Non-alcoholic fatty liver disease and diabetic retinopathy: Is there an association?

Background: Studies have not proven whether an association exists between diabetic retinopathy (DR) and non-alcoholic fatty liver disease (NAFLD). The reports from various parts of the world have not used uniform criteria, and hence, results are inconclusive. Both DR and NAFLD are common conditions encountered in primary care. Methods: A total of 130 patients with type 2 diabetes from the medical wards of a tertiary care hospital were enrolled. After documentation of clinical and biochemical data, they underwent ultrasonography (USG) of the abdomen and fibroscan grading of liver. Retinopathy was assessed and classified as per the Early Treatment Diabetic Retinopathy Study. Results: The mean age of the patients included in the study was 46.5+/-8.8 with 55% of the participants being male and 45% female. The mean HbA1c was 7.168+/2.4. The association between DR and hepatic fibrosis was assessed by fibroscan (p 0.003) and USG (p 0.001) and was significant on univariate analysis. Multivariate analysis did not confirm this. There was no association between increasing grades of either condition. Although fibroscan and USG significantly concorded in diagnosing NAFLD, fibroscan diagnosed more cases as compared to USG (83 vs 73). Conclusion: Larger studies should be conducted to conclusively determine the association in order to investigate pathogenetic factors and treatment strategies.

Molecular markers for early stratification of disease severity and progression in COVID-19.

COVID-19 infections have imposed immense pressure on the healthcare system of most countries. While the initial studies have identified better therapeutic and diagnostic approaches, the disease severity is still assessed by close monitoring of symptoms by healthcare professionals due to the lack of biomarkers for disease stratification. In this study, we have probed the immune and molecular profiles of COVID-19 patients at 48-h intervals after hospitalization to identify early markers, if any, of disease progression and severity. Our study reveals that the molecular profiles of patients likely to enter the host-immune response-mediated moderate or severe disease progression are distinct even in the early phase of infection when severe symptoms are not yet apparent. Our data from 37 patients suggest that at hospitalization, interleukins (IL6) (>300 pg/ml) and IL8 levels (>200 pg/ml) identify cytokine-dependent disease progression. Monitoring their levels will facilitate timely intervention using available immunomodulators or precision medicines in those likely to progress due to cytokine storm and help improve outcomes. Additionally, it will also help identify cytokine-independent progressive patients, not likely to benefit from immunomodulators or precision drugs.

The effect of l-arginine supplementation on amelioration of oxygen support in severe COVID-19 pneumonia.

BACKGROUND & AIMS: l-Arginine (l-Arg) has been shown to help reduce respiratory support requirements in coronavirus disease 2019 (COVID-19), in an Italian study. We investigated the effect of l-Arg supplementation on the reduction in respiratory support for patients with severe COVID-19 pneumonia in an Indian population. METHODS: A parallel-group, triple-blinded, randomized controlled trial (RCT) was conducted on patients with severe COVID-19 pneumonia on oxygen (O2) support. Patients received either 3 g of oral l-Arg or placebo, daily under supervision, until they were off O2 support, or for a maximum of 10 days, whichever was earlier. The primary outcome was cessation in O2 support. Other outcomes were time to cessation of O2 support, duration of hospitalization, and incidence of adverse thrombotic events. RESULTS: We did an intention-to-treat analysis on 74 patients who were randomized into l-Arg (n = 38) or placebo group (n = 36). There were no significant differences between the two groups in the outcomes. At end of the study, 28 patients (73.6%) in l-Arg and 26 patients (72.2%) in the placebo group were weaned off oxygen support. The median number of days to the cessation of O2 support estimated using Kaplan Meir survival analysis, was 3 days in the l-Arg group (95% confidence interval [CI]: 1.2, 4.7) and 5 days in the placebo group (95% CI, 4.1,5.8); P = 0.27. CONCLUSION: In this group of patients with severe COVID-19 pneumonia, l-Arg supplementation did not show any significant difference in outcomes when compared to placebo supplementation.

Readings from a book by Victoria Sweet: A novel medical ethics learning experience.

As part of the postgraduate ethics sensitisation programme at St. John's Medical College, the faculty and students read excerpts from the book "God's Hotel" by Dr. Victoria Sweet. The reading was followed by personal reflection by the speaker and the session concluded with a discussion among the audience. Summarised below are the passages from the book and the reflections from each speaker, with feedback from the audience. The stories explore various dimensions of the doctor-patient relationship, respecting the wishes of patients, care of the terminally ill, coping with colleagues, and dilemmas in patient management.

Central obesity in low BMI as a risk factor for COVID-19 severity in South Indians.

BACKGROUND AND OBJECTIVES: South Asians are known to have excess adiposity at a lower body mass index, with truncal fat accumulation. Whether this confers higher risk to develop severe COVID-19 is not known. This study evaluated body mass index, body fat mass and waist circumference as risk factors for COVID-19 severity and its progression, in South Asian adults. METHODS AND STUDY DESIGN: Details of COVID-19 patients (19-90 years) were obtained prospectively, along with weight, height, waist circumference and body fat mass assessed by bioelectrical impedance analysis. Binomial logistic and Poisson regression were performed to test associations between waist circumference, body fat mass and body mass index to evaluate the adjusted OR or relative risk for disease severity at admission and length of stay. RESULTS: After adjusting for age, sex, height and co-morbidities, body mass index >23 kg/m2 (adjusted OR 2.758, 95% CI 1.025, 7.427), waist circumference (adjusted OR 1.047, 95% CI 1.002, 1.093) and body fat mass (adjusted OR 1.111, 95% CI 1.013, 1.219) were associated with a significant risk for disease severity at admission, while only waist circumference (adjusted relative risk 1.004, 95% CI 1.001, 1.008), and body fat mass (adjusted relative risk 1.011, 95% CI 1.003, 1.018), were associated with a significantly longer length of stay. CONCLUSIONS: Body mass index, at a lower cut-off of >23 kg/m2, is a significant risk factor for COVID-19 disease severity in the group of patients studied. The waist circumference and body fat mass are also good indicators for both severity at admission and length of stay.

Microbiologic profile and clinical practices in urinary tract infections in a tertiary care center in Southern India.

CONTEXT: Studies reported differences in clinical profiles of urinary tract infections (UTIs) in patients with and without type 2 diabetes mellitus (T2DM). Studies on the impact of the pattern of antibiotic resistance of organisms causing UTI on actual clinical practice are lacking. OBJECTIVES: 1. To study the clinical and microbiologic profiles of UTIs. 2. To compare treatment given with the prevailing antimicrobial sensitivity. SETTINGS AND DESIGN: This is a cross-sectional study conducted in a tertiary care hospital. METHODS AND MATERIALS: Retrospective chart review of inpatients with UTI (N = 200, 100 each of patients with and without T2DM), aged >18 years with a positive urine culture. STATISTICAL ANALYSIS: We used the statistical package SPSS version 17. The categorical variables were analyzed by the Chi-square test. Data were considered significant if P value was less than 0.05. RESULTS: Similar to previous Indian studies, T2DM patients with UTI had significantly more asymptomatic bacteriuria, asymptomatic bacteriuria (32% vs. 6%), previous history of UTI (25% vs. 2%), and prior catheterization (16% vs. 1%). Escherichia coli (E. coli) was the most common organism isolated and showed sensitivity pattern of meropenem > netilmicin > amikacin > nitrofurantoin. Ceftriaxone was the most common empirical therapy given in spite the prevailing low sensitivity of E. coli to it. All ASB cases were treated unlike recommendations. CONCLUSIONS: Ceftriaxone is the most common empirical therapy given in spite the prevailing low sensitivity of E. coli to it. Cases of ASB were treated unlike recommendations.

Metabolic syndrome and cardiovascular disease risk assessment among human immunodeficiency virus-infected individuals on antiretroviral therapy.

BACKGROUND: The association of cardiovascular risk with first-line antiretroviral therapy (ART) in Indians has been a matter of concern with the background of a high risk in South Asians. AIMS: This study aimed to compare metabolic syndrome and its components, dyslipidemia, insulin resistance, and cardiovascular risk among patients on first-line ART (Group 1) with age-matched, ART-naïve human immunodeficiency virus (HIV)-infected patients (Group 2) and normal controls (Group 3). METHODS: Patients attending a tertiary care center in Mysore were enrolled in the study after obtaining informed consent and controls were chosen from relatives of patients. RESULTS: The total number of patients enrolled in the study was 217 (males 111; females 106), and the mean age of these patients was 34.1 ± 7.4 years. The number of patients in Group 1 (HIV+, ART experienced) was 76; in Group 2 (HIV+, ART naïve) was 71, and in Group 3 (HIV-) was 70. There was no statistically significant difference in the prevalence of metabolic syndrome between the three groups. On comparing the components of metabolic syndrome, serum triglycerides (mg/dl) were significantly higher in the ART group (Group 1: 149.5 [interquartile range (IQR): 84-187], Group 2: 108 [IQR: 74-152], and Group 3: 141.5 [IQR: 89-192]; P = 0.014) and serum high-density lipoprotein cholesterol was higher in HIV-uninfected individuals (Group 1: 37.5 ± 11.83, Group 2: 31.5 ± 12.23, and Group 3: 40.1 ± 12.09; P = 0.0002). There was no association between metabolic syndrome, duration of HIV, and type of first-line ART. Total and low-density lipoprotein (LDL) cholesterol were significantly higher in the ART group. Homeostatic model assessment and Framingham scores did not reveal any significant difference across the three groups. CONCLUSION: HIV-infected individuals on ART had higher levels of triglycerides, LDL, and total cholesterol, but no increased cardiovascular risk compared to other groups.

Thyroid dysfunction in patients on antiretroviral therapy: A perspective from southern India.

Background: Thyroid dysfunction in patients with human retroviral infection has been reported but the prevalence of thyroid function abnormalities in patients on highly active antiretroviral therapy (HAART) has not been studied. We aimed to assess the prevalence of thyroid dysfunction and autoimmunity (antithyroid peroxidase auto-antibodies [TPO-Ab]) in patients on first-line HAART, identify risk factors for thyroid dysfunction and determine any association of thyroid dysfunction with HAART. Methods: We screened and enrolled consecutive patients from the outpatient department if they were (i) diagnosed with HIV infection (enzyme-linked immunosorbent assay); (ii) aged more than 18 years; (iii) on HAART for 1 year or more; and (iv) clinically stable with no evidence of any acute illness in the past 2 months. We excluded patients who were on drugs that affect thyroid function. Thyroid function tests and CD4 counts were done. Results: A total of 159 patients on firstline HAART were included in the study. Their mean (SD) age was 43.3 (10) years and duration of HAART was 44.4 (33.54) months. The mean CD4 count was 502.8 (274.45). Forty-seven patients (29.6%) had thyroid dysfunction. TPO-Ab positivity was noted in 6 patients. No association was seen between thyroid dysfunction and any type of regimen or drug. There was a significant negative correlation between CD4 counts and thyroid-stimulating harmone (TSH) suggesting that thyroid dysfunction may be more prevalent when immunity is low. Conclusions: There is a high prevalence of thyroid dysfunction, predominantly subclinical hypothyroidism, in patients on HAART. Thyroid autoimmunity is low in this subset of patients. Lower immunity is associated with higher TSH levels. Larger longitudinal studies are required to determine the course of hypothyroidism in patients on HAART.

The Epidemiology of IRIS in Southern India: An Observational Cohort Study.

Immune reconstitution inflammatory syndrome (IRIS) is an uncommon but dynamic phenomenon seen among patients initiating antiretroviral therapy (ART). We aimed to describe incidence, risk factors, clinical spectrum, and outcomes among ART-naive patients experiencing IRIS in southern India. Among 599 eligible patients monitored prospectively between 2012 and 2014, there were 59.3% males, with mean age 36.6 ± 7.8 years. Immune reconstitution inflammatory syndrome incidence rate was 51.3 per 100 person-years (95% confidence interval: 44.5-59.2). One-third (31.4%) experienced at least 1 IRIS event, at a median of 27 days since ART initiation. Mucocutaneous infections and candidiasis were common IRIS events, followed by tuberculosis. Significant risk factors included age >40 years, body mass index <18.5 kg/m2, CD4 count <100 cells/mm3, viral load >10 000 copies/mL, hemoglobin <11 g/dL, and erythrocyte sedimentation rate >50 mm/h. Immune reconstitution inflammatory syndrome-related morality was 1.3% (8 of 599); 3 patients died of complicated diarrhea. These findings highlight the current spectrum of IRIS in South India and underscore the importance of heightened vigilance for anemia and treatment of diarrhea and candidiasis during ART initiation.

Exercise in patients with Type 2 diabetes: Facilitators and barriers - A qualitative study.

INTRODUCTION: Diabetes is a major noncommunicable disease affecting more than 65 million Indians. Although treatment algorithms suggest lifestyle measures (diet and exercise) along with medications data regarding adherence to exercise as well as facilitators and barriers to the practice of physical activity in such patients are limited. Hence, this qualitative study was conducted. OBJECTIVES: The objective of this study is to describe the factors which (1) Facilitated and (2) hindered the practice of regular exercise in patients with Type 2 diabetes. METHODOLOGY: The study was conducted on 13 diabetic patients admitted to a tertiary care center in Bengaluru - St. John's Medical College Hospital, to explore factors that acted as facilitators and barriers to physical activity. Data saturation with the coded themes was achieved on interviewing 13 patients, after which, thematic analysis was done, and final themes reported. RESULTS: The age of the study participants (7 males, 6 females) ranged from 40 to 80 years. Among those who did exercise, factors such as awareness regarding the benefits of exercise and complications linked with diabetes, positive family support, and emphasis by nursing staff emerged as facilitators. Lack of time, obligations to others, inability to link exercise with blood sugar control, lack of perception of obesity as a health issue, inadequate emphasis by physicians, social/cultural issues, lack of infrastructure, and physical restriction were the factors that acted as barriers to physical activity. In addition to the above, a clear lack of adherence to standard guidelines, while advising patients by physicians was also noted. CONCLUSION: A comprehensive approach by both doctors and nurses, based on standard guidelines, could help in implementing adherence to exercise in patients with diabetes.

Vitamin D Supplementation in Adults with Vitamin D Deficiency and Its Effect on Metabolic Syndrome - A Randomized Controlled Study.

BACKGROUND: Inverse relationship between metabolic syndrome (MetS) and 25-hydroxyvitamin D (25(OH) D) levels is controversial. Hypovitaminosis-D has long been suspected as a risk factor for glucose intolerance. AIM: A randomized double blind placebo controlled study to evaluate effects of vitamin D supplementation on insulin resistance in subjects with hypovitaminosis-D and MetS. MATERIALS AND METHODS: Subjects were randomized to receive either oral 25(OH) D3 supplement (60000 (IU) per week for 8 weeks followed by 60,000 IU monthly for 4 months) or a placebo for six months. The parameters measured were blood pressure, vitamin D, fasting blood sugar (FBS), insulin, homeostasis model assessment (HOMA), quantitative insulin sensitivity check index (QUICKI), body mass index (BMI), and waist circumference (WC). RESULTS: There were no significant changes in parameters of vitamin-D group compared to placebo group except serum vitamin-D was significantly increased in vitamin-D group (p < 0.0001). In vitamin-D group, mean WC at baseline was 95.9 ± 6.66, which significantly changed to 94.6 ± 7.47 (p = 0.001). Mean BMI at baseline was 29.1 ± 4.06 which significantly changed to 28.5 ± 4.16 (p = 0.001). The mean vitamin-D concentration at baseline was 15.4 ± 9.03 which significantly (p < .0001) increased to 26.1 ± 11.8. In placebo group mean insulin levels was 10.7 ± 4.81IU / L which increased significantly (p = 0.03) to 15.4 ± 14.0. Mean QUICKI at baseline was 0.34 ± 0.03 which decreased significantly (p = 0.02) to 0.32 ± 0.03. CONCLUSION: In this study the relationship between vitamin D supplementation and MetS or IR was not established. Whether achieving vitamin D sufficiency in large population-based trials with a longer duration would produce more favorable results needs to be assessed.

Serum lipids and diabetic retinopathy: A cross-sectional study.

AIM: To evaluate the association of elevated serum lipids with retinal hard exudates formation, the occurrence clinically significant macular edema (CSME), occurrence and severity of diabetic retinopathy (DR) and loss of vision in type 2 diabetics. MATERIALS AND METHODS: Type 2 diabetic patients seeking ocular evaluation for diabetic retinopathy were included in this cross-sectional study. They were assessed for presence and severity of diabetic retinopathy (DR), presence of hard exudates, clinically significant macular oedema (CSME) and best corrected visual acuity (BCVA). Retinal findings were correlated to serum lipids levels using univariate and multivariate analysis. RESULTS: Totally 330 patients were included, of which 141/330 had diabetic retinopathy of any grade. Retinal hard exudate formation, was found to have statistically significant correlation with the presence of dyslipidemia (p=0.02), increased total cholesterol (p=0.002) and LDL levels (p=0.001). On multivariate analysis, after correcting for duration, glycemic control and albuminuria, increased cholesterol remained significantly associated with increased hard exudate formation (p=0.02). Elevated cholesterol also showed independent association with visual loss (p=0.04). The occurrence CSME showed a statistically significant correlation with dyslipidemia (p=0.04) and increased LDL levels (0.04), which did not persist on multivariate analysis. However the there was no correlation with the occurrence and severity of diabetic retinopathy. CONCLUSION: Elevated serum lipids showed a significant association with retinal hard exudate formation, CSME and loss of vision in type 2 diabetics. Lipid lowering agents may help in reducing the occurrence of these retinal findings and loss of vision in diabetic patients.

Autonomic nervous system function in type 2 diabetes using conventional clinical autonomic tests, heart rate and blood pressure variability measures.

BACKGROUND: There are currently approximately 40.9 million patients with diabetes mellitus in India and this number is expected to rise to about 69.9 million by the year 2025. This high burden of diabetes is likely to be associated with an increase in associated complications. MATERIALS AND METHODS: A total of 23 (15 male and 8 female) patients with type 2 diabetes of 10-15 years duration and their age and gender matched controls (n=23) were recruited. All subjects underwent detailed clinical proforma, questionnaire related to autonomic symptoms, anthropometry, peripheral neural examination and tests of autonomic nervous system including both conventional and newer methods (heart rate and blood pressure variability). RESULTS: Conventional tests of cardiac parasympathetic and sympathetic activity were significantly lower in patients with diabetes compared to the controls (P<0.05). The diabetic patients group had significantly lower high frequency and low-frequency HRV when expressed in absolute units (P<0.05) and total power (P<0.01) compared to the controls. CONCLUSION: Data from the current study demonstrated that diabetics had both cardiac sympathetic and cardiac parasympathetic nervous system involvement. The presence of symptoms and involvement of both components of the autonomic nervous system suggest that dysfunction has been present for a while in these diabetics. There is a strong need for earlier and regular evaluation of autonomic nervous system in type 2 diabetics to prevent further complications.