Metabolic Syndrome and Its association with macro vascular complications of Diabetes Mellitus among women in an urban poor population: A Cross Sectional study

OBJECTIVES : The study aims to assess the association between metabolic syndrome and macrovascular complications of diabetes mellitus among women in an urban poor population. METHODS : In this cross sectional study, newly or previously diagnosed female diabetic patients above the age of 30 years were recruited to the study from the out patient department of the Low Cost Effective Care Unit, a primary heath centre affiliated to the Christian Medical College and Hospital, catering to the urban poor population of Vellore city. All patients were screened for the metabolic syndrome according to the International Diabetes Federation criteria and evaluated for macrovascular complications of Diabetes Mellitus namely, ischemic stroke, ischemic heart disease and peripheral vascular disease. Data was analysed using Chi square test to determine the association between metabolic syndrome as a risk factor for prevalent macrovascular complications of Diabetes Mellitus. RESULTS : 75.3% of diabetic patients fulfilled the IDF criteria for the metabolic syndrome. The study showed a trend towards significant association between metabolic syndrome and macrovascular complications of diabetes mellitus with the overall prevalence of macro vascular complications being 60.3 % in diabetics with the metabolic syndrome and 47.4 % in those without the syndrome.( OR: 1.6, 95% CI :0.6 – 4.8 , p = 0.321 ) These results suggest the possibility of using the metabolic syndrome as a cost effective clinical tool in risk stratification in diabetics to aid in reducing the burden of Diabetes and its macro vascular complications in the urban poor population. CONCLUSIONS : Of the 77 female diabetics above the age of 30 years enrolled in the study, 58 patients (75.3%) satisfied the IDF criteria for metabolic syndrome, namely a waist circumference of more than or equal to 80 cm along with one of the following three criteria, HDL 150 mg/dl or use of statins or a BP>/=130/80 mm Hg or use of antihypertensives. The high prevalence of the metabolic syndrome is consistent with published reports from South India reporting a prevalence of 83.3% in women. (34) in an urban population in Chennai. The criteria met by patients in decreasing order of frequency was low HDL levels in 87.9% of patients, BP>/=130/80 mg Hg or use of anti hypertensives in 63.8% and elevated TGL levels in 46.6% of patients. These results corroborate with the evidence that the Indian population have lower HDL‟s when compared to their Caucasian counterparts. The study showed a trend towards significant association between metabolic syndrome and macro vascular complications of Diabetes Mellitus, namely, ischemic heart disease or peripheral vascular disease. The overall prevalence of macro vascular complications ( both ischemic heart disease and peripheral vascular disease ) was 60.3 % in diabetics with the metabolic syndrome and 47.4 % in those without the syndrome( OR : 1.69, 95% CI 0.6 – 4.8, p = 0.321 ). The prevalence of Ischemic heart disease was 29.3% in diabetics with the metabolic syndrome and 10.5 % in those without the syndrome ( OR : 3.52, 95% CI 0.7 – 16.9, p = 0.099) .The prevalence of peripheral vascular disease was 50% in diabetics with the metabolic syndrome and 36.8 % in those without the syndrome ( OR: 1.71, 95% CI 0.6 – 5.0, p = 0.318 ). The cross sectional study provided a glimpse into the health parameters of women with Type 2 diabetes mellitus ,belonging to the urban poor population of Vellore, with particular reference to the prevalence of the metabolic syndrome and macrovascular complications of diabetes in this group. The study reinforces the observation that the epidemiology of chronic diseases like Diabetes Mellitus in rural India is changing. The high prevalence of the metabolic syndrome as well as macrovascular complications of diabetes among diabetics in the urban rural population has great implications on the health statistics of the urban poor. The strength of association between metabolic syndrome and macrovascular complications in diabetics as shown in this study could support the clinical utility of the metabolic syndrome as a simple risk stratification tool in early identification and targeted management strategies aiding in reducing the burden of Diabetes Mellitus and its macro vascular complications on the urban poor population of India

Thiamine deficiency disorders: a clinical perspective

Thiamine is an essential water-soluble vitamin that plays an important role in energy metabolism. Thiamine deficiency presents many challenges to clinicians, in part due to the broad clinical spectrum, referred to as thiamine deficiency disorders (TDDs), affecting the metabolic, neurologic, cardiovascular, respiratory, gastrointestinal, and musculoskeletal systems. Concurrent illnesses and overlapping signs and symptoms with other disorders can further complicate this. As such, TDDs are frequently misdiagnosed and treatment opportunities missed, with fatal consequences or permanent neurologic sequelae. In the absence of specific diagnostic tests, a low threshold of clinical suspicion and early therapeutic thiamine is currently the best approach. Even in severe cases, rapid clinical improvement can occur within hours or days, with neurological involvement possibly requiring higher doses and a longer recovery time. Active research aims to help better identify patients with thiamine-responsive disorders and future research is needed to determine effective dosing regimens for the various clinical presentations of TDDs. Understanding the clinical diagnosis and global burden of thiamine deficiency will help to implement national surveillance and population-level prevention programs, with education to sensitize clinicians to TDDs. With concerted effort, the morbidity and mortality related to thiamine deficiency can be reduced

Mortality from gastrointestinal congenital anomalies at 264 hospitals in 74 low-income, middle-income, and high-income countries: a multicentre, international, prospective cohort study

Summary Background Congenital anomalies are the fifth leading cause of mortality in children younger than 5 years globally. Many gastrointestinal congenital anomalies are fatal without timely access to neonatal surgical care, but few studies have been done on these conditions in low-income and middle-income countries (LMICs). We compared outcomes of the seven most common gastrointestinal congenital anomalies in low-income, middle-income, and high-income countries globally, and identified factors associated with mortality. Methods We did a multicentre, international prospective cohort study of patients younger than 16 years, presenting to hospital for the first time with oesophageal atresia, congenital diaphragmatic hernia, intestinal atresia, gastroschisis, exomphalos, anorectal malformation, and Hirschsprung’s disease. Recruitment was of consecutive patients for a minimum of 1 month between October, 2018, and April, 2019. We collected data on patient demographics, clinical status, interventions, and outcomes using the REDCap platform. Patients were followed up for 30 days after primary intervention, or 30 days after admission if they did not receive an intervention. The primary outcome was all-cause, in-hospital mortality for all conditions combined and each condition individually, stratified by country income status. We did a complete case analysis. Findings We included 3849 patients with 3975 study conditions (560 with oesophageal atresia, 448 with congenital diaphragmatic hernia, 681 with intestinal atresia, 453 with gastroschisis, 325 with exomphalos, 991 with anorectal malformation, and 517 with Hirschsprung’s disease) from 264 hospitals (89 in high-income countries, 166 in middleincome countries, and nine in low-income countries) in 74 countries. Of the 3849 patients, 2231 (58·0%) were male. Median gestational age at birth was 38 weeks (IQR 36–39) and median bodyweight at presentation was 2·8 kg (2·3–3·3). Mortality among all patients was 37 (39·8%) of 93 in low-income countries, 583 (20·4%) of 2860 in middle-income countries, and 50 (5·6%) of 896 in high-income countries (p<0·0001 between all country income groups). Gastroschisis had the greatest difference in mortality between country income strata (nine [90·0%] of ten in lowincome countries, 97 [31·9%] of 304 in middle-income countries, and two [1·4%] of 139 in high-income countries; p≤0·0001 between all country income groups). Factors significantly associated with higher mortality for all patients combined included country income status (low-income vs high-income countries, risk ratio 2·78 [95% CI 1·88–4·11], p<0·0001; middle-income vs high-income countries, 2·11 [1·59–2·79], p<0·0001), sepsis at presentation (1·20 [1·04–1·40], p=0·016), higher American Society of Anesthesiologists (ASA) score at primary intervention (ASA 4–5 vs ASA 1–2, 1·82 [1·40–2·35], p<0·0001; ASA 3 vs ASA 1–2, 1·58, [1·30–1·92], p<0·0001]), surgical safety checklist not used (1·39 [1·02–1·90], p=0·035), and ventilation or parenteral nutrition unavailable when needed (ventilation 1·96, [1·41–2·71], p=0·0001; parenteral nutrition 1·35, [1·05–1·74], p=0·018). Administration of parenteral nutrition (0·61, [0·47–0·79], p=0·0002) and use of a peripherally inserted central catheter (0·65 [0·50–0·86], p=0·0024) or percutaneous central line (0·69 [0·48–1·00], p=0·049) were associated with lower mortality. Interpretation Unacceptable differences in mortality exist for gastrointestinal congenital anomalies between lowincome, middle-income, and high-income countries. Improving access to quality neonatal surgical care in LMICs will be vital to achieve Sustainable Development Goal 3.2 of ending preventable deaths in neonates and children younger than 5 years by 2030

Suspected thiamine deficiency presenting as peripheral neuropathy among peripartum women in a hospital in rural Assam: A neglected public health problem

Context: A single case of thiamine deficiency seen in a population reflects a public health problem which is preventable and easily treatable. Aim: This article describes suspected thiamine deficiency among peripartum women in a rural population in Assam presenting as clinically overt peripheral polyneuropathy. Materials and Methods: A retrospective review of the clinical presentation and electrodiagnostic features of peripartum women presenting with peripheral polyneuropathy during a 6-month period, showing improvement in clinical symptoms after administration of thiamine. Results: The clinical profile of 24 peripartum women described is consistent with features of thiamine deficiency presenting with peripheral polyneuropathy and/or cardiopathy. Of the patients followed up after thiamine supplementation, 90% (18) reported either improvement of neurological deficits or improvement in nerve conduction studies after an average of 10 days. Predominant use of polished rice, thiamine poor diet and habitual use of tea, betel nut, and fermented fish are observed to have precipitated the disease. Limitations of the study include the lack of biochemical measurement of tissue thiamine stores in patients. Conclusions: The observations made among peripartum women in this population assumes public health importance as thiamine deficiency is a preventable and easily treatable illness. There is an urgent need to initiate prospective studies including population surveys to conclusively prove the existence of clinically overt thiamine deficiency in this rural population and its likely causes so that effective public health strategies can be formulated to prevent the morbidity associated with this clinical entity

Genomic analysis unveils genome degradation events and gene flux in the emergence and persistence of S. Paratyphi A lineages.

Acknowledgements: We thank Prof. Nicholas Grassly, Imperial College London, for assistance with study design and research proposal development. We gratefully acknowledge Dr. Arif M. Tanmoy, Dr. Senjuti Saha and Dr. Yogesh Hooda (CHRF, Dhaka, Bangladesh) for help with the genotyping analysis. We acknowledge Dr. Duncan Steele, Ms. Megan Carey & Dr. Supriya Kumar, Bill & Melinda Gates Foundation for their technical support throughout the study on behalf of SEFI consortium. We thank all the lab members involved in SEFI reference lab activities, especially Dr. Anushree Amladi, Ms. Baby Abirami S, Ms. Dhanabhagyam K, Ms. Beebi E, Ms. Suganya S, Ms. Udaya and Mr. Ayyanraj N, CMC Vellore implicated in phenotypic testing and stock culture maintenance. We would also like to thank all the members of SEFI consortium, Wellcome Trust Research Laboratory, CMC Vellore and core sequencing teams at the Wellcome Trust Sanger Institute for their contribution to genome sequencing. The authors thank Ms Catherine Trueman (Clinical Pharmacist, CMC Vellore) for helping with language editing.Paratyphoid fever caused by S. Paratyphi A is endemic in parts of South Asia and Southeast Asia. The proportion of enteric fever cases caused by S. Paratyphi A has substantially increased, yet only limited data is available on the population structure and genetic diversity of this serovar. We examined the phylogenetic distribution and evolutionary trajectory of S. Paratyphi A isolates collected as part of the Indian enteric fever surveillance study "Surveillance of Enteric Fever in India (SEFI)." In the study period (2017-2020), S. Paratyphi A comprised 17.6% (441/2503) of total enteric fever cases in India, with the isolates highly susceptible to all the major antibiotics used for treatment except fluoroquinolones. Phylogenetic analysis clustered the global S. Paratyphi A collection into seven lineages (A-G), and the present study isolates were distributed in lineages A, C and F. Our analysis highlights that the genome degradation events and gene acquisitions or losses are key molecular events in the evolution of new S. Paratyphi A lineages/sub-lineages. A total of 10 hypothetically disrupted coding sequences (HDCS) or pseudogenes-forming mutations possibly associated with the emergence of lineages were identified. The pan-genome analysis identified the insertion of P2/PSP3 phage and acquisition of IncX1 plasmid during the selection in 2.3.2/2.3.3 and 1.2.2 genotypes, respectively. We have identified six characteristic missense mutations associated with lipopolysaccharide (LPS) biosynthesis genes of S. Paratyphi A, however, these mutations confer only a low structural impact and possibly have minimal impact on vaccine effectiveness. Since S. Paratyphi A is human-restricted, high levels of genetic drift are not expected unless these bacteria transmit to naive hosts. However, public-health investigation and monitoring by means of genomic surveillance would be constantly needed to avoid S. Paratyphi A serovar becoming a public health threat similar to the S. Typhi of today

List of functional gene inactivation mutations identified between phylogenetic lineages.

List of functional gene inactivation mutations identified between phylogenetic lineages.</p

List of whole genome sequenced isolates collected from the participating sites of the SEFI network.

List of whole genome sequenced isolates collected from the participating sites of the SEFI network.</p

Lineage-defining missense mutations in <i>S</i>. Paratyphi A genomes.

Lineage-defining missense mutations in S. Paratyphi A genomes.</p

Distribution of <i>S</i>. Typhi and <i>S</i>. Paratyphi A isolates collected across the participating sites of the SEFI network.

Distribution of S. Typhi and S. Paratyphi A isolates collected across the participating sites of the SEFI network.</p

List of <i>S</i>. Paratyphi A genomes used in this study with accession IDs and metadata.

List of S. Paratyphi A genomes used in this study with accession IDs and metadata.</p