Immune-mediated musculoskeletal (MSK) manifestation is one of the most prevalent phenotypes of rheumatic disorders. Diabetes Mellitus (DM), the modern epidemic, acts as a great mimicker of rheumatic diseases in terms of MSK involvement. Numerous attempts have been made in various strands of scientific research to identify the level of association of these disorders with DM but unfortunately, the results are not uniform. In daily clinical practice, it is sometimes difficult to differentiate diabetes-related joint and muscle problems from pure rheumatic disorders without proper background knowledge. Rheumatic manifestations often amplify the magnitude of diabetes-related morbidities. In the modern era, treating the primary disease is often not sufficient; we need to go further ahead to tackle its long-term complications also to mitigate the suffering of patients. The identification and management of diabetes-related rheumatic problems in the ocean of rheumatology needs sufficient evidence-based knowledge, expertise, as well as clinical experience. In our article, we intend to discuss various MSK problems related to diabetes, their pathogenesis, clinical features, important clues for diagnosis, and overall management strategies.

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Background: Diabetes mellitus (DM) is a major health problem globally. It is estimated that approximately 50% of people with diabetes suffer from diabetes peripheral neuropathy (DPN). All patients with diabetes should be screened for peripheral neuropathy. Therefore, this study was undertaken to explore and determine the factors associated with peripheral neuropathy. Materials and Methods: A cross-sectional study was conducted on patients with type 2 DM and with peripheral neuropathy at a patient visiting diabetes clinic of a tertiary care center. Neuropathy analysis was done by a peripheral neuropathy analyzer (Vibrotherm: EN ISO 13485:2012). The test consisted of four different steps: The first step was vibration perception for a six-point assessment of each foot; then, cold perception; hot perception; and finally, a 10g Semmes-Weinstein monofilament test. Descriptive and inferential statistics were used for data analysis. Result: Out of 50 patients, the maximum were male (70%); mean age was 55.80 ± 11.48 years; 50% were living in urban areas, 40% in rural areas, and 10% in semi-urban areas; 34% were farmers, 26% were doing jobs, 24% were housewives, and 16% were businessmen. The mean duration of type 2 DM was 8.34 ± 7.89 years, and HbA1c (glycated hemoglobin) was 9.47 ± 3.17. Overall, 44 patients had neuropathy; among them, 29 had only large fiber neuropathy, 42 had small fiber neuropathy, and 27 had both small and large fiber neuropathy. Large fiber neuropathy was found to be significantly associated with HbA1c level and the duration of DM, and mixed fiber neuropathy was found to be significantly associated with the age of the participants (P < 0.05). Conclusion: Peripheral neuropathy is very common in patients with type 2 DM; it is associated with age, level of HbA1c, and the duration of DM, so early action should be taken to mitigate its occurrence.

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Background: Text messaging health service is used to improve quality of life of people living with diabetes in Eastern Nepal. It has been projected that the number of diabetic patients has increased to 170% from 1995 to 2025 in developing countries and to 41% in developed world. The objectives of the study were to assess the quality of life of people living with diabetes, to prepare and provide health education, and to evaluate the effectiveness of health education program and mobile/telephone health services provided to the diabetes patients. Materials and Methods: The study was conducted among consecutive stable ambulatory patients, >18 years old, and 396 patients diagnosed with diabetes for at least 3 months were included in the study. The education intervention was continued for 6 months by the principal investigator and a trained nurse. Results: Most of the respondents (53.3%) were of the age group 40–60 years; female (59.34%); Hindus (97%); and of the Janjati ethnic group (52.5%). The majority (96.5%) were married and self-employed (70.7%). About 30% of the respondents belonged to the poor economic status group. Most of the respondents had type II diabetes mellitus; about 34% of the respondents had a family history of (sibling) diabetes. Most of them were non-vegetarians (88.9%). About 16% of the respondents were obese. Regarding habits, 14% had tobacco chewing, 5% had gutka chewing, 8% had smoking, and around 8% had alcohol consumption habits. Regarding treatment, about 84% were on oral hypoglycemic agent, 22% on insulin therapy, 68% on diet control therapy, 58% on weight control, and 4.5% on herbal therapy. It was found that the mean knowledge score before education intervention was 22.53 and after education intervention was 35.32. It was found that the difference in the mean score calculated using t-test between knowledge before and after education intervention program was significant (P < 0.01). Conclusion: It can be concluded that the education intervention program and SMS mobile service provided to diabetes patients were found to be very effective.

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Aim: The primary objective was to study the electrocardiogram (ECG) findings of normal pregnant women in their third trimester. The secondary objective was to compare the ECG findings of pregnant women in their third trimester with the ECG findings during the postpartum period. Materials and Methods: An Electrocardiography recording was done for 60 pregnant women during their third trimester and on postpartum day 7. Results: The common ECG findings during pregnancy found in our study were sinus tachycardia, and conspicuous Q wave (LV dilation) and an inverted P wave (nonspecific) in lead II. We also found left axis deviation of a mean of 15° (QRS axis) when compared with the QRS axis of the same patient postpartum (P < 0.05). Conclusion: There are physiological changes in an ECG during pregnancy. A routine antenatal ECG is safe, feasible, economic, and possibly advantageous to lower maternal mortality and morbidity. The ECG findings must be interpreted carefully during pregnancy.

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The difference addressed earlier may not be a very hype intervention, unlike what science has been giving us, but this can do a lot in setting us free from this very pandemic, COVID-19. The fight against COVID-19 is a biological warfare that cannot be won at the cost of ammunitions but with proper knowledge, information, and communication, through various advertisements, banners, and posters. This is an hour-saving time where COVID-19 is rapidly evolving. The entire focus is placed on caring for the patient and on abandoning community spread of the disease in order to decrease disease burden; nevertheless, the rapidity of COVID-19 has proven to be grave for medical education and severely disrupted the medical curriculum.

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A bone is basically a combination of the organic matrix, inorganic minerals (calcium phosphate), and vitamins that make the structural framework. The two counteracting processes, bone formation and bone resorption, make the bone a metabolically active tissue that undergoes continuous remodeling. The laboratory evaluation of serological and urinary markers is important in the diagnosis of suspected bone disease such as osteoporosis, rickets/osteomalacia, fluorosis, and primary hyperparathyroidism, which are common metabolic bone diseases (MBD), whereas a few rare MBDs include Paget’s disease, fibrous dysplasia, osteogenesis imperfecta, tumor-induced osteomalacia, etc. Calcium and phosphate level in serum and urine reflects the status of metabolism of bone. Markers of one formation include: alkaline phosphatase (ALP), osteocalcin (OCn), and procollagen I peptides: the amino (N-) terminal propeptide (PINP) and the carboxy (C-) terminal propeptide (PICP). Markers of bone resorption include hydroxyproline (OHP), hydroxylysine (HYL), deoxypyridinoline (DPD), pyridinoline (PYD), bone sialoprotein (BSP), osteopontin (OP), tartrate-resistant acid phosphatase 5b (TRAP 5b), carboxy-terminal crosslinked telopeptide of type 1 collagen (CTX-1), amino-terminal crosslinked telopeptide of type 1 collagen (NTX-1), cathepsin K (CTSK), urinary calcium, and acid phosphatase. Novel biochemical markers such as periostin, cathepsins, RANK-L, secreted frizzled-related proteins (sFRP), Wnt inhibitory factor-1 (WIF1), Dickkopfs (Dkk) 1–4, sphingosine-1-phosphate (S1P), sclerostin, fibroblast growth factor (FGF)-23, and miRNA are also the markers of bone metabolism. Biochemical markers of bone metabolism provide a potentially important clinical tool for assessing and monitoring MBD. These markers are quick to appear after any derangement in physiology. Still, we must keep in mind that the characteristics of any marker are at present primarily a function of the assay used for the assessment of the marker. That continued efforts aimed at improving the analysis and interpretation of markers that are known today must continue.

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Diabetes and cancer are two severe, heterogeneous, and multifactorial chronic diseases. The frequency of these diseases occurring in the same individual is increasing worldwide at an alarming rate. Multiple research studies indicate the presence of shared modifiable and non-modifiable risk factors between the two diseases. Hyperinsulinemia is one such condition which favors cancer development in patients with diabetes as insulin shares some pre-eminent metabolic and mitogenic effects. While the drugs which are used to treat diabetes exhibit a lower risk of cancer development, the drugs taken to treat cancer may either cause diabetes or worsen pre-existing diabetes. Other hypothesized mechanisms comprehending the relationship between diabetes and cancer include insulin resistance, insulin-like growth factor-1, hyperglycemia, and dyslipidemia. Meta-analyses of many studies indicate that diabetes and cancer are the two sides of the same coin. There may also be a risk of escalation of one disease while treating the other. This phenomenon of reverse effect has been reported in cases of liver and pancreatic cancer, which leads to the progression of diabetes. In our review, we highlight some of the most promising mechanisms which attempt to comprehend this relationship between the two diseases. We conclude that diabetes and cancer have a very complex relationship that requires more clinical attention and better-designed studies.

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Background: Metabolic syndrome is associated with increased cardiovascular death. The objectives of this study were to find the frequency of metabolic syndrome among Nigerians with type 2 diabetes and to compare the modified National Cholesterol Education Program on the detection, evaluation, and treatment of high blood cholesterol in adults—Adults Treatment Panel III (NCEP ATP III) criteria and the International Diabetes Federation (IDF) criteria. Materials and Methods: The study involved 134 participants. Sixty-seven were cases with type 2 diabetes, whereas the rest were the controls without type 2 diabetes. Ethical approval was granted by the Institutional Ethics Review Committee. Anthropometric, clinical, and laboratory parameters were obtained using standard protocols. Data were analyzed with SPSS version 22. Means were compared with Student’s t-test, whereas proportions were compared with Pearson’s χ² test. Point biserial correlation was used to determine the association between the dichotomous variables and interval variables. Agreement between the criteria was tested with Cohen’s kappa test. Results: Type 2 diabetes was associated with a higher prevalence of hypertension and truncal obesity. The frequency of metabolic syndrome was lower with the IDF criteria compared with the modified NCEP criteria (65.7% vs. 71.6%). Although there was a strong agreement between the IDF and the modified NCEP criteria (κ=0.862; P<0.0001), the IDF criteria missed 8.3% of diabetic individuals diagnosed with metabolic syndrome by the modified NCEP criteria. Cardiovascular risk is better predicted when the modified NCEP criteria were used to diagnose metabolic syndrome. Conclusion: Metabolic syndrome is very common among Nigerians with type 2 diabetes, and it is better diagnosed with the modified NCEP ATP III criteria.

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Background: Pregnancy is associated with significant but reversible changes in thyroid functions, which may exacerbate thyroid disorders or improve thyroid disorders. Objectives: The present study was done to find out changes in thyroid function tests in each trimester in normal pregnant women when compared with non-pregnant women in a tertiary healthcare center. Materials and Methods: A cross-sectional study of 80 euthyroid women in the age group of 16–40 years was done. Twenty were non-pregnant and 20 were from first, second, and third trimesters each. Serum level measurement of T3, T4, and TSH was done with chemiluminescence technique. Results: The results of the study showed a progressive decrease in the mean values of FT3 and FT4, with a significant decrease in FT3 (P-value < 0.0001) and FT4 (P-value =0.0129) only in the third trimester. There was a progressive increase in the mean TSH levels through the pregnancy; however, there was no significant increase when compared with the non-pregnant women. Conclusion: There is a significant increase in serum T3 and T4 in pregnancy. Specific reference intervals should be used to identify the patients at risk and to take early interventions of treatment.

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Diabetes self-management education (DSME), considered as the cornerstone of treatment for all people with diabetes, helps people with diabetes, or newly diagnosed diabetics, learn how to successfully manage their disease. The goal of DSME is to help people practice diabetes self-care behaviors daily and be as healthy as possible.

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Carbon monoxide (CO) can cause intoxication without the victim being aware of it. Its exposure is common in Northern India but is infrequently reported because the clinical features are non-specific. In CO poisoning, myocardial injury is a significant predictor of mortality. We present a case of a middle-aged male, found unconscious inside a closed room on a winter morning. Upon presentation, the patient was drowsy with hypotension. CO oximetry showed carboxyhemoglobin (CO-Hb) of 28.6% and brain imaging, suggestive of hypodensities in bilateral globus pallidus. The patient was managed with high flow oxygen following which his sensorium improved gradually but hypotension persisted with echocardiography showing global left ventricular dysfunction. A session of hyperbaric oxygen therapy was given after which he improved hemodynamically with resolution of cardiac dysfunction over the next 3 days. We highlight the importance of early diagnosis of cardiomyopathy as CO-induced cardiomyopathy may be reversed if timely intervention is done.

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Background: Preeclampsia is a multisystem heterogeneous disorder occurring in 4%–7% of all pregnancies. Objectives: This study was conducted to define the relation between arterial stiffness and perinatal outcome in a tertiary care center. The relationship between maternal pulse wave augmentation index and adverse perinatal outcome is explored in this study. Materials and Methods: Peripheral pulse waveform of the brachial artery and mean arterial pressure measurement was performed in the second trimester in women with singleton pregnancy. Preeclampsia was recorded in (7%) of all pregnancies. Results: Abnormal peripheral pulse wave augmentation in the second trimester is a good tool for the prediction of preeclampsia (sensitivity 91.23% and specificity 99.06%, P < 0.05). Conclusion: Increased peripheral augmentation index (>2 SD) and mean arterial pressure measurement in combination have better detection rates for early-onset preeclampsia and fetal growth restriction (FGR).

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Pericardial effusion is one of the common medical conditions in clinical practice. It can present as ranging from asymptomatic to shock as in cardiac tamponade. Underlying etiology is diverse, including infections, metabolic, autoimmune, and neoplastic. Cardiac tamponade is a medical emergency, making it crucial for identification. It is treated with immediate pericardiocentesis for symptomatic management, followed by identifying the underlying cause. Here we present an interesting case, presented as cardiac tamponade with underlying malignancy.

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Context: Maize silk (Zea mays) is used in traditional medicine to treat high blood pressure, diabetes and obesity. It is also used as an immunostimulant but few scientific studies are available to validate these properties. Aims: The aim of this study was to scientifically validate the traditional use of maize silk in the regularization of lipid profile and blood glucose level. Material and Methods: Hydroalcoholic extract of maize silk (HAEMS) was prepared by decoction (30:70 Water-Ethanol) from the dry powder of corn silk (250 g/L). Hyperglycemia was induced by repeated single daily subcutaneous injection (s.c) of dexamethasone (5 mg/kg); dexamethasone negative control group (DNC) received dexamethasone exclusively throughout 14 days while negative normal control group (NNC) received only vehicle during the same period. Positive control group (glibenclamide) and plant extract groups (50 and 100 mg/kg) received dexamethasone from the eighth day and each group consisted of six animals. All the parameters (fasting blood glucose level, TC, HDL, LDL, VLDL, atherogenic index (AI) and TG) were measured on the first, seventh and fourteenth day of the experiment. Lipid profile was performed using a BIOLABO^® Kit and fasting blood glucose level was measured using a glucometer VivaCheck™ Ino. Results: Compared to the DNC group, HAEMS significantly reduced (P<0.001) on days seven and fourteen, fasting blood glucose level, TC, LDL, VLDL, artherogenic AI and TG (on day seven). In addition, only the dose of 50 mg/kg significantly increased serum HDL on the seventh (P<0.01) and fourteenth day (P<0.001). Conclusion: The results obtained in this study suggest that HAEMS have hypoglycemic and antihyperlipidemic properties.

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Diabetes mellitus is a major health problem globally that increases the economic burden of every country. According to the International Diabetes Federation (IDF) in 2021, 1 in 10 adults are living with diabetes. About 352 million adults have uncontrolled glycemic profiles worldwide. Diabetes is likely to affect 552 million people worldwide by 2030. Diabetes and its complications are emerging as the leading cause of morbidity and mortality. Diabetes neuropathies are estimated to affect approximately 50% of people suffering with diabetes. Neuropathy, the most prevalent microvascular complication of diabetes mellitus, includes distal symmetric polyneuropathy, radiculoplexus neuropathy, autonomic neuropathy, mononeuropathy, and treatment-induced neuropathy. Early diagnosis and appropriate management of diabetic neuropathy are essential to alleviate disabling symptoms and to improve the quality of life of patients. This review discusses clinical manifestations and evaluation of diabetic neuropathies as well as appropriate objective tests helpful in diagnosing diabetic neuropathies.

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Background: Cardiac autonomic neuropathy (CAN) is a serious complication of diabetes mellitus that strongly associated with increased risk of cardiovascular mortality. Aim: The aim of this study was to evaluate the association between diabetic retinopathy (DR) and early CAN in patients with type 2 diabetes (T2D). Materials and Methods: The study was conducted on 60 patients with T2D, divided into two groups; group I included 30 patients with T2D complicated with DR and group II included 30 patients with T2D not complicated with DR. All participants underwent a detailed medical history, examination and laboratory measurements including, hemoglobin A1c (HbA1c) and urinary albumin/creatinine ratio (UACR). CAN was determined based on the results of tilt-table test which was done to all study participants. Results: On comparing tilt table test positive results of group I and group II, the results showed a significant difference between both groups (P = 0.004), being higher in group I (43.33% of group I were tilt table test positive) than in group II (only 10% of the group were positive). In group I, on comparing patients with positive tilt table test (CAN) and those with negative tilt table test (without CAN) regarding fundus findings, the results showed that 69.23% of patients with positive tilt table test had proliferative diabetic retinopathy (PDR), and 30.77% had non-proliferative diabetic retinopathy (NPDR), while in patients with negative tilt table test, 17.65% had PDR, and 82.35% had NPDR, the odd‘s ratio was 10.5 (P = 0.007). Regression of determinants for the presence of cardiac autonomic neuropathy in patients with T2D showed that, the increased duration of diabetes (P = 0.010) and the increased level of UACR (P = 0.001) were significantly associated with CAN in type 2 diabetic patients. Conclusion: DR is a strong predictor for CAN. So, fundus photography may be an alternative to autonomic function testing where facilities for the latter test are unavailable.

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Background: Cardiac autonomic neuropathy (CAN) is a known complication in diabetes patients but often remain underdiagnosed because of lack of proper investigation and long asymptomatic period. The study aimed to assess the spectrum of cardiac autonomic neuropathy prevailing among type 2 diabetes mellitus patients visiting a tertiary care hospital. Materials and Methods: The study was conducted as an observational cross-sectional study among the type 2 diabetes patients visiting the diabetic clinic. A total of 60 participants were included in the study, including both males and females, over one month. A cardiac autonomic neuropathy system analyser, manufactured by the Diabetik Foot Care India Pvt Limited (DFCI), Chennai (CANS 504), was used to screen for cardiac autonomic neuropathy (CAN). Results: A total of 60 patients were enrolled in the study. The mean age of the participants was 55.72 ± 12.62 (Mean ± SD). 38 (63.3%) of the participants were male, and 22 (36.7%) were Female. Early CANS dysfunction was seen among 21 (35.0%), Moderate CANS dysfunction in 9 (15.0%) and definite CANS dysfunction in 29 (48.3%) patients and only one patient had normal CAN study. Conclusion: CAN is a common microvascular complication highly prevalent among diabetes patients and may remain asymptomatic until an advanced stage, so screening of type 2 diabetes patients must be done at the time of diagnosis.

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Hypertension is one of the most common noncommunicable diseases prevalent in the community. Its treatment is largely dependent on pharmacological and nonpharmacological strategies. The pharmacological treatment is often associated with vivid side effects both common and rare adverse events. Here we report a rare adverse effect of a common antihypertensive drug, Telmisartan. The adverse event was suspected based on temporal association of starting the drug and appearance of headache. It was further strengthened by disappearance once the drug was withdrawn.

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Background: In current COVID-19 pandemic, India had lockdown from 25^th March 2020 followed by relaxation in phases from 1^st June. The aim of the study was assessment of lockdown impact on metabolic and liver disease status of non-COVID patients of liver diseases. Materials and Methods: OPD data of all consecutive patients of liver disease without COVID-19 infection from 1^st January 2020 to 31^st December was analyzed. The primary objective was to assess lockdown impact on liver stiffness. Fibroscan, BMI and laboratory data was compared before and after implementation of lockdown in three groups (Group1-noncirrhotics, Group2- compensated cirrhotics, Group3- decompensated cirrhotics). Results: 230 patients (77% M) were analyzed. In all the three groups, there was no significant change in the liver stiffness and fat content by fibroscan, complete blood count, liver and kidney function tests. In Group1, there was significant increase in BMI (25.3 ± 6.0 vs 26.4 ± 6.1, P < 0.01), sugar (mg/dl) fasting (101.5 ± 30.1 vs110.7 ± 31.8, P < 0.01), post prandial (131 ± 31.6 vs 156.5 ± 35.5, P < 0.01), LDL (mg/dl) (111.1 ± 33.1 vs 119.1 ± 26.8, P = 0.036), total lipid/HDL ratio (4.04 ± 1.39 vs 4.58 ± 1.58, P = 0.01) and reduction in HDL (mg/dl) (45.8 ± 12.7 vs 40.4 ± 10.1, P < 0.01). In Group2, significant increase in LDL (97.3 ± 32.5 vs 114.3 ± 29.8, P = 0.01), LDL/HDL ratio (2.36 ± 1.26 vs 2.70 ± 1.03, P = 0.04) and decrease in HDL (45.6 ± 12.1 vs 40.9 ± 11.2, P < 0.01) was seen, with no significant change in BMI, and sugar fasting, post prandial, HbA1c. In Group3, there was no significant change in any of the parameters analysed. Conclusions: There was no impact of lockdown due to Covid pandemic on liver disease status. However, lockdown worsened metabolic parameters of non-cirrhotics and compensated cirrhotics.

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