality and healthcare budgets. Meanwhile the wild female Aedes aegypti continues to breed offspring, surviving and evading conventional interventions for vector control.

Adipocytokine zinc α2 glycoprotein (ZAG) as a novel urinary biomarker for normo-albuminuric diabetic nephropathy.

OBJECTIVE: A substantial proportion of diabetic nephropathy individuals are non-albuminuric. Using a proteomic approach, we searched for novel urinary biomarkers. METHODS: We studied three groups (n = 6 per group) of males with Type 2 diabetes: (1) normal renal function; (2) classical diabetic nephropathy (urinary albumin-creatinine ratio > 1000 mg/g and glomerular filtration rate < 60 ml/min.1.73 m(2) ) and (3) non-albuminuric diabetic nephropathy (glomerular filtration rate < 60 ml/min.1.73 m(2) and urinary albumin-creatinine ratio < 30 mg/g). We used two-dimensional fluorescence differential gel electrophoresis, matrix-assisted laser desorption/ionization time-of-flight mass spectrometry peptide identification and western blot validation in the study. RESULTS: Sixty protein spots were differentially abundant between the non-albuminuric and macro-albuminuric subjects (> 2.5-fold, P < 0.05). In the non-albuminuric subjects, in addition to previously reported α(1) -microglobulin, the next most interesting spot (upregulated 3.44-fold, P = 0.0026) was human zinc-α(2) -glycoprotein, a novel adipose-cytokine associated with glomerular injury. This was confirmed by western blot and replicated in female diabetic nephropathy subjects. CONCLUSIONS: From our preliminary results, human zinc-α(2) -glycoprotein may be a novel urinary biomarker for non-albuminuric diabetic nephropathy.

Standardized extract of Syzygium aqueum: a safe cosmetic ingredient.

Syzygium aqueum, a species in the Myrtaceae family, commonly called the water jambu is native to Malaysia and Indonesia. It is well documented as a medicinal plant, and various parts of the tree have been used in traditional medicine, for instance as an antibiotic. In this study, we show S. aqueum leaf extracts to have a significant composition of phenolic compounds, protective activity against free radicals as well as low pro-oxidant capability. Its ethanolic extract, in particular, is characterized by its excellent radical scavenging activity of EC(50) of 133 µg mL(-1) 1,1-diphenyl-2-picryl-hydrazyl (DPPH), 65 µg mL(-1) 2,2'-azino-bis(3-ethylbenzthiazoline-6-sulphonic acid) (ABTS) and 71 µg mL(-1) (Galvinoxyl), low pro-oxidant capabilities and a phenolic content of 585-670 mg GAE g(-1) extract. The extract also displayed other activities, deeming it an ideal cosmetic ingredient. A substantial tyrosinase inhibition activity with an IC(50) of about 60 µg mL(-1) was observed. In addition, the extract was also found to have anti-cellulite activity tested for its ability to cause 98% activation of lipolysis of adipocytes (fat cells) at a concentration of 25 µg mL(-1). In addition, the extract was not cytotoxic to Vero cell lines up to a concentration of 600 µg mL(-1). Although various parts of this plant have been used in traditional medicine, this is the first time it has been shown to have cosmeceutical properties. Therefore, the use of this extract, alone or in combination with other active principles, is of interest to the cosmetic industry.

Central obesity and smoking are key modifiable risk factors for elevated C-reactive protein in Asian individuals who are not eligible for statin therapy.

OBJECTIVE: Statin therapy reduces coronary heart disease (CHD) and mortality in individuals with elevated C-reactive protein (CRP) but low-density lipoprotein cholesterol below the threshold at which statin therapy is recommended. We determined the proportion of individuals with elevated CRP in whom statin therapy was not indicated, and examined predictors for elevated CRP in a multi-ethnic Asian population. DESIGN: We studied 3404 participants (Chinese, Malays and Asian-Indians) without a history of hypercholesterolemia living in Singapore (mean age±s.d.: 48.9±11.2 years). Eligibility for statin therapy was determined based on the National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III (ATPIII)) guideline. CRP was measured by high-sensitivity enzyme-linked immunosorbent assay method. CRP level greater than 2 mg l(-1) was considered as elevated. RESULTS: Elevated CRP was found in 29.3% participants who were not eligible for statin therapy (n=2974). Elevated CRP was more common in females and amongst those of Malay or Asian-Indian ethnicity. Compared with participants with low CRP, those with elevated CRP were shown to have higher levels of obesity, blood pressure, triglyceride and insulin resistance (IR), but lower high-density lipoprotein cholesterol levels (all Ps<0.001). After multivariate analysis, gender (odds ratio (OR) 3.34 for females), ethnicity (Malay OR 1.57, 95% confidence interval (CI) 1.25-1.96; Asian-Indian OR 1.97, 95% CI 1.55-2.50), waist circumference (OR 1.06, 95% CI 1.05-1.07), smoking (OR 1.49, 95% CI 1.08-2.05) and IR (OR 1.14, 95% CI 1.07-1.22) were significant predictors of CRP (all Ps--values<0.05). CONCLUSION: Routine measurement of CRP identifies a substantial number of Asian individuals at risk of CHD in whom statin therapy is not currently indicated, particularly in women and certain ethnic groups (Malays and Asian Indians). Weight loss and smoking cessation are important measures to reduce the proportion of individuals with elevated CRP.

Automated identification of diabetes type-2 subjects with and without neuropathy using eigenvalues.

Diabetes is a disorder of metabolism and has been a leading healthcare burden throughout the world. The most typical form of diabetes is type-2 diabetes. It is commonly developed in adults of age 40 and older. The purpose of this study is to identify the plantar pressure distribution in normal subjects, diabetic type-2 subjects with neuropathy, and diabetic type-2 subjects without neuropathy. Foot scan images were obtained using the F-Scan (Tekscan USA) in-shoe measurement system. The eigenvalues were evaluated from principal-component analysis after performing continuous wavelets transformation (CWT). The eigenvalues of CWT in regions 5 and 7 had shown excellent p values of more than 95 per cent confidence level when subjected to an analysis-of-variance test. These parameters were then presented to an artificial neural network (ANN) and a Gaussian mixture model (GMM) for automatic classification. The results show that the ANN classifier performs better than the GMM and is able to identify the unknown class with a sensitivity of 100 per cent and a specificity of 72 per cent.

Juxtarenal/pararenal Wilms' tumour in a six-year-old Malay girl.

We report a six-year-old Malay girl who presented with a right retroperitoneal tumour that measured 7.5 cm in diameter. A wide excision of the lesion was performed. The tumour was separated from a normal-appearing right kidney by a capsule. Microscopically, this well-encapsulated tumour was composed of classical triphasic components: epithelial, mesenchymal and blastemal areas. The immunohistochemical study showed WT1 expression in the blastemal area. Thus, a diagnosis of Wilms' tumour with favourable histology was made. The patient was well for 12 months. Extrarenal Wilms' tumour is uncommon, with the majority of cases occurring in the retroperitoneal and inguinal areas. Wilms' tumour that is not arising from the intrarenal area but shares a common capsule with the ipsilateral kidney, is even rarer. Indeed, our case would be more appropriately classified as juxtarenal/pararenal Wilms' tumour. Despite its rarity, an extrarenal or even juxtarenal/pararenal Wilms' tumour should be included in the differential diagnosis of retroperitoneal tumour.

Microarray analysis of multiple candidate genes and associated plasma proteins for nephropathy secondary to type 2 diabetes among Chinese individuals.

AIMS/HYPOTHESIS: Evolving research suggests that common and rare alleles jointly constitute the genetic landscape of complex disease. We studied the association between 43 pathway-related candidate genes with 'intermediate phenotype' (i.e. corresponding plasma protein) and diabetic nephropathy in a customised microarray of 1,536 SNPs. METHODS: In this case-control study of type 2 diabetic Chinese individuals with and without diabetic nephropathy, cases (n = 545) were defined on the basis of a spot urinary albumin/creatinine ratio (ACR) > 113 mg/mmol; the value for controls (n = 503) was ACR < 3.3 mg/mmol. Genotyping was performed using Illumina GoldenGate assay. RESULTS: No single nucleotide polymorphism (SNP) remained significant in single locus analysis after correction for multiple testing. Therefore, we explored the best approximately 1% SNPs. Of these 13 SNPs, four clustered to a 5' end NADPH oxidase homologue 4 (NOX4) haplotype (GGCC frequency = 0.776) with estimated OR for diabetic nephropathy of 2.05 (95% CI 1.04-4.06) (heterozygous) and 2.48 (1.27-4.83) (homozygous) (p = 0.0055). The haplotype was correlated with plasma Cu/Zn superoxide dismutase (SOD) concentration, suggesting increased oxidative burden. Endothelin-1 SNP (rs1476046G>A, frequency = 0.252) was correlated with plasma C-terminal pro-endothelin-1 concentrations with an estimated OR for diabetic nephropathy of (heterozygous) 1.26 (0.96-1.66) and (homozygous) 1.87 (1.13-3.12) (p = 0.0072). Nitric oxide synthase 1 (NOS1) 5' haplotype (TGTC frequency = 0.38) also revealed a suggestive association with diabetic nephropathy: heterozygous 1.26 (0.95-1.67), homozygous 1.57 (1.04-2.35) (p = 0.0073). A rare NADPH oxidase homologue 1 (NOX1)-coding non-synonymous SNP (Arg315His, frequency = 0.006) was found exclusively among cases. CONCLUSIONS/INTERPRETATION: Our preliminary observations suggest that common haplotypes from NOX4 and endothelin-1 SNP correlated with plasma Cu/Zn SOD and C-terminal pro-endothelin-1 concentrations, respectively, and might have conferred diabetic nephropathy susceptibility. Common NOS1 and rare NOX1 variants also revealed a suggestive association with diabetic nephropathy. Future studies to validate our observation are needed.