Frequency and risk factors of diabetic retinopathy in patients with type 2 diabetes presenting at a tertiary care hospital Abstract Objective To evaluate frequency and risk factors of diabetic retinopathy in patients with type 2 diabetes. Methodology This prospective observational study was conducted from January 2017 to June 2017 at the outpatient department of Baqai Institute of Diabetology and Endocrinology (BIDE) and Baqai Medical University a tertiary care diabetes hospital of Karachi, Pakistan. Convenience sampling was done. Demographic, anthropometric, clinical, and biochemical data were collected, and ophthalmic screening was performed by funduscopy at a slit lamp biomicroscopy with the help 90 D fundus lens. Grading of diabetic retinopathy was done according to the modified Early Treatment Diabetic Retinopathy Disease Severity Scale (ETDRS) criteria. Result Retinopathy was present in 17.5% of patients. Non-sight-threatening retinopathy was found in 15.2% and sight-threatening retinopathy was found in 17.6%. In table 4, logistic regression analysis determined the relationship between retinopathy and its possible risk factors. In univariate logistic regression model, Age, poor glycemic control and longer duration of diabetes were found to be significant risk factors for developing retinopathy. In multivariate logistic regression model, duration of diabetes remained significantly associated with the development of retinopathy. Additionally, gender was not significantly associated in univariate analysis but it became significant after adjustment in multivariate model. Conclusion An early screening program reduces the risk of incidence of diabetic retinopathy. Hence, screening of retinopathy should be done once in a year.

The tear VEGF and IGFBP3 in healthy and diabetic retinopathy Abstract Background/ purpose Diabetic retinopathy is an important problem worldwide. The purposes of this study were to measure and analyze VEGF and IGFBP3 level changes in tears of type 2 diabetics with and without retinopathy. Methods In a case–control study, tear samples of 30 diabetes patients without diabetic retinopathy (DNR) were collected, as well as tears of 30 patients with diabetes retinopathy (DR), and 30 healthy subjects without diabetes as the control group by Schirmer’s standard strip, who were matched in terms of age and sex with the other groups. VEGF and IGFBP3 concentration was measured by ELISA method. HbA1c, VEGF, and IGFBP3 were measured in all 3 groups and statistically analyzed. Results The percentage of HbA1C in the DNR group was clearly higher than the control group. Also, there was a significant difference in the percentage of HbA1C between DR and DNR groups. The concentration of VEGF in tears statistically increased in comparison with control (P < 0.05) but the IGFBP3 level did not change. Discussion The VEGF level in tears is clearly linked with the process of DR; however, there wasn’t any significant relationship between the level of IGFBP3 in tears and diabetic retinopathy. It is concluded that VEGF can be used as a noninvasive method for the diagnosis of diabetic retinopathy.

Knowledge, attitude, and practices of fasts in patients with type 2 diabetes among different religions in North India Abstract Background and objectives There is no data regarding knowledge, attitude, and practices (KAP) of fasts in subjects with type 2 diabetes (T2DM) among different religions in India. Study was done to assess KAP regarding fasts among subjects with T2DM from various religions. Material and methods A total of 300 consecutive participants with T2DM (age ≥ 25 years) from 3 diabetes clinics in North India after consent were subjected to predesigned study pro forma. Result A total of 300 subjects participated in the study with 76.3% being Hindus, 11% Muslims, 4.3% Sikhs, and 5.7% from other religions (Christians and Buddhists). Knowledge and attitude regarding fasts in context of diabetes were poor in majority of subjects. 59.7% participants agreed that diabetic patients can fast. 36.3% participants believed that people with poor glycemic control (HbA1c ≥ 10%) can also observe fast. 40.7% believed medicines/insulins are not allowed during fasts because of religious reasons. 46.7% participants were aware of hypoglycemic symptoms. Among Hindus 2 most common fasts were Navratri (observed by 53%) and Karva Chauth (observed by 47.6%). Overall, 66.7% of Muslims observed Ramadan. Only 1.3% of participants discussed with their doctors before observing fast. 51.7% of participants who observed fasts had symptoms suggestive of hypoglycemia during fasts. 60.4% of subjects missed their medications during fasting. 28.8% altered their drug regimen by themselves without doctors’ consultation. 78.5% of participants observed fasts because of social obligations. Hindus were more likely to consult doctors during fasts and experienced comparatively lesser hypoglycemia and hyperglycemia as compared with Muslims and other religions. Women had greater inhibition to disclose about diabetes during fasts, were more likely to consult doctor during fasts, and perceived greater changes in body weight, hypoglycemia, and hyperglycemia during fasts. Conclusion The study showed significant gaps in knowledge and attitude regarding fasts among subjects with T2DM, in spite of fasting being common among all religions. The different nature and duration of different fasts and associated religious practices may contribute to these differences.

Factors associated with silent myocardial ischemia, autonomic or peripheral neuropathies, and survival in diabetes mellitus type 2 patients without cardiovascular symptoms Abstract Introduction Complications from diabetes mellitus (DM) include cardiovascular system, peripheral neuropathy (PN), and autonomic dysfunction (AD). Goal: Assess the association of silent myocardial ischemia, AD, and PN in cardiovascular asymptomatic type 2 diabetics. Methods As part of a multicenter project, 40 patients with type 2 DM were studied, with > 5 years of known disease and a baseline electrocardiogram non suggestive of coronary artery disease. Myocardial SPECT was performed with exercise stress test measuring corrected QT interval (QTc) and heart rate recovery (HRR) post-exercise (abnormal QTc ≥ 450 ms at rest and HRR < 14 beats at the first minute in maximum exercise). After 3 years, it was possible to re-study 32 cases. PN was evaluated with Michigan Neuropathy Screening Instrument (MNSI). Logistic regression analysis was performed to determine associated factors for AD, PN, SI, and survival analysis. Results Thirty-four percent of the group had ischemia in SPECT; QTc was prolonged in 23.3%; 31% fulfilled criteria of PN; and 25% of AD due to HRR alteration. With bivariate and multivariate analyses, associations were observed between lipid, glycemic parameters, ischemia, PN, and AD. The follow-up (mean 119 months) consigned 4 cardiac-related deaths; ischemia, glycemic control parameters, and microalbuminuria had significant value in bivariate analysis. Conclusion In our small sample of asymptomatic cardiovascular type 2 DM patients, myocardial ischemia, glycemic control, and microalbuminuria have influence on survival, requiring a more intensive global therapeutic approach.

Association of Helicobacter pylori infection with metabolic and inflammatory profile in type 2 diabetes mellitus Abstract Objective To evaluate the effect of Helicobacter pylori (H. pylori) infection upon metabolic and inflammatory parameters in type 2 diabetes mellitus (T2DM). Methods A total of 72 patients with T2DM were included in the study. These patients were divided into two groups as H. pylori infection positive or negative. For each patient, the following data were collected: age, gender, duration of diabetics, anti-diabetic treatment, the body mass index (BMI), and laboratory parameters (lipid profile, GLU, HbA1c, HCY, HsCRP, ghrelin, leptin, leukocyte, and platelet counts). Results Totally 47 patients (65.28%) were H. pylori positive and 25 patients (34.72%) were H. pylori negative. Diabetic patients infected by H. pylori showed significantly increased Lpa (297.83 ± 299.51 vs 154.24 ± 83.63, p < 0.05), higher HbA1c (9.21 ± 2.15 vs 8.00 ± 1.77, p < 0.05), and decreased leptin (4.59 ± 7.55 vs 9.82 ± 10.76, p < 0.05) than non-infected patients. Additionally, 72.2% of the patients with HbA1c > 7% were found to be H. pylori positive and 44.4% of the patients with HbA1c ≤ 7% were H. pylori positive. The levels of other parameters were not significantly different between two groups (p > 0.05), although CRP levels determined by high-sensitivity assay showed mild and variable increases in H. pylori infection. Conclusion H. pylori affects glycemic control in T2DM and might promote the development of diabetes.

The use of ABI in screening for diabetes-related lower limb peripheral arterial disease in IDF middle- and low-income countries: a scoping review Abstract Background The burden of disease from diabetic foot ulcers linked to peripheral arterial disease (PAD) is complicated by limited resources in low- to middle-income countries (LMIC). This precludes the widespread use of sophisticated imaging methods. Screening for PAD can include the use of low-cost tests such as the ankle brachial index (ABI). A scoping review was performed to identify what is known about the use of ABI in screening for diabetes-related PAD in LMIC. Methods LMIC were defined as per the International Diabetes Federation Atlas. The following databases were searched using a comprehensive search term: Cochrane Library, EbscoHost, PubMed, Web of Science, Science Direct, Scopus, and Google Scholar. A total of 400 records were gleaned. The publication abstracts were screened through several rounds to select only those in which ABI was used in the context of screening for PAD to prevent diabetic foot disease. Results Twenty publications were included, from MLIC countries such as Brazil, Nigeria, Kenya, Uganda, South Africa, India, China, Singapore, Korea, Taiwan, Hong Kong, Indonesia, Thailand, and the Philippines. Ten ancilliary publications were identified. Conclusions The widespread reporting and large scale use of ABI in PAD screening in Asia are evident, compared to fewer reports from Africa and South America. Many Asian publications report using faster, automated ABI equipment in conjunction with handheld Doppler evaluation of flow signals. Despite concerns regarding the potential for false elevations secondary to vessel calcification and non-compressibility, ABI remains a useful first encounter test in screening for PAD. Asian publications endorse and report the use of ABI firmly within the core clinical examination and consideration of other risk factors for PAD. No publications were found on large-scale use of automated ABI in the South African or greater African context of diabetic foot screening.

The clinical relevance of lipohypertrophy

Impact of calorie restriction on glycemic control in overweight patients with type 2 diabetes mellitus Abstract Introduction Calorie restriction is emerging as a tool to achieve remission in type 2 diabetes mellitus. We conducted a clinical trial to assess its effectiveness and durability in our setting. Methods This was a single-arm clinical trial (CTRI/2017/05/008711) conducted at JIPMER hospital, Pondicherry. Nine adult patients with type 2 diabetes mellitus and with a BMI of more than 23 kg/m2 were included into the study from December 2016. They were admitted to the hospital and given a 700 kcal per day balanced diet for 1 week following which either weight maintaining or weight reducing diet was advised. Patients were followed up monthly for the initial 3 months and were reassessed later after 12 months. Results One patient was lost to follow-up and hence results have been provided for eight patients. The mean age was 50.5 years. All patients were males. The duration of diabetes was a median of 2.5 years. All patients tolerated the low calorie diet. The mean weight loss was 4.2 kg after a median of 12 months. The average HbA1c declined from a baseline value of 7.98% to 7.13% after a median of 12 months (p = 0.27). Four patients were off any antidiabetic medication at 12 months of follow-up. Conclusion The intervention of a short duration of calorie restriction may be effective in reducing HbA1C in overweight patients with diabetes and the effect can last for a year.

Importance of the Madras Diabetes Research Foundation-Indian Diabetes Risk Score (MDRF-IDRS) for mass screening of type 2 diabetes and its complications at primary health care centers of North India Abstract Diabetes in combination with abdominal obesity and hypertension is the leading cause of cardiovascular diseases (CVD) and death. Type 2 diabetes (T2DM) increases CVD risk in two- to fourfold. The prevalence of CVD is constantly rising in India and is higher in urban areas. In addition, more than 50% of diabetic patients are still undiagnosed in the general population. The Madras Diabetes Research Foundation-Indian Diabetes Risk Score (MDRF-IDRS) is a cost-effective and very simple tool, which can be used at a primary health care center routinely. It is observed that people with increasing age, sedentary lifestyle, greater abdominal obesity, and family history of diabetes are at a high risk for diabetes and its complications. MDRF-IDRS is helpful for mass screening of diabetes and its complications in North Indian population to prevent the incidence of diabetes and with lifestyle interventions, knowledge, and awareness, it helps to reduce and revert the complications of diabetes. It is suggested that regular practice of MDRF-IDRS-based screening at primary health care center may also reduce the burden at the critical care center in North India.

Lower quality of life, lower limb pain with neuropathic characteristics, female sex, and ineffective metabolic control are predictors of depressive symptoms in patients with type 2 diabetes mellitus treated in primary care Abstract The primary objective of this study was to identify if lower limb pain with neuropathic characteristics is predictive of depressive symptoms in patients with type 2 diabetes mellitus (T2DM) treated in primary care in Brazil. It was investigated if diabetic and non-diabetic related variables could influence depressive symptoms. A quantitative and cross-sectional study was carried out in two Basic Health Units with users of the Brazilian Public Healthcare System, who were evaluated for depressive symptoms (BDI), quality of life (QoL, SF6D), pain intensity, neuropathy (loss of plantar sensitivity—LOPPS), body composition (DEXA), biochemical tests, sociodemographic variables, and comorbidities. The patients were stratified into four groups: N+P+, N+P−, N−P+, and N−P− (N = neuropathy and P = pain). One hundred twenty-one diabetics were selected by random sampling between August 2016 and June 2017. Neuropathy affected 53.8% of these individuals, and 59.5% reported intense pain. Overall depressive symptoms scores showed a positive correlation with pain intensity and a negative correlation with QoL. Depressive symptoms were reported by 66.9% of the sample, mostly female, with better levels of cholesterol, HDL and LDL; comorbidities; worse QoL; greater intensity of pain; impaired sleep; and painful neuropathy (N+P+). The predictive factors for depressive symptoms were lower QoL, pain with neuropathic characteristics, female sex, obesity, and ineffective glycemic control. These data may contribute to the understanding of the complexity of patients with T2DM who are treated in primary care and to public policies planning of care directed at the needs of this population.