admission. This proportion could already be greater in some parts of the country and may increase if referrals of cases of self-poisoning increase faster than the facilities for their assessment and management. The provision of social work and psychiatric expertise in casualty departments may be one means of preventing unnecessary medical admissions without risk to the patients. Dr Blake's and Dr Bramble's figures do not demonstrate, however, that any advantage would attach to medical teams taking over assessment from psychiatrists except that, by implication, assessments would be completed sooner by staff working on the ward full time. What the figures actually suggest is that if assessment of overdoses were left to house doctors there would be an increase in admissions to psychiatric units (by 19°U), outpatients (by 5O°'), and referrals to social services (by 140o). So for house doctors to assess overdoses would provide no economy for the psychiatric or social services. The study does not tell us what the consequences would have been for the six patients who the psychiatrists would have admitted but to whom the house doctors would have offered outpatient appointments. E J SALTER

Vitamin D deficiency.

Contrast-enhanced computed tomography (CT) of the neck-thorax-abdomen and pelvis, including 3-phase examination of the liver, constitutes the basic imaging for primary neuroendocrine tumor (NET) diagnosis, staging, surveillance, and therapy monitoring. CT characterization of lymph nodes is difficult because of inadequate size criteria (short axis diameter), and bone metastases are often missed. Contrast-enhanced magnetic resonance imaging (MRI) including diffusion-weighted imaging is preferred for the examination of the liver, pancreas, brain and bone. MRI may miss small lung metastases. MRI is less well suited than CT for the examination of extended body areas because of the longer examination procedure. Ultrasonography (US) frequently provides the initial diagnosis of liver metastases and contrast-enhanced US is excellent to characterize liver lesions that remain equivocal on CT/MRI. US is the method of choice to guide the biopsy needle for the histopathological NET diagnosis. US cannot visualize thoracic NET lesions for which CT-guided biopsy therefore is used. Endocopic US is the most sensitive method to diagnose pancreatic NETs, and additionally allows for biopsy. Intraoperative US facilitates lesion detection in the pancreas and liver. Somatostatin receptor imaging should be a part of the tumor staging, preoperative imaging and restaging, for which 68Ga-DOTA-somatostatin analog PET/CT is recommended, which is vastly superior to somatostatin receptor scintigraphy, and facilitates the diagnosis of most types of NET lesions, for example lymph node metastases, bone metastases, liver metastases, peritoneal lesions, and primary small intestinal NETs. 18FDG-PET/CT is better suited for G3 and high G2 NETs, which generally have higher glucose metabolism and less somatostatin receptor expression than low-grade NETs, and additionally provides prognostic information.

/pdf/enets-consensus-guidelines-for-the-standards-of-care-in-1pi0dqk7j6.pdf

ENETS Consensus Guidelines for the Standards of Care in Neuroendocrine Tumors: Radiological, Nuclear Medicine and Hybrid Imaging

Background The worldwide prevalence of diabetes mellitus has risen dramatically in the developing countries over the past two decades. Regular screening of adults is essential for early detection and care. There are limited studies on diabetes awareness and prevalence in rural communities. Hence this prevalence and knowledge assessment study was undertaken. Such data are extremely important to plan the public health policies with specific reference to implementation of National Diabetic Control Program. Aims To study the prevalence and awareness of diabetes mellitus in rural areas. Settings and design Cross-sectional, household study. Materials and methods A study on adults and elderly age group in Tamaka village was undertaken. Structured questionnaire was used to assess the knowledge of diabetes and capillary blood screening tests done to detect diabetes. Statistical analysis used SPSS - 11 software. Results and conclusions Ten per cent of the 311 adults screened had hyperglycemia. Half of the interviewed population had some awareness about diabetes and its symptoms. But more than half (75%) of them were not aware of the long term effects of diabetes and diabetic care. The common perception about diet in diabetes was to avoid sweets, rice and fruits and to consume more ragi, millet and wheat chapattis. Diabetes in young adults is common. Relevant knowledge about diabetes is poor in rural population. Hence community level awareness programs have to be organized. Healthcare providers must be aware of community perceptions and practices.

Prevalence and awareness regarding diabetes mellitus in rural Tamaka, Kolar.

located in the lung (55.3%), mediastinum-thymus (7.9%), pancreas (8.5%), adrenal glands (6.4%), gastrointestinal tract (5.4%), thyroid (3.7%), and other sites (12.8%), and primary tumors were mostly bronchial neuroendocrine tumors (NETs) (54.8%), pancreatic NETs (8%), mediastinum-thymusNETs(6.9%),gastrointestinalNETs(5.3%),pheochromocytoma(6.4%),neuroblastoma(3.2%), andmedullarythyroidcarcinoma(3.2%).TumorswerelocalizedbyCTin66.2%(137/207),magnetic resonance imaging in 51.5% (53/103), OCT in 48.9% (84/172), FDG-PET in 51.7% (46/89), F-DOPAPET in 57.1% (12/21), 131/123 I-metaiodobenzylguanidine in 30.8% (4/13), and 68 Gallium-SSTRPET/CT in 81.8% (18/22) of cases. Molecular imaging discovered 79.1% (53/67) of tumors unidentified by conventional radiology, with OCT the most commonly used, revealing the tumor in 64%, followedbyFDG-PETin59.4%.F-DOPA-PETwasusedinonlysevencovertcases(sensitivity,85.7%). Notably, 68 Gallium-SSTR-PET/CT had 100% sensitivity among covert cases. Conclusions:Nuclear medicine improves the sensitivity of conventional radiology when tumor site identification is problematic. OCT offers a good availability/reliability ratio, and FDG-PET was proven useful. 68 Gallium-SSTR-PET/CT use was infrequent, despite offering the highest sensitivity. (J Clin Endocrinol Metab 100: 3231–3244, 2015)

/pdf/conventional-and-nuclear-medicine-imaging-in-ectopic-cushing-224ud929v6.pdf

Conventional and nuclear medicine imaging in Ectopic Cushing's syndrome: A systematic review

Although several evidence-based guidelines for managing diabetes are available, few, if any, focus on the psychosocial aspects of this challenging condition. It is increasingly evident that psychosocial treatment is integral to a holistic approach of managing diabetes; it forms the key to realizing appropriate biomedical outcomes. Dearth of attention is as much due to lack of awareness as due to lack of guidelines. This lacuna results in diversity among the standards of clinical practice, which, in India, is also due to the size and complexity of psychosocial care itself. This article aims to highlight evidence- and experience-based Indian guidelines for the psychosocial management of diabetes. A systemic literature was conducted for peer-reviewed studies and publications covering psychosocial aspects in diabetes. Recommendations are classified into three domains: General, psychological and social, and graded by the weight they should have in clinical practice and by the degree of support from the literature. Ninety-four recommendations of varying strength are made to help professionals identify the psychosocial interventions needed to support patients and their families and explore their role in devising support strategies. They also aid in developing core skills needed for effective diabetes management. These recommendations provide practical guidelines to fulfill unmet needs in diabetes management, and help achieve a qualitative improvement in the way physicians manage patients. The guidelines, while maintaining an India-specific character, have global relevance, which is bound to grow as the diabetes pandemic throws up new challenges.

National recommendations: Psychosocial management of diabetes in India.

A Practical Guide to Diabetes Mellitus

Aims and Objectives : To determine the level of awareness and knowledge about diabetes in the community, to identify their risk factors for diabetes, the relationship between anthropometric measures and diabetes risk and estimate the burden of diabetes in this rural North-East Indian population with an objective to identify target areas for future healthcare planning. Materials and methods : A healthcare team conducted a community-based survey of the residents of Khowai district, Tripura. All household members above the age of 25 years were eligible to participate, following voluntary consent. Survey questionnaires were administered with interpreter assistance including demographic information, diabetes knowledge, family history, smoking, diet, healthcare access and the international physical activity questionnaire (IPAQ). Anthropometric measurements were taken and blood glucose testing performed. Results : One hundred and forty four participants completed the survey, 66 males and 78 females with a mean age of 44.4 ± 14.8 years Although 91% had heard about diabetes and 44% were concerned about developing it in the future, only 39% were aware of its association with overweight status and 37% knew it required long-term treatment. Nine percent were known to have pre-existing diabetes mellitus and a further 9% were newly detected to have diabetes mellitus or impaired glucose tolerance. Fifteen percent were hypertensive and 8% had a family history of diabetes. Their mean BMI was 21.2 kg/m 2 and 31% were overweight, despite high levels of physical activity in 47%. For each predictor of increased risk - waist circumference (female >80cm, male >94cm), waist-height ratio >50% or BMI>23 kg/m 2 , subjects measuring above the cut-off were more likely to have abnormal glucose tolerance than those in the normal range (27% vs 14.3% p=0.08, 26.5% vs 9.5% p=0.008, 27.3% vs 13.3% p=0.043, respectively.) with waist-height ratio being the best predictor of an abnormal BGL: OR 3.45 CI (1.34 – 8.88). Conclusion : This is the first rural survey for diabetes in North-East India. This population had a low baseline knowledge and awareness about diabetes, despite significant diabetes prevalence. A greater emphasis on health education and risk factor modification for diabetes is warranted in the North-East part of the country.©

Healthcare planning in north-east India: a survey on diabetes awareness, risk factors and health attitudes in a rural community.

Objective Ketosis-prone diabetes (KPD), an atypical form of diabetes, has emerged as a heterogeneous syndrome in multiple ethnic groups. The objectives of this study were to look into the clinical characteristics of adult Asian Indian patients with recently diagnosed, antibody negative diabetes presenting with unprovoked ketoacidosis (A − β + KPD) and to determine the natural course of recovery of beta-cell functions on serial follow-up over one year. Research design and methods Newly diagnosed adult diabetes patients (n = 11) with suspected KPD (A − β +) were prospectively studied over a period of 1-year with serial evaluations of clinical, biochemical and beta-cell secretion characteristics. These were compared with a control group (n = 23) of KPD (A + β −) (classical Type 1A diabetes) with similar presentation. Beta-cell secretion was assessed by fasting and stimulated C-peptide values after a standard mixed meal challenge. Glycaemic control and treatment outcomes were also documented. Results In comparison to the A + β − KPD controls, the A − β + KPD patients had a significantly older age, higher BMI, stronger family history of type 2 diabetes, more severe ketoacidosis and higher fasting and stimulated C-peptide level at presentation. On serial follow-up, the patients with KPD achieved complete recovery of their beta-cell function with remission from insulin-dependence within 3–4 months without further recurrences of DKA. Conclusions This is the first reported series of A − β + KPD from India. The phenotype of Indian A − β + KPD patients differs from their Western counterparts in that they are relatively younger and leaner, though the male preponderance and natural history of recovery of beta-cell dysfunction bears similarity.

Clinical characteristics, beta-cell dysfunction and treatment outcomes in patients with A-β+ Ketosis-Prone Diabetes (KPD): The first identified cohort amongst Asian Indians.

OBJECTIVE
A number of imaging modalities have been used in the preoperative localization of insulinomas. Computed tomography (CT) is the most commonly employed modality. Endoscopic ultrasound (EUS) allows the transducer to be placed in close proximity to the pancreas, thereby yielding higher quality images, which facilitates accurate localization, minimally invasive surgery, and a lower occurrence of residual tumors, all of which contribute to a better clinical outcome.


METHODS
We analyzed the hospital records of all adult patients (age >18 years) diagnosed with insulinoma between October 2004 and September 2010. The diagnosis was based on the clinical practice guidelines of the American Endocrine Society. We compared the sensitivities of EUS and multidetector computed tomography (MDCT) in lesion.


RESULTS
Eighteen patients were seen over a period of 6 years, and all underwent EUS. MDCT scans were carried out in 17 patients. EUS had greater sensitivity (89%) in localizing insulinomas compared to CT (69%). In this series, the lesions that were missed on CT but picked up on EUS were smaller (<12 mm, P<.001). Lesions that were near mesenteric vessels and those located in the head of the pancreas were more likely to be missed on CT.


CONCLUSIONS
EUS has a greater sensitivity in identifying and localizing insulinomas. As availability increases, EUS should be part of a preoperative insulinoma workup.

Endoscopic ultrasonography is a sensitive tool in the preoperative localization of insulinoma

This study from southern India showed that the trabecular microarchitecture and proximal hip geometry were significantly impaired in postmenopausal women with diabetes as compared to age and BMI matched non-diabetic controls. This is despite there being no significant difference in bone mineral density at the femoral neck and hip not between both groups. One-third of the study subjects with type 2 diabetes had prevalent vertebral fractures. Bone mineral density assessment as a standalone tool may not adequately reflect bone health in subjects with diabetes. There is limited information with regard to bone health in Indian postmenopausal women with type 2 diabetes. We studied the bone mineral density (BMD), trabecular bone score (TBS), prevalent vertebral fractures (VF), proximal hip geometry, and bone mineral biochemistry in ambulatory postmenopausal women with and without type 2 diabetes mellitus (T2DM). This was a cross-sectional study conducted at a tertiary care center. BMD, TBS, prevalent vertebral fractures, and hip structural analysis (HSA) were assessed using a dual-energy X-ray absorptiometry (DXA) scanner. Bone mineral biochemical profiles were also studied. A total of 202 ambulatory postmenopausal women known to have type 2 diabetes mellitus with mean (SD) age of 65.6 (5.2) years and 200 age and BMI matched non-diabetic controls with mean (SD) age of 64.9 (4.7) years were recruited from the local community. Although the prevalence of lumbar spine osteoporosis was significantly lower among cases (30.7%) as compared to controls (42.9%), the prevalence of degraded bone microarchitecture (TBS < 1.200) was significantly higher among cases (51%) than in controls (23.5%); P < 0.001. Prevalent vertebral fractures were not significantly different in cases and controls. The various geometric indices of the proximal hip were significantly impaired in subjects with diabetes as compared to controls. This study may highlight the utility of the trabecular bone score and hip structural analysis in subjects with diabetes, where the bone mineral density tends to be paradoxically high, and may not adequately predict fracture risk.

Do proximal hip geometry, trabecular microarchitecture, and prevalent vertebral fractures differ in postmenopausal women with type 2 diabetes mellitus? A cross-sectional study from a teaching hospital in southern India

H S Asha

Papers

A Practical Guide to Diabetes Mellitus

Healthcare planning in north-east India: a survey on diabetes awareness, risk factors and health attitudes in a rural community.

Clinical characteristics, beta-cell dysfunction and treatment outcomes in patients with A-β+ Ketosis-Prone Diabetes (KPD): The first identified cohort amongst Asian Indians.

Endoscopic ultrasonography is a sensitive tool in the preoperative localization of insulinoma

Do proximal hip geometry, trabecular microarchitecture, and prevalent vertebral fractures differ in postmenopausal women with type 2 diabetes mellitus? A cross-sectional study from a teaching hospital in southern India