Day 1 :
- Diabetic foot problems
Associate Professor, GGMC, J J Hopsital, Mumbai, India
Dr. Milind Ruke is among the few Diabetologists in the country who specializes in Podiatry and foot care. He holds several qualifications in his domain, and apart from being a medical practitioner, he is also an academician.
The world is facing a major epidemic of diabetes mellitus (DM) & available reports suggest that all these patients are at risk of developing diabetic foot ulcer (DFU). Approximately 50 – 60% of all DFUs can be classified as neuropathic. Signs or symptoms of vascular compromise are observed in 40 to 50% of all patients with the vast majority having neuro-ischemic ulcers, and only a minority of patients has purely ischemic ulcers. Diabetic foot infections are usually polymicrobial in nature, involving both aerobes and anaerobes, which can decay any part of the body especially the distal part of the lower leg. However, one of the hidden barriers to wound healing is the presence of biofilm in chronic DFUs. Biofilms are difficult to identify & diagnose, recalcitrant to topical antibiotics & can reoccur even after sharp debridement. More than 90% of chronic wounds are complicated with biofilms. Hence, early identification and management of diabetic foot infections becomes imperative in order to prevent complications & amputation. Debridement is considered to be the gold standard treatment approach for managing DFU manifested with necrotic tissue. However, biofilm can reform even after sharp debridement and can delay healing & recovery. Also, antibiotics & few antiseptics have limited role in managing DFUs complicated with biofilm. Until recently, Cadexomer iodine, a new generation iodine formulation with microbead technology has taken a different profile in wound care. It can effectively manage biofilm along with exudate & possesses superior desloughing action. Additionally, appropriate ways of offloading, dressings & use of newer treatment strategies like negative pressure wound therapy (NPWT), hyperbaric oxygen therapy (HBOT) and / or use of growth factors can ensure faster healing & early wound closure. Although, commendable efforts in recent years have been taken in the diagnosis and treatment of DFU, it still remains a major public health concern.
Biofilm like infections are found to be an important cause of amputations in Diabetic foot patients, worldwide. In south-east Asia, especially in India, the incidence is increasing .This presentation on Management of diabetic foot Biofilms would go in a big way in explaining the evidence we have now to treat this aspect of Diabetic foot & helping in Limb salvage and hence prevent Amputation.
- Adrenal Insufficiency and Adrenal Crisis
Endocrinology Research Centre, Moscow, Russian Federation
This research was conducted under the research grant “Autoimmune endocrinopathies multiple organ failure that are genomic, postgenomic and metabolic markers. Genetic risk prediction, monitoring, early predictors, personalized correction and rehabilitation.” Project number is 17-75-30035.
Introduction: Autoimmune polyendocrine syndromes (APS) are a heterogeneous group of diseases characterized by the presence of autoimmune dysfunction of two or more endocrine glands and other non-endocrine organs.
The aim of the study was to determine the association of chronic adrenal insufficiency with polymorphism of HLA II, CTLA-4 and PTPN22 genes among patients with APS 2,3,4 types and patients with Graves’ disease. The focus of the study was on the revealing of protective genes for Addison’s disease in APS 3 type patients and in patients with Graves’ disease.
Materials and methods: The case-control study involved 116 patients with APS 2, 3, 4 types, 95 patients with Graves’ disease and 109 healthy subjects. Alleles of the HLA II class genes, CTLA4 and PTPN22 were identified by the multiprimer allele-specific PCR method. The statistical analysis was carried out using the exact two-sided Fisher test. The association of the chronic adrenal insufficiency was determined by the value of the odds ratio (OR - odd's ratio), the value of 95% confidence interval (95% CI).
Results: Haplotypes DR3-DQ2 (p < 0,0001; OR = 4.06), DR4-DQ8 (p < 0,0001; OR = 5.78), DQA1*0301 allele (p=0.000; OR = 4.27), genotype DQA1*0301/DQA1*0501 (p=0.000; OR = 13.89), and especially genotype DR3/DR4 (p=0.000; OR = 19.7) HLA II class genes predispose to the development of APS type 2, 3 and 4 in adults compared to the control group.
Genotype DR3/DR4 HLA II genes found the strongest association with the development of adrenal insufficiency in patients with APS (p < 0,0001; OR = 4.28). It is an independent risk factor of the development of APS type 2, 4 in patients with APS type 3 and patients with one autoimmune disease - Graves' disease.
Haplotype DRB1*01-DQA1*0101-DQB1*0501 has been determined as protective for the development of Addison’s disease. Frequency of DRB1*01-DQA1*0101-DQB1*0501 was significantly lower in the group of APS type 2, 4 comparing to the group of APS type 3 (Ñ€<0,01; OR=0.0769), Graves’ disease (p <0.05; OR=0.095) and the control group (Ñ€<0,01; OR=0.1138)
There were no significant differences in the frequency of occurrence of the haplotype - DRB1*01-DQA1*0101-DQB1*0501 - in the type 3 APS groups, in patients with Graves' disease and in the control group.
Gene polymorphisms CTLA-4+ 49A/G (rs231775) and PTPN22 +1858C> T (rs2476601) are predisposing to the development of APS 2, 3 types compared with the group of Graves' disease patients and the control group
A significant association between APS type 2, 3 and carriage of the CTLA-4 +49 A/G genotype (p < 0.01; OR 2.63) and PTPN22 +1858 CT genotype (p< 0.05; OR 3,96) was confirmed
Conclusion: The revealing of predisposing and protective genes to Addison’s disease in patients with APS type 3 and Graves’ disease will allow better predicting the risks of developing of the chronic adrenal insufficiency and the sudden onset of potential life-threatening complications (adrenal crisis) within the syndrome.
- Diabetes Diet, Eating, & Physical Activity
Studio Kineteos - Turin, Italy
‘Diabesity’ is a term for diabetes occurring in the context of obesity. The positive effect of LCHF diets (low carb, high fat diets) is well documented: LCHF diets are at least as effective as other dietary strategies for reducing body weight, improving glycaemic control and reducing both hyperinsulinaemia and blood glucose (reduction of HbA1c) in type 2 diabetes and have unique positive effects on blood lipid concentrations and cardiovascular risk factors1. Also, in obese insulin-resistant women, food fried in extra-virgin olive oil significantly reduced both insulin and C-peptide responses after a meal2. In this case study, I show how combining both dietary strategies produces a strong effect on blood glucose, resulting in a “forced” reduction of exogenous insulin injection to avoid the problem of hypoglycaemia. Blood tests after 3 months of this dietary treatment show how HbA1c, triglycerides and blood lipid profile (LDL, HDL, total Cholesterol) are improved despite reduction of exogenous insulin injection of 80%. Also, body weight decrease of 15%. For continuous glucose monitoring (CGM) the patient used FreeStyle Libre before and after the dietary treatment. In order to check general body functions and glycosuria the patient used the urine test Multistix 10 SG Siemens.
Accumulation of Reactive Oxygen Species (ROS) and methlyglyoxal (MG) causes endothelial dysfunction in diabetes-related complications. Endothelial function in high glucose (HG) is improved by resveratrol (RSV), however the mechanisms underlying such beneficial effect are still unclear. In particular, the role of sirtuin-dependent regulation of cytoprotective mechanisms remains unknown.
Here we investigated molecular details glycative/oxidative perturbations in HG-challenged endothelial cells, and whether SIRT1 was essential for RSV to protect cells against HG through the regulation of MG- and ROS-targeting defences.
Human umbilical vein endothelial cells (HUVECs) were kept in 5.55 mM glucose (CTR) or 30.55 mM glucose (HG), and co-incubated with either RSV (5 µM) or RSV+EX527 (SIRT1 inhibitor) (5 µM+13.4 µM, respectively). Through morphological, molecular and biochemical methods, we evaluated: cell viability, apoptosis, expression of SIRT1, CAT (catalase), SOD1 (Cu/Zn-superoxide dismutase), SOD2 (mitochondrial Mn-superoxide dismutase), glyoxalase 1 (GLO1), ROS- and MG-dependent damages, and redox balance of glutathione. The involvement of mitochondria was verified by investigating the expression of SIRT3 and acetylated SOD2.
We found that HG impaired MG/ROS scavenging activities in HUVECs, and that RSV effectively rescued such impairments by up-regulating SIRT1. Interestingly, the response involved mitochondria, as seen by both changed expression of SIRT3 and altered levels of SOD2.
consultant of public health, community and preventive medicine at national research center-Egypt
BACKGROUND: Egypt is among the world top 10 countries in diabetes prevalence. It is the first country among the MENA region. Healthy lifestyle education and support help people with diabetes to improve health outcomes. Many physical and psychological barriers can hinder patients from following a healthy lifestyle.
AIM: This study aimed to examine the effect of lifestyle modification educational sessions in helping Egyptian patients to overcome main barriers of diabetes self-management through improving nutritional behaviors, physical activity, medication compliance, and blood glucose monitoring.
METHODS: A cohort study included 205 patients with type 2 diabetes. Baseline assessment of patients' lifestyle behaviors and barriers using personal diabetes questionnaire of Louisville University, with both anthropometric and blood glucose assessment. Interventional lifestyle health education was provided weekly through multiple integrated techniques, followed by a post-intervention assessment to evaluate the effect of the health education sessions. Statistical analysis was done to identify any statistically significant difference before and after the health education intervention.
RESULTS: There was a significant improvement of the post-education mean scores of the studied behaviors when compared with the pre-education scores of the participants’ behaviors (p < 0.001). There was also a significant reduction in the barriers facing patients to diabetes self-management including nutritional barriers (P < 0.001), medication compliance barriers (P < 0.001) with a percent change (43%), physical activity barriers (p < 0.001), and blood glucose monitoring (p < 0.001) with a percent change (44%).There was a statistically significant positive correlation between improvement of medication compliance (P = 0.027), blood glucose monitoring(P = 0.045), and glycated haemoglobin of the study participants
CONCLUSION: lifestyle modification education of type 2 diabetic patients can overcome the main barriers of following a healthy lifestyle and improve their anthropometric measures and blood glucose level
- Diabetes Diagnosis and Treatment
Mekelle University, Ethiopia
Abstract: To study the anti-diabetic effects of the crude leaves extract and fractions of Thymus schimperi Ronniger in normal and steptozotocin induced diabetic mice. The crude extract and the fractions were screened for antidiabetic activities in streptozotocin induced diabetic mice. A normoglycemic mice model and oral glucose tolerance test were also undertaken to assess the hypoglycemic and antihyperglycemic effect of the crude extract in normoglycemic and glucose loaded mice, respectively. The methanolic crude extract has significantly reduced blood glucose level in streptozotocin induced diabetic mice at all given doses compared to the negative control and the percentage reduction observed was in a dose dependent manner i.e. [250 mg/kg (14.76±6.1%), 500 mg/kg (25.12±11.5%) and 750 mg/kg (27.15±10.0%)]. The crude methanol extract was devoid of hypoglycemic effect in normoglycemic mice but significantly reduced post prandial hyperglycemia starting from 1 h post glucose administration. Among the fractions, higher percentage reduction was recorded in the n-butanol fraction at a dose level of 500 mg/kg (36±7.3%) compared to 250 mg/kg (22.2±4.3%). The aqueous fraction 250 mg/kg and 500 mg/kg also reduced the blood glucose level by 17.6%±6.0% and 18.4±5.0%, respectively. This study revealed that methanol extract as well as butanol and aqueous fractions of T schimperi possess anti-diabetic activity. Keywords: Thymus Schimperi Ronniger, Diabetes mellitus, Hypoglycemic, Streptozotocin
- Pituitary and Thyroid Disorders
Enocrine Research Center, Institute of Endocrinology and Metabolism, Iran University of Medical Science (IUMS), Tehran, Iran
Pituitary germinomas are difficult to be differentiated from lymphocytic hypophysitis due to similar clinical, radiological and even histological findings. However, it is of great importance to make the distinction between them because of different therapeutic approaches of the two diseases. We report a case of neurohypophysial germinoma who initially was misdiagnosed as lymphocytic hypophysitis. The patient was a 26-year-old man who first presented with central
diabetes insipidus and subsequent pan-hypopituitarism. Magnetic resonance imaging (MRI) of the pituitary which first had shown mild pituitary enlargement, revealed a pituitary mass of unusual feature after 1 year. Pathological diagnosis of the lesion, biopsied through
trans-sphenoidal route, was lymphocytic hypophysitis. Corticosteroid was initiated for him. Despite, intensive treatment clinical symptoms worsened and the patient developed visual field defect. Follow-up MRI revealed enlargement of the pituitary mass with suprasellar extension and involvement of optic chiasm. Surgical resection of the mass was performed, and the second histological examination confirmed the diagnosis of germinoma. Subsequently, the patient underwent radiotherapy, and complete remission was achieved; however, pan-hypopituitarism persisted. In conclusion, the possibility of neurohypophyseal germinoma should be considered in patients with the diagnosis of lymphocytic hypophysitis who do not respond to corticosteroid therapy.
Key words: Germ cell tumor, Pituitary germinoma, Hypophysitis.
- Common Challenging Procedures of Diabetes and Endocrinology
King Saud University, KSA
Dr. Satish Kumar David working as Researcher & Head of the Information Technology Department in the Strategic Center for Diabetes Research, College of Medicine, King Saud University, Riyadh, Saudi Arabia. Over 23 years of professional experience as a department head, assistant professor, researcher, IT specialist. Research interests include data mining, mHealth, computer networks, AI. Several publications in reputed international journals and has been a reviewer for few journals. Also, co-author with Mohamed Rafiullah, of Novel Health Mobile Technology as an Emerging Strategy in Diabetes Management (IntechOpen, 2017) and co-author with Saeb, A. T., Rafiullah, M., & Rubeaan, K. of Classification Techniques and Data Mining Tools Used in Medical Bioinformatics (IGI-Global,2019). Take up higher responsibilities to grow with the organization.
Diabetes is a chronic disease that needs patient awareness, education, and self-management of the disease by patients. Mobile revolution and the availability of IT technologies can serve as a connecting bridge in healthcare system to facilitate the treatment of lifestyles diseases such as diabetes. However, the effectiveness of these techniques needs to be assessed rigorously. Therefore, the authors have systematically reviewed the recent clinical studies using Mobile Health applications for diabetes management.
Original articles that were published in ISI indexed journals from PubMed database from 2007 to 2014 were collected using search specific key phrases. Selected papers were classified into ‘mobile applications for diabetes management’ which included applications related to diabetes management, ‘mobile applications for patient education’ which included all the articles where smart phone was used as a tool for health education and ‘mobile applications for patient behavior modifications’ which included studies that looked into mobile applications which would affect and contribute to behavior changes.
Mobile health interventions resulted in significant clinical improvement in most of the studies. Educational SMS produced significant results but was inferior to the apps or teleconsultations which are more engaging with patients. It seems phone calls are less preferred, as there were only two studies where phone calls were used as intervention. Most of Smartphone apps were evaluated for patient management and education. Implementing reliable mobile health platform in real-life setups may be a challenging task and would require adequate infrastructure. Cost benefit and cost-effectiveness analysis are essential before implementation of such systems.
Ms. Sabyata Gautam has completed her M. Pharm on 2010 from Kathmandu University and doing doctoral studies from Shri JJT University, Institute of Pharmacy. She is the associate professor, in National Model College for Advanced Learning (NMCAL), NIST college. She has published more than 5 papers in reputed journals and has been involved in social works too.
This study aims to find impact of pharmacist’s counselling on medication adherence among diabetic patients in Kathmandu valley. Data collection was done from Jan 2017 till June 2018. In our descriptive cum exploratory study, of total 321 patients, the mean age of diabetic patients was 57.5 ± 12.47years. Metformin 500mg was found to be prescribed mostly (n= 107 patients). When calculated in per day cost of OHAs, minimum was Rs.2 and maximum was Rs. 103.42 with average cost of Rs. 25.10. While undergoing KAP assessment, the knowledge score wasn’t found to be satisfactory, though results on practice and attitude were satisfactory. MARS 5 and MARS were used to measure compliance before and after counselling. MARS-5 contains likert scale questions with total score of 25. MARS 5 scoring after counseling had mean of 24.06 ± 1.54, which was 23.17 ± 2.40 before counselling (P ≤ 0.000). Similarly, the study found the mean values of 8.21 ± 1.24 (before counselling) and 9.03 ±0.89 (after counselling) while using 10 item MARS questionnaire (P ≤ 0.000). Thus, counselling from pharmacist is effective in improving the compliance among diabetic patients. Knowledge and attitude scores of the patients were found to be statistically significant with medication compliance (P< 0.05). Notable improvement in patient’s blood sugar levels (F, R, PP) were also observed after counselling. Since most of the patients, with reference to the self, admitted that lack of knowledge regarding disease was major reason for non-adherence, awareness programs are much in need.
Key words: Diabetes, Adherence, Causes of Non-adherence, Counselling, KAP, MARS
Day 2 :
- Diabetes and Cancer
Department of Internal Medicine, Amasya University Research Hospital, Amasya, Turkey
Introduction and purpose
Primer hyperparathyroidism is the most common cause of hypercalcemia in patients referred to policlinics. In Primer hyperparathyroidism, parathyroid hormone (PTH) is excessively secreted. The most common causes are adenomas, hyperplasia while carcinomas is the rare cause of primer hyperparathyroidism. Although thyroid cancer is the most common endocrin malignancy, coexistence of parathyroid carcinoma and thyroid carcinoma is very rare. Thyroid Cancer (CA) was observed approximately by 1% in all cancers. It has been increasing most common type and consisting about 80% of the thyroid cancers. Coexistence of nonmeduller thyroid CA and primer hyperparathyroidism is very rare situation.
A 29 year old woman, has been treating for urolithiazis for four years. She had 2 months history of appetite and weight loss, fatigue, easily tiring that affected her daily performance, based on 5 days history of nausea and vomiting records. Her Ca content was measured as 14.50mg/dl. Parathyroid Hormone (PTH) level was found as 851.5 pg/ml ( 11,1-79,5 pg/ml). Thyroid usg and Tc-99m MIBI parathyroid scintigraphia was performed. In right lobe anterior segment 16x10mm, properly limited, including internal punctuate calcifications, hypo echoic and hyper vascular nodule was observed. Also there exists a 21x28 mm lobulated, containing internal echogenic septation solid nodules starting from central part of the right lobe ongoing up to posterior. In both lobes colloidal cystic nodules were observed in mill metric scale. She was referred to a tertiary center for the operation. Pathology results were reported as papillary thyroid Carcinoma (ca) and parathyroid carcinoma. Tumor was infiltrated to surrounding muscles tissue and to the front wall of esophagus.
In this article, coexistence of thyroid papillary CA and parathyroid carcinoma in hypercalcemic 29 year old woman treated for urolithiasis is presented. In patients who admitted to policlinics without a specific complaints, weakness, fatigue, nausea analysing serum electrolytes has vital importance in early diagnosis. Ca must be added to these parameters. In such patients Coexistence of parathyroid carcinoma and thyroid malignancies should be kept in mind.
Keywords: Hypercalcemia; Parathyroid carcinoma; Thyroid papillary carcinoma
Metabolic syndrome (MetS), a cluster of multiple risk factors for atherosclerosis such as obesity, elevated blood pressure (BP), elevated glucose, and atherogenic dyslipidemia, increase the risk of all-cause mortality and cardiovascular (CV) morbidity and mortality. The most accepted clinical definition, established by the National Cholesterol Education Program’s Adult Treatment Panel III (NCEP-ATP
III) in 2001, recognizes multiple components of the syndrome related to atherosclerotic CV disease risk: abdominal obesity, atherogenic dyslipidemia, BP, and insulin resistance (IR) with or without glucose intolerance. However, these criteria do not fully encompass the pathophysiological complexity of the syndrome, recognize predisposition to different types of end-organ damage, or account for health disparities according to race, sex, or socioeconomic status, in screening for or treating the syndrome.
Due to previous reasons, there is a need to develop new, sensitive and minimally invasive diagnostic approaches to improve diagnosis and trace the prognosis of Mets.
Micro ribonucleic acids (microRNAs) are short single-stranded noncoding ribonucleic acids (ncRNAs), ranging in length from 18–25 nucleotides (nts), that are found in eukaryotic cells. They are created from hairpin-like precursors that base pair to their corresponding target messenger ribonucleic acids (mRNAs) in the RNA-induced silencing complex (RISC). As a result of base pairing with complete or incomplete complementarity to their target, microRNAs (miRNAs) then degrade or block translation of the mRNAs
MicroRNAs regulate multiple pathways including insulin signaling, immune mediated inflammation, adipokine expression, adipogenesis, lipid metabolism, and food intake regulation. Thus, miRNA-based therapeutics represent an innovative and attractive treatment modality, with non-human primate studies showing great promise. In addition, miRNAs measurement in plasma or bodily fluids may be used as disease biomarkers and predictors of metabolic disease
- Diabetes Mellitus
Type 2 diabetes is a metabolic disorder characterized by insulin resistance and decreased insulin secretion. Several mechanisms have been described to explain impaired insulin secretion and function in type 2 diabetes and these mechanisms are glucotoxicity, lipotoxicity, oxidative stress, endoplasmic reticulum stress & amyloi deposition. These are linked with each other & they cause inflammation in tissues. Inflammation in islet cells cause destruction or failure of β cells. This leads to defect of insulin secretion. Inflammation also occurs in insulin sensitive tissues e.g., liver,muscle & adipose tissue. When a person gains weight, his adipocytes become phenotypically different. Macrophages infiltrate & inflammatory mediators are secreted – leading to inflammation & ultimately development of insulin resistance. IL - 1β & NLRP 3 inflammasome are important mediators of these inflammation. Similar things happen in muscle or liver also. These findings are mainly from preclinical studies. Even studies in humans also revealed association between inflammatory markers & type 2 diabetes. So all of this show that type 2 diabetes develops due to tissue inflammation precipitated by obesity. So some anti-inflammatory agents are currently undergoing trials to evaluate their effect on type 2 diabetes or prediabetes. IL- 1 blockers, IL - 1β specific antibodies, salsalate are some of those agents. Few studies have shown to improve insulin sensitivity & reduction of glycemic parameters. Others are expected to be completed in near future. So they can be a new group of drugs which can prevent or control type 2 diabetes.
Diabetologist, Medilink Hospital, India
Background: Diabetic Dyslipidemia (DD) is highly atherogenic condition, which is associated with high triglycerides (TG), high small dense low density lipoprotein cholesterol (sdLDL-C) and low high density lipoprotein cholesterol (HDL-C). In India, low HDL-C and high TG are commonly observed dyslipidemia pattern1. Saroglitazar, a dual PPAR α/γ (Peroxisome proliferator activated receptor) agonist, is approved in India for the treatment of diabetic dyslipidemia (DD) not controlled with statins.
Aims: This observational study was done to evaluate effect of Saroglitazar in type 2 diabetes patients with elevated TG (>150mg/dl) and safety profile at 12 and 24 weeks.
Method: Total 100 T2D patients were enrolled with TG>150 mg/dl and were given saroglitazar 4mg once daily for 24 weeks. The effects of saroglitazar on lipid and glycemic parameters, and safety by recording adverse events were evaluated at 12 weeks and 24 weeks by using paired t-test.
Results: At 12 weeks the primary end point showed a significant reduction in TG (from 155.42 ± 18.9 mg/dl to 128.33 ± 16.3 mg/dl; p<0.001) and non-HDL-C (from 173.02 ± 20.76 to 144.62 ± 16.0; p<0.001). These effect were continued upto 6 months, where significant reduction was observed in TG and Non-HDL from baseline by 29.8% (p<0.001), 26.6% (p<0.001), respectively. Of the secondary end points the values of TC, HDL-C, LDL-C and HbA1c were also significantly improved at 12 and 24 weeks (Table 1). No major adverse event reported during the study period.
Discussion: High TG should be reduced, if not controlled by statin therapy in diabetes patients. In this study, saroglitazar is reducing TG with other lipid parameters, without any major adverse events.