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   Table of Contents - Current issue
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January-February 2018
Volume 22 | Issue 1
Page Nos. 1-177

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EDITORIAL  

Trimester-specific thyroid-stimulating hormone: An Indian perspective Highly accessed article p. 1
Sanjay Kalra, Sameer Agarwal, Rashmi Aggarwal, Salam Ranabir
DOI:10.4103/ijem.IJEM_107_17  PMID:29535927
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ORIGINAL ARTICLES Top

Normative Trimester-Specific Thyroid Function Data from India: The State of the Nation Highly accessed article p. 5
Subramanian Kannan, Sanjay Kalra
DOI:10.4103/ijem.IJEM_596_17  PMID:29535928
Background: International guidelines recommend using local trimester-specific normative data for TSH (thyroid stimulating hormone). However, there are no unified Indian data for the same. Material and Methods: This review collates recently published data from various Indian centres and discusses the state of trimester-specific TSH ranges in the country. Results: The authors describe the strengths and limitations of available data, and support the need for pan-India data. Conclusion: To ensure effective screening and action, harmonized research is necessary to establish national normative data for TSH in India.
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A systematic review on normative values of trimester-specific thyroid function tests in Indian women Highly accessed article p. 7
Subramanian Kannan, Shriraam Mahadevan, Alben Sigamani
DOI:10.4103/ijem.IJEM_211_17  PMID:29535929
Background: Small cross-sectional studies are published on the trimester-specific normal ranges of thyrotropin and thyroxine levels in Indian women from various parts of the country. Objective: We sought to review the published literature on thyroid function tests in normal pregnant Indian women to see if the pooled data from various studies can define normative data and hypothyroidism in pregnancy. Methods: We retrieved 56 studies from online databases with detailed search using multiple search terms. Unanimously eight studies were finalized. Results: Data of 2703 pregnant women (age 16–45 years; 966 were in the first trimester, 1072 in their second trimester, and 1037 women in their third trimester) were analyzed. All eight studies included singleton pregnancies from the northern and eastern part of India with seven studies being cross-sectional in nature. The exclusion criteria in all studies included those with historical/clinical evidence of thyroid dysfunction, those with family history of thyroid dysfunction, infertility and those with history of recurrent miscarriages (usually >3). Ultrasound evidence of thyroid disease, urinary iodine assessment, and thyroid antibodies were included as additional exclusion criteria in two, three, and four studies, respectively. None of the studies included the outcome of pregnancy as part of follow-up. As part of the pooled data analysis, the 5th–95th centile values of normal TSH extended from 0.09 to 6.65 IU/mL in the first trimester, 0.39–6.61 IU/mL in the second trimester, and 0.70–5.18 IU/mL in the third trimester. The FT4 levels (5th–95th centile values) extended from 8.24 to 25.74 pmol/L in the first trimester, 6.82–26.0 pmol/L, and 5.18–25.61 pmol/L in the third trimester. Conclusions: With due limitations imposed by the quality of the available studies, the current review suggests that upper normal limit of TSH values can extend up to 5–6 IU/mL in pregnancy.
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Prevalence of hypothyroidism in term pregnancies in North India Highly accessed article p. 13
Bharti Kalra, Meenu Choudhary, Meenakshi Thakral, Sanjay Kalra
DOI:10.4103/ijem.IJEM_189_17  PMID:29535930
Background: Hypothyroidism is common in pregnancy. No study has determined the prevalence of hypothyroidism in term pregnancies in India. Aim: This study aims to determine the prevalence and correlates of hypothyroidism in women who delivered at a center in Karnal, Haryana, North India. Results: Indoor records of all women who had delivered at this centre from April 2016 to March 2017 were reviewed. The prevalence of hypothyroidism was 12.3%, of which 15.5% were diagnosed during pregnancy. The dose requirement of L-thyroxine ranged from 25 to 200 μg (mean 76.38 +- 43.02). With this, 80% were able to achieve trimester-specific thyroid-stimulating hormone targets. Hypothyroidism did not correlate with any medical or obstetric complications. Conclusion: Hypothyroidism is common in term pregnancies. If treated adequately, healthy fetomaternal outcomes can be achieved.
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Maternal and infantile adiponectin as marker for anthropometric parameters of lactating mothers and their breast-fed infants p. 16
Ahmed Ragab Fakhreldin
DOI:10.4103/ijem.IJEM_249_17  PMID:29535931
Background: Breast milk adiponectin could play a role in the regulation of infants' growth during lactation. Aim of Work: The aim is to evaluate adiponectin concentration in human milk and to investigate its relationship with serum adiponectin concentration in lactating mothers and their breastfed infants and with anthropometric parameters of infants and mothers. Materials and Methods: Sixty healthy term infants and their healthy lactating mothers are included at infant age of 1 month then repeated again at the age of 4 months. All subjects included in this study were subjected to history, clinical examination, investigations including serum level of adiponectin of infants and their mothers by RIA test, human milk level of adiponectin by ELISA test. Results: There was a significant decrease in serum adiponectin of infant and mothers and maternal breast milk at the age of 4 months when compared to them at the age of 1 month. There was a significant positive correlation between infant serum adiponection, maternal serum adiponectin and breast milk adiponectin at infant's age of 1 month and at infant's age of 4 months. There was a significant negative correlation between maternal serum adiponectin and BMI of mothers. There was a significant negative correlation between infant serum adiponectin and their weight and length of infants at the age of 1 month and at the age of 4 months. Conclusions: There's a metabolic link between mothers and their infants through breast milk during the first 6 months of life. A gradual decline in adiponectin level in maternal breast milk is associated with a gradual increase in infant growth up to 6 months of age.
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Prevalence of Obesity among Rehabilitated Urban Slum Dwellers and Altered Body Image Perception in India (PRESUME) p. 23
Jeffrey Pradeep Raj, Shervin Ploriya
DOI:10.4103/ijem.IJEM_363_17  PMID:29535932
Background: An understudied risk factor for overweight/obesity in our population is distorted body image perception where studies from the west have proved a clear association between the two. We therefore aimed to evaluate the same and document the prevalence of overweight/obesity among rehabilitated slum dwellers. Materials and Methods: It was a cross-sectional study conducted during February 2015. The participants were recruited from among permanent residents of Tamil Nadu Slum Clearance Board residential apartment blocks. Systematic random sampling followed by cluster sampling was done. All consenting individuals above 18 years of age were included. Pregnant women, bed-ridden patients, and those who had an acute illness in the last 2 weeks were excluded. Data were collected using a semi-structured standardized pilot-tested questionnaire which included Stunkard's figure rating scale. Results: Number of families included was 170 comprising 315 individuals. Prevalence of overweight was 36.5% and prevalence of obesity was 12.4%. Prevalence of body image dissatisfaction was 68.3% (women 68.9% and men 67%), and prevalence of body image distortion was 59% (women 57.5% and men 62.1%). Distorted body image (adjusted odds ratio [aOR]; 95% confidence interval [95% CI]: 1.927; 1.057, 3.514) and underestimating body image size (aOR; 95% CI: 8.001; 4.223, 15.159) were highly significant predictors of obesity as estimated by logistic regression. Conclusion: Although majority of population belonged to daily wage laborer workforce, prevalence of overweight is high. Distorted ideal and current body image perception is also significantly high and is a definite risk factor for obesity.
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Diabetic retinopathy awareness and associations with multiple comorbidities: Insights from DIAMOND Study p. 30
Kiran Shah, Alka Gandhi, Sundaram Natarajan
DOI:10.4103/ijem.IJEM_240_17  PMID:29535933
Background: Diabetic retinopathy (DR) is leading cause of visual impairment in working-age adults. Macular edema can occur with or without other signs of retinopathy. Methods: This was a single-center, retrospective study conducted over 2 years in patients (>40 years of age) having type 2 diabetes mellitus (T2DM). Outcome measures were to analyze awareness and prevalence of DR and association of DR with identified risk factors. Results: Overall 6000 T2DM patients over 2 years were retrospectively evaluated. Almost 63% (n = 3780) of patients were unaware that diabetes affects the retina. Almost 65% (n = 3894) of patients were reported to have DR. Total 78.98% of males, and 69.50% of females had DR. There was a significant increase in the incidence of DR with age (P < 0.00001). Almost 60.80% (n = 3653) of patients having DR were from working age group (40–70 years). Evidently, 42% (n = 2520) of patients having DR had HbA1c > 9% (P < 0.00001). Overall 52.02% (n = 1820) of smokers were reported of DR (P < 0.00001). With the increase in total cholesterol and triglycerides, there was a significant increase in DR incidence (P < 0.00001). A strong association was observed between hypertension and DR, with 42.6% (n = 2556) of patients having coexistence of hypertension and DR (P < 0.00001). Patients having diabetic kidney disease (DKD) also reported DR. A high proportion of patients (49.11%, n = 2947) had co-existence of cardiac morbidity and DR. Almost 47% (n = 2845) of patients having DR were also reported anemia. Totally 43.85% (n = 2631) of patients with microalbuminuria had two times more risk of developing proliferative DR (P < 0.00001). The statistical significance for the association of DR with risk factors, calculated by Pearson Chi-Square method of analysis was found statistically significant (P < 0.00001). Conclusion: The study reported the high prevalence and significantly high unawareness for DR in T2DM patients. All the risk factors are independently and significantly associated with DR (P < 0.00001).
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Prevalence rates of ADIPOQ polymorphisms in Indian population and a comparison with other populations p. 36
Sandhya Kiran Pemmasani, Rasika Raman, Anuradha Acharya
DOI:10.4103/ijem.IJEM_294_17  PMID:29535934
Introduction: The adiponectin gene, ADIPOQ, encodes an adipocytokine, known as adiponectin hormone. This hormone is known to be associated with insulin sensitization, fat metabolism, immunity, and inflammatory response. Polymorphisms in ADIPOQ gene lower the adiponectin levels, increasing the risk for diabetes and cardiovascular diseases. Aims: The study aimed to calculate the prevalence rates of ADIPOQ polymorphisms in Indian population and to compare those prevalence rates with that of other populations. Subjects and Methods: Microarray-based genotypic data of 14 ADIPOQ polymorphisms from 703 individuals of Indian origin were used. Statistical Analysis Used: Frequency estimation, identity-by-descent, Hardy–Weinberg equilibrium, Chi-square test of significance were used for statistical analysis. Results: Allelic and genotypic frequencies of ADIPOQ polymorphisms, Chi-square tests of significance for allelic and genotypic frequencies across various populations. Conclusions: East Asians are very different from Indians in terms of allelic and genotypic frequencies of ADIPOQ polymorphisms. Europeans have similar genotypic and allelic patterns with Indians. Admixture Americans and Africans also showed significant differences with polymorphisms of the Indian population.
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Efficacy and safety of teneligliptin in Indian patients with inadequately controlled Type 2 diabetes mellitus: A randomized, double-blind study p. 41
Piyush Agarwal, Chhavi Jindal, Vinayak Sapakal
DOI:10.4103/ijem.IJEM_97_16  PMID:29535935
Aims: This study evaluated the efficacy and safety of teneligliptin in patients with inadequately controlled type 2 diabetes mellitus (T2DM). Settings and Design: This was a randomized, doubleblind, placebocontrolled, parallelgroup, multicenter, Phase III study. Subjects and Methods: Patients with T2DM and inadequate glycemic control (glycosylated hemoglobin [HbA1c]: >7.0-≤8.5%) were enrolled. Patients were randomly assigned (ratio: 2:1) to receive teneligliptin 20 mg (Glenmark) or placebo. The primary efficacy variable was change from baseline in HbA1c at week 16. Additional analyses included the proportion of patients who achieved target of HbA1c ≤7.0%, changes in fasting plasma glucose (FPG), and postprandial glucose (PPG). Statistical Analysis: Mean change in HbA1c was analyzed using an analysis of covariance model, least square (LS) means, 95% confidence intervals (CIs), and P values were calculated. Results: Overall, 237 patients were included. Patients of the teneligliptin group showed reduced HbA1c levels (LS mean difference = −0.304% for intent-to-treat [ITT]; −0.291% for per-protocol (PP) populations) after 16 weeks of treatment, and a statistically significant difference was observed between the ITT (LS mean difference = 0.555; 95% CI: 0.176–0.934; P = 0.0043) and PP populations (LS mean difference = 0.642; 95% CI: 0.233–1.052; P = 0.0023). Target HbA1c level was achieved by a greater proportion of teneligliptin group patients (ITT, 43.4%; PP, 43.6%) than placebo group patients (ITT, 27.3%; PP, 26.6%). Reduction in FPG levels was observed in ITT (LS mean difference: 8.829; 95% CI: −4.357–22.016; P = 0.1883) and PP populations (LS mean difference: 11.710 mg/dL; 95% CI: −2.893-26.312; P = 0.1154). Reduction in PPG levels was higher in teneligliptin group than placebo group in both ITT (LS mean difference = 25.849 mg/dL; 95% CI: 7.143–44.556; P = 0.0070) and PP populations (LS mean difference = 25.683 mg/dL; 95% CI: 5.830–45.536; P = 0.0115). Overall, 44 patients (18.6%) experienced at least one adverse event. Three or more hypoglycemic events were experienced by 2.5% patients of teneligliptin group and none in placebo group. Conclusion: Treatment with once-daily teneligliptin led to statistically significant and clinically meaningful reductions in HbA1c and PPG, and was well tolerated in Indian patients with T2DM.
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Waist–thigh Ratio: A Surrogate marker for Type 2 diabetes mellitus in Asian North Indian patients p. 47
Shivanjali Kumar, Kamal Kumar, Sarita Bajaj, Ranjana Kumar, Atul Gogia, Atul Kakar, Shrishti Paul Byotra
DOI:10.4103/ijem.IJEM_181_17  PMID:29535936
Introduction: Diabetes is a major world-wide healthcare problem. Cost effective markers for screening and diagnosis of T2DM are the need of the day especially in developing and under-developed countries. Simple anthropometric measurements may help us in identifying individuals likely to have diabetes. Material and Methods: Data from 1055 North-Indian subjects was analysed. Results: Out of several anthropometric measurements studied, Waist-Thigh ratio (WTR) correlated significantly and positively with all three measures of diabetes i.e. FPG, RPG and PPG. (P < .0001) suggesting that it is the best predictor of diabetes. Subjects with diabetes had greater WTR (mean 2.088) than those without (mean1.842). (P < .0001). A thresh-hold effect was evident at a cut-off WTR of 2.3. Out of those subjects who were diagnosed to have diabetes by AACE/AHA guidelines, 82% had WTR greater than this value (P < 0.001). Conclusion: WTR may prove to be a simple and inexpensive marker for detecting Type 2 diabetes. Larger studies are required to develop population norms.
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Comparison of Hemoglobin A1c with fasting and 2-h plasma glucose tests for diagnosis of diabetes and prediabetes among high-risk South Indians p. 50
Pedapati Radhakrishna, Kolar Vishwanath Vinod, Akkilagunta Sujiv, Rathinam Palamalai Swaminathan
DOI:10.4103/ijem.IJEM_254_17  PMID:29535937
Background: Glycosylated hemoglobin (HbA1c) has not been evaluated extensively for diabetes and prediabetes diagnosis and short-term variability of fasting plasma glucose (FPG), 2-h PG post-75 g glucose load (2 hPG) and HbA1c has not been studied among Indians. Objectives: The study aimed to compare the sensitivity of HbA1c, FPG and 2 hPG for diabetes and prediabetes diagnosis as per the American Diabetes Association criteria, assess short-term variability of three tests and determine optimal HbA1c cutoffs for diabetes and prediabetes diagnosis among high-risk south Indians. Methods: This diagnostic accuracy study, conducted at a tertiary care teaching hospital located in South India, enrolled 332 adults at high risk for diabetes and subjected them to testing (FPG, 2 hPG, and HbA1c) twice at 2–3 weeks interval. Sensitivity of three tests for diagnosing diabetes and prediabetes was determined based on the final diagnosis of normoglycemia/prediabetes/diabetes made with six test results for each participant. Optimal HbA1c cutoffs for diabetes and prediabetes were determined based on the final diagnosis of glycemic status made with four test results of FPG and 2 hPG. Results: FPG, 2 hPG, and HbA1c, at American Diabetes Association recommended values, had sensitivity of 84.4%, 97%, and 93.8% respectively for diabetes diagnosis. HbA1c had lowest short-term variability (CVw = 1.6%). Receiver operating characteristic curve plotted with mean (of two values) HbA1c for each participant showed optimal HbA1c cutoffs of 6.5% for diabetes (area under curve [AUC] =0.990, sensitivity = 95.8%, specificity = 96.2%, accuracy = 95.2%) and 5.9% for prediabetes (AUC = 0.893, sensitivity = 84.3%, specificity = 80%, accuracy = 75.6%) diagnosis respectively. HbA1c <5.6% had 100% negative predictive value to exclude prediabetes/diabetes. Conclusions: HbA1c ≥6.5% is a convenient and reliable alternative to plasma glucose tests to diagnose diabetes among high-risk South Indians. HbA1c ≥5.9% is optimal for prediabetes diagnosis and value <5.6% excludes prediabetes/diabetes.
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Normative values for electrochemical skin conductance measurements for quantitative assessment of sudomotor function in healthy Indian adults p. 57
C Shivaprasad, Amit Goel, Alice Vilier, Jean-Henri Calvet
DOI:10.4103/ijem.IJEM_389_17  PMID:29535938
Context: Electrochemical skin conductance (ESC) test is a widely accepted objective technique for quantitatively assessing sudomotor dysfunction, which is one of the earliest-detected neurophysiologic abnormalities in diabetic patients with distal symmetric polyneuropathy. Aims: This study aimed to provide normative data for ESC values among healthy Indian participants and assess the potential influence of age, sex, and body mass index (BMI) on ESC measurements. Settings and Design: A sample of 217 healthy participants aged 18–75 years were recruited and assessed for parameters including age, gender, BMI, and ESC measurements of the hands and feet. Statistical Analysis Used: The Shapiro–Wilk test was used to assess the normality of the data. Pearson's correlation was used to evaluate the association between age, gender, and BMI, and ESC measurements. Results: The mean age of the participants was 43.3 ± 13.2 years, and mean BMI was 26.0 ± 4.3 kg/m2. Mean ESC for the hands and feet was 68.9 ± 13.1 and 71 ± 12.9 micro-Siemens, respectively, and there was a significant correlation between values from the right and left hands and feet (r = 0.9, P < 0.0001). A significant correlation was also observed between ESC measurements of the hands and feet (r = 0.94, P < 0.0001). ESC values of both hands and feet declined with age. A weak but significant inverse correlation between ESC and age was observed for the hands (r = 0.02, P = 0.01) and for the feet (r = 0.12, P < 0.0001). There was no significant difference in hand or feet ESC measurement between male and female participants. No significant correlation was observed between BMI and ESC of hands or feet. Only age was identified as a significant determinant of ESC on multivariate logistic regression analysis. Conclusions: Normative values for Indians are lower than that reported for Caucasians.
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A prospective, observational study of osteoporosis in men p. 62
Narendra Kotwal, Vimal Upreti, Amit Nachankar, K V. S Hari Kumar
DOI:10.4103/ijem.IJEM_414_16  PMID:29535939
Context: The number of men afflicted with osteoporosis is unknown. Aims: This study aims to determine the prevalence of osteoporosis in men. Settings and Design: This was a prospective, observational study. Subjects and Methods: A total of 200 male attendants of patients attending endocrine outpatient department and who were >55 years were recruited for the study. All the patients with osteopenia and osteoporosis were advised lifestyle interventions, supplementation with calcium carbonate (1000–1500 mg/day) and 25-hydroxyl-Vitamin D (400–600 IU/day) and bisphosphonates if indicated. Vitamin D3 60,000 IU once a week for 8 weeks and once a month thereafter was prescribed to Vitamin D-deficient patients. Androgen-deficient patients were given replacements of either injectable testosterone or oral testosterone undecanoate. Statistical Analysis Used: Two sample t-test and paired t-test were used to compare pre- and post-test parameters. Results: Overall 80 (40%) subjects had low bone mass, 93 (43.5%) had Vitamin D deficiency/insufficiency, and 39 (19.5%) had androgen deficiency. Osteoporosis was found in 8.5% patients. All patients were above 70 years (Mean age: 73.82 ± 2.79 years). Seventy percentage of these patients had low serum testosterone and 70% of patients had Vitamin D deficiency/insufficiency. About 31.5% of patients had osteopenia (mean age of 67.47 ± 6.35 years). Thirty-five percentage of these patients were androgen deficient and 25% were Vitamin D-deficient/insufficient. Age >70 years, serum testosterone <3 ng/ml, Vitamin D <30 ng/ml were strong risk factors for osteoporosis. Vitamin D supplementation, androgen replacement, and bisphosphonate therapy had beneficial effect on bone mineral density (BMD). Conclusions: Low bone mass was common (40%) in males over 55 years of age. Age >70 years, low androgen (<3 ng/ml), steroid use, and low Vitamin D (<20 ng/ml) were independent risk factors of male osteoporosis. Calcium and Vitamin D are effective in improving BMD. Androgen replacement has beneficial effect on BMD in hypogonadism patients.
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Prevalence of osteoporosis in apparently healthy adults above 40 years of age in Pune City, India p. 67
Nidhi S Kadam, Shashi A Chiplonkar, Anuradha V Khadilkar, Vaman V Khadilkar
DOI:10.4103/ijem.IJEM_438_17  PMID:29535940
Purpose: The aim of study was to assess the prevalence of osteoporosis and changes in bone mass with increasing age and compare bone health status of apparently healthy men, premenopausal and postmenopausal women. Methods: Data were collected on anthropometric and sociodemographic factors in 421 apparently healthy Indian adults (women = 228), 40–75 years of age, in a cross-sectional study in Pune city, India. Bone mineral density (BMD) was measured by dual-energy X-ray absorptiometry at two sites-lumbar spine (LS) and left femur. Individuals were classified as having osteoporosis or osteopenia based on the World Health Organization criteria of T-scores. Results: Mean age of study population was 53.3 ± 8.4 years. Of the total women, 44.3% were postmenopausal with 49.2 ± 3.5 years as mean age at menopause. Postmenopausal women showed a rapid decline in BMD with age till 50 years while men showed a gradual decline. Premenopausal women showed no significant decline in BMD with age (P > 0.1). Significantly lower T-scores were observed at LS in men compared to premenopausal (P < 0.05). At left femur, T-scores were lower in men compared to premenopausal women (P < 0.05) but not postmenopausal women (P > 0.1). The prevalence of osteoporosis in men at LS was lower than postmenopausal women but higher than premenopausal women. Conclusion: In Indian men, a low T-score compared to women indicates higher susceptibility to osteoporosis. In women, menopause causes a rapid decline in BMD. Therefore, both Indian men and postmenopausal women require adequate measures to prevent osteoporosis during later years in life.
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Effectiveness of a patient education module on diabetic foot care in outpatient setting: An open-label randomized controlled study p. 74
Hammadur Sk Rahaman, Viveka P Jyotsna, V Sreenivas, Anand Krishnan, Nikhil Tandon
DOI:10.4103/ijem.IJEM_148_17  PMID:29535941
Background: A large number of patients with diabetes mellitus are unaware of foot care and are at risk of developing foot ulcer and amputation. This increases healthcare burden due to preventable complication of diabetes. Aims: We conducted this study to assess the effectiveness of a foot care education module for diabetes developed by us. Materials and Methods: One hundred and twenty-seven patients with diabetes mellitus attending our outpatient were randomized into intervention (n = 63) and control groups (n = 64). At first visit, 1 and 3 months later, both groups filled a questionnaire regarding foot care knowledge and practice. The intervention group was administered foot care education module and the control group received routine care at baseline and 1 month. Patient education module consisted of an audio-visual display and a pamphlet on diabetes foot care. Change in score at 3 months was assessed by Student's t-test. Results: Knowledge scores in the intervention group at first, second, and third visits were 9.8 ± 1.8, 10.2 ± 1.6, and 11.0 ± 1.7, respectively. The knowledge scores in the control group at first, second, and third visits were 9.9 ± 1.7, 9.8 ± 1.6, and 10.0 ± 1.8, respectively. The change in knowledge score was statistically significant (P < 0.001) at third visit compared to first in the intervention group but not in the control group (P = 0.62). Practice score also improved significantly (P < 0.001) in the intervention group in the second visit but not in the control group. Conclusion: Audio-visual foot care patient education module in outpatient setting is an effective means to improve foot care knowledge and practice in patients with diabetes.
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Evaluation of oxidative stress and proinflammatory cytokines in gestational diabetes mellitus and their correlation with pregnancy outcome p. 79
KA Sudharshana Murthy, Ambarisha Bhandiwada, Shivani L Chandan, Surakshith L Gowda, G Sindhusree
DOI:10.4103/ijem.IJEM_232_16  PMID:29535942
Background: Prevalence of Gestational Diabetes Mellitus in India is increasing. In addition to performing physiological role in fetoplacental unit during pregnancy, cytokines also play pathophysiological role if expressed in abnormal amounts or sites. Objective: To estimate Proinflammatory Cytokines TNF-α, IL-6, IL-8 and anti-oxidants Glutathione Peroxidase (GTX), Superoxide dismutase (SOD), uric acid and Bilirubin levels in GDM and correlate with pregnancy outcome. Results: Pregnant women were screened for GDM using Diabetes In Pregnancy Study group, India criteria. The subjects with elevated glucose were grouped into cases (n = 30) and with normal values were taken as controls (n = 30). Mean Uric acid in cases was 4.53 ± 1.2 mg% whereas in controls 3.13 ± 0.58 mg%, mean TNF-α among cases was 6.06 ± 3.6 pg/ml and controls 2.81 ± 1.03 pg/ml. Antioxidants SOD and GTX were markedly decreased with mean value of 4979.21 ± 1006.3 and 13.68 ± 1.5 in cases and 9625.10 ± 1074.1 and 15.86 ± 1.2 in controls. Cytokines IL-6 (2.96 + 1.37 vs 2.88 + 1.21) and IL-8 (7.76 + 3.86 vs 2.60 + 1.45) were increased in subjects with GDM. Those with GDM developed preeclampsia (5%), Preterm labour (2%) and Polyhydromnios (5%). Foetal complications Macrosomia (13.3%) and intra uterine death (3.3%) were observed in GDM mothers. The proinflammatory cytokine levels except IL-6 were significantly increased and antioxidant markers were significantly reduced in GDM group with maternal and foetal complications. Conclusion: GDM worsens the oxidative stress and weakens anti-oxidant state. Uric acid, TNF-α and IL-8 were higher with foeto-maternal complications in GDM. Serum bilirubin, GTX and SOD is significantly lower in foeto-maternal complications. TNF-α significantly associated with preeclampsia in GDM mothers.
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Risk factors associated with microalbuminuria in children and adolescents with diabetes in Bangladesh p. 85
Bedowra Zabeen, Jebun Nahar, Nasreen Islam, Kishwar Azad, Kim Donaghue
DOI:10.4103/ijem.IJEM_269_17  PMID:29535943
Introduction: Diabetic nephropathy is leading cause of morbidity and mortality of type 1 diabetes mellitus (DM). Microalbuminuria is the first clinical sign of nephropathy. Methods: This was a cross-section study with longitudinal evaluation of urinary albumin xcretion in 199 children with type 1 diabetes attending CDiC Clinic in BIRDEM over a period of two years. The aim of the study was to assess the frequency of microalbuminuria and to determine other risk factors. We collected blood and early morning spot urinary sample and analyzed for HbA1c by Clover A1c and urinary microalbumin by a DCA analyzer. Children had urinary microalbumin 30-300 mg/L on at least two occasions were categorized as having persistent microalbuminuria. Demographic and clinical data were recorded including age at onset of diabetes, age during registration, gender and duration of diabetes which were compared between patients without microalbuminuria and with microalbuminuria. Result: Microalbuminuria developed in forty nine children and adolescents (25%). Among them 24% were Type 1, 27% were with Fibrocalculous pancreatic diabetes (FCPD) and 68% were Type 2 diabetes. Median HbA1c was higher 10.8 [9.4-12.4] vs 9.5 [8.0-11.2] (P.006) in adolescents with microalbuminuria. On logistic regression univariate analysis independent predictors of microalbuminuria were older age, systolic blood pressure, BMI SDS and mean HbA1c which remained significant in multivariate analysis as predictors of microalbuminuria. Conclusion: We found high prevalence of microalbuminuria which was associated with higher age, systolic blood pressure, BMI SDS and HbA1c.
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Lipid profile in relation to glycemic control in Type 1 diabetes children and adolescents in Bangladesh p. 89
Bedowra Zabeen, Ana Margarida Balsa, Nasreen Islam, Mukta Parveen, Jebun Nahar, Kishwar Azad
DOI:10.4103/ijem.IJEM_217_17  PMID:29535944
Introduction: Dyslipidemia and hyperglycemia are metabolic abnormalities commonly found in young patients with Type 1 diabetes mellitus (T1DM) and both increase the risk of cardiovascular disease. Methods: This cross-sectional study was aimed to evaluate the pattern of dyslipidemia and its relationship with other risk factors in children and adolescents with T1DM. A total of 576 T1DM patients aged 10–18 years who attended Changing Diabetes in Children, a pediatric diabetes clinic in Bangladesh Institute of Research and Rehabilitation for Diabetes, Endocrine and Metabolic Disorders over 1 year period from July 2015 to June 2016 were included in this study.Results: The overall frequency of dyslipidemia was 65%. The high triglyceride, high cholesterol, high low-density lipoprotein (LDL) and low high-density lipoprotein were found in 50%, 66%, 75%, and 48%, respectively. Compared to patients without dyslipidemia, patients with dyslipidemia had significantly lower mean body mass index (kg/m2) (18.4 [interquartile range; 16.2–21.4] vs. 19.5 [17.3–21.5] (P = 0.005)); significantly higher median fasting blood sugar (12.7 [9.9–15.2] vs. 10.6 [7.9–12.6] (P < 0.0001)) and higher median glycosylated hemoglobin (9.8 [8.4–11.8] vs. 7.9 [9.3–10.5] (P < 0.0001)). Hypertension was significantly higher in dyslipidemic patients (9.4% vs. 2.5% P < 0.002). Conclusion: More than half (65%) of our children and adolescents with T1DM had dyslipidemia, among them high LDL was the most common. These findings emphasize the screening of lipid profile in T1DM children and adolescents.
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Correlation of serum adiponectin and leptin levels in obesity and Type 2 diabetes mellitus p. 93
Arundhati G Diwan, Aniket A Kuvalekar, Siddharth Dharamsi, Aditya M Vora, Vivek A Nikam, Abhijit A Ghadge
DOI:10.4103/ijem.IJEM_491_15  PMID:29535945
Introduction: Indian phenotype includes higher waist circumference despite lower body mass index, thereby making Indians more prone to diabetes and its complications. Aim: The present study aimed to analyze the serum levels of adiponectin and leptin in the participants with type 2 diabetes mellitus (T2DM) and obesity and their correlation with hypertension and dyslipidemia. Materials and Methods: In the study, 50 diabetics and 50 controls aged between 40 and 60 years were included in the study. Results: Adiponectin levels were significantly higher in diabetics than in nondiabetic participants irrespective of gender (P ≤ 0.04 in males, P ≤ 0.02 in females). Leptin levels were significantly higher in diabetics compared to nondiabetics (P ≤ 0.001) in both males and females. Conclusion: Adiponectin and leptin levels may be used as important clinical markers for T2DM and obesity.
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Application of chromosomal microarray for evaluation of idiopathic short stature in Asian Indian children: A pilot study p. 100
Hema Singh, Pradeep Tiwari, Vijay Bhavi, Praveen Singh Chaudhary, Prashanth Suravajhala, M Krishna Mohan, Sandeep Kumar Mathur
DOI:10.4103/ijem.IJEM_202_17  PMID:29535946
Background: Human height is a classic polygenic trait and currently available data explains only 10% of the phenotypic variation in height. Almost 60%–80% of the children coming to pediatric and endocrinology outpatient department for the evaluation of short stature are still labeled as idiopathic. Objectives: The aim of this study is to identify various chromosomal alterations causing idiopathic short stature (ISS) and short stature with dysmorphic features not pertaining to known genetic syndromes. Materials and Methods: After exclusion of all nutritional, systemic, endocrine, and syndromic causes of short stature, 19 patients with height <2 standard deviation scores were subjected to chromosomal microarray (CMA) study using Affymetrix CytoScan 750K array and CMA Scanner 3000 platform. Results: We identified total 61 copy-number variant (CNV) and polymorphs (33 gains, 11 loss, and 17 gain-mosaics) not described as normal variants in database of genomic variations. We identified SHOX haploinsufficiency as a cause of short stature in two patients, whereas one patient was gain-mosaic for SHOX. All three had normal conventional karyotype. One of these patients also had deletion of PAX3, which could be the cause of both short stature and associated mild intellectual impairment in this patient. We also found a long noncoding RNA, namely, KIAA0125 and a pseudogene ADAM6 in 18 out of our 19 patients which might have a regulatory role. Conclusion: This study shows that CMA is a very promising tool for the identification of pathogenic CNVs in patients with ISS. It can also help to identify novel genes controlling height and can open up new insight into pathophysiologic mechanisms underlying ISS, and thus may help to unfold new therapeutic targets for treatment of this condition. The association of CNV having genes for long noncoding RNAs, such as KIAA0125 and pseudogene such as ADAM6 with ISS suggest that they may play a role in controlling the expression of height-related genes and it needs further investigations.
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Prevalence of Charcot arthropathy in Type 2 diabetes patients aged over 50 years with severe peripheral neuropathy: A retrospective study in a Tertiary Care South Indian Hospital p. 107
Dharmadas Salini, Kumar Harish, Pillay Minnie, Karimassery R Sundaram, Bal Arun, Chirukandath J Sandya, Thacho S Mangalanandan, Lakshmanan Vivek, Valiyaparambil P Praveen
DOI:10.4103/ijem.IJEM_257_17  PMID:29535947
Aims: Available literature on the prevalence of Charcot arthropathy (CA) represents mainly Western population. No study has been reported from India so far. Hence we attempted to study the prevalence of CA in patients with type 2 diabetes mellitus and severe peripheral neuropathy (T2DMPN), belonging to Indian population amongst whom type 2 diabetes is on the rise in alarming proportions. Materials and Methods: Medical records of 3387 patients who performed an objective vibration perception threshold test during the year 2015 were screened for T2DMPN. Out of these, 1475 T2DMPN patients above 50 years were selected and analyzed in detail for CA. CA was diagnosed based on clinical features and/or radiological investigations. The anatomical localization of the disease distribution of the affected foot was done according to Brodsky's classification. Results: The prevalence of CA in T2DMPN patients was found to be 9.8%. The mean age of patients diagnosed with CA was 63 ± 8.36 years, and mean duration of DM for CA to develop was 18.01 ± 8.23 years. About 62.5% of the patients were male and 37.5% female. Bilateral presentation of CA was observed in 20.8% of patients. Multiple sites of the foot were affected in 48.6% of patients and belonged to type 4 classification of Brodsky. Conclusions: A high prevalence of CA (9.8%) was observed in the present study conducted on T2DMPN patients who presented to the endocrinology department of a tertiary care South Indian hospital. In the majority of patients, the area of foot affected belonged to type 4 classification of Brodsky.
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Thyroid status in patients with Type 2 diabetes attending a Tertiary Care Hospital in Eastern India p. 112
Subhodip Pramanik, Sujoy Ghosh, Pradip Mukhopadhyay, Rana Bhattacharjee, Bidisha Mukherjee, Samim Ali Mondal, Ipsita Ghosh, Ranajit Bari, Subhankar Chowdhury
DOI:10.4103/ijem.IJEM_572_17  PMID:29535948
Objective: Type 2 diabetes mellitus and thyroid dysfunction (TD) are two major public health endocrine problem, but the prevalence of TD and iodine status in patients with T2 DM in India is less studied. The study objective was to explore the prevalence of TD and to evaluate iodine health in type 2 diabetes patients attending a tertiary care center in Eastern India. Methods: Consecutive 100 patients with diabetes attending outpatient department were evaluated clinically and biochemically (thyrotropin [TSH], free thyroxine, anti-TPO antibody, and urinary iodine). We excluded pregnant women or patients taking drugs that can alter thyroid function. Subclinical hypothyroid and overt hypothyroidism were diagnosed as per standard definitions. Results: Out of 100 patients were analyzed, 51 (51%) were male. Mean (±standard deviation) age was 45.4 ± 11.2 years, body mass index 24.1 ± 4.28 kg/m2, and duration of diabetes 7.76 ± 5.77 years. The prevalence of subclinical hypothyroidism and overt hypothyroidism was 23/100 (23%) and 3/100 (3%), respectively. Thyroid autoantibody was positive in 13 (13.1%) patients. All patients were iodine sufficient. A trend toward increased neuropathy (r = 0.45) and nephropathy (r = −0.29) was associated with rising TSH. Conclusion: Almost one in four people living with diabetes are suffering from TD. Thus, routine screening should be implemented. Salt iodination program is a huge success in this part of the country.
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Maternal and perinatal outcome in gestational diabetes mellitus in a Tertiary Care Hospital in Delhi p. 116
Rajesh Kumari, Venus Dalal, Garima Kachhawa, Ipshita Sahoo, Rajesh Khadgawat, Reeta Mahey, Vidushi Kulshrestha, Perumal Vanamail, JB Sharma, Neerja Bhatla, Alka Kriplani
DOI:10.4103/ijem.IJEM_582_17  PMID:29535949
Background: Gestational diabetes mellitus (GDM) is defined as a carbohydrate intolerance first diagnosed in pregnancy and may be associated with adverse maternal and perinatal outcome. Aim: The aim of the study was to determine the maternal and perinatal outcome in GDM during pregnancy. Materials and Methods: It is a retrospective analysis of women diagnosed with GDM who got antenatal care and delivered in our hospital in previous 5 years. Another 191 women with normal pregnancy without GDM and other medical conditions were taken as control. The baseline characteristics (age, body mass index, religion, and socioeconomic status) were noted in all cases. Diagnosis of GDM was made using oral glucose tolerance test with 75 g glucose. GDM patients were started on diet following which insulin or oral hypoglycemic agents were given if required. Maternal and perinatal outcome was noted in all women.Results: The prevalence of GDM was 5.72% (170/2970). Most patients (79.41%) could be controlled on diet alone. However, 21 (12.35%) needed insulin and 14 (8.23%) needed oral hypoglycemic agents. Middle socioeconomic status was more common in GDM than control and pregnancy-induced hypertension was more common in GDM (13.5%) than in control (6.3%) (P = 0.019). Mode of delivery was not different in two groups. Instrumental deliveries and postpartum hemorrhage were also similar. However, mean birth weight was significantly higher in GDM (2848 ± 539 g) than in control (2707 ± 641 g) (P = 0.004). Incidence of large-for-date babies was also higher (28.2%) in GDM than control (19.4%) (P = 0.005). In neonatal complication, hypoglycemia was significantly higher in GDM (20.6%) than in control (5.2%) (P = 0.001). However, the incidence of hyperbilirubinemia and congenital malformations was not significantly different in two groups. Conclusion: The prevalence of GDM was 5.72% in this study. Adequate treatment of GDM on diet, oral hypoglycemic agents, or insulin to achieve euglycemia can achieve near-normal maternal and neonatal outcome.
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Exocrine dysfunction correlates with endocrinal impairment of pancreas in Type 2 diabetes mellitus p. 121
HR Prasanna Kumar, H Basavana Gowdappa, Tejashwi Hosmani, Tejashri Urs
DOI:10.4103/ijem.IJEM_139_17  PMID:29535950
Background: Diabetes mellitus (DM) is a chronic abnormal metabolic condition, which manifests elevated blood sugar level over a prolonged period. The pancreatic endocrine system generally gets affected during diabetes, but often abnormal exocrine functions are also manifested due to its proximity to the endocrine system. Fecal elastase-1 (FE-1) is found to be an ideal biomarker to reflect the exocrine insufficiency of the pancreas. Aim: The aim of this study was conducted to assess exocrine dysfunction of the pancreas in patients with type-2 DM (T2DM) by measuring FE levels and to associate the level of hyperglycemia with exocrine pancreatic dysfunction. Methodology: A prospective, cross-sectional comparative study was conducted on both T2DM patients and healthy nondiabetic volunteers. FE-1 levels were measured using a commercial kit (Human Pancreatic Elastase ELISA BS 86-01 from Bioserv Diagnostics). Data analysis was performed based on the important statistical parameters such as mean, standard deviation, standard error, t-test-independent samples, and Chi-square test/cross tabulation using SPSS for Windows version 20.0. Results: Statistically nonsignificant (P = 0.5051) relationship between FE-1 deficiency and age was obtained, which implied age as a noncontributing factor toward exocrine pancreatic insufficiency among diabetic patients. Statistically significant correlation (P = 0.003) between glycated hemoglobin and FE-1 levels was also noted. The association between retinopathy (P = 0.001) and peripheral pulses (P = 0.001) with FE-1 levels were found to be statistically significant. Conclusion: This study validates the benefit of FE-1 estimation, as a surrogate marker of exocrine pancreatic insufficiency, which remains unmanifest and subclinical.
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REVIEW ARTICLES Top

Premarriage counseling in Type 1 diabetes p. 126
Gagan Priya, Bharti Kalra, Emmy Grewal, Inderpreet Kaur Dardi
DOI:10.4103/ijem.IJEM_550_17  PMID:29535951
Type 1 diabetes is a challenging illness and needs lifelong diabetes self-care. At the same time, there is a significant stigma associated with it, especially with relation to marriage. There are concerns related to premarriage disclosure, marital relationship, ability to procreate, risk during pregnancy in women, and the risk of disease in children. In this document, we discuss the issue of disease-related stigma which may become a significant challenge for a prospective spouse and the impact of type 1 diabetes on marital relationships and procreation. We also highlight the need for premarriage counseling to ensure long-term success in achieving both individual and interpersonal well-being.
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Consensus recommendations on sulfonylurea and sulfonylurea combinations in the management of Type 2 diabetes mellitus – International Task Force Highly accessed article p. 132
Sanjay Kalra, Silver Bahendeka, Rakesh Sahay, Sujoy Ghosh, Fariduddin Md, Abbas Orabi, Kaushik Ramaiya, Sameer Al Shammari, Dina Shrestha, Khalid Shaikh, Sachitha Abhayaratna, Pradeep K Shrestha, Aravinthan Mahalingam, Mazen Askheta, Aly Ahmed A. Rahim, Fatimah Eliana, Hari K Shrestha, Sandeep Chaudhary, Nancy Ngugi, Jean Claude Mbanya, Than Than Aye, Tint Swe Latt, Zhanay A Akanov, Abbas Raza Syed, Nikhil Tandon, AG Unnikrishnan, SV Madhu, Ali Jawa, Subhankar Chowdhury, Sarita Bajaj, Ashok Kumar Das
DOI:10.4103/ijem.IJEM_556_17  PMID:29535952
For decades, sulfonylureas (SUs) have been important drugs in the antidiabetic therapeutic armamentarium. They have been used as monotherapy as well as combination therapy. Focus on newer drugs and concerns about the risk of severe hypoglycemia and weight gain with some SUs have led to discussion on their safety and utility. It has to be borne in mind that the adverse events associated with SUs should not be ascribed to the whole class, as many modern SUs, such as glimepiride and gliclazide modified release, are associated with better safety profiles. Furthermore, individualization of treatment, using SUs in combination with other drugs, backed with careful monitoring and patient education, ensures maximum benefits with minimal side effects. The current guidelines, developed by experts from Africa, Asia, and the Middle East, promote the safe and smart use of SUs in combination with other glucose-lowering drugs.
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COMMENTARY Top

Commentary on “Consensus recommendations on sulfonylurea and sulfonylurea combinations in the management of type 2 diabetes mellitus: International Task Force” p. 158
SK Singh
DOI:10.4103/ijem.IJEM_22_18  PMID:29535953
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BRIEF COMMUNICATIONS Top

High concentration insulin p. 160
Sanjay Kalra
DOI:10.4103/ijem.IJEM_300_17  PMID:29535954
This communication reviews available high concentration insulins and their basic as well as clinical pharmacology. It classifies all high concentration insulins, and describes their pharmacokinetic and pharmacodynamic properties. The article discusses the utility of high concentrations insulins, lists indications for these preparations, highlights caveats for their safe use, and proposes pragmatic contraindications to their prescription.
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Metformin + Sodium-glucose Co-transporter-2 Inhibitor: Salutogenic Lifestyle Mimetics in a Tablet? p. 164
Sanjay Kalra, Jubbin Jacob, Manash P Baruah
DOI:10.4103/ijem.IJEM_266_17  PMID:29535955
Salutogenesis is an accepted approach for chronic disease management. Calorie restriction and exercise are two evidence based salutogenic interventions in diabetes treatment. Calorie restriction mimetics and exercise mimetics may be used as pharmacological tools to help manage diabetes in a sulutogenic manner. This article discusses the biochemical basis and pharmacology of metformin and sodium glucose cotransporter 2 inhibitors. It describes how a combination of these drugs can be used as a calories restriction and exercise mimetic, to help improve diabetes control.
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The renal pentad p. 167
Sanjay Kalra, Manisha Sahay, Dinesh Dhanda, Rakesh Sahay
DOI:10.4103/ijem.IJEM_288_17  PMID:29535956
Diabetes management is a comprehensive exercise which encompasses not only glycemic control, but vascular risk reduction as well. Accepted clinical models such as the glycemic pentad and metabolic pentad list the glucose related and metabolic aspects which influence ling term vascular outcomes. This paper describes a 'renal pentad' which consists of 5×2 easily measurable parameters, which influence renal outcomes. Renal function ,acute health concerns, chronic health concerns, glycemic control and comorbid concerns from the five components of this pentad. The 5 pointed rubric serves as a teaching and clinical tool, and assists in appropriate choice and targets of therapy in diabetic kidney disease.
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Salutogenesis in Type 2 diabetes care: A biopsychosocial perspective p. 169
Sanjay Kalra, Manash P Baruah, Rakesh Sahay
DOI:10.4103/ijem.IJEM_224_17  PMID:29535957
Type 2 diabetes has emerged as a major threat to global public health. In spite of best efforts by health care professionals, persons with diabetes, and the community at large, remain unsatisfied with the approach to diabetes management .This brief communication utilizes Antonovsky's concept of salutogenesis, to suggest a person friendly and community friendly framework for diabetes care. Salutogenesis is used as a means of studying the biopsychosocial domains of diabetes , and as a guiding principle for health related communication . Adoption of a salutogenic approach to diabetes care should help improve outcomes and satisfaction with health care.
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LETTERS TO THE EDITOR Top

Diabetes Day 2017 p. 173
Jyothi Mariam Idiculla
DOI:10.4103/ijem.IJEM_636_17  PMID:29535958
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Parathyromatosis p. 173
Vipul D Yagnik
DOI:10.4103/ijem.IJEM_548_17  PMID:29535959
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Parathyroid Lipoadenoma: A Rare Entity p. 174
Ajay Aggarwal, Roopak Wadhwa, Vivek Aggarwal
DOI:10.4103/ijem.IJEM_273_17  PMID:29535960
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Obesity as the Presenting Feature of Sellar-Suprasellar Tuberculoma p. 176
Devi Dayal, Balasubramaniyan Muthuvel, Kushaljit Singh Sodhi
DOI:10.4103/ijem.IJEM_542_17  PMID:29535961
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