Impaired Cardiovagal Activity as a Link Between Hyperglycemia and Arterial Stiffness in Adults With Type 2 Diabetes Mellitus Among an Eastern Indian Population: A Cross-sectional Study.

OBJECTIVES: Cardiac autonomic neuropathy (CAN) is one of the most common yet overlooked complications of type 2 diabetes mellitus (T2DM). Individuals with T2DM with CAN have a 5-fold higher rate of cardiovascular morbidity and mortality. The presence of CAN in T2DM could potentially lead to arterial stiffness. However, only sparse data are available suggesting any association between autonomic dysfunction and arterial stiffness in T2DM. METHODS: We recruited 80 people with T2DM and 74 healthy controls for our study. Heart rate variability (HRV) testing was performed to assess autonomic function. Assessment of arterial stiffness was done by measuring the brachial pulse wave velocity (baPWV) and augmentation index (AI). RESULTS: The time-domain parameters were significantly decreased (p<0.001) and frequency-domain parameters, such as total power and high-frequency band expressed as a normalized unit, were found to be significantly reduced in people with T2DM (p<0.001). Both baPWV and AI were significantly higher in people with T2DM compared with healthy controls (p<0.001). We observed a moderate correlation between standard deviation of normal to normal interval (SDNN) and baPWV (r=-0.437, p=0.002) and AI (r=-0.403, p=0.002). A multiple linear regression model showed an association between SDNN and arterial stiffness parameters, such as baPWV and AI, which were statistically significant (p<0.05) in a fully adjusted model that included the conventional risk factors for atherosclerosis. CONCLUSIONS: Impaired cardiovagal activity is an independent risk factor for the development of arterial stiffness. Incorporation of HRV testing into the diabetes management protocol would have potential benefits for identifying individuals at high risk of developing cardiovascular events. Hence, preventive measures can be taken as early as possible to improve patient outcomes.

Impact of Cardiac Autonomic Dysfunction on Cognitive Event-Related Potential in Type 2 Diabetes Mellitus Patients: A Cross-Sectional Study.

Introduction: Type 2 diabetes mellitus (T2DM) is a chronic metabolic condition that is responsible for various long-term complications. Cognitive impairment is one of the most common complications, but the underlying mechanisms are still undetermined. The autonomic imbalance is a major cause for CVS morbidity in T2DM which could also potentially affect cognition. But there is sparse data available in the literature to prove the association between autonomic dysfunction and cognitive impairment. Methodology: We recruited 40 T2DM patients and 40 healthy controls. The assessment of cognitive functions was done by cognitive P300 event-related potential (ERP) and MoCA. Heart rate variability (HRV) was done to assess autonomic function. Results: The P300 ERP latency in Fz, Cz and Pz sites was significantly prolonged in T2DM patients (P < 0.001). We found moderate correlation is present between P300 latency and total power (r = -0.466, P < 0.01) and LFnu (r = -0.423, P < 0.01) in T2DM patients. The total power and HbA1C show independent association with P300 latency after adjustment for confounding factors like age and duration of diabetes (P < 0.05). Conclusion: As the incidence of Alzheimer's disease is rising among T2DM patients increasing their dependency, making necessary lifestyle measures at earliest to improve autonomic balance may prevent or delay the onset of cognitive decline and alleviate its consequences and improve the quality of life in T2DM patients.

Association of peripheral neuropathy with skeletal muscle mass and function in type two diabetes mellitus patients: A cross-sectional study.

BACKGROUND & OBJECTIVE: Diabetic peripheral neuropathy (DPN) is considered to be a risk factor for development of sarcopenia. Therefore, our study aimed to detect the association between peripheral neuropathy with skeletal muscle mass and function in type two diabetes mellitus (T2DM) patients. METHODS: A total of 176 participants, ≥45 years were included in the study. Out of 176, 60 were healthy volunteers, 60 had T2DM without neuropathy, 56 had T2DM with neuropathy. In all the participants peripheral nerve function was assessed by nerve conduction studies (Common peroneal and Sural nerve) and sarcopenia parameters were evaluated according to the Asian Working Group for Sarcopenia (AWGS) criteria. RESULTS: The present study suggested that diabetic peripheral neuropathy (DPN) was associated with decline in muscle mass, which was found only in men. Our study showed a positive correlation between appendicular skeletal muscle index (ASMI) and common peroneal nerve amplitude and sural nerve amplitude with r=0.527, p<0.05; r=0.847, p<0.001 respectively. Furthermore, in multiple linear regression analyses, we found a positive relationship between ASMI and sural nerve amplitude after adjustment for confounders like age, duration of diabetes, and HbA1C (B=0.739; p<0.001). CONCLUSION: As DPN patients are more prone to developing sarcopenia, and periodic assessment of skeletal muscle mass and function is warranted to initiate early lifestyle interventions in these patients, which will improve their quality of life.

Assessment of the Diagnostic Utility of Serum Omentin 1 and IL-6 in Early Stages of Diabetic Nephropathy.

In India, diabetic nephropathy (DN) is the most common cause of chronic kidney disease. Timely detection of microalbuminuria and appropriate intervention can reverse or arrest the progress of nephropathy. The pathogenesis of diabetic nephropathy has revealed that during the early onset of kidney involvement in diabetics, inflammation and fibrosis progress from tubular to glomerular damage. This study was designed to elucidate the association of chemokines, Omentin 1, and interleukin 6 (IL-6) with microalbuminuria. MATERIAL: Settings and Design: This cross-sectional observational study was conducted as a collaborated study in the Departments of General Medicine and Biochemistry, All India Institute of Medical Sciences, Bhubaneswar, India, during 2019-2020. METHODS AND MATERIAL: Our study group comprised 116 diabetes mellitus patients. They were grouped into two, each of 58 on the basis of their urine albumin levels; Group 1 (controls) had UACR < 30 µg/mg, eGFR> 90ml/ min and Group 2 (cases) had UACR ≥ 30 µg/mg and < 300 µg/mg, eGFR>60ml/min and < 90ml/min. Serum omentin 1 and IL-6, creatinine, glycated haemoglobin (HbA1c), fasting (FBS) and postprandial blood sugar (PPBS), lipid profile, total protein, albumin, and fasting insulin, HOMA-IR were studied. OBSERVATION: Our study showed that Omentin 1 levels were decreased, and IL-6 levels were increased in the DN group compared to the T2DM without DN. The risk estimates calculated revealed that diabetes mellitus patients having an IL-6: omentin ratio ≥ 0.26 had Odds of 3.97 of developing DN, which was statistically significant (CI 2.36-6.68). Therefore, a ratio of ≤ 0.26 was found to be kidney protective among diabetes mellitus patients. CONCLUSION: From the results of this present study, we recommend that estimation of serum IL-6: omentin 1 ratio of T2DM will aid in identifying early stages of DN before the onset of microalbuminuria.

Aesthetic Outcome of Gynecomastia Management with Conventional Liposuction and Cross-Chest Liposuction: A Prospective Comparative Study.

BACKGROUND: Liposuction is the most accepted technique for treatment of gynecomastia at present with or without residual gland tissue excision. Conventional liposuction uses incisions for introduction of cannula, made usually at the inframammary crease or axilla resulting in consequent scars. Cross-chest liposuction technique was introduced to avoid these additional scars and improve the aesthetic outcome. This study aimed to evaluate the difference between aesthetic outcome of conventional liposuction and cross-chest liposuction in treatment of gynecomastia. METHOD: A prospective comparative study between 2 groups with 15 patients in each was conducted, one with conventional and the other cross-chest liposuction. Excision of residual gland tissue was performed through circum-areolar incision in both the groups. Aesthetic outcome was evaluated in both the groups using Likert scale and compared. RESULT: The mean age of the patients was 22.6 years and the mean duration of presentation was 8.13 years. Satisfaction rate with conventional and cross-chest liposuction was 80% and 86%, respectively, as assessed by the patients. The rate was 80% and 77%, respectively, in both the groups as assessed by independent observer. The complication rate was 13.3% in conventional and 20% in cross-chest group. The difference in outcome was not statistically significant between two groups. Difference between the mean Likert scores of pre-operative and post-operative satisfaction was statistically significant for both the techniques. CONCLUSION: The conventional and the cross-chest liposuction, both yield comparable results when used for treatment of gynecomastia in terms of aesthetic outcome. LEVEL OF EVIDENCE III: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.

Type 2 diabetes mellitus, physical activity, and neuromusculoskeletal complications.

Objectives: The objectives of the study were to investigate the neuromusculoskeletal complications of Type 2 diabetes mellitus (T2DM) and their associated factors, including the level of physical activity (PA) and clinicodemographic characteristics. Materials and Methods: In this cross-sectional analysis, we included 370 participants diagnosed with T2DM for no <1 year who satisfied the inclusion and exclusion criteria. Demographic and clinical characteristics were noted and a thorough clinical examination was performed on all the participants. International PA Questionnaire-Short Form was used to evaluate the level of PA of the participants. The continuous data is presented as mean ± SD and the categorical data is presented as the number of participants (n) and percentage (%). A logistic regression model was used to investigate the predictors for the prevalence of the complications. Results: The mean duration of T2DM was 7.32 ± 5.53 years and the mean hemoglobin A1C (HbA1c) level (%) was 8.16±1.67. A majority of the participants were having uncontrolled diabetes with an HbA1c level ≥7.5% (n = 190; 51.35%). The level of PA was low in a substantial proportion of the participants (n = 276; 74.59%). A total of 162 (43.78%) participants were diagnosed with neuromusculoskeletal complications. Low back pain was the most common complication and degenerative disk disease was the most common diagnosis overall. Longer duration of diabetes, poor glycemic control, and low PA were associated with the prevalence of neuromusculoskeletal complications (P < 0.05). Conclusion: Neuromusculoskeletal complications of T2DM are common and can result in significant disability in this population. Low PA is very common among T2DM patients and an important contributor to the development of complications. Health-care providers should consider PA an integral component of the management protocol for T2DM patients.

Complete Resolution of the Pituitary Mass Lesion and Improvement of Pituitary Function with Corticosteroid in Autoimmune Hypophysitis: A Case Report.

BACKGROUND: Autoimmune hypophysitis is the consequence of an immune-mediated inflammation of the pituitary gland, which is rare, and most frequently occurs in females during postpartum periods. It usually responds well to corticosteroid treatment with reported resolution of the pituitary mass lesion. CASE REPORT: A 51 years male presented with a one-month history of lethargy, headache, nausea, proximal muscle weakness with intermittent flushing. He was a diabetic with metformin 500mg twice daily. No other remarkable medical history or family history of autoimmune disease. On examination, he had no neurological deficit with a normal visual field. His initial biochemical evaluation showed features of secondary hypothyroidism as evidenced by low free FT4 and suppressed TSH with normal electrolytes. The subsequent evaluation of his hormonal profile revealed panhypopituitarism. Contrast MRI of pituitary showed an enhanced homogenous mass and minimal stalk thickening with a dural tail and preserved posterior bright spot. He was managed with glucocorticoid 20 mg once daily for two weeks along with levothyroxine and testosterone replacement. After two weeks of treatment, he improved clinically. Repeat MRI imaging of the pituitary showed complete resolution of the homogenous mass. CONCLUSION: Although autoimmune hypophysitis is rare in males, a careful clinical history with necessary hormonal investigations is required for the suspicion about the inflammatory pituitary disorders This current case highlights glucocorticoid as the primary modality of treatment and the need for long-term follow-up with periodic clinical assessment.

Effect of Vitamin D Supplementation on Thyroid Autoimmunity among Subjects of Autoimmune Thyroid Disease in a Coastal Province of India: A Randomized Open-label Trial.

OBJECTIVE: Hashimoto's thyroiditis (HT) is a variant of autoimmune thyroid disorders (AITD) which has been associated with vitamin D (vit-D) deficiency. However, whether vit-D supplementation is linked to reduction of thyroid autoantibodies and improvement of thyroid function is not well characterized. The present study was planned to evaluate the effect of vit-D supplementation on possible improvement of thyroid autoantibody titer and thyroid hormone profile in patients with AITD subjects. METHODS: Twenty-three patients of HT were given weekly supplementation of 60,000 IU vit-D for 8 weeks followed by once a month for another 4 months. After 6 months of vit-D supplementation, thyroid autoantibody titer (TPO antibody) and thyroid hormone profile was rechecked. RESULTS: Mean serum vit-D was increased significantly from 15.33 ± 5.71 to 41.22 ± 12.24 ng/mL (normal levels) after supplementation. There was significant increase in thyroid autoantibody titre (from 746.8 ± 332.2 to 954.1 ±4 59.8 IU/ml; P = 0.006) and TSH level (7.23 ± 3.16 to 3.04 ± 2.62 (mIU/L); P = 0.01) following 6 months of vit-D supplementation. CONCLUSION: Vitamin-D levels were low in AITD patients in eastern India and, its supplementation in HT patients increased thyroid antibody titer and there was significant reduction in serum TSH and increased in free T4.

Graves' Disease in Eutopic Thyroid with Ectopic Mediastinal Thyroid Tissue: Role of Single Photon Emission Computed Tomography-Computed Tomography.

Ectopic thyroid is a rare embryological aberration due to defective migration. Most patients with ectopic thyroid tissue have absent thyroid gland in normal anatomical position and present with hypothyroidism. We present a patient with Graves' disease in the eutopic thyroid with ectopic thyroid tissue in the mediastinum and usefulness of single-photon emission computed tomography-computed tomography.

Graves' Disease with Pancytopenia and Hepatic Dysfunction: A Rare Case Presentation.

Pancytopenia due to thyrotoxicosis is a rare but serious complication. In this report, we describe a rare case of Graves' disease confirmed on thyroid scintigraphy presented with coexisting pancytopenia and liver dysfunction. There was complete recovery of blood counts and hepatic enzyme level to normal after antithyroid treatment and radioiodine ablation.

Resting energy expenditure in subjects with fibro-calculous pancreatic diabetes.

BACKGROUND: Fibro-calculous pancreatic diabetes is an indigenous disorder present in populations largely in tropical regions. Energy expenditure through indirect calorimetry has not been studied in this disorder and may provide important clues as to the pathogenesis of diabetes in these patients. METHODS: A total of 51 males in three groups comprising fibrocalculous pancreatic diabetes (FCPD) (group 1; n = 24), type 2 diabetes (group 2; n = 15) and healthy controls (group 3; n = 12) were studied. The body composition was measured using Dual Energy X-ray Absorptiometry (DEXA) and the REE was estimated using indirect calorimetry. The predicted energy expenditure (PEE) was calculated using three different equations. RESULTS: Patients in both groups with diabetes had a higher mean waist-hip ratio than the controls (P = 0.002). However patients with type 2 diabetes alone had a significantly higher mean body mass index (P = 0.012), percentage of fat (P = 0.016) and total fat content (P = 0.031). There was no significant difference in REE among the three groups. After adjustment of body mass index (BMI), the REE was significantly higher in patients with FCPD than in those patients with Type 2 diabetes. PEE correlated poorly with indirect calorimetry. CONCLUSIONS: Energy expenditure in patients with diabetes varies according to the composition and distribution of body fat and is lower in patients with FCPD. Standard predictive equations were not accurate for the assessment of energy expenditure in patients with FCPD. Further research is required to recommend specific nutritional therapy for this group of patients.

Acute adrenal insufficiency due to primary antiphospholipid antibody syndrome.

INTRODUCTION: We report a case of acute adrenal insufficiency (AAI) in a patient with antiphospholipid syndrome (APS). CASE REPORT: A 44-year-old female patient presented to us with acute abdominal pain associated with recurrent vomiting and giddiness. On examination, her blood pressure was 80/50 mm Hg. Systemic examination was normal. Further evaluation revealed hypocortisolemia with elevated plasma adrenocorticotropin hormone indicative of primary adrenal insufficiency. Her abdominal computed tomography scan showed features of evolving bilateral adrenal infarction. Etiological work-up revealed prolonged activated thromboplastin time, which didn't correct with normal plasma, her anti-cardiolipin antibody and lupus anticoagulant were also positive. She was diagnosed to have APS with adrenal insufficiency and she was started on intravenous steroids and heparin infusion. CONCLUSION: AAI due to the APS can present with acute abdominal pain followed by hypotension. A high index of suspicion is needed to make the correct diagnosis and to initiate appropriate treatment.

Mazabraud syndrome.

A 25 year old lady presented with pain and swelling of left thigh. On examination she was found to have tenderness of left femur with a separate soft tissue swelling within the thigh muscle. Further evaluation revealed expansile bony lesion on X-ray of left tibia and multiple hot spots on bone scan suggestive of fibrous dysplasia. The soft tissue swelling on excision and histopathological examination was found to be intramuscular myxoma. The combination of the above two, called Mazabraud syndrome is being reported.

Neurofibromatosis type 1, pheochromocytoma with primary hyperparathyroidism: A rare association.

Primary hyperparathyroidism (PHP) with pheochromocytoma and neurofibromatosis type 1 is a rare clinical association. We present a case of PHP and pheochromocytoma occurring in a 33-year-old male with familial cutaneous neurofibromatosis.