Frequency of foot ulcers in people with type 2 diabetes, presenting to specialist diabetes clinic at a Tertiary Care Hospital, Lahore, Pakistan.

BACKGROUND: Diabetic foot ulceration is a serious limb-threatening complication of diabetes. It is the common cause of hospital admissions and amputations. The objective of the study was to determine the prevalence of diabetic foot ulcers (DFU) and its association with age, gender, duration of diabetes, peripheral neuropathy (PN), peripheral arterial disease (PAD) and HbA1c. METHODS: A total of 1940 people (≥ 30 years of age) with type 2 diabetes coming to the Sakina Institute of Diabetes and Endocrine Research (specialist diabetes clinic) at Shalamar Hospital, Lahore, Pakistan, were recruited over a period of 1 year from January 2016 to January 2017. The foot ulcers were identified according to the University of Texas classification. PN was assessed by biothesiometer and PAD by ankle-brachial index (< 0.9). Body weight, height, body mass index (BMI), HbA1c and duration of diabetes were recorded. RESULTS: The prevalence of DFU was 7.02%, of which 4.5% of the ulcers were on the planter and 2.6% on the dorsal surface of the foot; 8.5% of the persons had bilateral foot ulcers and 0.4% subjects had Charcot deformity. There was significant association of foot ulcers with age, duration of diabetes, HbA1c, PN and PAD, whereas no association was observed with gender and BMI. PN and PAD were observed in 26.3 and 6.68% of people with diabetes respectively. Neuropathic ulcers and neuro-ischemic ulcers were identified in 74 and 19% of the study population. Logistic regression analysis revealed significant odds ratio for peripheral neuropathy 23.9 (95% confidence interval (5.41-105.6). CONCLUSIONS: Peripheral neuropathy is the commonest cause of foot ulcers. An optimum control of blood glucose to prevent neuropathy and regular feet examination of every person with diabetes may go a long way in preventing foot ulceration.

Evidence of male hypogonadism at an early age as a familial risk of type 2 diabetes.

OBJECTIVE: Previous investigations provide evidence of an association of hypogonadism with type 2 diabetes in men, and low testosterone levels have been regarded a risk factor for the disease. Since a strong genetic predisposition to type 2 diabetes has been demonstrated, here we investigate a possible tendency towards hypogonadism in young male offspring of diabetic parents. MATERIAL AND METHODS: The study compares 32 male offspring of diabetic parents with 31 male offspring of nondiabetic parents matched by age. The subjects comprised boys (9-17 years) and young adults (19-25 years). Anthropomorphic measurements were made in all subjects. Fasting blood samples were analyzed for glucose and serum concentrations of testosterone (T), sex hormone-binding globulin (SHBG), luteinizing hormone (LH), insulin and leptin were measured by ELISA. Free testosterone (FT) was calculated using T and SHBG levels. RESULTS: Serum T, FT and bioavailable T (BAT) levels in offspring of diabetic parents were significantly lower than those of offspring of nondiabetic parents across all age groups. Mean serum LH levels were also lower in offspring of diabetic parents compared to the controls. Although LH levels in young adults with diabetic parents, tended to be lower than those of age-matched controls but the difference was not statistically significant. Serum insulin and leptin, and insulin resistance measured by HOMA-IR were significantly raised in older offspring of diabetic parents but were within the normal range. CONCLUSION: Whereas hypogonadism was the only indicator of a possible predisposition to metabolic dysfunction in peripubertal children of diabetic parents, a significant change in other metabolic markers becomes apparent at a more advanced age.

Role of leptin G-2548A polymorphism in age- and gender-specific development of obesity.

Leptin is involved in the regulation of food intake and energy expenditure, and therefore, is central to adipositysensing pathway. We examined the relationship of the leptin G-2548A polymorphism with obesity and obesityrelated anthropometric and metabolic parameters in a total of 394 (239 obese and 155 non-obese) subjects between 5 and 45 years of age. Body weight, height, waist circumference (WC), hip circumference (HC) and blood pressure (BP) were measured. Body mass index (BMI) and waist-to-hip ratio (WHR) were calculated. Levels of fasting blood glucose (FBG), insulin, leptin and leptin receptor were determined, and homeostasis model assessment of insulin resistance (HOMA-IR) was calculated. Genotyping was carried out by polymerase chain reaction-restriction fragment length polymorphism (PCR-RFLP). The LEP G-2548A polymorphism showed association with obesity in children and adolescents (less than or equal to 18 years of age) but not in adults. However, analysis by gender stratification revealed association with obesity in girls only. In addition, G-2548A polymorphism showed association with BMI, WC, HC, fasting blood glucose and serum leptin levels. This suggests that G-2548A polymorphism may influence the susceptibility to metabolic disturbances and obesity at an early life. Further investigation with a larger sample size is required to validate the effect of LEP G-2548A polymorphism in obese Pakistani girls.

Charcot osteoarthropathy in type 2 diabetes persons presenting to specialist diabetes clinic at a tertiary care hospital.

BACKGROUND: Charcot osteoarthropathy or charcot foot is a rare, chronic, non-communicable condition of bones and joints which may results into severe deformity and more prone to develop ulcers possibly leading to amputation. The purpose of this study was to determine the prevalence of Charcot osteoarthropathy and its association with age, BMI, gender, duration of diabetes, HBA1c and peripheral neuropathy. METHODS: A total of 1931 subjects with type 2 diabetes having mean age 50.72 ± 10.66 years presenting in a specialist diabetes clinic at shalamar hospital, Lahore, Pakistan were enrolled. The diagnosis of Charcot osteoarthropathy was made by examination of both dorsal and plantar surfaces of foot for swelling, erythema, increase in temperature and any musculoskeletal deformity which was later confirmed by radiographs. Assessment of neuropathy was carried out by checking the sense of pressure, joint position and vibration. BMI (Body Mass Index), fasting blood glucose (FBG) and HbA1C were determined. RESULTS: In all subjects including male 704 (36.45 %) and female 1227 (63.55 %), 0.4 % subjects had charcot deformity, while 0.2 %, 0.15 % and 0.05 % subjects having right, left and bilateral deformity respectively. Bilaterally symmetrical neuropathy was diagnosed in 25.4 % in subjects. There was a significant association (p < 0.05) of deformity with duration of diabetes, HbA1C and neuropathy, however no significant association (p > 0.05) was found with age, BMI, weight, height and gender. CONCLUSION: There is a need to have a special care of persons with diabetes regarding blood glucose control and development of peripheral neuropathy. Early identification and management of risk factors may prevent the occurrence of charcot deformity. Patients must be educated about the foot care.

Lack of association of the NPAS2 gene Ala394Thr polymorphism (rs2305160:G>A) with risk of chronic lymphocytic leukemia.

BACKGROUND: NPAS2 is a product of the circadian clock gene. It acts as a putative tumor suppressor by playing an important role in DNA damage responses, cell cycle control and apoptosis. Chronic lymphocytic leukemia (CLL) appears to be an apoptosis related disorder and alteration in the NPAS2 gene might therefore be directly involved in the etiology of CLL. Here, the Ala394Thr polymorphism (rs2305160:G>A) in the NPAS2 gene was genotyped and melatonin concentrations were measured in a total of seventy-four individuals, including thirty-seven CLL cases and an equal number of age- and sex-matched healthy controls in order to examine the effect of NPAS2 polymorphism and melatonin concentrations on CLL risk in a Pakistani population. MATERIALS AND METHODS: Genotyping of rs2305160:G>A polymorphism at NPAS2 locus was carried out by amplification refractory mutation system-polymerase chain reaction (ARMS-PCR). Melatonin concentrations were determined by enzyme linked immunosorbent assay (ELISA). Statistical analysis was performed using Statistical Package for Social Sciences software. RESULTS: Our results demonstrated no association of the variant Thr genotypes (Ala/ Thr and Thr/Thr) with risk of CLL. Similarly, no association of rs2305160 with CLL was observed in either females or males after stratification of study population on a gender basis. Moreover, when the subjects with CLL were further stratified into shift-workers and non-shift-workers, no association of rs2305160 with CLL was seen in either case. However, significantly low serum melatonin levels were observed in CLL patients as compared to healthy subjects (p<0.05). Also, lower melatonin levels were seen in shift-workers as compared to non-shift-workers (p<0.05). There was no significant difference (p>0.05) in the melatonin levels across NPAS2 genotypes in all subjects, subjects with CLL who were either shift workers or non-shift-workers. General Linear Model (GLM) univariate analysis revealed no significant association (p>0.05) of the rs2305160 polymorphism of the NPAS2 gene with melatonin levels in any of the groups. CONCLUSIONS: While low melatonin levels and shift-work can be considered as one of the risk factors for CLL, the NPAS2 rs2305160 polymorphism does not appear to have any association with risk of CLL in our Pakistani population.

Prostate cancer: leading and misleading routes to TRAIL of death.

Prostate cancer is a multifaceted disease that arises because of misrepresentation of linear and integrated signaling cascades that regulate gene network in normal and cancer cells. Programmed cell death is modulated by intracellular regulators within each cell and various lines of evidence suggest that there is under- expression and over-expression of pro-apoptotic and anti-apoptotic gene subsets respectively. Apoptosis is a response to the cellular microenvironment, and the cell microenvironment can be regulated by multiple signaling cascades at a higher organizational level by suppressing survival signals notably at genetic, epigenetic, transcriptional and post-transcriptional level. Unquestionably, drug-discovery approaches over the last decade aiming at neutralizing anti-apoptotic proteins, over-expressing pro-apoptotic proteins and enhancing the cell surface appearance of TRAIL receptors have revolutionized our current information about inducing and maximizing TRAIL mediated signaling in resistant prostate cancer phenotype. In this mini-review we outline outstanding developments in the field of prostate cancer that have played a role in understanding the underlying mechanisms that control TRAIL mediated apoptosis in prostate cancer cells, which may be helpful in the development of cancer therapies based on the apoptotic pathway.

Deregulated expression of circadian clock and clock-controlled cell cycle genes in chronic lymphocytic leukemia.

Circadian rhythms are endogenous and self-sustained oscillations of multiple biological processes with approximately 24-h rhythmicity. Circadian genes and their protein products constitute the molecular components of the circadian oscillator that form positive/negative feedback loops and generate circadian rhythms. The circadian regulation extends from core clock genes to various clock-controlled genes that include various cell cycle genes. Aberrant expression of circadian clock genes, therefore, may lead to genomic instability and accelerated cellular proliferation potentially promoting carcinogenesis. The current study encompasses the investigation of simultaneous expression of four circadian clock genes (Bmal1, Clock, Per1 and Per2) and three clock-controlled cell cycle genes (Myc, Cyclin D1 and Wee1) at mRNA level and determination of serum melatonin levels in peripheral blood samples of 37 CLL (chronic lymphocytic leukemia) patients and equal number of age- and sex-matched healthy controls in order to indicate association between deregulated circadian clock and manifestation of CLL. Results showed significantly down-regulated expression of Bmal1, Per1, Per2 and Wee1 and significantly up-regulated expression of Myc and Cyclin D1 (P < 0.0001) in CLL patients as compared to healthy controls. When expression of these genes was compared between shift-workers and non-shift-workers within the CLL group, the expression was found more aberrant in shift-workers as compared to non-shift-workers. However, this difference was found statistically significant for Myc and Cyclin D1 only (P < 0.05). Serum melatonin levels were found significantly low (P < 0.0001) in CLL subjects as compared to healthy controls whereas melatonin levels were found still lower in shift-workers as compared to non-shift-workers within CLL group (P < 0.01). Our results suggest that aberrant expression of circadian clock genes can lead to aberrant expression of their downstream targets that are involved in cell proliferation and apoptosis and hence may result in manifestation of CLL. Moreover, shift-work and low melatonin levels may also contribute in etiology of CLL by further perturbing of circadian clock.

Common variant of FTO gene, rs9939609, and obesity in Pakistani females.

Numerous studies confirmed the association of FTO (fat mass and obesity associated gene) common variant, rs9939609, with obesity in European populations. However, studies in Asian populations revealed conflicting results. We examined the association of rs9939609 variant of FTO gene with obesity and obesity-related anthropometric and metabolic parameters in Pakistani population. Body weight, height, waist circumference, hip circumference, and blood pressure (BP) were measured. BMI and waist-to-hip ratio (WHR) were calculated. Levels of fasting blood glucose (FBG), insulin, leptin, and leptin receptors were measured by enzyme linked immunosorbent assay (ELISA), and homeostasis model assessment of insulin resistance (HOMA-IR) was calculated. The results showed association of FTO gene, rs9939609, with obesity in females (>18 years of age). FTO minor allele increased the risk of obesity by 2.8 times (95% CI = 1.3-6.0) in females. This allele showed association with body weight, BMI, waist circumference, hip circumference, WHR, BP, plasma FBG levels, HOMA-IR, plasma insulin levels, and plasma leptin levels. In conclusion, FTO gene, rs9939609, is associated with BMI and risk of obesity in adult Pakistani females. Association of rs9939609 variant with higher FBG, plasma insulin, and leptin levels indicates that this polymorphism may disturb the metabolism in adult females and predispose them to obesity and type 2 diabetes. However, the above-mentioned findings were not seen in children or males.

Leptin deficiency and leptin gene mutations in obese children from Pakistan.

BACKGROUND: Congenital leptin deficiency is a rare human genetic condition clinically characterized by hyperphagia and acute weight gain usually during the first postnatal year. The worldwide data on this disorder includes only 14 cases and four pathogenic mutations have been reported in the leptin gene. STUDY OBJECTIVE: The objectives of this study were to measure serum leptin levels in obese children and to detect leptin gene mutations in those found to be leptin deficient. PATIENTS AND RESULTS: A total of 25 obese children were recruited for the study. Leptin deficiency was detected in nine of them. Leptin gene sequencing identified mutations in homozygous state in all the leptin deficient children. Two cases carried novel mutations (c.481_482delCT and c.104_106delTCA) and each of the remaining seven the previously reported frameshift mutation (c.398delG). CONCLUSION: The results suggest that leptin deficiency caused by mutations in the leptin gene may frequently be seen in obese Pakistani children from Central Punjab.

Male offspring of both diabetic parents have higher insulin resistance and serum leptin levels compared to those with one diabetic parent.

OBJECTIVE: We studied the influence of positive family history (FH) of type 2 diabetes mellitus (T2DM) in male offspring using multiple metabolic and endocrine parameters in order to assess whether one or more of these parameters can be used as indicators for T2DM development later in life. DESIGN: Fifty male subjects with one diabetic parent (ODP) and thirty with both diabetic parents (BDP) were compared with fifty, age-matched, offspring of non-diabetic parents (NDP). Body weight, height, BMI and blood pressure were determined in all subjects. Fasting blood samples were analyzed for glucose, HbA1-c, insulin, C-peptide, leptin and lipid profile. A 2h oral glucose tolerance test (2h-OGTT) was also carried out. Insulin resistance (IR) was assessed by HOMA-IR index. RESULTS: Mean serum levels of glucose (fasting and following 2h-OGTT), C-peptide and leptin in male offspring of diabetic parents were higher than in male offspring of NDP. Mean fasting serum insulin and triglycerides were higher in boys of BDP compared to those of ODP and NDP. HOMA-IR was markedly high in ODP and BDP groups when compared with the NDP group. No stastically significant difference was observed in the HbA1-c values between any of the groups studied. CONCLUSIONS: These results indicate that T2DM associated risk factors are more vigorously expressed in male offspring with a history of diabetes in both parents, thus underscoring the importance of genetic determinants in the onset of T2DM. The results of this study may provide useful indicators of potential susceptibility to T2DM at an early stage of life.