An Expert Group Consensus Statement on “Approach and Management of Prediabetes in India”

The prevalence of prediabetes, a forerunner of diabetes is very high, and its conversion to diabetes is also more rapid among Asian Indians. Prediabetes also predisposes to the development of macrovascular and to a lesser extent of microvascular complications of diabetes. In a large community-based epidemiological study, the Indian Council of Medical Research–India Diabetes (ICMR–INDIAB), data reported an overall prevalence of prediabetes of 10.3%, derived from 15 Indian states. This shows that the diabetes epidemic is far from over as many of them may soon convert to diabetes. Prediabetes, however, should not be considered a path to diabetes rather it should be a window of opportunity for the prevention of diabetes. This early screening, detection, and treatment of prediabetes should be made a national priority. Several countries have introduced lifestyle programs to prevent diabetes and, when indicated, pharmacological intervention with metformin as well. This consensus statement outlines the approaches to screening and lifestyle and pharmacological management of prediabetes in Asian Indians.

Prevalence and risk factors for work-related musculoskeletal disorder among female domestic workers employed in private homes in South India: A cross-sectional study

Objectives: Musculoskeletal disorders (MSDs) are the most common occupational health problem accounting for a larger number of compensation days and disability among workers. An invisible workforce of female domestic workers (FDWs) is involved in back-breaking jobs in the informal job sectors, and yet, there are no studies to quantify their work-related MSD’s (WMSDs). The objective of the study is to determine the prevalence of WMSDs among FDWs employed at private houses in Bengaluru, South India. Material and Methods: A cross-sectional study was conducted among 408 randomly selected FDWs with a comparative group. The trained interviewer assessed WMSDs using a standardized Nordic Musculoskeletal questionnaire and psychosocial distress using the general health questionnaire–12. Results: A high prevalence of WMSD was reported in the neck (19.6%), shoulder (23.8%), elbow (12%), upper back (31.9%), and ankle (26%) in domestic workers than the non-domestic workers. Age above 37 years (AOR: 1.77, 95% CI: 1.03–3.06), house cleaning ([>1715 h/year – AOR: 1.30, 95% CI: 0.60–2.84] [1714–555 h/year – AOR: 1.30, 95% CI:0.66–2.59]), and clothing ([Care >1460 h/year – AOR: 2.44, 95% CI: 1.12–5.35] [109–1459 h/year – AOR: 1.98, 95% CI: 0.95–4.10]) were factors associated with neck pain in FDW. Moreover, work experience of more than 10 years (AOR: 2.10, 95% CI: 1.32–3.34) and distress (AOR: 2.13, 95% CI: 1.25–3.61) was a factor associated with lower back pain in FDW. Conclusion: FDWs are substantially affected by WMSDs in the neck and lower back due to house cleaning and clothing care tasks performed in the workplace setting, respectively

Management of Hypertension in Patients with Diabetes: A Comprehensive Review of the Perceptions and Practices of Health Care Providers in India

Objectives: This study evaluated the perception and practices of health care providers (physicians, diabetologists, and endocrinologists) regarding the treatment of hypertension in patients with diabetes in India. Methods: Health care providers throughout India who treated patients with diabetes and hypertension were invited to participate in an online survey and periodic 21 virtual meetings. They were questioned about their perception and practices in managing these patients, and strategies to improve blood pressure (BP). Results: The online survey was completed by 2,513 health care providers, and 344 participated in virtual meetings. More than 50% reported that 31–50% of their patients with diabetes also had hypertension. Home BP monitoring was recommended by 88%, and lifestyle modifications were consistently recommended. Choice of antihypertensive treatment varied based on comorbidities, and a renin–angiotensin system blocker plus a calcium channel blocker (CCB) was the most common combination for dual antihypertensive therapy. Suggested strategies to improve BP control included patient awareness/education, lifestyle modifications, better follow-up/monitoring, and optimization of therapy. Conclusion: Indian health care providers were aware of clinical recommendations and practices regarding treatment of patients with diabetes and hypertension, and generally make clinical decisions consistent with current guidelines. Optimization of care for these patients is essential to reduce cardiovascular disease risk and improve patient outcomes.

Comparison between caudal epidural block and popliteal nerve block for postoperative analgesia in children undergoing foot surgery: a randomized controlled trial

Background: Pain following surgery in children cause discomfort, restlessness and agitation in the postoperative period which may result in an increased incidence of nausea, vomiting and maladaptive behavioural changes. Regional anaesthesia is commonly used as an adjunct to general anaesthesia for perioperative analgesia in children as part of a multimodal approach of pain relief. This study is to compare between caudal epidural block and popliteal nerve block for postoperative analgesia in children undergoing foot surgery.Methods: A prospective randomized single blind study was carried out on 30 children aged 1-12 years of either sex undergoing foot surgery. Patients were randomly assigned into caudal epidural block group and Popliteal nerve block group, 15 children each. Both groups receive 1 ml/kg of 0.25% bupivacaine. Foot surgery was carried out under general anesthesia along with regional block for all children. After completion of surgery, children were shifted to PACU and HR, BP, SPO2 were monitored. Patient was discharged from PACU after CHEOPS (1-5 years) or VAS (6-12 years) <4. Parental satisfaction, sedation score, PONV, and any other side effects were recorded.Results: Demographic data and baseline vital signs were comparable between two groups. Statistically significant difference (p=0.025) in number of attempts in giving block in group A (1.20±0.41) than group B (1.80±0.86). The mean postoperative pain scores, CHEOPS and VAS were comparable in both groups.Conclusions: Both caudal epidural block and popliteal nerve block provides comparable and adequate analgesia in children undergoing elective foot surgery.

Assessment of diabetic retinopathy in type 1 diabetes in a diabetes care center in South India—Feasibility and awareness improvement study

The prevalence of youth-onset diabetes, both type 1 diabetes (T1D) and young-onset type 2 diabetes (YT2D) are gradually increasing in India. Early and repetitive screening for diabetic retinopathy (DR) is essential to provide timely management, and thereby prevent visual impairment due to the silent sight-threatening microvascular complication of diabetes. A study was undertaken at a diabetes care center in Chennai, south India, to assess the feasibility of screening for DR in T1D in a diabetes clinic and determine the burden of sight-threatening DR (STDR) in individuals with T1D. 315 people with T1D were screened for DR (mean age at onset of diabetes 12.3 ± 6.4 years) by digital retinal color photography, at the urban diabetes center, in a semi-urban and rural diabetes clinic. Counseling about diabetes and the importance of annual screening for retinopathy was provided by diabetes educators. Participants were reviewed after 6 months/1 year based on ophthalmologist's advice. DR was detected in 37.1% (n = 117), 42 (13%) of whom had STDR.Three-quarter participants were compliant with the annual follow-up retinal examination. The peer support group was established for participants with T1D and their families to foster interactions with service providers. The peer group meetings helped to increase the awareness of retinopathy among the parents and individuals with T1D. This narrative provides details of the study that shows that screening for DR among individuals with T1D in a diabetes clinic is a feasible model, irrespective of its location.

A partnership model for capacity-building of primary care physicians in evidence-based management of diabetic retinopathy in India

In India, more than 72 million people have diabetes. Diabetic retinopathy (DR), a vision-threatening complication of people with diabetes, is an important cause of avoidable blindness. The delay in the detection of DR is due to lack of awareness and shortage of ophthalmologists trained in the management of DR. With this background, in 2015, we initiated a capacity-building program “Certificate Course in Evidence Based Management of Diabetic Retinopathy (CCDR)” with an objective to build the skills and core competencies of the physicians across India in the management of diabetes and DR. The program has completed four cycles and 578 physicians have been trained. The course elicited an excellent response, which reflects the much-felt need for skill improvement in DR diagnosis and management for physicians in India. This model demonstrates an innovative modality to address DR-related avoidable blindness in a resource-restraint country like India.

Accuracy of the smartphone-based nonmydriatic retinal camera in the detection of sight-threatening diabetic retinopathy

Purpose: To evaluate the sensitivity and specificity of smartphone-based nonmydriatic (NM) retinal camera in the detection of diabetic retinopathy (DR) and sight-threatening DR (STDR) in a tertiary eye care facility. Methods: Patients with diabetes underwent retinal photography with a smartphone-based NM fundus camera before mydriasis and standard 7-field fundus photography with a desktop mydriatic fundus camera after mydriasis. DR was graded using the international clinical classification of diabetic retinopathy system by two retinal expert ophthalmologists masked to each other and to the patient's identity. The sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) to detect DR and STDR by NM retinal imaging were assessed. Results: 245 people had gradable images in one or both eyes. DR and STDR were detected in 45.3% and 24.5%, respectively using NM camera, and in 57.6% and 28.6%, respectively using mydriatic camera. The sensitivity and specificity to detect any DR by NM camera was 75.2% (95% confidence interval (CI) 68.1–82.3) and 95.2% (95%CI 91.1–99.3). For STDR the values were 82.9% (95% CI 74.0–91.7) and 98.9% (95% CI 97.3–100), respectively. The PPV to detect any DR was 95.5% (95% CI 89.8–98.5) and NPV was 73.9% (95% CI 66.4–81.3); PPV for STDR detection was 96.7% (95% CI 92.1–100)) and NPV was 93.5% (95% CI 90.0–97.1). Conclusion: Smartphone-based NM retinal camera had fairly high sensitivity and specificity for detection of DR and STDR in this clinic-based study. Further studies are warranted in other settings.

Are excess carbohydrates the main link to diabetes & its complications in Asians?

Dietary carbohydrates form the major source of energy in Asian diets. The carbohydrate quantity and quality play a vital function in the prevention and management of diabetes. High glycaemic index foods elicit higher glycaemic and insulinaemic responses and promote insulin resistance and type 2 diabetes (T2D) through beta-cell exhaustion. This article reviews the evidence associating dietary carbohydrates to the prevalence and incidence of T2D and metabolic syndrome (MS) in control of diabetes and their role in the complications of diabetes. Cross-sectional and longitudinal studies show that higher carbohydrate diets are linked to higher prevalence and incidence of T2D. However, the association seems to be stronger in Asian-Indians consuming diets high in carbohydrates and more marked on a background of obesity. There is also evidence for high carbohydrate diets and risk for MS and cardiovascular disease (CVD). However, the quality of carbohydrates is also equally important. Complex carbohydrates such as brown rice, whole wheat bread, legumes, pulses and green leafy vegetables are good carbs. Conversely, highly polished rice or refined wheat, sugar, glucose, highly processed foods such as cookies and pastries, fruit juice and sweetened beverages and fried potatoes or French fries are obviously 'bad' carbs. Ultimately, it is all a matter of balance and moderation in diet. For Indians who currently consume about 65-75 per cent of calories from carbohydrates, reducing this to 50-55 per cent and adding enough protein (20-25%) especially from vegetable sources and the rest from fat (20-30%) by including monounsaturated fats (e.g. groundnut or mustard oil, nuts and seeds) along with a plenty of green leafy vegetables, would be the best diet prescription for the prevention and management of non-communicable diseases such as T2D and CVD.

Pros & cons of some popular extreme weight-loss diets

Obesity has now become a huge public health issue not only in the developed world but also in developing countries. In view of the health hazards associated with obesity and more importantly for cosmetic reasons, many people, particularly the youth, have started resorting to 'extreme' weight-loss diets to achieve a rapid reduction in weight. These extreme diets are either very low in carbohydrate or very low in fat. Such extreme diets not only make the diet unbalanced but also have safety issues. Moreover, these are not sustainable in the long run. The weight that is lost is regained within a short period of time when people go off these extreme diets. This explains why the popularity of most extreme diets peaks as well as wanes rapidly. Instead of resorting to such extreme diets, correction of obesity is best achieved with balanced, healthy, nutritious diets which are low in calories, combined with adequate physical activity (exercise). Motivational counselling can also help people to initiate weight loss and sustain this weight loss over longer periods of time.

Clinical outcome and regression patterns of retinoblastoma treated with systemic chemoreduction and focal therapy: A prospective study.

Purpose: To prospectively study the clinical outcome and regression patterns of early retinoblastoma (Groups A and B) after systemic chemotherapy and focal consolidation in Indian children. Materials and Methods: Group A eyes were treated with focal therapy (transpupillary thermotherapy/cryotherapy) and Group B with systemic chemoreduction and focal therapy. Outcome measures were efficacy and safety of treatment, risk factors for treatment failure, regression patterns, and factors predictive of regression patterns. Results: Of 119 eyes (216 tumors), 14 (11.8%) were Group A and 105 (88.2%) were Group B eyes. The mean follow‑up was 22.6 months. Tumor control was achieved in 111/119 eyes (93.3% overall, 100% Group A, 92.4% Group B). Eight Group B eyes (6.7%) had treatment failure. No serious systemic side‑effects were noted. Risk factors for failure included larger tumors (P = 0.001) and proximity to posterior pole (P = 0.014). Regression patterns were Type 4 (50.2%), Type 3 (31.7%), Type 1 (11.1%), and Type 2 (7%). Factors predictive of Type 4 regression were smaller tumors, anterior location, younger age; Type 3 regression was associated with larger tumors, macular location, and older age. Conclusions: Systemic chemoreduction and focal therapy provided effective tumor control in Indian children. Factors predictive of regression patterns included age, tumor size and its location, and the modality of treatment.

Revised IAP Growth Charts for Height, Weight and Body Mass Index for 5- to 18-year-old Indian Children.

Justification: The need to revise Indian Academy of Pediatrics (IAP) growth charts for 5- to 18-year-old Indian children and adolescents was felt as India is in nutrition transition and previous IAP charts are based on data which are over two decades old. Process: The Growth Chart Committee was formed by IAP in January 2014 to design revised growth charts. Consultative meeting was held in November 2014 in Mumbai. Studies performed on Indian children’s growth, nutritional assessment and anthropometry from upper and middle socioeconomic classes in last decade were identified. Committee contacted 13 study groups; total number of children in the age group of 5 to 18 years were 87022 (54086 boys). Data from fourteen cities (Agartala, Ahmadabad, Chandigarh, Chennai, Delhi, Hyderabad, Kochi, Kolkata, Madurai, Mumbai, Mysore, Pune, Raipur and Surat) in India were collated. Data of children with weight for height Z scores >2 SD were removed from analyses. Data on 33148 children (18170 males, 14978 females) were used to construct growth charts using Cole’s LMS method. Objectives: To construct revised IAP growth charts for 5-18 year old Indian children based on collated national data from published studies performed on apparently healthy children and adolescents in the last 10 years. Recommendations: The IAP growth chart committee recommends these revised growth charts for height, weight and body mass index (BMI) for assessment of growth of 5-18 year old Indian children to replace the previous IAP charts; rest of the recommendations for monitoring height and weight remain as per the IAP guidelines published in 2007. To define overweight and obesity in children from 5-18 years of age, adult equivalent of 23 and 27 cut-offs presented in BMI charts may be used. IAP recommends use of WHO standards for growth assessment of children below 5 years of age.

Modulatory activity of a polyphenolic fraction of Cinnamomum zeylanicum L. bark on multiple arms of immunity in normal and immunocompromised mice.

To evaluate immunomodulatory activity of polyphenolic fraction of Cinnamomum zeylanicumbark (PP-CZ) against infection-related conditions using normal and immune-compromised mice. The normal and cyclophosphamide (CYP)-induced immune-compromised mice were sensitized with SRBCs and PP-CZ (10, 25, and 50 mg/kg, p.o.) was administered orally for 7 days. The haemagglutinin (HA) antibody titres (primary and secondary) and delayed type hypersensitivity (DTH) response was measured at 7- and 14-days postimmunization, respectively. In separate experiments, effects of PP-CZ on numbers of resident peritoneal macrophages in peripheral blood mononuclear cell (PBMC), against host resistance (E coli-induced abdominal sepsis) and phagocytic activity against Candida albicans were evaluated in mice. PP-CZ had shown a have beneficial effects on multiple arms of theimmune system in animal models and improves humoral (antibody production), cellular (DTH) and innate (PMN phagocytosis) responses of the immune system, as well as numbers of resident peritoneal macrophages. PP-CZ also showed protection to mice against lethal E. coli abdominal sepsis. PP-CZ demonstrated significant immunomodulatory activity through multiple arms of immunity in normal and infection-related immuno-compromised conditions.

Investigation of the morphology of longus colli among patients with neck pain using ultrasonography – a preliminary study

Objective: Longus colli provides stability to cervical spine during movements. In clinical practice, the clinicians teach exercises to longus colli to manage neck pain. The aim of this study was to investigate differences in thickness or anterior-posterior dimension (APD), shape ratio and contraction ratio of longus colli between subjects with neck pain and healthy controls. Materials and methods: A total of 12 subjects (6 with neck pain and 6 healthy controls) were recruited by predefined selection criteria. Ultrasound imaging of bilateral longus colli was conducted at the level C5-C6. Anterior-posterior dimension (APD) and lateral dimension (LD) were measured using Ultrasonography. Shape ratio (LD/APD) and contraction ratio (APD during contraction/APD during rest) were calculated. Mann-Whitney U test was used to compare the thickness of longus colli between healthy and neck pain subjects. Results and discussion: The results showed that the subjects with neck pain had smaller APD (Mean Rank=4.83, n=6) than healthy subjects (Mean Rank=8.17, n=6), U=16.00, z=-1.601 (corrected for ties), p=0.109, two tailed. Also, shape ratio showed higher values in neck pain subjects (Mean Rank=7.17, n=6) than normal subjects (Mean Rank=5.83, n=6), U=14.00, z=-0.641(corrected for ties) p=0.522, two tailed. In addition, contraction ratio was smaller in neck pain subjects (Mean Rank=4.83, n=6) than those healthy subjects (Mean Rank=8.17, n=6), U=8.00, z=- 1.601(corrected for ties) p=0.109, two tailed. Conclusion: There is a trend of reduced size of longus colli with the median of APD and smaller contraction ratio among patients with neck pain when compared to healthy controls.

The Outcomes of Short Term Inspiratory Muscle Training (IMT) Combined with Chest Physiotherapy in Hospitalized COPD Patients.

Objective: The objective of this study was to identify the outcomes of short term inspiratory muscle training (IMT) combined with chest physiotherapy (CP) on lung function, inspiratory muscle strength, exercise tolerance and quality of life of COPD patients. Materials and Methods: This randomized-controlled trial was conducted at the Terendak Armed Forces Hospital, Melaka. Eighteen hospitalized COPD patients (FEV1 50% to = 80% predicted) were randomized into intervention (IG) and control group (CG). The IG received IMT and CP treatments whilst the CG received only CP for a period of 4 weeks. Assessments of lung function (FEV1/FVC), inspiratory muscle strength (PImax), exercise tolerance (6MWT) and quality of life (SGRQ score) were taken at baseline and after 4 weeks. Results: Analysis showed IG group increased in FEV1/FVC by 19.4%, PImax by 54.7%, 6MWT by 33.2% and quality of life by 52.6% (All, p<0.05). The control group increased in FEV1/FVC by 8.7% (p>0.05), PImax by 15% (p<0.05), 6MWT by 18.9% (p<0.05) and quality of life by 15.6% (p<0.05). Conclusion: The present study has established that by combining inspiratory muscle training (IMT) and chest physiotherapy, provides superior effects on lung function, inspiratory muscle strength, exercise tolerance and quality of life among COPD patients.

Antiulcer effect of Feronia elephantum Correa leaf and bark extract in indomethacin induced albino rats.

In the present study, the gastro protective effect of Feronia elephantum leaves and bark in a model of NSAIDinduced ulcer in rat was analyzed. The lyophilized extract was given by oral gavages (500 mg/kg) three times at 12 hr intervals before administering Indomethacin at 20 mg/kg. Pretreatment with extract significantly decreased the ulcerated area. The volume and acidity of the gastric juice decreased in the pretreated rats. In conclusion, F. elephantum was able to decrease the acidity and increase the mucosal defense in the gastric areas, there by justifying its use as an antiulcerogenic agent.

GC-MS Analysis of Bioactive Components of Aerial parts of Fluggea leucopyrus Willd. (Euphorbiaceae).

The present investigation was carried out to analyze the active constituents present in aerial parts of Fluggea leucopyrus (Euphorbiaceae). Fourteen compounds were identified by Gas Chromatography-Mass Spectrometry (GC-MS) analysis. The prevailing compounds were hexadecanoic acid ethyl ester (46.06%), lupeol (13.62%), vitamin E (8.70%), linoleic acid ethyl ester (5.78%), a-sitosterol (5.66%), 9,12- octadecadienoic acid (Z,Z)-, 2- hydroxy-1- (hydroxymethyl) ethyl ester (3.98%), stigmasterol (3.94%), phytol (2.70%), nonadecane, 2-methyl- (2.27%).

Stimulatory effect of the ethanol extract of Melastoma malabathricum L. (Melastomataceae) leaf on the reproductive system of male albino rats.

Fertility enhancement effect of ethanol extract of leaf of Melastoma malabathricum was observed in male albino rats. The relative weight of the testis and epididymis were increased. The epididymal sperm count, motility and sperm abnormality were increased significantly in treated rats. There was an increase in serum protein, albumin, globulin, urea, creatinine and the activity of liver marker enzymes (SGOT, SGPT and ALP) levels of treated rats. The activities of serum antioxidants (CAT, SOD. GPX, GST and GRD) in leaf extract treated rats were increased. The results of the hormonal assay showed that increased serum levels of LH and testosterone but decreased in the serum levels of FSH and estrogen compared to control. The results of fertility test indicated that the treated adult male rats increased the number of female’s impregnation. In addition, the number of implantations and the number of viable fetuses were also increased. The results of the present study concluded that, ethanol extract of leaf of Melastoma malabathricum enhanced sperm concentration, motility and testosterone which might produce positive result in the male fertility.