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Thomas Z, Bhurchandi SK, Saravanan B, Christina F, Volena R, Rebekah G, Samuel VM, Gaikwad P, Chandy B, Samuel A, Cherian KE, Varghese S, Jebasingh FK, Thomas N. Diabetic foot ulcers, their characteristics, and trends in survival: Real world outcomes at a tertiary care facility in India. Diabetes Metab Syndr 2024; 18:103011. [PMID: 38685187 DOI: 10.1016/j.dsx.2024.103011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2023] [Revised: 04/08/2024] [Accepted: 04/11/2024] [Indexed: 05/02/2024]
Abstract
AIMS Characteristics of diabetes-related foot ulcers (DFU), association with recurrence and amputation are poorly described in the Asian Indian population. METHODS A prospectively maintained database was reviewed to characterize DFU and its association with amputation and recurrence. RESULTS Of 200 patients, 63.5 % were male, the median age was 62 years (Min-Max:40-86), and median BMI was 27.90 kg/m2 (Min-Max:18.5-42.7). Median duration of Diabetes mellitus was 15 years (Min-Max:2-43). Complete healing occurred at a median of three months (Min-Max:0.23-37.62). Amputation for the current ulcer was required in 43.4 % of individuals. Ulcer recurrence was documented in 42.4 % instances, 66.1 % evolving on the ipsilateral side. Previous amputation was associated with the risk of subsequent amputation (Adjusted OR-3.08,p-0.047). Median time to ulcer recurrence was 4.23 years among those with amputation, in contrast to 9.61 years in those with healing. Cardiovascular death was the commonest cause of mortality, followed by sepsis. At a median follow up of 6.08 years, mortality at 1,3,5 and 10 years was 2.5 %,2.5 %,8.2 % and 30.9 % respectively among those who underwent amputation versus 0 %,0 %,10.1 % and 24.5 % respectively for those who achieved healing. CONCLUSIONS Patients with DFU in India incur amputations at rates higher than conventionally described. With previous amputation, subsequent amputation risk triples. Ten-year mortality is 25%-30 %. Underestimates of the burden of recurrence and mortality are consequential of limited follow-up.
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Affiliation(s)
| | | | | | | | - Ruth Volena
- Department of Endocrinology, Diabetes and Metabolism, India
| | | | | | | | - Bobeena Chandy
- Department of Physical Medicine and Rehabilitation, India
| | | | | | | | | | - Nihal Thomas
- Department of Endocrinology, Diabetes and Metabolism, India
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Lontchi-Yimagou E, Dasgupta R, Anoop S, Kehlenbrink S, Koppaka S, Goyal A, Venkatesan P, Livingstone R, Ye K, Chapla A, Carey M, Jose A, Rebekah G, Wickramanayake A, Joseph M, Mathias P, Manavalan A, Kurian ME, Inbakumari M, Christina F, Stein D, Thomas N, Hawkins M. An Atypical Form of Diabetes Among Individuals With Low BMI. Diabetes Care 2022; 45:1428-1437. [PMID: 35522035 PMCID: PMC9184261 DOI: 10.2337/dc21-1957] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2021] [Accepted: 03/28/2022] [Indexed: 02/03/2023]
Abstract
OBJECTIVE Diabetes among individuals with low BMI (<19 kg/m2) has been recognized for >60 years as a prevalent entity in low- and middle-income countries (LMICs) and was formally classified as "malnutrition-related diabetes mellitus" by the World Health Organization (WHO) in 1985. Since the WHO withdrew this category in 1999, our objective was to define the metabolic characteristics of these individuals to establish that this is a distinct form of diabetes. RESEARCH DESIGN AND METHODS State-of-the-art metabolic studies were used to characterize Indian individuals with "low BMI diabetes" (LD) in whom all known forms of diabetes were excluded by immunogenetic analysis. They were compared with demographically matched groups: a group with type 1 diabetes (T1D), a group with type 2 diabetes (T2D), and a group without diabetes. Insulin secretion was assessed by C-peptide deconvolution. Hepatic and peripheral insulin sensitivity were analyzed with stepped hyperinsulinemic-euglycemic pancreatic clamp studies. Hepatic and myocellular lipid contents were assessed with 1H-nuclear magnetic resonance spectroscopy. RESULTS The total insulin secretory response was lower in the LD group in comparison with the lean group without diabetes and the T2D group. Endogenous glucose production was significantly lower in the LD group than the T2D group (mean ± SEM 0.50 ± 0.1 vs. 0.84 ± 0.1 mg/kg · min, respectively; P < 0.05). Glucose uptake was significantly higher in the LD group in comparison with the T2D group (10.1 ± 0.7 vs. 4.2 ± 0.5 mg/kg · min; P < 0.001). Visceral adipose tissue and hepatocellular lipids were significantly lower in LD than in T2D. CONCLUSIONS These studies are the first to demonstrate that LD individuals in LMICs have a unique metabolic profile, suggesting that this is a distinct entity that warrants further investigation.
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Affiliation(s)
| | - Riddhi Dasgupta
- Department of Endocrinology, Diabetes and Metabolism, Christian Medical College, Vellore, Vellore, India
| | - Shajith Anoop
- Department of Endocrinology, Diabetes and Metabolism, Christian Medical College, Vellore, Vellore, India
| | | | | | | | - Padmanaban Venkatesan
- Department of Endocrinology, Diabetes and Metabolism, Christian Medical College, Vellore, Vellore, India
| | - Roshan Livingstone
- Department of Endocrinology, Diabetes and Metabolism, Christian Medical College, Vellore, Vellore, India
| | - Kenny Ye
- Albert Einstein College of Medicine, Bronx, NY
| | - Aaron Chapla
- Department of Endocrinology, Diabetes and Metabolism, Christian Medical College, Vellore, Vellore, India
| | - Michelle Carey
- Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, MD
| | - Arun Jose
- Department of Biochemistry, Christian Medical College, Vellore, Vellore, India
| | - Grace Rebekah
- Department of Biostatistics, Christian Medical College Vellore, Vellore, India
| | | | - Mini Joseph
- Department of Endocrinology, Diabetes and Metabolism, Christian Medical College, Vellore, Vellore, India
| | | | | | - Mathews Edatharayil Kurian
- Department of Endocrinology, Diabetes and Metabolism, Christian Medical College, Vellore, Vellore, India
| | - Mercy Inbakumari
- Department of Endocrinology, Diabetes and Metabolism, Christian Medical College, Vellore, Vellore, India
| | - Flory Christina
- Department of Endocrinology, Diabetes and Metabolism, Christian Medical College, Vellore, Vellore, India
| | | | - Nihal Thomas
- Department of Endocrinology, Diabetes and Metabolism, Christian Medical College, Vellore, Vellore, India
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Naik D, Hesarghatta Shyamasunder A, Doddabelavangala Mruthyunjaya M, Gupta Patil R, Paul TV, Christina F, Inbakumari M, Jose R, Lionel J, Regi A, Jeyaseelan PV, Thomas N. Masked hypoglycemia in pregnancy. J Diabetes 2017; 9:778-786. [PMID: 27625296 DOI: 10.1111/1753-0407.12485] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2016] [Revised: 08/10/2016] [Accepted: 09/08/2016] [Indexed: 01/29/2023] Open
Abstract
BACKGROUND Hypoglycemia is a major hindrance for optimal glycemic control in women with gestational diabetes mellitus (GDM) on insulin. In the present study, masked hypoglycemia (glucose <2.77mmol/L for ≥30 min) was estimated in pregnant women using a continuous glucose monitoring (CGM) system. METHODS Twenty pregnant women with GDM on insulin (cases) and 10 age-matched euglycemic pregnant women (controls) between 24 and 36 weeks gestation were recruited. Both groups performed self-monitoring of blood glucose (SMBG) and underwent CGM for 72 h to assess masked hypoglycemia. Masked hypoglycemic episodes were further stratified into two groups based on interstitial glucose (2.28-2.77 and ≤2.22 mmol/L). RESULTS Masked hypoglycemia was recorded in 35% (7/20) of cases and 40% (4/10) of controls using CGM, with an average of 1.28 and 1.25 episodes per subject, respectively. Time spent at glucose levels between 2.28 and 2.77 mmol/L did not differ between the two groups (mean 114 vs 90 min; P = 0.617), but cases spent a longer time with glucose ≤2.2 mmol/L. Babies born to women with GDM were significantly lighter than those born to controls (2860 vs 3290 g; P = 0.012). There was no significant difference in birth weight within the groups among babies born to women with or without hypoglycemia. CONCLUSION Euglycemic pregnant women and those with GDM on insulin had masked hypoglycemia. Masked hypoglycemia was not associated with adverse maternal or fetal outcomes. Therefore, low glucose levels in the hypoglycemic range may represent a physiologic adaptation in pregnancy. This response is exaggerated in women with GDM on insulin.
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Affiliation(s)
- Dukhabandhu Naik
- Department of Endocrinology, Diabetes and Metabolism, Christian Medical College, Vellore, India
| | | | | | - Rita Gupta Patil
- Department of Endocrinology, Diabetes and Metabolism, Christian Medical College, Vellore, India
| | - Thomas Vizhalil Paul
- Department of Endocrinology, Diabetes and Metabolism, Christian Medical College, Vellore, India
| | - Flory Christina
- Department of Endocrinology, Diabetes and Metabolism, Christian Medical College, Vellore, India
| | - Mercy Inbakumari
- Department of Endocrinology, Diabetes and Metabolism, Christian Medical College, Vellore, India
| | - Ruby Jose
- Department of Obstetrics and Gynaecology, Christian Medical College, Vellore, India
| | - Jessie Lionel
- Department of Obstetrics and Gynaecology, Christian Medical College, Vellore, India
| | - Annie Regi
- Department of Obstetrics and Gynaecology, Christian Medical College, Vellore, India
| | | | - Nihal Thomas
- Department of Endocrinology, Diabetes and Metabolism, Christian Medical College, Vellore, India
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Doddabelavangala Mruthyunjaya M, Chapla A, Hesarghatta Shyamasunder A, Varghese D, Varshney M, Paul J, Inbakumari M, Christina F, Varghese RT, Kuruvilla KA, V. Paul T, Jose R, Regi A, Lionel J, Jeyaseelan L, Mathew J, Thomas N. Comprehensive Maturity Onset Diabetes of the Young (MODY) Gene Screening in Pregnant Women with Diabetes in India. PLoS One 2017; 12:e0168656. [PMID: 28095440 PMCID: PMC5240948 DOI: 10.1371/journal.pone.0168656] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2015] [Accepted: 12/05/2016] [Indexed: 02/03/2023] Open
Abstract
Pregnant women with diabetes may have underlying beta cell dysfunction due to mutations/rare variants in genes associated with Maturity Onset Diabetes of the Young (MODY). MODY gene screening would reveal those women genetically predisposed and previously unrecognized with a monogenic form of diabetes for further clinical management, family screening and genetic counselling. However, there are minimal data available on MODY gene variants in pregnant women with diabetes from India. In this study, utilizing the Next generation sequencing (NGS) based protocol fifty subjects were screened for variants in a panel of thirteen MODY genes. Of these subjects 18% (9/50) were positive for definite or likely pathogenic or uncertain MODY variants. The majority of these variants was identified in subjects with autosomal dominant family history, of whom five were in women with pre-GDM and four with overt-GDM. The identified variants included one patient with HNF1A Ser3Cys, two PDX1 Glu224Lys, His94Gln, two NEUROD1 Glu59Gln, Phe318Ser, one INS Gly44Arg, one GCK, one ABCC8 Arg620Cys and one BLK Val418Met variants. In addition, three of the seven offspring screened were positive for the identified variant. These identified variants were further confirmed by Sanger sequencing. In conclusion, these findings in pregnant women with diabetes, imply that a proportion of GDM patients with autosomal dominant family history may have MODY. Further NGS based comprehensive studies with larger samples are required to confirm these finding.
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Affiliation(s)
| | - Aaron Chapla
- Department of Endocrinology, Diabetes & Metabolism, Christian Medical College, Vellore, India
| | | | - Deny Varghese
- Department of Endocrinology, Diabetes & Metabolism, Christian Medical College, Vellore, India
| | - Manika Varshney
- Department of Endocrinology, Diabetes & Metabolism, Christian Medical College, Vellore, India
| | - Johan Paul
- Department of Endocrinology, Diabetes & Metabolism, Christian Medical College, Vellore, India
| | - Mercy Inbakumari
- Department of Endocrinology, Diabetes & Metabolism, Christian Medical College, Vellore, India
| | - Flory Christina
- Department of Endocrinology, Diabetes & Metabolism, Christian Medical College, Vellore, India
| | - Ron Thomas Varghese
- Department of Endocrinology, Diabetes & Metabolism, Christian Medical College, Vellore, India
| | | | - Thomas V. Paul
- Department of Endocrinology, Diabetes & Metabolism, Christian Medical College, Vellore, India
| | - Ruby Jose
- Department of Obstetrics and Gynaecology, Christian Medical College, Vellore, India
| | - Annie Regi
- Department of Obstetrics and Gynaecology, Christian Medical College, Vellore, India
| | - Jessie Lionel
- Department of Obstetrics and Gynaecology, Christian Medical College, Vellore, India
| | - L. Jeyaseelan
- Department of Biostatistics, Christian Medical College, Vellore, India
| | - Jiji Mathew
- Department of Obstetrics and Gynaecology, Christian Medical College, Vellore, India
| | - Nihal Thomas
- Department of Endocrinology, Diabetes & Metabolism, Christian Medical College, Vellore, India
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