Assessment of microbial flora and pesticidal effect of vermicast generated from Azadirachta indica (neem) for developing a biofertilizer-cum-pesticide as a single package

The soil comprising organic matter, nutrients, serve as substrate for plant growth and various organisms. In areas where there are large plantations, there is a huge leaf litter fall. The leaf litter upon decomposition releases nutrients and helps in nutrient recycling, for which the soil engineers such as earthworms, ants and termites are important key players. In this context, the present study was conducted to assess the characteristics of the vermicast obtained by vermicomposting neem leaf litter in terms of microbial flora, plant growth promoting properties and antagonistic activities of the vermicast against phytopathogens. Vermicomposting of neem leaf litter was done using two epigeic earthworm species Eisenia fetida and Eudrilus eugeniae. The vermicast exhibited antagonistic potential against plant pathogens. Out of the four vermiwash infusions studied, the 75 % formulation reduced the disease incidence against mealybug by 82 % in the tree Neolamarkia cadamba. The result of the study suggests that vermicast made from neem leaf litter may be a potent combination of a biofertilizer and a pesticide.

Design and analysis of solitary AC-AC converter using reduced components for efficient power generation system

Considering different applications that require varied power and voltage conversion levels between AC grids and AC loads, AC-AC power conversion between AC grids has become an inevitable technology of energy management systems. An isolated converter for performing AC-to-AC transmission is proposed with minimal components for reduced losses and enhanced system efficiency. Single-phase direct buck-boost AC to AC converter with minimum components constituted with two dual IGBT control units (IGBT 1-IGBT 4), inductor (Lf), and capacitor (Cf) is proposed in this work. The MATLAB/Simulink platform is used to provide in-depth analysis of the circuit and components along with the design guidelines, and simulation outcomes of this proposed model. The voltage gains of G = 2.13, power factor of 0.97, and overall efficiency of 98% are achieved in the proposed system with minimum components of 4 switches, 2 conductors, and 1 capacitor and inductor respectively. The obtained results are compared with existing technology to evaluate the proposed system.

The association of fatigue severity with pain level, obesity indices and functional performances in women with knee osteoarthritis

INTRODUCTION

Knee osteoarthritis is most common among women with obesity. It may lead to physical inactivity that, in turn, causes fatigue or lack of physical enthusiasm to perform meaningful daily activities. Hence, this study aimed to examine whether pain level, obesity indices and functional performances are associated with fatigue severity in women with knee osteoarthritis (KOA).

MATERIALS AND METHODS

This cross-sectional study recruited women referred to physiotherapy to manage OA. The measurements included fatigue severity (fatigue severity scale); pain level (numerical rating scale); obesity indices (body mass index, fat %, waist circumference); functional performances (upper limb strength, lower limb strength, mobility, exercise capacity and quality of life). A simple linear regression analysis was used to determine which independent variable may be associated with fatigue severity.

RESULTS

Ninety-six women with unilateral KOA participated in this study (Mean age, 55.70, Standard Deviation, SD 6.90) years; Mean fatigue severity, 34.51, SD 14.03). The simple linear regression analysis showed that pain level (β=4.089, p<0.001), fat % (β=0.825, p<0.001) and QoL (β=0.304, p<0.001) were significantly associated with fatigue. After controlling for pain level, only fat % was significantly associated with fatigue (β=0.581, p=0.005).

CONCLUSION

Pain level, fat %, and QoL appear to be associated with fatigue severity in women with KOA. In addition, pain symptoms may interact with factors associated with fatigue severity.

A novel mutation in the KCNJ11 gene (p.Val36Glu), predisposes to congenital hyperinsulinemia

The hypoglycemia induced by insulin hypersecretion in congenital hyperinsulinemia (CHI), a rare life-threatening condition can lead to irreversible brain damage in neonates. Inactivating mutations in the genes encoding K_ATP channel (ABCC8 and KCNJ11) as well as HNF4A, HNF1A, HADH, UCP2, and activating mutations in GLUD1, GCK, and SLC16A1 have been identified as causal. A 3-month-old male infant presenting tonic-clonic seizures and hyperinsulinemia was clinically assessed and subjected to genetic analysis. Besides the index patient, his parents were clinically investigated, and a detailed family history was also recorded. The laboratory investigations and the genetic test results of the parents were compared with the index patient. The biochemical and hormonal profile of the patient confirmed his suffering from CHI and did not respond to diazoxide treatment. The genetic testing revealed that the subject harbored a novel homozygous missense mutation in the KCNJ11 gene, (c.107T>A, p.Val36Glu.). The bioinformatic analysis revealed that valine is highly conserved and predicted that the variant allele (p.Val36Glu) is likely pathogenic and causal for CHI. Parents were heterozygous carriers and did not report any abnormal metabolic profile. Identification of such mutations is critical and likely to change the therapeutic interventions for such patients in the future.

South Asian medical cohorts reveal strong founder effects and high rates of homozygosity

The benefits of large-scale genetic studies for healthcare of the populations studied are well documented, but these genetic studies have traditionally ignored people from some parts of the world, such as South Asia. Here we describe whole genome sequence (WGS) data from 4806 individuals recruited from the healthcare delivery systems of Pakistan, India and Bangladesh, combined with WGS from 927 individuals from isolated South Asian populations. We characterize population structure in South Asia and describe a genotyping array (SARGAM) and imputation reference panel that are optimized for South Asian genomes. We find evidence for high rates of reproductive isolation, endogamy and consanguinity that vary across the subcontinent and that lead to levels of rare homozygotes that reach 100 times that seen in outbred populations. Founder effects increase the power to associate functional variants with disease processes and make South Asia a uniquely powerful place for population-scale genetic studies.

Venous Leak Embolization in Patients with Venogenic Erectile Dysfunction via Deep Dorsal Penile Vein Access: Safety and Early Efficacy

PURPOSE

This all-comers registry aimed to assess safety and early efficacy of venous embolization in patients with venogenic erectile dysfunction due to venous leak in an unselected cohort.

METHODS

Between October 2019 and September 2022, patients with venogenic erectile dysfunction resistant to phosphodiesterase-5-inhibitors were treated with venous embolization using ultrasound-guided anterograde access via a deep dorsal penile vein in a single center. A mix of ethiodized oil and modified cyanoacrylate-based glue n-butyl 2 cyanoacrylate (NBCA) monomer plus methacryloxy-sulpholane monomer (Glubran-2, GEM, Italy) was used as liquid embolic agent. Prior to embolization, venous leak had been verified based on penile duplex sonography and computed tomography cavernosography. Procedural success was defined as technically successful and complete target vein embolization. The primary safety outcome measure was any major adverse event 6 weeks after the procedure. The primary feasibility outcome measure was IIEF-15 (International Index of Erectile Function-15) score improvement ≥ 4 points in ≥ 50% of subjects on 6 weeks follow-up post intervention.

RESULTS

Fifty consecutive patients (mean age 61.8 ± 10.0 years) with severe erectile dysfunction due to venous leak underwent venous embolization. Procedural success was achieved in 49/50 (98%) of patients with no major adverse events on follow-up. The primary feasibility outcome measure at 6 weeks was reached by 34/50 (68%) of patients.

CONCLUSION

Venous leak embolization via deep dorsal penile vein access using a liquid embolic agent was safe for all and efficacious in the majority of patients with severe venogenic erectile dysfunction on 6 weeks follow-up.

A265 TEMPORAL DYNAMICS OF SYMPTOMS AND GUT MICROBIOTA IN EPISODES OF IRRITABLE BOWEL SYNDROME

Background

Irritable bowel syndrome (IBS) is a disorder of gut-brain axis that manifests with chronic abdominal pain, altered bowel habits, and frequent psychiatric comorbidities. Despite mounting evidence showing gut microbiota composition and associated metabolites being altered in IBS, the mechanisms by which they drive the symptoms are unclear. We have previously shown that several IBS symptoms co-occur, that their severity vary among IBS subtypes (10.1093/jcag/gwab049.050), and that several bacterial taxa are differentially modulated during periods of symptom flares and remission. Here we investigate whether the changes in gut microbiome and bacterial metabolites are linked to symptom occurrence and severity.

Purpose

To investigate temporal associations of IBS symptoms with gut microbiota profiles and metabolites.

Method

16S rRNA gene sequencing was performed on stool samples of 28 IBS patients (IBS-D n=20, IBS-C n=8) and 10 healthy controls (HC), collected weekly over a period of 25 weeks, during which gut and mood symptoms were recorded (total of 950 samples). Correlations between principal ordinates obtained from symptom scores and microbiota beta diversity were studied using Procrustes analysis in R. Metabolomics was performed by Mass Spectrometry and analysed using MetaboAnalyst 5.0. Statistical significance was set at p<0.05.

Result(s)

Significant correlation was found between the symptom scores and microbiota beta diversity ordinates over time in 7 patients (5 IBS-D and 2 IBS-C subjects) out of 28 IBS patients. Metabolomics performed on samples selected based on Procrustes analysis and symptom severity scores of individual subjects showed that several pathways are altered in IBS patients (both subtypes) compared to HC, including primary bile acid biosynthesis, beta alanine metabolism, pyrimidine and histidine metabolism. Furthermore, during symptom flares, ornithine, citrulline and gluconic acid vary in IBS-D, while amino acids cysteine, methionine, threonine, and glycine vary in IBS-C subjects.

Conclusion(s)

Our results suggest that IBS symptoms and changes in gut microbiota composition and metabolites must be studied in conjunction, in order to understand the mechanisms underlying IBS pathophysiology. We found that same pathways are altered in IBS subjects irrespective of their subtype, suggestive of a basal metabolic shift in IBS patients. This shift may make them sensitive to further gut microbial modulation of carbohydrate and protein metabolism in IBS-D and IBS-C subjects, respectively, leading to symptom flares. Further analyses are needed to investigate these metabolites and associated bacteria, as they can help identifying subsets of patients with specific disease mechanisms. This will be a steppingstone in moving away from symptom-based subtyping towards mechanism-based grouping and developing effective treatment strategies accordingly.

Disclosure of Interest

None Declared

Management of diabetic dyslipidemia in Indians: Expert consensus statement from the Lipid Association of India

In 2021 an estimated 74 million individuals had diabetes in India, almost all type 2 diabetes. More than half of patients with diabetes are estimated to be undiagnosed and more 90% have dyslipidemia that is associated with accelerated development of atherosclerotic cardiovascular disease (ASCVD). Patients of Indian descent with diabetes have multiple features that distinguish them from patients with diabetes in Western populations. These include characteristics such as earlier age of onset, higher frequency of features of the metabolic syndrome, more prevalent risk factors for ASCVD, and more aggressive course of ASCVD complications. In light of the unique features of diabetes and diabetic dyslipidemia in individuals of Indian descent, the Lipid Association of India developed this expert consensus statement to provide guidance for management of diabetic dyslipidemia in this very high risk population. The recommendations contained herein are the outgrowth of a series of 165 webinars conducted by the Lipid Association of India across the country from May 2020 to July 2021, involving 155 experts in endocrinology and cardiology and an additional 2880 physicians.

High prevalence of asymptomatic left ventricular diastolic dysfunction and its detection among South Asian patients with Type 2 Diabetes Mellitus compared with White Europeans

Background

Heart failure (HF) is an important manifestation of Type 2 Diabetes (T2D). The development of HF in T2D may be preceded by Stage B HF. Asymptomatic left ventricular impairment, especially left ventricular diastolic dysfunction (LVDD), is a defining early feature of Stage B HF. Detection of Stage B HF is crucial as it provides an opportune target for intervention with cardio-protective therapy to prevent the development of symptomatic HF in T2D. The risk of T2DM is higher in South Asian populations resulting in increased risk of macrovascular and microvascular complications. The prevalence of Stage B HF in South Asian patients with T2DM is not known.

Purpose

(i) To compare the prevalence of Stage B HF in South Asians in India compared with White Europeans in Scotland; (ii) To test the role of NT-proBNP in identifying Stage B HF

Methods

This study involved the comparison between two independently conducted, cross-sectional studies. The patients were asymptomatic patients with T2DM with no prior history of cardiovascular disease from Chennai, India (n=246) and Tayside, Scotland (n=246). All patients underwent transthoracic echocardiogram (echo) examination to detect the presence of structural and functional echo features of Stage B HF: left atrial enlargement (LAE), left ventricular hypertrophy (LVH), LVDD and LV systolic dysfunction (LVSD). Receiver operating curves (ROC) were used to determine the predictive ability of NT-proBNP to predict LAE/LVDD/LVD/LVSD.

Results

The prevalence of Stage B HF was high in South-Asian patients with T2DM (median age of 55 [49, 62] with a high prevalence of LVDD (5% had LVH, 7.3% had LAE, 70% had LVDD and 0% had LVSD (Figure 1B). 10% of the South Asian patients had at least 2 factors contributing to Stage B HF and these patients had higher NT-proBNP titres (703.4 [500.0, 949.2] vs 423.7 [35.0, 754.2], p&lt;0.001). ROC curves show that NT-proBNP can predict these participants with 2 or more echo features [Figure 2B, AUC: 0.7043 (0.6159, 0.7928) p&lt;0.05]. The prevalence of Stage B HF among White Europeans (median age of 67 [61, 72].) was lower compared with South Asian patients: 15% had LVH, 13% had LAE, 19% had LVDD and 2% had LVSD (Figure 1A). 8% of White Europeans had at least 2 factors contributing to Stage B HF and these had higher NT-proBNP titres (368.9 [154.6, 1087.8] vs 186.8 [79.7, 411.5], p=0.02). ROC curves show that NT-proBNP can predict participants with 2 or more factors [Figure 2A, AUC: 0.6399 (0.5122, 0.7676) p&lt;0.05].

Conclusion

Our study has shown that South Asian patients with T2DM have a high prevalence of Stage B HF compared with White Europeans and that the predominant Stage B HF feature is LVDD.

We also found that NTproBNP could potentially be used to detect Stage B HF and help identify at-risk patients for cardio-protective therapy such as SGLT2 inhibitor therapy that has been shown to prevent the development of future HF events.

Funding Acknowledgement

Type of funding sources: None.

Management of Hypertension in Patients with Diabetes: A Comprehensive Review of the Perceptions and Practices of Health Care Providers in India

OBJECTIVES

This study evaluated the perception and practices of health care providers (physicians, diabetologists, and endocrinologists) regarding the treatment of hypertension in patients with diabetes in India.

METHODS

Health care providers throughout India who treated patients with diabetes and hypertension were invited to participate in an online survey and periodic 21 virtual meetings. They were questioned about their perception and practices in managing these patients, and strategies to improve blood pressure (BP).

RESULTS

The online survey was completed by 2,513 health care providers, and 344 participated in virtual meetings. More than 50% reported that 31-50% of their patients with diabetes also had hypertension. Home BP monitoring was recommended by 88%, and lifestyle modifications were consistently recommended. Choice of antihypertensive treatment varied based on comorbidities, and a renin-angiotensin system blocker plus a calcium channel blocker (CCB) was the most common combination for dual antihypertensive therapy. Suggested strategies to improve BP control included patient awareness/education, lifestyle modifications, better follow-up/monitoring, and optimization of therapy.

CONCLUSION

Indian health care providers were aware of clinical recommendations and practices regarding treatment of patients with diabetes and hypertension, and generally make clinical decisions consistent with current guidelines. Optimization of care for these patients is essential to reduce cardiovascular disease risk and improve patient outcomes.

Altered levels of neurobiological biomarkers at the interface of depression and gestational diabetes mellitus in Asian Indian women

AIM

Gestational diabetes mellitus (GDM) might predispose the mothers to depression. Studies have reported the role of biomarkers either in GDM or depression, but very few have examined them in GDM with depression. The present study profiled the circulating levels of brain-derived neurotrophic factor (BDNF), Beta Endorphin (BE) and nesfatin-1 in women with GDM (with and without depression).

METHODS

160 pregnant women at 24-28 weeks of pregnancy (NGT/GDM with & without depression, n = 40 each) were randomly selected from the ongoing STRiDE (STratification of Risk of Diabetes in Early pregnancy) study. Depression score was derived using PHQ-9 questionnaire and ELISA was used to quantify the biomarkers.

RESULTS

Circulatory levels of BDNF, BE and nesfatin-1 were lower in GDM women with or without depression compared to NGT without depression, however, nesfatin-1 levels were higher in NGT with depression. Notably, GDM with depression had the lowest levels of BDNF and BE. Both BDNF and BE levels were negatively correlated with depression, 1 h and 2 h plasma glucose. Regression analysis confirmed that each standard deviation decreases in BDNF and BE were independently associated with higher odds of GDM with or without depression even after adjusting for potential confounders.

CONCLUSION

Our study has identified altered levels of a panel of neurobiological biomarkers (BDNF/BE/nesfatin-1) in those with combined GDM and depression. BDNF/BE could be potential biomarkers to assess the higher risk of coexisting depression and GDM.

IoT based fault identification in solar photovoltaic systems using an extreme learning machine technique

Due to the shortage of fossil fuel usage, the solar Photovoltaic (PV) energy has increased grownup over the last decade. Most conventional applications of renewable energy are being phased out in order to reduce costs and save the environment. PV plants undergo numerous failures in faults detection and ultimate power developments. These consequences demonstrate in the environmental field and internal components. Even when internal standards are followed, the faults are unavoidable and undetectable. Due to this performance of manufacturing plants are not predictable. As a result, a proper fault detection mechanism is required for a PV system to detect faults and avoid energy losses. To address these issues, this research work proposed Internet of Things (IoT) sensor-based fault identification in a solar PV system. The PV panel status is monitored using pressure, light intensity, voltage, and current sensors. These sensor data’s are stored in the cloud for further analysis using a web-based control server. To classify the sensor data, models of Support Vector Machine (SVM), and Extreme Learning Machine (ELM) are utilized. The experimental results indicate that ELM achieves a classification accuracy of 96.32%. Which is higher than SVM and other optimization control techniques. The proposed model uses the IoT cloud to provide real-time monitoring and fault detection in plant environmental and electrical parameters.

Role and importance of high fiber in diabetes management in India

BACKGROUND & AIMS

India is facing a triple burden of pre-diabetes, diabetes, and obesity. Unhealthy eating habits and physical inactivity have been linked to the onset and progression of type 2 diabetes mellitus (T2DM). Despite dietary recommendations, individuals consume inadequate amounts or unsuitable type of dietary fiber (DF) which needs correction. An Expert group attempted to review and report on the role and importance of high DF in the management of T2DM and offer practical guidance on high fiber use in daily diet.

METHODOLOGY

Twelve diabetologists and two expert dietitians from India were chosen to ensure diversity of the members both in professional interest and cultural background. The authors convened virtually for one group meeting and actively participated in a detailed discussion. Multiple reviews of the draft document followed by focused teleconference calls & email helped to reach consensus on final recommendations between Aug 2021 and Dec 2021.

RESULTS

Evidence has shown that medical nutrition therapy (MNT) is a valuable approach and an essential component of T2DM prevention and management. Studies have shown that fiber rich diabetes nutrition (FDN) has multi-systemic health benefits, including, improvement in glycemic control, reduction in glucose spikes, decrease in hyperinsulinemia, improvement in plasma lipid concentrations and weight management in T2DM patients.

CONCLUSION

A high fiber diet is vital for people with diabetes and associated conditions. Increasing fiber intake, preferably through food or through dietary supplement, may help. Fiber rich diabetes nutrition (FDN) is recommended in order to prevent and manage T2DM.

Association between number of abnormal glucose values and severity of fasting plasma glucose in IADPSG criteria and maternal outcomes in women with gestational diabetes mellitus

AIMS

The International Association for Diabetes in Pregnancy Study Group (IADPSG) criteria recommend a single-step diagnostic oral glucose tolerance test (OGTT) for diagnosis of gestational diabetes mellitus (GDM). The aim of this study was to examine the association between the number of abnormal glucose values and levels of FPG with pregnancy outcomes.

METHODS

Pregnant women (n=1,044) were screened for GDM at maternity centers in South India using IADPSG criteria. OGTTs were classified based on the number of abnormal glucose values (any one value or more than one value high) and fasting plasma glucose (FPG) values (<92mg/dl,92-100mg/dl,>100mg/dl) and correlated with pregnancy outcomes. Odds ratio were adjusted for age, BMI, gestational week at diagnosis, family history of diabetes, previous history of GDM, gestational week at delivery and birth weight. For macrosomia and large for gestation age, birth weight was excluded from the model.

RESULTS

Risk of caesarean section was significantly higher in women with any one abnormal glucose value (OR: 1.49; 95%CI: 1.07-2.09). This further increased in those with >1 value (OR: 1.35; 95%CI: 0.87-2.10), when compared to women with all values normal. Risk of large for gestation age (LGA) was higher in women with FPG 92-100mg/dl (OR: 1.37; 95%CI: 0.80-2.35) and in those with FPG >100mg/dl (OR: 1.87; 95%CI: 1.04-3.35), compared to those with FPG <92mg/dl.

CONCLUSIONS

The risk for poor pregnancy outcomes starts in those with one abnormal value in the OGTT or with FPG >92mg/dl but becomes significantly higher in those with higher abnormal values.

A51 ROLE OF GUT MICROBIOTA IN THE EPISODIC NATURE OF SYMPTOMS IN IRRITABLE BOWEL SYNDROME

Background

Irritable bowel syndrome (IBS) is a complex functional gastrointestinal disorder with likely heterogenous pathophysiology, multiple symptoms, and comorbidities. Growing evidence shows that the gut microbiota composition and function are altered in IBS patients. However, identifying the critical drivers of clinical expression remains challenging due to the episodic occurrence of IBS symptoms, the inherent variability in composition of gut microbiota across individuals, and high sensitivity of gut microbiota to dietary and environmental cues.

Aims

To identify whether changes in gut microbiota composition accompany or, predict the occurrence of symptoms.

Methods

28 IBS patients (IBS-D n=20, IBS-C n=8) and 10 healthy controls (HC) were followed longitudinally for 25 weeks, collecting stool samples, and recording their symptoms weekly. Stool microbiota profiles were assessed by 16S rRNA gene sequencing using Illumina platform. The sequences were preprocessed, filtered, and annotated using DADA2 and phyloseq pipelines; statistical analyses were performed using FactomineR and microbiomeanalyst packages in R. Statistical significance was set at p<0.05.

Results

Multifactorial analysis of clinical data classified 950 samples in 6 clusters. Distribution of samples among the clusters was based on Bristol stool scale defining symptomatic periods (scores <3 and >4 indicating abnormal stool) and asymptomatic periods (scores 3 or 4), with several gut and mood symptoms varying significantly between the two categories. IBS-D patients, but not IBS-C patients presented with changes in symptoms severity, such as pain, diarrhea, constipation, and anxiety during the symptomatic periods. Depression scores were, however, higher in IBS-C compared to IBS-D patients. In contrast, immune makers such as fecal b-defensin-2 and calprotectin were higher during asymptomatic periods in IBS-D, but not in IBS-C patients. Bacterial diversity profiles differed among IBS patients (IBS-D and IBS-C) and HC, namely Shannon index and Bray-Curtis distance, but they did not change significantly between the symptomatic and asymptomatic periods within each subtype. Despite this, several bacterial taxa unique to each cluster were identified using linear mixed models.

Conclusions

Our results demonstrate the need to study patterns of co-occurrence of IBS symptoms and their severity during symptomatic and asymptomatic periods to better understand the role of identified bacterial taxa in the symptom generation. Identifying their temporal changes and cross-feeding patterns in individual patients will shed light on the underlying mechanistic role of gut microbiota in IBS, which might be otherwise obscured by group generalizations.

Funding Agencies

CIHR

COVID-19 and tobacco cessation: lessons from India

OBJECTIVES

The Government of India prohibited the sale of tobacco products during the COVID-19 lockdown to prevent the spread of the SARS-CoV-2 virus. This study assessed the tobacco cessation behaviour and its predictors among adult tobacco users during the initial COVID-19 lockdown period in India.

METHODS

A cross-sectional study was conducted with 801 adult tobacco users (both smoking and smokeless tobacco) in two urban metropolitan cities of India over a 2-month period (July to August 2020). The study assessed complete tobacco cessation and quit attempts during the lockdown period. Logistic and negative binomial regression models were used to study the correlates of tobacco cessation and quit attempts, respectively.

RESULTS

In total, 90 (11.3%) tobacco users reported that they had quit using tobacco after the COVID-19 lockdown period. Overall, a median of two quit attempts (interquartile range 0-6) was made by tobacco users. Participants with good knowledge on the harmful effects of tobacco use and COVID-19 were significantly more likely to quit tobacco use (odds ratio [OR] 2.2; 95% confidence interval [CI] 1.2-4.0) and reported more quit attempts (incidence risk ratio 5.7; 95% CI 2.8-11.8) compared to those with poor knowledge. Participants who had access to tobacco products were less likely to quit tobacco use compared to those who had no access (OR 0.3; 95% CI 0.2-0.5].

CONCLUSIONS

Access restrictions and correct knowledge on the harmful effects of tobacco use and COVID-19 can play an important role in creating a conducive environment for tobacco cessation among users.

COVID-19 associated mucormycosis: A Descriptive Multisite Study from India

BACKGROUND AND AIMS

Mucormycosis is an invasive fungal infection and carries a significant morbidity and mortality. A number of cases of mucormycosis have been reported in association with COVID-19. In this study, a consortium of clinicians from various parts of India studied clinical profile of COVID-19 associated mucormycosis (CAM) and this analysis is presented here.

METHODS

Investigators from multiple sites in India were involved in this study. Clinical details included the treatment and severity of COVID-19, associated morbidities, as well as the diagnosis, treatment and prognosis of mucormycosis. These data were collected using google spreadsheet at one centre. Descriptive analysis was done.

RESULTS

There were 115 patients with CAM. Importantly, all patients had received corticosteroids. Diabetes was present in 85.2% of patients and 13.9% of patients had newly detected diabetes. The most common site of involvement was rhino-orbital. Mortality occurred in 25 (21.7%) patients. On logistic regression analysis, CT scan-based score for severity of lung involvement was associated with mortality.

CONCLUSION

Universal administration of corticosteroids in our patients is notable. A large majority of patients had diabetes, while mortality was seen in ∼1/5th of patients, lower as compared to recently published data.

The ORNATE India project: Building research capacity and capability to tackle the burden of diabetic retinopathy-related blindness in India

The ORNATE India project is an interdisciplinary, multifaceted United Kingdom (UK)–India collaborative study aimed to build research capacity and capability in India and the UK to tackle the burden of diabetes-related visual impairment. For 51 months (October 2017–December 2021), this project built collaboration between six institutions in the UK and seven in India, including the Government of Kerala. Diabetic retinopathy (DR) screening models were evaluated in the public system in Kerala. An epidemiological study of diabetes and its complications was conducted through 20 centers across India covering 10 states and one union territory. The statistical analysis is not yet complete. In the UK, risk models for diabetes and its complications and artificial intelligence-aided tools are being developed. These were complemented by joint studies on various aspects of diabetes between collaborators in the UK and India. This interdisciplinary team enabled increased capability in several workstreams, resulting in an increased number of publications, development of cost-effective risk models, algorithms for risk-based screening, and policy for state-wide implementation of sustainable DR screening and treatment programs in primary care in Kerala. The increase in research capacity included multiple disciplines from field workers, administrators, project managers, project leads, screeners, graders, optometrists, nurses, general practitioners, and research associates in various disciplines. Cross-fertilization of these disciplines enabled the development of several collaborations external to this project. This collaborative project has made a significant impact on research capacity development in both India and the UK.

The effect of eating on the uptake of PSMA ligands in the salivary glands

Rationale

PSMA-directed therapy for metastatic prostate cancer is gaining adoption as a treatment option. However, accumulation of ¹⁷⁷Lu/²²⁵Ac-PSMA in the salivary glands remains a problem, with risk of dose-limiting xerostomia and potentially severe effect on the quality of life. Gustatory stimulation is an approach that has commonly been used in radioactive iodine therapy to reduce accumulation in the salivary glands. However, based on theoretical differences in biodistribution, it was hypothesized that this could potentially lead to adverse increased toxicity for PSMA-ligand therapy. The primary objective of this work was to determine if gustatory stimulation by eating an assortment of sweet/fatty/acidic foods during the biodistribution phase of [¹⁸F]DCFPyl could result in a clinically relevant (> 30%) change in the uptake of the tracer in the salivary glands.

Methods

10 patients who already received a whole-body [¹⁸F]DCFPyl PET/CT scan for evaluation of prostate cancer, underwent a repeat (intervention) PET/CT scan within a month of the first (control) scan. During the intervention scan, patients chose from an assortment of sweet/fatty/acidic foods, which they then chewed and swallowed for a period of time starting 1 min before tracer administration to 10 min thereafter. Data from both scans were analyzed by placing VOIs on the major salivary glands and segmenting them using relative thresholds.

Results

A slight increase in PSMA uptake in the parotid glands was observed on the intervention scan when compared to the baseline scan (+ 7.1% SUL_mean and + 9.2% SUL_max, p < 0.05). No significant difference in PSMA uptake in the submandibular glands was seen.

Conclusions

Eating only slightly increases uptake of [¹⁸F]DCFPyl in the parotid glands. We nonetheless recommend refraining from gustatory stimulation during the administration and early biodistribution phase of radionuclide therapy with PSMA-ligands to reduce the risk of avoidable additional toxicity.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13550-021-00838-y.

Decreased Sestrin levels in patients with type 2 diabetes and dyslipidemia and their association with the severity of atherogenic index

PURPOSE

We earlier reported that Sestrin2 regulates monocyte activation and atherogenic events through AMPK-mTOR nexus under high-glucose and dyslipidemic conditions. However, the statuses of Sestrins in diabetes and dyslipidemia are not known. We report here on the status of Sestrins and their association with diabetic dyslipidemia and atherosclerosis.

METHODS

Individuals with normal glucose tolerance (NGT) (n = 46), dyslipidemia (n = 42), and patients with Type 2 diabetes with (n = 41) and without dyslipidemia (n = 40) were recruited from a tertiary diabetes centre, Chennai, India to study the mRNA expression levels of Sestrins (1, 2, and 3) in monocytes by RT-qPCR. Serum levels of Sestrins were measured using ELISA. Atherogenic index of plasma was calculated as log (triglyceride/HDL).

RESULTS

mRNA expressions of Sestrin1 and Sestrin3 were significantly reduced in monocytes under dyslipidemic conditions but not in diabetes condition. Interestingly, Sestrin2 mRNA expression was significantly reduced in all disease conditions including dyslipidemia, and diabetes with and without dyslipidemia. Sestrin2 mRNA levels were negatively correlated with glycemic and lipid parameters and plasma atherogenic index. Furthermore, circulatory Sestrin2 was also found to be significantly decreased in dyslipidemia (415.2 ± 44.7 pg/ml), diabetes (375 ± 45 pg/ml), and diabetes with dyslipidemia (319.2 ± 26.3 pg/ml) compared to NGT (706.3 ± 77 pg/ml) and negatively correlated with glycemic, lipid parameters, and plasma atherogenic index.

CONCLUSION

We report for the first time that Sestrins levels are significantly decreased in diabetes and dyslipidemic conditions. More strikingly, Sestrin2 had a strong association with atherogenic risk factors and severity of atherogenic index and we suggest that Sestrin2 may be used as a biomarker for assessing atherogenesis.

Race/ethnicity and challenges for optimal insulin therapy

AIMS

We aimed to review insulin dosing recommendations, insulin regulation and its determinants, glycaemic response to carbohydrates, and the efficacy and safety of insulin therapy in different races/ethnicities.

METHODS

We searched for articles in PubMed and Google Scholar databases up to 31 March 2021, with the following keywords: "ethnicity", "diabetes", "insulin", "history of insulin", "insulin therapy", "food/rice", "carbohydrate intake", "insulin resistance", "BMI", "insulin dosing", "insulin sensitivity", "insulin response", "glycaemic index", "glycaemic response", "efficacy and safety", with interposition of the Boolean operator "AND".In addition, we reviewed the reference lists of the articles found.

RESULTS

The differential effect of race/ethnicity has not yet been considered in current insulin therapy guidelines. Nevertheless, body size and composition, body mass index, fat distribution, diet, storage, and energy expenditure vary significantly across populations. Further, insulin sensitivity, insulin response, and glycaemicresponse to carbohydrates differ by ethnicity. These disparities may lead to different insulin requirements, adversely impacting the efficacy and safety of insulin therapy among ethnic groups.

CONCLUSIONS

Race/ethnicity affects glucose metabolism and insulin regulation.Until now, international guidelines addressing racial/ethnic-specific clinical recommendations are limited. Comprehensive updated insulin therapy guidelines by ethnicity are urgently needed.

Muscarinic inhibition of salivary glands with glycopyrronium bromide does not reduce the uptake of PSMA-ligands or radioiodine

RATIONALE

Salivary glands are highly perfused and express the prostate-specific membrane antigen (PSMA) receptor as well as the sodium-iodide symporter. As a consequence, treatment with ¹⁷⁷Lu/²²⁵Ac-PSMA for prostate cancer or ¹³¹I for thyroid cancer leads to a high radiation dose in the salivary glands, and patients can be confronted with persistent xerostomia and reduced quality of life. Salivation can be inhibited using an antimuscarinic pharmaceutical, such as glycopyrronium bromide (GPB), which may also reduce perfusion. The primary objective of this work was to determine if inhibition with GPB could provide a considerable (> 30%) reduction in the accumulation of administered ¹²³I or ⁶⁸Ga-PSMA-11 in salivary glands.

METHODS

Ten patients who already received a whole-body ⁶⁸Ga-PSMA-11 PET/CT scan for (re)staging of prostate cancer underwent a repeat PET/CT scan with tracer administration at 90 min after intravenous injection of 0.2 mg GPB. Four patients in follow-up after thyroid cancer, who had been treated with one round of ablative ¹³¹I therapy with curative intent and had no signs of recurrence, received ¹²³I planar scintigraphy at 4 h after tracer administration without GPB and a repeated scan at least one week later, with tracer administration at 30 min after intramuscular injection of 0.4 mg GPB. Tracer uptake in the salivary glands was quantified on PET and scintigraphy, respectively, and values with and without GPB were compared.

RESULTS

No significant difference in PSMA uptake in the salivary glands was seen without or with GPB (Mean SUL_mean parotid glands control 5.57, intervention 5.72, p = 0.50. Mean SUL_mean submandibular glands control 6.25, intervention 5.89, p = 0.12). Three out of 4 patients showed increased ¹²³I uptake in the salivary glands after GPB (Mean counts per pixel control 8.60, intervention 11.46).

CONCLUSION

Muscarinic inhibition of salivation with GPB did not significantly reduce the uptake of PSMA-ligands or radioiodine in salivary glands, and can be dismissed as a potential strategy to reduce toxicity from radionuclide therapies.

The increasing potential of nuclear medicine imaging for the evaluation and reduction of normal tissue toxicity from radiation treatments

Radiation therapy is an effective treatment modality for a variety of cancers. Despite several advances in delivery techniques, its main drawback remains the deposition of dose in normal tissues which can result in toxicity. Common practices of evaluating toxicity, using questionnaires and grading systems, provide little underlying information beyond subjective scores, and this can limit further optimization of treatment strategies. Nuclear medicine imaging techniques can be utilised to directly measure regional baseline function and function loss from internal/external radiation therapy within normal tissues in an in vivo setting with high spatial resolution. This can be correlated with dose delivered by radiotherapy techniques to establish objective dose-effect relationships, and can also be used in the treatment planning step to spare normal tissues more efficiently. Toxicity in radionuclide therapy typically occurs due to undesired off-target uptake in normal tissues. Molecular imaging using diagnostic analogues of therapeutic radionuclides can be used to test various interventional protective strategies that can potentially reduce this normal tissue uptake without compromising tumour uptake. We provide an overview of the existing literature on these applications of nuclear medicine imaging in diverse normal tissue types utilising various tracers, and discuss its future potential.

Impact on health and provision of healthcare services during the COVID-19 lockdown in India: a multicentre cross-sectional study

INTRODUCTION

The COVID-19 pandemic resulted in a national lockdown in India from midnight on 25 March 2020, with conditional relaxation by phases and zones from 20 April. We evaluated the impact of the lockdown in terms of healthcare provisions, physical health, mental health and social well-being within a multicentre cross-sectional study in India.

METHODS

The SMART India study is an ongoing house-to-house survey conducted across 20 regions including 11 states and 1 union territory in India to study diabetes and its complications in the community. During the lockdown, we developed an online questionnaire and delivered it in English and seven popular Indian languages (Hindi, Tamil, Marathi, Telegu, Kannada, Bengali, Malayalam) to random samples of SMART-India participants in two rounds from 5 May 2020 to 24 May 2020. We used multivariable logistic regression to evaluate the overall impact on health and healthcare provision in phases 3 and 4 of lockdown in red and non-red zones and their interactions.

RESULTS

A total of 2003 participants completed this multicentre survey. The bivariate relationships between the outcomes and lockdown showed significant negative associations. In the multivariable analyses, the interactions between the red zones and lockdown showed that all five dimensions of healthcare provision were negatively affected (non-affordability: OR 1.917 (95% CI 1.126 to 3.264), non-accessibility: OR 2.458 (95% CI 1.549 to 3.902), inadequacy: OR 3.015 (95% CI 1.616 to 5.625), inappropriateness: OR 2.225 (95% CI 1.200 to 4.126) and discontinuity of care: OR 6.756 (95% CI 3.79 to 12.042)) and associated depression and social loneliness.

CONCLUSION

The impact of COVID-19 pandemic and lockdown on health and healthcare was negative. The exaggeration of income inequality during lockdown can be expected to extend the negative impacts beyond the lockdown.

Health and economic impact of air pollution in the states of India: the Global Burden of Disease Study 2019

BACKGROUND

The association of air pollution with multiple adverse health outcomes is becoming well established, but its negative economic impact is less well appreciated. It is important to elucidate this impact for the states of India.

METHODS

We estimated exposure to ambient particulate matter pollution, household air pollution, and ambient ozone pollution, and their attributable deaths and disability-adjusted life-years in every state of India as part of the Global Burden of Disease Study (GBD) 2019. We estimated the economic impact of air pollution as the cost of lost output due to premature deaths and morbidity attributable to air pollution for every state of India, using the cost-of-illness method.

FINDINGS

1·67 million (95% uncertainty interval 1·42-1·92) deaths were attributable to air pollution in India in 2019, accounting for 17·8% (15·8-19·5) of the total deaths in the country. The majority of these deaths were from ambient particulate matter pollution (0·98 million [0·77-1·19]) and household air pollution (0·61 million [0·39-0·86]). The death rate due to household air pollution decreased by 64·2% (52·2-74·2) from 1990 to 2019, while that due to ambient particulate matter pollution increased by 115·3% (28·3-344·4) and that due to ambient ozone pollution increased by 139·2% (96·5-195·8). Lost output from premature deaths and morbidity attributable to air pollution accounted for economic losses of US$28·8 billion (21·4-37·4) and $8·0 billion (5·9-10·3), respectively, in India in 2019. This total loss of $36·8 billion (27·4-47·7) was 1·36% of India's gross domestic product (GDP). The economic loss as a proportion of the state GDP varied 3·2 times between the states, ranging from 0·67% (0·47-0·91) to 2·15% (1·60-2·77), and was highest in the low per-capita GDP states of Uttar Pradesh, Bihar, Rajasthan, Madhya Pradesh, and Chhattisgarh. Delhi had the highest per-capita economic loss due to air pollution, followed by Haryana in 2019, with 5·4 times variation across all states.

INTERPRETATION

The high burden of death and disease due to air pollution and its associated substantial adverse economic impact from loss of output could impede India's aspiration to be a $5 trillion economy by 2024. Successful reduction of air pollution in India through state-specific strategies would lead to substantial benefits for both the health of the population and the economy.

FUNDING

UN Environment Programme; Bill & Melinda Gates Foundation; and Indian Council of Medical Research, Department of Health Research, Ministry of Health and Family Welfare, Government of India.

Incidence and Predictors of Dysglycemia and Regression to Normoglycemia in Indian Adolescents and Young Adults: 10-Year Follow-Up of the ORANGE Study

Background: The prevalence of diabetes in youth is increasing worldwide in parallel with the obesity epidemic. This study aimed to determine the incidence rates of dysglycemia (diabetes or prediabetes) and evaluate the predictors of its progression or regression to normal glucose tolerance (NGT) in a cohort of children and adolescents studied in Chennai, South India. Methods: A longitudinal follow-up of the Obesity Reduction and Awareness of Noncommunicable Diseases through Group Education (ORANGE) cohort was performed after a median of 7.1 years (n = 845; 5928 person-years of follow-up). To determine their diabetes status at follow-up, participants underwent an oral glucose tolerance test (n = 811 with NGT and 34 with prediabetes at baseline), excluding those with diabetes at baseline. Incidence rates for dysglycemia were reported per 1000 person-years of follow-up. Cox proportional hazards model was used to estimate the predictors of progression and regression. Results: Out of 811 individuals with NGT at baseline, 115 developed dysglycemia giving an incidence rate of 20.2 per 1000 person-years (95% confidence interval: 16.8-24.2). Among those with prediabetes at baseline, 70.6% of the individuals converted to NGT and the remaining 29.4% either got converted to diabetes or remained as prediabetes. Higher age, body mass index, fasting plasma glucose, 2-hour plasma glucose (2-h PG), positive family history of diabetes, and systolic blood pressure (BP) were independent predictors of incident dysglycemia, whereas lower age, waist circumference, 2-h PG, systolic BP, and triglycerides predicted regression to normoglycemia. Conclusions: This study highlights the growing burden of dysglycemia in Asian Indian youth and emphasizes the need for targeted preventive actions.

The increased risk of microvascular complications in South Asians with type 1 diabetes is influenced by migration

AIM

We aimed to explore the association between South Asian ethnicity and complications of type 1 diabetes, and whether this is affected by migration.

METHODS

In this retrospective cohort study, data on diabetes control and complications were obtained for South Asians in India (South Asians_India , n = 2592) and the UK (South Asians_UK , n = 221) and white Europeans in the UK (n = 1431). Multivariable logistic regression was used to identify associations between ethnicity and diabetic kidney disease, retinopathy and neuropathy adjusting for age, sex, BMI, disease duration, HbA_1c , blood pressure (BP) and cholesterol.

RESULTS

South Asians_India had significantly greater adjusted odds of diabetic kidney disease [odds ratio (OR) 5.0, 95% confidence intervals (CI) 3.6-7.1] and retinopathy (OR 1.8, 95% CI 1.2-2.5), but lower odds of neuropathy (OR 0.5, 95% CI 0.4-0.6) than white Europeans. South Asians_India had significantly greater adjusted odds of diabetic kidney disease (OR 3.0, 95% 1.8-5.3) than South Asians_UK , but there was no significant difference in the odds of other complications.

CONCLUSIONS

In this hypothesis-generating study, we report that South Asian ethnicity is associated with greater risk of diabetic kidney disease and retinopathy, and lower risk of neuropathy than white European ethnicity. Part of the excess diabetic kidney disease risk is reduced in South Asians_UK . These associations cannot be accounted for by differences in vascular risk factors. Our findings in South Asians with type 1 diabetes mirror previous findings in type 2 diabetes and now need to be validated in a study of the effect of ethnicity on type 1 diabetes complications where healthcare is provided in the same setting.

Healthcare utilisation and expenditure patterns for cardio-metabolic diseases in South Asian cities: the CARRS Study

OBJECTIVE

To estimate average annual expenditures per person, total economic burden and distress health financing associated with the treatment of five cardio-metabolic diseases (CMDs-hypertension, diabetes, heart disease (angina, myocardial infarction and heart failure), stroke and chronic kidney disease) in three metropolitan cities in South Asia.

DESIGN

Cross-sectional surveys.

SETTING

We analysed community-based baseline data from the Centre for cArdio-metabolic Risk Reduction in South Asia (CARRS) Study collected in 2010-2011 representing Chennai and New Delhi (India), and Karachi (Pakistan).

PARTICIPANTS

We used data from non-pregnant adults (≥20 years) from the aforementioned cities that responded to a cost-of-illness questionnaire. We estimated health utilisation and expenditures among those reporting taking treatment(s) for the aforementioned CMDs in the last 1 year. We converted all costs to International Dollars (Int$ 2011) and inflated to 2018 values. The annual costs per person were stratified by city, sociodemographic characteristics, contributor of costs and financing methods. The total economic burden of CMDs for each city was projected using age-standardised prevalence and per-person costs of diseases reported in CARRS, applying these to population data from the most recent census. We also calculated distress financing (DF) as having to borrow or sell assets to pay for CMD treatment and identified sociodemographic groups at most risk of DF using multiple regression.

RESULTS

Of 16 287 CARRS participants, 2883 (17.7%) reported receiving treatment for CMDs. The total annual expenditures reported per patient for CMDs ranged from Int$358 to Int$2425. Medications constituted 46% of total direct expenditures and out-of-pocket (OOP) expenditures accounted for nearly 80% of financing these health expenditures. Total economic burdens of CMDs were Int$0.42 billion, Int$3.4 billion and Int$1.4 billion in Chennai, New Delhi and Karachi, respectively. Overall, 36.1% experienced DF, and women (OR=4.4), unemployed (OR=10.7) and uninsured (OR=8.1) adults experienced higher odds of DF.

CONCLUSION

CMDs are associated with large economic burdens in South Asia. Due to most payments coming from OOP expenditures and limited insurance, the odds of DF are high.

A ProspectIve, OpeN-Label, Randomized Study Comparing EffIcacy and Safety of Teneligliptin VErsus Sitagliptin in Indian Patients with Inadequately Controlled Type 2 Diabetes Mellitus: INSITES Study

BACKGROUND

Teneligliptin is widely prescribed dipeptidyl peptidase-4 inhibitor (DPP-4i) in India because of its economical pricing. However, there is no headto-head trial comparing teneligliptin with any other DPP-4i in Indian setting. We evaluated the efficacy and safety of teneligliptin versus sitagliptin as add-on to metformin and/or sulfonylureas in patients with type 2 diabetes mellitus (T2DM).

METHODS

This prospective, open-label, randomized, active-controlled study enrolled 76 patients (1:1) at 2 centres. Patients received teneligliptin 20 mg or sitagliptin 100 mg orally once daily for 12 weeks as add-on to ongoing metformin or sulfonylurea therapy. Primary endpoint was mean change in glycosylated hemoglobin (HbA1c) from baseline at week 12.

RESULTS

Both arms were comparable (p>0.05) at baseline in terms of age, gender, metformin daily dose, sulfonylurea use, HbA1c, fasting and postprandial blood glucose (FBG and PPBG). At the end of 12 weeks, statistically significant reductions were observed in both teneligliptin and sitagliptin arms in HbA1c (-1.19 ± 1.16% p<0.0001 and -0.92 ± 0.95%, p<0.0001), in FBG (-28.3 ± 63.0 mg/dL, p= 0.01 and -22.9 ± 47.4 mg/dL, p=0.006) and PPBG (-41.3 ± 85.4 mg/dL, p=0.006 and -54.7 ± 85.6 mg/dL, p=0.0005). The reductions in all glycemic parameters were similar between the arms. Both gliptins were well-tolerated with no difference in the number of adverse events. There was no change in QT/QTc intervals or other ECG parameters at week 12 in both arms. In post-hoc comparison, percentage of patients achieving target HbA1c <7% (as per American Diabetes Association guidelines) at week 12 favored teneligliptin arm over sitagliptin arm (33.3% vs. 19.4% patients).

CONCLUSION

Teneligliptin provided similar glycemic control as compared to sitagliptin and reduced HbA1c, FBG and PPBG values significantly within 12 weeks of treatment. Both gliptins were found to be safe and well-tolerated in Indian patients with T2DM.

Isolated HbA1c identifies a different subgroup of individuals with type 2 diabetes compared to fasting or post-challenge glucose in Asian Indians: The CARRS and MASALA studies

AIMS

Guidelines recommend hemoglobin A1c (HbA1c) as a diagnostic test for type 2 diabetes, but its accuracy may differ in certain ethnic groups.

METHODS

The prevalence of type 2 diabetes by HbA1c, fasting glucose, and 2 h glucose was compared in 3016 participants from Chennai and Delhi, India from the CARRS-2 Study to 757 Indians in the U.S. from the MASALA Study. Type 2 diabetes was defined as fasting glucose ≥ 7.0 mmol/L, 2-h glucose ≥ 11.1 mmol/L, or HbA1c ≥ 6.5%. Isolated HbA1c diabetes was defined as HbA1c ≥ 6.5% with fasting glucose < 7.0 mmol/L and 2 h glucose < 11.1 mmol/L.

RESULTS

The age, sex, and BMI adjusted prevalence of diabetes by isolated HbA1c was 2.9% (95% CI: 2.2-4.0), 3.1% (95% CI: 2.3-4.1), and 0.8% (95% CI: 0.4-1.8) in CARRS-Chennai, CARRS-Delhi, and MASALA, respectively. The proportion of diabetes diagnosed by isolated HbA1c was 19.4%, 26.8%, and 10.8% in CARRS-Chennai, CARRS-Delhi, and MASALA respectively. In CARRS-2, individuals with type 2 diabetes by isolated HbA1c milder cardio-metabolic risk than those diagnosed by fasting or 2-h measures.

CONCLUSIONS

In Asian Indians, the use of HbA1c for type 2 diabetes diagnosis could result in a higher prevalence. HbA1c may identify a subset of individuals with milder glucose intolerance.

IMPACT India: Insights for Insulin Therapy in Routine Clinical Practice

OBJECTIVE

Widely used in the management of diabetes, insulin therapy is influenced by several patient preferences and physician choices. This article reports the findings of the IMPACT survey, designed to assess insights on various factors which influence the choice of insulin therapy in India.

METHODS

We administered a questionnaire which focused on the practice and patient profiles and the preferred regimens in specific clinical situations using a case scenario. Respondents were asked about preferred insulin regimens for various phases of life, comorbid conditions, dietary choices and psychological factors.

RESULTS

Overall, 314 doctors participated in the survey. Majority were general physicians (51%) and diabetologists (37%). In clinical practice, the most preferred regimens included premix insulin BD in adults (59%) and elderly (53%), and basal bolus therapy in pregnant women (>47%) and in acute illness (62%). Both regimens were equally preferred for symptomatic patients (41% basal bolus and 38% premix insulin) and those with renal or hepatic failure (36% each). Premix insulin was preferred for patients with high carbohydrate intake (73%) while basal bolus was preferred for patients with variable meal timings (39%) and in pronounced postprandial glucose excursions (45%). Insulin co-formulation and high-mix insulins were not a part of the survey questionnaire.

SUMMARY

Indian physicians exercise logic in the choice of insulin regimens. Preference is based on patient characteristics including glucophenotype, dietary patterns, psychosocial needs, clinical situations, and comorbid conditions.

Feasibility and Results of Cancer Registry and Noncommunicable Disease Cohort Data Linkages in India

Background: Cancer registries worldwide are vital to determine cancer burden, plan cancer control measures, and facilitate research. Population-based cancer registries are a priority for LMICs by the UICC; the National Cancer Registry Program (NCRP) of India oversees 28 such registries. A primary function of registries is to combine data for the same individual from multiple sources. For other disease cohorts where cancer is an outcome of interest, registries can potentially connect information by linking datasets together. Barriers to successful registration and linkages include systems in which cancer is not a notifiable disease, no universal unique individual identifier exists, and lack of trained personnel. This study utilizes technology and infrastructure to develop better linkages, surveillance, and outcomes. Aim: To assess the feasibility of linking large cohorts designed for cardio-metabolic disease research with cancer registries in New Delhi and Chennai; determine additional steps required for linkage accuracy and completeness; and develop detailed protocols for future applications. Methods: A pilot protocol for linkage between a large diabetes cohort and cancer registries in Delhi and Chennai was developed using MatchPro, a probabilistic record linkage program developed for cancer registries. Probabilistic software links datasets together in the presence of uncertainty (eg misspelled or abbreviated names) to identify record pairs with high probability of representing the same individual. For this study, algorithms were developed to address unique aspects of names and demographics in India. The software and algorithms focused on: detecting duplicates in cancer registries; and linking registries with external files from diabetes cohorts. In Delhi, 3 1-year datasets covering 3 years (2010, 2011, 2012) were linked with the diabetes cohort; in Chennai, the linkage included 3 5-year datasets covering 15 years (2000-04, '05-'09, '10-'14). The unique ID (Aadhaar) is not collected or linked systematically between different systems at this point in time. Results: Linkage attempts yielded potential matches ranked according to probabilistic scores; highest scores were reviewed to determine true matches. In Chennai, this process yielded: (2010-2014) 21% self-reported (SR) cases matching perfectly, 36% requiring follow-up, 13 nonreported (NR) cases found; 2005-2009: 33% SR cases matched perfectly, 1 NR case found; 2000-2004: 1 NR case. Also, 2 training workshops on data linkages and software were held. Conclusion: Linkages between cancer registries and other data sources are feasible in LMICs using probabilistic record linkage software augmented by manual matching. Future efforts to use existing epidemiologic resources (cohorts) and cancer research infrastructure (registries and clinical centers) can enhance research including understanding shared risk factors and pathophysiologic mechanisms e.g., between cancer and other NCD.

Norfloxacin salts of carboxylic acids curtail planktonic and biofilm mode of growth in ESKAPE pathogens

AIMS

To enhance the antimicrobial and antibiofilm activity of norfloxacin against the planktonic and biofilm mode of growth in ESKAPE pathogens using chemically modified norfloxacin salts.

METHODS AND RESULTS

Antimicrobial testing, synergy testing and time-kill curve analysis were performed to evaluate antibacterial effect of norfloxacin carboxylic acid salts against ESKAPE pathogens. In vivo efficacy to reduce bacterial bioburden was evaluated in zebrafish infection model. Crystal violet assay and live-dead staining were performed to discern antibiofilm effect. Membrane permeability, integrity and molecular docking studies were carried out to ascertain the mechanism of action. The carboxylic acid salts, relative to parent molecule norfloxacin, displayed two- to fourfold reduction in minimum inhibitory concentration against Staphylococcus aureus and Pseudomonas aeruginosa, in addition to displaying potent bacteriostatic effect against certain members of ESKAPE pathogens. In vivo treatments revealed that norfloxacin tartrate (SRIN2) reduced MRSA bioburden by greater than 1 log fold relative to parent molecule in the muscle tissue. In silico docking with gyrA of S. aureus showed increased affinity of SRIN2 towards DNA gyrase. The enhanced antibacterial effect of norfloxacin salts could be partially accounted by altered membrane permeability in S. aureus and perturbed membrane integrity in P. aeruginosa. Antibiofilm studies revealed that SRIN2 (norfloxacin tartrate) and SRIN3 (norfloxacin benzoate) exerted potent antibiofilm effect particularly against Gram-negative ESKAPE pathogens. The impaired colonization of both S. aureus and P. aeruginosa due to improved norfloxacin salts was further supported by live-dead imaging.

CONCLUSION

Norfloxacin carboxylic acid salts can act as potential alternatives in terms of drug resensitization and reuse.

SIGNIFICANCE AND IMPACT OF THE STUDY

Our study shows that carboxylic acid salts of norfloxacin could be effectively employed to treat both planktonic- and biofilm-based infections caused by select members of ESKAPE pathogens.