A new scoring system to predict the incidence of new onset diabetes after transplantation (NODAT)

Background. We performed this study to develop a new scoring system to stratify different levels of risk of developing new onset diabetes after transplantation (NODAT) in patients who underwent renal transplantation. Many prognostic variables have been previously described but few efforts have been made to group them in order to enhance their individual predictive power. Material and methods. In a first phase, 100 patients were prospectively analysed to determine which factors were significantly associated with the development of NODAT. A risk score ranging from 0 to 10 points was developed using a multivariate analysis. In a second phase, such score was validated in a new sample of 100 patients. Results. BMI ≥ 23.5 kg/m2, age ≥ 38.5 years, fasting blood sugar at 1st post-operative day ≥ 159.5 mg/dL, fasting blood sugar at 5th post-operative day ≥ 122.5 mg/dL and HOMA-IR ≥ 2.5 were found as independent prognostic variables. A clear distinction was shown among categories of low, intermediate and high risk, defined according to the risk score. Conclusion. This new scoring framework is basic and simple to accomplish. It permits a generally excellent stratification of risk of developing NODAT in patients undergoing renal transplantation. They might be separated in three risk stratification cohorts, which could be of help in early identification of NODAT

Changing profile of GAD and IA-2 antibody positivity in Indian children with recently diagnosed type 1 diabetes mellitus

Introduction. Published literature on type 1 diabetes (T1DM) patients from India suggests that a substantial number of them are negative to GAD 65 and IA-2 an­tibodies. Antibody positivity rates have been linked to dietary and socio-economic factors and more recently, to changes in the enterobiome. Our anecdotal evidence indicated that antibody positivity rates among newly diagnosed T1DM children were rising. In this presen­tation we have formally collated our data on these antibodies, a first, we believe, in the Indian pediatric population. Material and methods. T1DM was diagnosed by stand­ard clinical criteria advocated by American Diabetes Association including in all patients, the presence of diabetic ketoacidosis (DKA). We used plasma blood glucose rather than A1C to diagnose the acute onset of type 1 diabetes in individuals with symptoms of hy­perglycemia. All patients with this diagnosis had GAD (glutamic acid decarboxylase) and IA-2 (insulinoma antigen 2) antibodies measured as a routine procedure from 2007. Data on patients between the ages of 1 and 16 years as on 31st August 2016 were collected for this study. The antibodies were measured by standard RIA kits from the same manufacturer and performed in the endocrinology laboratory of one of the institutions. Results. We included 694 T1DM cases from 2007 till 2016, out of which 296 were antibody positive. A total of 172 were GAD antibody positive, 62 were IA-2 anti­body positive and 90 exhibited dual antibody positivity (GAD positive + IA-2 positive). The chi-square test for trend analysis showed a significant rising trend for IA-2 antibody alone positive (p < 0.001, chi-square for trend = 17.437, df = 1) and either antibody positive percentages (p < 0.001, chi-square for trend = 22.71, df = 1), but not in the GAD antibody positivity (p = 0.059, chi-square for trend = 3.567, df = 1) and in dual antibody positive percentages (p = 0.486, chi-square for trend = 0.485, df = 1) over a period of 9 years i.e. from 2007 to 2016. Conclusion. Antibody positivity rates in recently di­agnosed T1DM children have changed fairly rapidly over the last nine years. This surge in autoimmunity may also be a significant contributing factor towards the recent increased incidence of T1DM in India

Insulin Initiation with Insulin Degludec/Insulin Aspart versus Insulin Glargine in Oral Antidiabetic Drugs Failure Patients with Type 2 Diabetes Mellitus: A Real-World Study from India

Context: Oral antidiabetic drug (OAD) failure is an indication for starting insulin therapy, but there is still a dilemma as to whether basal insulin or a premixed/co-formulation analog should be the choice. Aim: To compare the safety and efficacy of once daily (OD) insulin degludec/insulin aspart (IDegAsp) to OD insulin glargine (IGlar U100) in insulin-naïve Indian subjects with type 2 diabetes mellitus (T2DM), inadequately controlled with OADs alone. Setting and design: Retrospective study. Methods and material: Data was retrieved from the author’s clinic database of OAD failure patients (18-80 years), who were started either with (IGlar U100, n = 120) or IDegAsp (n = 89) OD over and above the standard of care. Data of fasting plasma glucose (FPG), postprandial plasma glucose (PPG) and glycated hemoglobin (HbA1c) from baseline and at last follow-up visits were collected. Statistical analysis used: Baseline characteristics and change in study parameters during the follow-up period were computed between two groups (IGlar U100 vs. IDegAsp) by unpaired t-test and paired t-test, respectively. ANCOVA test was used to compute percentage reduction in body weight, body mass index (BMI), FPG, PPG and HbA1c in between two groups (IGlar U100 vs. IDegAsp). Results: IDegAsp caused a significantly greater reduction in FPG, PPG and HbA1c as compared to the IGlar U100 arm. There was no significant difference in the proportion of patients with hypoglycemia between IDegAsp and IGlar U100 groups (p = 0.208). No episodes of severe hypoglycemia were reported. Conclusion: Comparison of IDegAsp and IGlar U100 OD in T2DM patients indicated that both were relatively safe but the former controlled FPG and PPG levels more effectively

Insulin Initiation with Insulin Degludec/Insulin Aspart versus Insulin Glargine in Oral Antidiabetic Drugs Failure Patients with Type 2 Diabetes Mellitus: A Real-World Study from India

Context: Oral antidiabetic drug (OAD) failure is an indication for starting insulin therapy, but there is still a dilemma as to whether basal insulin or a premixed/co-formulation analog should be the choice. Aim: To compare the safety and efficacy of once daily (OD) insulin degludec/insulin aspart (IDegAsp) to OD insulin glargine (IGlar U100) in insulin-naïve Indian subjects with type 2 diabetes mellitus (T2DM), inadequately controlled with OADs alone. Setting and design: Retrospective study. Methods and material: Data was retrieved from the author’s clinic database of OAD failure patients (18-80 years), who were started either with (IGlar U100, n = 120) or IDegAsp (n = 89) OD over and above the standard of care. Data of fasting plasma glucose (FPG), postprandial plasma glucose (PPG) and glycated hemoglobin (HbA1c) from baseline and at last follow-up visits were collected. Statistical analysis used: Baseline characteristics and change in study parameters during the follow-up period were computed between two groups (IGlar U100 vs. IDegAsp) by unpaired t-test and paired t-test, respectively. ANCOVA test was used to compute percentage reduction in body weight, body mass index (BMI), FPG, PPG and HbA1c in between two groups (IGlar U100 vs. IDegAsp). Results: IDegAsp caused a significantly greater reduction in FPG, PPG and HbA1c as compared to the IGlar U100 arm. There was no significant difference in the proportion of patients with hypoglycemia between IDegAsp and IGlar U100 groups (p = 0.208). No episodes of severe hypoglycemia were reported. Conclusion: Comparison of IDegAsp and IGlar U100 OD in T2DM patients indicated that both were relatively safe but the former controlled FPG and PPG levels more effectively

The Pyramid of Transgender Health Therapeutics

Transgender care needs a multidisciplinary team approach. The awareness about transgender health has increased over the past few years in India. The pyramid of transgender health helps to demystify the care of transgender individuals. The 7 S\u27s of lifestyle modification need to be followed in the routine clinical care of transgender individuals. The individuals also need psychological care and support, metabolic and medical care, endocrine management, and later surgery in some cases. The policy makers can use the pyramid to decide about financial help to the community for their holistic care. The physicians involved in the care of transgender individuals can also take guidance about comprehensive care and management of transgender and gender diverse individuals

A Practitioner’s Toolkit for Insulin Motivation in Adults with Type 1 and Type 2 Diabetes Mellitus: Evidence-Based Recommendations from an International Expert Panel

Aim To develop an evidence-based expert group opinion on the role of insulin motivation to overcome insulin distress during different stages of insulin therapy and to propose a practitioner’s toolkit for insulin motivation in the management of diabetes mellitus (DM). Background Insulin distress, an emotional response of the patient to the suggested use of insulin, acts as a major barrier to insulin therapy in the management of DM. Addressing patient-, physician- and drug-related factors is important to overcome insulin distress. Strengthening of communication between physicians and patients with diabetes and enhancing the patients' coping skills are prerequisites to create a sense of comfort with the use of insulin. Insulin motivation is key to achieving targeted goals in diabetes care. A group of endocrinologists came together at an international meeting held in India to develop tool kits that would aid a practitioner in implementing insulin motivation strategies at different stages of the journey through insulin therapy, including pre-initiation, initiation, titration and intensification. During the meeting, emphasis was placed on the challenges and limitations faced by both physicians and patients with diabetes during each stage of the journey through insulinization. Review Results After review of evidence and discussions, the expert group provided recommendations on strategies for improved insulin acceptance, empowering behavior change in patients with DM, approaches for motivating patients to initiate and maintain insulin therapy and best practices for insulin motivation at the pre-initiation, initiation, titration and intensification stages of insulin therapy. Conclusions In the management of DM, bringing in positive behavioral change by motivating the patient to improve treatment adherence helps overcome insulin distress and achieve treatment goals

Diabetes is predominantly an intestinal disease

Diabetes mellitus (DM) is a chronic, progressive, medically incurable disease and is poorly controlled in a vast majority, in spite of tremendous advancements in pharmacotherapy. Altered gut microbiome can predict diabetes. There is strong and consistent evidence regarding role of the gut and many gut hormones like incretins in energy and glucose homeostasis. Incretin group of agents including glucagon-like peptide (GLP-1) receptor agonists and dipeptidyl peptidase IV (DPP-IV) inhibitors are efficacious therapeutic agents in diabetes treatment. A growing body of evidence, however, appears to indicate that type 2 DM (T2DM) may be an operable intestinal illness-a novel revolutionary concept about an old disease. This may facilitate research that can better clarify our understanding of the etiology of the disease and provide a new opportunity to develop new and more effective therapies. Future research should focus on an approach to bypass the bypass, that is, to replace the gastric bypass by equally effective but less invasive treatments for majority of diabetics

Advanced diabetic nephropathy with “Clean” eyes: An extreme phenotype

Introduction: It is generally accepted that renal and eye changes in diabetes are concordant. There are however a fair number of patients with diabetes who have end-stage renal disease (ESRD) without any of the typical eye changes. The present study highlights the discordance between retinopathy and nephropathy and describes a series of patients of long-standing diabetes undergoing renal transplant who had little or no evidence of retinopathy. Methods: All patients with ESRD undergoing renal transplants underwent comprehensive fundus evaluation including dilated indirect ophthalmoscopy, slit lamp biomicroscopy, and fundus photography. The patients' age, gender, physical parameters (body mass index and blood pressure), duration of diabetes, glycosylated hemoglobin (HbA1c), albumin creatinine ratio, and presence of diabetic peripheral neuropathy (DPN) were determined. Renal histopathology was reviewed, if available. Results: Five patients with diabetic nephropathy (DN) underwent renal transplant and had no evidence of diabetic retinopathy (DR) or up to two microaneurysms per fundus. All the patients were between 50 and 65 (mean ± standard deviation – 58.6 ± 4.67) years of age. The mean duration of diabetes was 16 ± 2.91 years. All had poor glycemic control with a mean HbA1c of 9.2 ± 0.837%. All had hypertension, macroalbuminuria, and DPN. Conclusion: There is a well-recognized association between retinopathy and nephropathy, in which nephropathy without retinopathy is rare but retinopathy without nephropathy is common. We have identified a subset of patients with kidney disease of sufficient severity to warrant renal transplant but who are protected from retinopathy. It is possible that there is an extreme phenotype of DN patients with unaffected eyes who carry genes protecting against DR

Childhood obesity: Determinants, evaluation, and prevention

Childhood obesity is a grave issue, which needs to be addressed urgently because it leads to several medical and psychosocial problems in children. High prevalence is being increasingly reported in children from developing countries as well. The combination of our genetic propensity to store fat, the ready availability of calorie dense foods, and sedentary lifestyle promotes overweight. The child′s food environment at home and parental obesity are strong determinants. Urban poor in developed countries and urban rich in developing countries are both at risk. In developing countries, a number of beliefs passed down over generations are other important determinants. Evaluation includes assessing the child′s lifestyle, excluding weight-promoting medication history; poor linear growth needs endocrine evaluation; genetic syndromes should be considered if there are clinical pointers. Overweight children should be evaluated for hypertension, dyslipidemia, T2DM, and NAFLD. Therapeutic lifestyle changes targeting food habits and physical activity through parental participation and social support are the cornerstones of preventing childhood obesity. Active travel and play by making the built environment more accessible, ban on ′junk′ food advertising, and effective health education through active participation of clinicians, school systems, and the media will go a long way in reversing anticipated trends in childhood obesity