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1. A mediation analysis evaluating change in self-stigma on diabetes outcomes among people with depression in urban India: A secondary analysis from the INDEPENDENT trial of the collaborative care model.

Author

Scott Halliday, Deepa Rao, Orvalho Augusto, Subramani Poongothai, Aravind Sosale, Gumpeny R Sridhar, Nikhil Tandon, Rajesh Sagar, Shivani A Patel, K M Venkat Narayan, Leslie C M Johnson, Bradley H Wagenaar, David Huh, Brian P Flaherty, Lydia A Chwastiak, Mohammed K Ali, Viswanathan Mohan, and INDEPENDENT Study Group

Subjects
Public aspects of medicine, RA1-1270
Abstract

Self-stigma-the internalization of negative community attitudes and beliefs about a disease or condition-represents an important barrier to improving patient care outcomes for people living with common mental disorders and diabetes. Integrated behavioral healthcare interventions are recognized as evidence-based approaches to improve access to behavioral healthcare and for improving patient outcomes, including for those with comorbid diabetes, yet their impact on addressing self-stigma remains unclear. Using secondary data from the Integrating Depression and Diabetes Treatment (INDEPENDENT) study-a trial that aimed to improve diabetes outcomes for people with undertreated and comorbid depression in four urban Indian cities via the Collaborative Care Model-we longitudinally analyzed self-stigma scores and evaluated whether change in total self-stigma scores on diabetes outcomes is mediated by depressive symptom severity. Self-stigma scores did not differ longitudinally comparing Collaborative Care Model participants to enhanced standard-of-care participants (mean monthly rate of change in Self-Stigma Scale for Chronic Illness-4 Item scores; B = 0.0087; 95% CI: -0.0018, 0.019, P = .10). Decreases in total self-stigma scores over 12 months predicted diabetes outcomes at 12 months (HbA1c, total effect; B = 0.070 95%CI: 0.0032, 0.14; P < .05), however depressive symptoms did not mediate this relationship (average direct effect; B = 0.064; 95% CI: -0.0043, 0.13, P = .069). Considering the local and plural notions of stigma in India, further research is needed on culturally grounded approaches to measure and address stigma in India, and on the role of integrated care delivery models alongside multi-level stigma reduction interventions. Trial registration : ClinicalTrials.gov, NCT02022111. https://clinicaltrials.gov/study/NCT02022111.

Published
2024
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2. Development and validation of a situational anxiety scale screening assessment among adults with type 2 diabetes during COVID-19 at a tertiary centre in Chennai, India

Author

Subramani Poongothai, Satish Latha, Mokkapati Lalasa, Karthikeyan Swetha, and Viswanathan Mohan

Subjects
anxiety, coronavirus, hospital, india, situational anxiety scale, trait anxiety inventory, type 2 diabetes, validation, Diseases of the endocrine glands. Clinical endocrinology, RC648-665
Abstract

Aim: The aim of this study was to develop and validate the situational anxiety scale (SAS) during COVID-19 among adults with type 2 diabetes attending a tertiary diabetes center in Southern India. Materials and Methods: A total of 100 individuals aged from 18 to 65 years with type 2 diabetes attending a tertiary care diabetes center completed a structured SAS at two visits. The first visit (visit 1) survey was conducted in April 2021 and the second visit (visit 2) survey was conducted in March 2022. The SAS was administered to all 100 individuals. The State Trait Anxiety Inventory Scale (STAI-S) consisting of 20 questions was administered to the same 100 individuals in addition to the SAS during Visit 2. Results: The SAS showed good internal consistency for visit 1 (α = 0.855) and visit 2 (α = 0.795). Exploratory factor analysis showed four factors and explained 69% of variance. The four factors identified were as follows: (1) fear, (2) desire for COVID-free state, (3) lack of interest and energy, and (4) financial worries. A weak positive correlation was observed between SAS visit 2 and STAI-S, and it was statistically significant (r = 0.223; P = 0.026). Conclusion: The SAS is a valid and reliable tool for measuring situational anxiety during pandemics and post-COVID anxiety levels, which can help in the development of a holistic approach.

Published
2023
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3. Strategies for participant retention in long term clinical trials: A participant –centric approaches

Author

Subramani Poongothai, Ranjit Mohan Anjana, Ramasamy Aarthy, Ranjit Unnikrishnan, K M Venkat Narayan, Mohammed K Ali, Kulasegaran Karkuzhali, and Viswanathan Mohan

Subjects
clinical trials, retention, stakeholders, Medicine, Medicine (General), R5-920
Abstract

A clinical trial is the most foolproof method to evaluate the efficacy of a new intervention. Successful completion of clinical trials depends on the retention of the participants enrolled. Poor participant retention can lead to significant time and cost burden and have potentially adverse biases on the results. A high retention rate of participants is an important criterion for the validity and credibility of randomized controlled clinical trials. Many long-term trials fail due to low retention of study participants. Efforts at participant retention should start even before the first participant is recruited into the study. Retention is not only the responsibility of the investigators but also all other stakeholders in a clinical trial. In recent years, retention materials, participant camps, and introduction of national study coordinators have helped in improving retention. Quality of the relationship developed between the research staff and the study participant is a key factor for success of any trial. In our experience, in the context of resource-challenged low- and middle-income countries, we have found that it is possible to achieve high retention rates, 95%–100%. The rapport built between the investigating team and the participant plays a vital role in retention. In addition, personalized care, including listening to the participant's problems and enabling to contact investigators or study team at any time of the day, has shown benefits in retention.

Published
2023
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4. Reliability and Validity of the Adolescence Stress Scale (ADOSS) for Indian Adolescents

Author

Narayanaswamy Jagannathan, Ranjit Mohan Anjana, Thaharullah Shah Mehreen, Kanniyappan Yuvarani, Dhanasekar Sathishkumar, Subramani Poongothai, Viswanathan Mohan, Sathish Latha, and Harish Ranjani

Subjects
Psychiatry, RC435-571
Abstract

Background: Stress levels increase tremendously in adolescence. Indian adolescents derive much of their stress from school and family pressures. Developing a standardized tool to assess adolescent stress can help early diagnosis. This article aimed to assess the reliability and validity of the ADOlescence Stress Scale (ADOSS). Methods: ADOSS was administrated by trained interviewers to 100 adolescents (10–17 years) of both sexes in Chennai, South India. Salivary cortisol was used as an objective measure of stress in 40 adolescents. Reliability was assessed within a two weeks interval. Exploratory factor analysis was done for the baseline ADOSS scores. The internal consistency (Cronbach’s alpha and spilt-half correlation), test-retest agreement (Kappa value), and inter-rater reliability (ICC) were assessed. Pearson correlation between salivary cortisol and ADOSS score was done. Results: The inter-factor correlation between the inherent four ADOSS factors (personal, academic, family, and social) was between 0.73 and 0.87, and split-half correlation was between 0.70 and 0.83, showing that the factors are reliable and coherent. Test-retest agreement was Kappa: 0.63, P = 0.001, and ICC was 0.84. Pearson correlation showed a statistically significant positive correlation between cortisol levels and ADOSS scores ( r = 0.87, P = 0.001). Conclusion: ADOSS is a reliable and valid tool to assess the overall stress of Indian adolescents in the age group of 10–17 years.

Published
2023
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5. Association of stress, depression and anxiety among individuals with microvascular complications in type 2 diabetes

Author

Jayaram Vidyulatha, Thyparambil Aravindakshan Pramodkumar, Rajendra Pradeepa, Subramani Poongothai, Somasundaram Thenmozhi, Ulagamathesan Venkatesan, Saravanan Jebarani, Ranjit Mohan Anjana, and Viswanathan Mohan

Subjects
anxiety, depression, microvascular complications, stress, type2 diabetes mellitus, Diseases of the endocrine glands. Clinical endocrinology, RC648-665
Abstract

Background and Aims: The impact of a chronic illness like diabetes on physical and mental wellbeing has been gaining more focus in the last few decades. This study aimed to investigate the association of stress, depression, and anxiety among individuals with type 2 diabetes mellitus (T2DM) and microvascular complications. Materials and Methods: This cross-sectional study included 315 participants aged ≥20 years with T2DM seen at a tertiary care diabetes centre who were screened for diabetic retinopathy, nephropathy, and neuropathy and assessed for stress, depression, and anxiety using the Depression, Anxiety Stress Scale 21 (DASS 21). Diabetic retinopathy was classified according to the Early Treatment Diabetic Reinopathy Study grading system diagnosed using retinal photography [Early Treatment DR Study grading system] i.e., presence of at least one distinct microaneurysm; nephropathy, if urinary albumin excretion was ≥30 mg/μg of creatinine; and neuropathy, if vibration perception threshold of the big toe using biothesiometry was ≥20 V. Results: Prevalence of stress was higher in those with neuropathy (60% vs 40%, P < 0.001), nephropathy (61% vs 39%, P < 0.001) and retinopathy (57% vs 43%, P < 0.05) compared to those without. Prevalence of depression was also higher in individuals with neuropathy (66% vs 34%,P < 0.001), nephropathy (58% vs 42%, P < 0.001) and retinopathy (55% vs 45%, P < 0.05). In multiple regression analysis, stress was significantly associated with retinopathy (OR=3.13,CI:1.75–5.58, P < 0.000), neuropathy (OR=2.50, CI:1.42–4.39,P < 0.001) and nephropathy (OR=2.06,CI:1.19–3.56, P < 0.010),depression was also significantly associated with retinopathy (OR=1.97,CI:1.04–3.73, P < 0.037), neuropathy (OR=2.77,CI:1.45–5.30,P < 0.002) and nephropathy (OR=2.59,CI:1.42–4.70,P < 0.002). Conclusions: Individuals with microvascular complications of diabetes should be screened for stress, depression,and anxiety so that proper counselling can be given.

Published
2022
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6. Prevalence and impact of stress among individuals with type 2 diabetes attending a tertiary diabetes center in South India

Author

Jayaram Vidyulatha, Thyparambil Aravindakshan Pramodkumar, Rajendra Pradeepa, Mohan Deepa, Subramani Poongothai, Ulagamathesan Venkatesan, Garudam Raveendiran Aarthi, Somasundaram Thenmozhi, Ranjit Mohan Anjana, and Viswanathan Mohan

Subjects
diabetes, india, prevalence, south india, stress, Diseases of the endocrine glands. Clinical endocrinology, RC648-665
Abstract

Aims and Objectives: Diabetes is a chronic health condition proving to be a major health challenge globally. Being a lifestyle-related disorder, psychosocial and behavioral factors are critical for its management, among which stress plays a contributory role. Diabetes is associated with increased risk of depression, anxiety, and stress due to its debilitating nature and complications. Stress not only affects glycemic control through biological pathways but also leads to unhealthy behavior such as binge eating, smoking, and alcohol. This study attempts to fill the lacuna between clinical and psychosocial aspects of stress and thereby determines the prevalence and impact of stress among type 2 diabetes individuals in a clinic population. Materials and Methods: This is a cross-sectional, case–control study that includes individuals with type 2 diabetes mellitus (T2DM) as well as those with normal glucose tolerance. Assessment of stress was done using a validated tool, the Depression Anxiety Stress Scale-21 (stress component). Sociodemographic characteristics, anthropometry, blood pressure, and biochemical parameters were collected in all the participants. Data were analyzed using Statistical Package for Social Sciences statistical software. Results: The prevalence of stress was significantly higher in T2DM compared to normal glucose tolerance (NGT; 43% vs 13%, P < .001). Both among T2DM and NGT, stress levels were higher in younger individuals with higher education, higher income levels, and professionals. Stress scores decreased with age at diagnosis of T2DM (16.6 [≤25 years] vs 15.6 [≥26–40 years] vs 12.7 [≥41 years], P < .001). T2DM was significantly associated with stress after adjusting for confounding factors. Conclusion: Individuals with T2DM had significantly higher prevalence of stress. Regular screening of stress could lead to better glycemic control.

Published
2022
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7. Impact of yoga intervention on physical and mental health of adults with type 2 diabetes: Study design and methodology

Author

Subramani Poongothai, Ashok Vidyulatha, Thameem Nisha, Mokkapati Lalasa, Balasundaram Bhavani Sundari, Kulasegaran Karkuzhali, Muniyandi Thanujah, and Satish Latha

Subjects
mental health, physical health, type 2 diabetes, yoga intervention, Diseases of the endocrine glands. Clinical endocrinology, RC648-665
Abstract

Objective: The aim of this study was to discuss the components of yoga intervention and experimental design used to assess its effectiveness in diabetes care centers in Chennai. Materials and Methods: An interventional, randomized prospective study design was adopted. The study was conducted over a 6-month period. Based on inclusion and exclusion criteria, participants were selected from Dr Mohan’s Diabetes Specialities Centre. Informed consent was obtained, and participants were randomly assigned to either the intervention or the control group in a 1:1 ratio. Participants in the intervention group underwent yoga training every 2 weeks for up to 3 months. Each yoga session lasted 35 min and included a variety of asanas and pranayama techniques. Participants were also given an audio recording (CD) of the yoga instructions, and they were encouraged to practice yoga at home and advised to keep track of their progress in a dairy provided. Diabetes care was provided to the control group on a routine basis. In addition to biochemical parameters, mental health parameters were also assessed. Independent t-test was performed using SPSS 24.0. Results: A total of 152 participants were screened and randomized with 76 in the intervention arm and 76 in the control arm. There were no challenges in participants recruitment and retention. Data were collected during enrollment, 13 and 26 weeks. At baseline, the intervention arm’s mean HbA1c (%) was 8.4 ± 1.1%, whereas in the control arm, it was 8.3 ± 1.1% (P = 0.290), and fasting blood glucose levels were 142± 27 mg/dL in the intervention arm and 141 ± 29 mg/dL in the control arm (P = 0.811). There was no significant difference between groups in terms of lipid profile or mental health parameters at baseline. Conclusion: There is a major lacuna for controlled trials with methodological rigor in yoga intervention; this study may contribute to fill this requirement by systematically elucidating the role of yoga in the management of diabetes and to prevent complications. This study will provide a cost-effective care for people with diabetes. TRIAL REGISTRATION: CTRI/2018/04/013169

Published
2021
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8. Perspectives from training the care coordinators—A new cadre to support team-based diabetes and depression care in India: INDEPENDENT study

Author

Balasundaram Bhavani Sundari, Subramani Poongothai, Ranjit Mohan Anjana, Deepa Rao, Nikhil Tandon, Gumpeny R Sridhar, Aravind R Sosale, Radha Shankar, Rajesh Sagar, Mohammed K Ali, Viswanathan Mohan, and Lydia Chwastiak

Subjects
care coordinator, collaborative care, comorbid conditions, diabetes and depression, diabetes and mental health, task sharing, training, Diseases of the endocrine glands. Clinical endocrinology, RC648-665
Abstract

Purpose: Comorbid depression and type 2 diabetes are associated with poor glycemic control, increased complications, and poor self-management, compared to either condition alone. The Integrating Depression and Diabetes Treatment (INDEPENDENT) clinical trial demonstrated the effectiveness of an integrated care model in improving diabetes and depression outcomes, in diabetes-specialty clinics in India. The INDEPENDENT model used task sharing to address the shortage of mental health professionals in India. Care coordinators (CCs) who were dietitians or counsellors were a key component of this care model. This article details the training and support provided to the CCs during the INDEPENDENT trial. Materials and Methods: CCs were nonphysician and nonpsychiatrist health specialists who supported patients in self-management of diabetes and depression, helping them set achievable goals and monitored progress. During the clinical trial, the CCs underwent both offsite and on-site trainings. The trainings equipped them with various lifestyle management tools for self-care, including one-on-one education sessions and motivational interviewing for self-monitoring, adherence to medication, diet, exercise regimes, and cessation of smoking, among others. Results: Nine CCs from the four sites were trained effectively during the course of the INDEPENDENT study from 2014 to 2018. Conclusions: Given the paucity of mental health professionals in India, the use of collaborative care and a team of well-trained CCs may be an effective strategy for the management of comorbid depression and diabetes. This model of care could help fill deficiencies in the delivery of care for comorbidity of depression and diabetes care in India.

Published
2021
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9. Strategies adopted in conduct of clinical trials amidst coronavirus disease-2019 (COVID-19)

Author

Subramani Poongothai, Ranjit Mohan Anjana, Ramasamy Aarthy, Selvam Kasthuri, Mohamed Althab Begum, Kulasegaran Karkuzhali, Kannikan Viswanathan, Balasundaram Bhavani Sundari, Ravi Pavitha, Boopathi Hemalatha, Abdul Ali Tameem Nisha, Mahalakshmi Ravisankar, Rajkumar Marappan, and Jagannathan Ramesh

Subjects
challenges, clinical trials, covid-19, Diseases of the endocrine glands. Clinical endocrinology, RC648-665
Abstract

The conduct of clinical trials is crucial to all research stakeholders and very challenging to the investigators, study teams, and participants during (coronavirus disease-2019) COVID-19 pandemic. The main challenges include difficulties in maintaining complete adherence to approved protocol, regulatory provisions applicable guidelines, recruitment of subjects, protection of rights, safety and well-being of trial subjects (participants), is of paramount importance. The CDSCO (Central Drugs Standard Control Organization), EMA (European Medicines Agency), and FDA (Food and Drug Administration) have come out with the guidelines on the management of clinical trials during the COVID-19. This article describes the process of conducting clinical trials at Department of Clinical Trials at Madras Diabetes Research Foundation (MDRF), Chennai, during the COVID-19 pandemic. Effective strategies taken at our site include compliance with scheduled visits of subjects, laboratory testing (investigations), administration of investigational product(s), assessment of safety and efficacy parameters, reporting of SAEs (serious adverse event). These strategies could be a useful reference to investigators, doctors, and research staff across hospital sites in India and elsewhere.

Published
2020
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11. Input of stakeholders on reducing depressive symptoms and improving diabetes outcomes in India: Formative work for the INtegrated DEPrEssioN and Diabetes TreatmENT study

Author

Deepa Rao, Lauren Lipira, Shuba Kumar, Rani Mohanraj, Subramani Poongothai, Nikhil Tandon, G R Sridhar, Wayne Katon, K M Venkat Narayan, Lydia Chwastiak, Viswanathan Mohan, and Mohammed K Ali

Subjects
Depression, diabetes, integrated care models, South Asia, Specialties of internal medicine, RC581-951
Abstract

Context: Depression and diabetes are highly comorbid, adversely affecting treatment adherence, and resulting in poor outcomes. To improve treatment and outcomes for people dually affected by diabetes and depression in India, we aimed to develop and test an integrated care model. Aims: In the formative phase of this INtegrated DEPrEssioN and Diabetes TreatmENT (INDEPENDENT) study, we sought stakeholder perspectives to inform culturally-sensitive adaptations of the intervention. Settings and Design: At our Delhi, Chennai, and Visakhapatnam sites, we conducted focus groups for patients with diabetes and depression and interviewed health-care workers, family members, and patients. Subjects and Methods: Key informants were asked about experiences with diabetes and depression and for feedback on intervention materials. Analysis: Qualitative data were analyzed using a grounded theory approach. Results: Three major themes emerged that have bearing on adaptation of the proposed intervention: importance of family assistance, concerns regarding patient/family understanding of diabetes, and feedback regarding the proposed intervention (e.g., adequate time needed for implementation; training program, and intervention should address stigma). Conclusions: Based on our findings, the following components would add value when incorporated into the intervention: (1) engaging families in the treatment process, (2) clear/simple written information, (3) clear nonjargon verbal explanations, and (4) coaching to help patients cope with stigma.

Published
2016
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12. Association of depression with common carotid artery intima media thickness and augmentation index in a large Urban South Indian population- The Chennai Urban Rural Epidemiology Study (CURES - 138)

Author

Subramani Poongothai, Rajendra Pradeepa, Karunakaran Indulekha, Jayagopi Surendar, and Viswanathan Mohan

Subjects
Asian Indians, atherosclerosis, augmentation index, depression, diabetes, intima media thickness, South Asians, Diseases of the endocrine glands. Clinical endocrinology, RC648-665, Diseases of the digestive system. Gastroenterology, RC799-869
Abstract

AIM: The aim of the study was to assess the relationship of depression with carotid intima media thickness and augmentation index in Asian Indians. Research Design and Methods : For this study, 1505 subjects were randomly selected from a population based study conducted in Chennai, South India. Right common carotid artery intima medial thickness [IMT] was determined using high-resolution B-mode ultrasonography. Augmentation index [AI] was measured using the Sphygmocor apparatus. Depressive symptoms were assessed using a previously validated instrument, the Patient Health Questionnaire -12 (PHQ -12). Results : Of the 1505 subjects included in this study, depressive symptoms were present in 16.6% (n = 250) of the subjects. The mean IMT and AI values among subjects with depression were significantly higher than those without depression [0.83 ± 0.43 mm vs 0.73 ± 0.12 mm, P < 0.001] and IMT was higher in females with depression while AI was higher in males with depression. However, both IMT and AI were higher among those with depression in both genders. In multiple logistic regression model, depressive symptoms were associated with IMT even after adjusting for age, gender, body mass index, fasting plasma glucose, serum cholesterol and hypertension (Odds ratio [OR] =2.17, 95% Confidence intervals [CI]:1.01- 4.63, P = 0.047) but in the case of AI, the significance was lost in the adjusted model (OR = 1.01, 95% CI: 0.991-1.02, P = 0.445). Conclusion: Among Asian Indians, presence of depressive symptoms was associated with carotid intima media thickness and Augmentation index, even after adjusting for potential confounders.

Published
2015
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13. Why are clinical trials necessary in India?

Author

Subramani Poongothai, Ranjit Unnikrishnan, Jeyakumar Balasubramanian, Mohan Damodaran Nair, and Viswanathan Mohan

Subjects
Clinical trials, good clinical practice, India, Medicine, Medicine (General), R5-920
Abstract

Clinical trials are emerging as an important activity in India as it is an essential component of the drug discovery and development program to which India is committed. The only robust way to evaluate a new medicine is by doing properly designed clinical trials. In addition to advancing science, clinical trials offer myriad benefits to the participants. The recent hue that created in India about clinical trials is probably an exaggeration of facts. However, these points to the need for ensuring proper compliance with the regulatory norms and proper training of concerned personnel in good clinical practice (GCP). This will ensure that India continues to reap the benefits of clinical trials and also become a world leader in this field.

Published
2014
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14. Prevalence of depression in a large urban South Indian population--the Chennai Urban Rural Epidemiology Study (CURES-70).

Author

Subramani Poongothai, Rajendra Pradeepa, Anbhazhagan Ganesan, and Viswanathan Mohan

Subjects
Medicine, Science
Abstract

BACKGROUND: In India there are very few population based data on prevalence of depression. The aim of the study was to determine the prevalence of depression in an urban south Indian population. METHODS AND FINDINGS: Subjects were recruited from the Chennai Urban Rural Epidemiology Study (CURES), involving 26,001 subjects randomly recruited from 46 of the 155 corporation wards of Chennai (formerly Madras) city in South India. 25,455 subjects participated in this study (response rate 97.9%). Depression was assessed using a self-reported and previously validated instrument, the Patient Health Questionnaire (PHQ) - 12. Age adjustment was made according to the 2001 census of India. The overall prevalence of depression was 15.1% (age-adjusted, 15.9%) and was higher in females (females 16.3% vs. males 13.9%, p

Published
2009
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15. Reliability and Validity of the Adolescence Stress Scale (ADOSS) for Indian Adolescents

Author

Narayanaswamy Jagannathan, Ranjit Mohan Anjana, Thaharullah Shah Mehreen, Kanniyappan Yuvarani, Dhanasekar Sathishkumar, Subramani Poongothai, Viswanathan Mohan, Sathish Latha, and Harish Ranjani

Subjects
Clinical Psychology, Psychiatry and Mental health
Abstract

Background: Stress levels increase tremendously in adolescence. Indian adolescents derive much of their stress from school and family pressures. Developing a standardized tool to assess adolescent stress can help early diagnosis. This article aimed to assess the reliability and validity of the ADOlescence Stress Scale (ADOSS). Methods: ADOSS was administrated by trained interviewers to 100 adolescents (10–17 years) of both sexes in Chennai, South India. Salivary cortisol was used as an objective measure of stress in 40 adolescents. Reliability was assessed within a two weeks interval. Exploratory factor analysis was done for the baseline ADOSS scores. The internal consistency (Cronbach’s alpha and spilt-half correlation), test-retest agreement (Kappa value), and inter-rater reliability (ICC) were assessed. Pearson correlation between salivary cortisol and ADOSS score was done. Results: The inter-factor correlation between the inherent four ADOSS factors (personal, academic, family, and social) was between 0.73 and 0.87, and split-half correlation was between 0.70 and 0.83, showing that the factors are reliable and coherent. Test-retest agreement was Kappa: 0.63, P = 0.001, and ICC was 0.84. Pearson correlation showed a statistically significant positive correlation between cortisol levels and ADOSS scores ( r = 0.87, P = 0.001). Conclusion: ADOSS is a reliable and valid tool to assess the overall stress of Indian adolescents in the age group of 10–17 years.

Published
2022

16. The impact of a collaborative care model on health trajectories among patients with co–morbid depression and diabetes: The INDEPENDENT study.

Author

Balasundaram, Bhavani, Mohan, Anjana, Subramani, Poongothai, Ulagamathesan, Venkatesan, Tandon, Nikhil, Sridhar, Gumpeny, Sosale, Aravind, Shankar, Radha, Sagar, Rajesh, Rao, Deepa, Chwastiak, Lydia, Mohan, Viswanathan, Ali, Mohammed, and Patel, Shivani

Subjects
INTEGRATED health care delivery, COMORBIDITY, MENTAL depression, MEDICAL care, PATIENT participation
Abstract

Context: Collaborative care models for depression have been successful in a variety of settings, but their success may differ by patient engagement. We conducted a post-hoc analysis of the INDEPENDENT trial to investigate the role of differential engagement of participants on health outcomes over 3 years. Settings and Design: INDEPENDENT study was a parallel, single-blinded, randomised clinical trial conducted at four socio-economically diverse clinics in India. Participants were randomised to receive either active collaborative care or usual care for 12 months and followed up for 24 months. Method: We grouped intervention participants by engagement, defined as moderate (≤7 visits) or high, (8 or more visits) and compared them with usual care participants. Improvements in composite measure (depressive symptoms and at least one of three cardio-metabolic) were the primary outcome. Statistical Analysis: Mean levels of depression and cardio-metabolic measures were analysed over time using computer package IBM SPSS Statistics 25. Results: The composite outcome was sustained the highest in the moderate engagers [27.5%, 95% confidence interval (CI): 19.5, 36.7] and the lowest in high engagers (15.8%, 95% CI: 8.1, 26.8). This pattern was observed for individual parameters – depressive symptoms and glycosylated haemoglobin. Progressive reductions in mean depressive symptom scores were observed for moderate engagers and usual care group from baseline to 36 months. However, in high engagers of collaborative care, mean depressive symptoms were higher at 36 months compared to 12 months. Conclusion: Sustained benefits of collaborative care were larger in participants with moderate engagement compared with high engagement, although a majority of participants relapsed on one or more outcome measures by 36 months. High engagers of collaborative care for co-morbid depression and diabetes may need light touch interventions for longer periods to maintain health and reduce depressive symptoms. [ABSTRACT FROM AUTHOR]

Published
2023
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17. Cost-effectiveness of a collaborative care model among patients with type 2 diabetes and depression in India

Author

Karl M.F. Emmert-Fees, Michael Laxy, Shivani A. Patel, Kavita Singh, Subramani Poongothai, Viswanathan Mohan, Lydia Chwastiak, K.M. Venkat Narayan, Rajesh Sagar, Aravind R. Sosale, Ranjit Mohan Anjana, Gumpeny R. Sridhar, Nikhil Tandon, and Mohammed K. Ali

Subjects
Advanced and Specialized Nursing, Endocrinology, Diabetes and Metabolism, Internal Medicine
Abstract

OBJECTIVE To assess the cost-effectiveness of collaborative versus usual care in adults with poorly controlled type 2 diabetes and depression in India. RESEARCH DESIGN AND METHODS We performed a within-trial cost-effectiveness analysis of a 24-month parallel, open-label, pragmatic randomized clinical trial at four urban clinics in India from multipayer and societal perspectives. The trial randomly assigned 404 patients with poorly controlled type 2 diabetes (HbA1c ≥8.0%, systolic blood pressure ≥140 mmHg, or LDL cholesterol ≥130 mg/dL) and depressive symptoms (9-item Patient Health Questionnaire score ≥10) to collaborative care (support from nonphysician care coordinators, electronic registers, and specialist-supported case review) for 12 months, followed by 12 months of usual care or 24 months of usual care. We calculated incremental cost-effectiveness ratios (ICERs) in Indian rupees (INR) and international dollars (Int’l-$) and the probability of cost-effectiveness using quality-adjusted life-years (QALYs) and depression-free days (DFDs). RESULTS From a multipayer perspective, collaborative care costed an additional INR309,558 (Int’l-$15,344) per QALY and an additional INR290.2 (Int’l-$14.4) per DFD gained compared with usual care. The probability of cost-effectiveness was 56.4% using a willingness to pay of INR336,000 (Int’l-$16,654) per QALY (approximately three times per-capita gross domestic product). The willingness to pay per DFD to achieve a probability of cost-effectiveness >95% was INR401.6 (Int’l-$19.9). From a societal perspective, cost-effectiveness was marginally lower. In sensitivity analyses, integrating collaborative care in clinical workflows reduced incremental costs by ∼47% (ICER 162,689 per QALY, cost-effectiveness probability 89.4%), but cost-effectiveness decreased when adjusting for baseline values. CONCLUSIONS Collaborative care for patients with type 2 diabetes and depression in urban India can be cost-effective, especially when integrated in clinical workflows. Long-term cost-effectiveness might be more favorable. Scalability across lower- and middle-income country settings depends on heterogeneous contextual factors.

Published
2022

18. Long-term Effects of a Collaborative Care Model on Metabolic Outcomes and Depressive Symptoms: 36-Month Outcomes from the INDEPENDENT Intervention

Author

Kara Suvada, Mohammed K. Ali, Lydia Chwastiak, Subramani Poongothai, Karl M. F. Emmert-Fees, Ranjit Mohan Anjana, Rajesh Sagar, Radha Shankar, Gumpeny R. Sridhar, Madhu Kasuri, Aravind R. Sosale, Bhavana Sosale, Deepa Rao, Nikhil Tandon, K. M. Venkat Narayan, Viswanathan Mohan, and Shivani A. Patel

Subjects
India, Collaborative Care, Depression, Pragmatic Trial, Type 2 Diabetes, Internal Medicine
Abstract

BACKGROUND: Collaborative care (CC) is a multicomponent team-based approach to providing mental health care with systematic integration into outpatient medical settings. The 12-month INDEPENDENT CC intervention improved joint disease control measures in patients with both depression and diabetes at 12 and 24 months following randomization. OBJECTIVE: This study investigated the durability of intervention effects on patient outcomes at 36 months following randomization. PARTICIPANTS: Adult patients with poorly controlled T2D and depression in India randomized to CC or usual care. DESIGN: Post hoc analyses of between-group differences in patient outcomes at 36 months post-randomization (N = 331) and maintenance of outcomes from 12 to 36 months (N = 314). MAIN MEASURES: We evaluated combined risk factor improvement since baseline, defined as ≥ 50.0% reduction in Symptom Checklist Depression Scale (SCL-20) scores along with reduction of at least 0.5 percentage point hemoglobin A1C, 5 mmHg systolic blood pressure, or 10 mg/dL low-density lipoprotein cholesterol. Improvements in single risk factors were also examined. KEY RESULTS: There were no between-group differences in improvements since baseline in multiple or single risk factors at 36 months. Patients in the CC group with improved outcomes at 12 months were more likely to maintain a ≥ 50.0% reduction since baseline in SCL-20 scores (CC [54.9%] vs. UC [40.9%]; RR: 1.27 [95% CI: 1.04, 1.56]) and 0.5 percentage point reduction since baseline in hemoglobin A1C (CC [31.9%] vs. UC [19.5%]; RR: 1.64 [95% CI: 1.11, 2.41]) at 36 months. CONCLUSIONS: While improvements since baseline in patient outcomes did not differ between the collaborative care and usual care groups at 36 months, patients who received CC were more likely to maintain improvements in depressive symptoms and glucose levels at 36 months if they had achieved these improvements at the end of active intervention. TRIAL REGISTRATION NUMBER: NCT02022111.

Published
2022

19. Perspectives from training the care coordinators—A new cadre to support team-based diabetes and depression care in India: INDEPENDENT study

Author

BalasundaramBhavani Sundari, Subramani Poongothai, RanjitMohan Anjana, Deepa Rao, Nikhil Tandon, GumpenyR Sridhar, AravindR Sosale, Radha Shankar, Rajesh Sagar, MohammedK Ali, Viswanathan Mohan, and Lydia Chwastiak

Subjects
diabetes and depression, training, care coordinator, comorbid conditions, collaborative care, General Earth and Planetary Sciences, RC648-665, diabetes and mental health, task sharing, Diseases of the endocrine glands. Clinical endocrinology, General Environmental Science
Abstract

Purpose: Comorbid depression and type 2 diabetes are associated with poor glycemic control, increased complications, and poor self-management, compared to either condition alone. The Integrating Depression and Diabetes Treatment (INDEPENDENT) clinical trial demonstrated the effectiveness of an integrated care model in improving diabetes and depression outcomes, in diabetes-specialty clinics in India. The INDEPENDENT model used task sharing to address the shortage of mental health professionals in India. Care coordinators (CCs) who were dietitians or counsellors were a key component of this care model. This article details the training and support provided to the CCs during the INDEPENDENT trial. Materials and Methods: CCs were nonphysician and nonpsychiatrist health specialists who supported patients in self-management of diabetes and depression, helping them set achievable goals and monitored progress. During the clinical trial, the CCs underwent both offsite and on-site trainings. The trainings equipped them with various lifestyle management tools for self-care, including one-on-one education sessions and motivational interviewing for self-monitoring, adherence to medication, diet, exercise regimes, and cessation of smoking, among others. Results: Nine CCs from the four sites were trained effectively during the course of the INDEPENDENT study from 2014 to 2018. Conclusions: Given the paucity of mental health professionals in India, the use of collaborative care and a team of well-trained CCs may be an effective strategy for the management of comorbid depression and diabetes. This model of care could help fill deficiencies in the delivery of care for comorbidity of depression and diabetes care in India.

Published
2021

20. Acceptability and Utilization of Newer Technologies and Effects on Glycemic Control in Type 2 Diabetes: Lessons Learned from Lockdown

Author

Anandakumar Amutha, Ranjit Mohan Anjana, Coimbatore Subramanian Shanthi Rani, Harish Ranjani, Nagaraj Manickam, Saravanan Jebarani, Mohan Deepa, Rajendra Pradeepa, Vasudevan Sudha, Subramani Poongothai, Somasundaram Jaya Parvathi, Venkatesan Radha, Muthuswamy Balasubramanyam, Ranjit Unnikrishnan, Ulagamathesan Venkatesan, and Viswanathan Mohan

Subjects
Adult, Blood Glucose, Male, medicine.medical_specialty, Telemedicine, Cross-sectional study, Endocrinology, Diabetes and Metabolism, Pneumonia, Viral, Population, India, 030209 endocrinology & metabolism, Type 2 diabetes, Betacoronavirus, 03 medical and health sciences, 0302 clinical medicine, Endocrinology, Diabetes mellitus, Health care, medicine, Humans, 030212 general & internal medicine, education, Pandemics, Glycemic, Response rate (survey), education.field_of_study, SARS-CoV-2, business.industry, Blood Glucose Self-Monitoring, COVID-19, Middle Aged, Patient Acceptance of Health Care, medicine.disease, Medical Laboratory Technology, Cross-Sectional Studies, Diabetes Mellitus, Type 2, Patient Satisfaction, Family medicine, Quarantine, Female, Coronavirus Infections, business
Abstract

Aim: To evaluate the effects of a prolonged lockdown due to Coronavirus (COVID-19) on the adoption of newer technologies and changes in glycemic control on patients with type 2 diabetes (T2D) in India. Methods: The study population included a random list of 3000 individuals with T2D derived from 30,748 individuals who had visited a large tertiary diabetes center during the past year. The survey was carried out through a telephonic interview. A structured questionnaire was used to collect information on changes in lifestyle, access and challenges to diabetes care and use of technologies such as telemedicine facilities and use of self-monitoring of blood glucose (SMBG), etc. Results: Of the 2510 individuals successfully interviewed (83.7% response rate), 382 (15.2%) reported having attempted to consult their health care providers during the lockdown, of whom only 30.6% utilized the telemedicine facility. However, 96 (82%) of those who utilized the telemedicine facility (n = 117) were happy with their experience and 68 (58.1%) were willing to continue to use the facility in the future. Only 11.4% of participants utilized online support for management of diabetes. Use of SMBG increased significantly from 15.5% to 51.3% during the lockdown. There was an improvement in glycemic control during the lockdown (HbA1c:before vs. during lockdown: 8.2% ± 1.9% vs. 7.7% ± 1.7%, P < 0.001) in a nonrandomly selected subset of subjects (n = 205). Conclusions: Acceptance of telemedicine facilities remains suboptimal in this Asian Indian population, in spite of high levels of satisfaction among those who utilized it. The COVID-19 pandemic and the subsequent lockdown have not adversely affected metabolic control in our patients, and indeed there appears to be an improvement in HbA1c levels. Greater accessibility and acceptance of technology could help individuals with diabetes to maintain better contact with their physicians and ensure better metabolic control in the future.

Published
2020

21. Adaptations and patient responses to behavioral intervention components in a depression-focused chronic disease care model implemented in India

Author

Subramani Poongothai, Lydia Chwastiak, Deepa Rao, Viswanathan Mohan, Sosale R Aravind, Ranjit Mohan Anjana, Nikhil Tandon, Leslie Johnson, Gumpeny R. Sridhar, and Mohammed K. Ali

Subjects
030505 public health, Depression, Adaptation and implementation of diabetes prevention and management in five international settings with varied resources: Local implementation to global learnings, India, Context (language use), Sample (statistics), Health Promotion, Integrated care, 03 medical and health sciences, Behavioral Neuroscience, 0302 clinical medicine, Patient satisfaction, Health promotion, Nursing, Behavior Therapy, Diabetes management, Intervention (counseling), Chronic Disease, Humans, 030212 general & internal medicine, 0305 other medical science, Psychology, Applied Psychology, Depression (differential diagnoses)
Abstract

Integrated care models offer one approach to treat patients with chronic multimorbidity. However, because these models consist of multiple components designed to provide individualized care, they should be adapted to best meet the needs of patients in diverse settings. This paper presents qualitative and quantitative data from a realist process evaluation embedded in the INtegrating DEPrEssioN and Diabetes treatmENT (INDEPENDENT) study to uncover what worked, for whom, how, and in what circumstances. We aimed to examine adaptations made to a care coordinator-led behavioral intervention, and how patients responded to adaptations, through a secondary analysis of these data. A purposive sample of 62 patients and 3 care coordinators were recruited based on their involvement with the INDEPENDENT care model across two clinics. Patients were interviewed and surveyed about their experiences in the care model and care coordinators were interviewed about their experiences implementing intervention components. Interview data were coded for reported modifications in intervention content, tools, and delivery; then, these adaptations were categorized by how they served to enhance implementation in the Indian context. Adaptations made in the delivery of this care model served two functions: (a) to improve health promotion communication between care coordinators and patients and (b) to improve patient engagement. Patients’ expressed needs were consistent with what care coordinators perceived. Patients were satisfied with adaptations designed to improve intervention fit for local contexts. Study findings demonstrate that adapting components of an integrated care model can enhance patient satisfaction and engagement with behavioral interventions.

Published
2020

22. Icosapent Ethyl Reduces Ischemic Events in Patients With a History of Previous Coronary Artery Bypass Grafting: REDUCE-IT CABG

Author

Verma, Subodh, primary, Bhatt, Deepak L., additional, Steg, Ph. Gabriel, additional, Miller, Michael, additional, Brinton, Eliot A., additional, Jacobson, Terry A., additional, Dhingra, Nitish K., additional, Ketchum, Steven B., additional, Juliano, Rebecca A., additional, Jiao, Lixia, additional, Doyle, Ralph T., additional, Granowitz, Craig, additional, Gibson, C. Michael, additional, Pinto, Duane, additional, Giugliano, Robert P., additional, Budoff, Matthew J., additional, Mason, R. Preston, additional, Tardif, Jean-Claude, additional, Ballantyne, Christie M., additional, Martens, Fabrice M.A.C., additional, Schut, Astrid, additional, Olshansky, Brian, additional, Chung, Mina, additional, Hallstrom, Al, additional, Pearce, Lesly, additional, Mehta, Cyrus, additional, Mukherjee, Rajat, additional, Chakrabarti, Anjan K., additional, Gelfand, Eli V., additional, Leary, Megan Carroll, additional, Pinto, Duane S., additional, Pride, Yuri B., additional, Ketchum, Steven, additional, Bhavanthula, Ramakrishna, additional, Chester, Gertrude, additional, Copland, Christina, additional, Diffin, Katelyn, additional, Doyle, Ralph, additional, Erz, Kurt, additional, Giaquinto, Alex, additional, Glanton, Paula, additional, Granger, Angela, additional, Iroudayassamy, Richard H., additional, Juliano, Rebecca, additional, Jin, James, additional, Klevak, Dimitry, additional, Panchal, Hardik, additional, Wang, Robert, additional, Wang, Shin-Ru, additional, Abate, Gerard, additional, Berry, Peggy J., additional, Braeckman, Rene, additional, Doogan, Declan, additional, Elson, Anne, additional, HauptmannBaker, Amy, additional, Lamela, Isabel, additional, Lubeck, Catherine, additional, Manku, Mehar, additional, Murphy, Sabina, additional, Sanford, Monica, additional, Stirtan, William, additional, Soni, Paresh, additional, Bastien, Arnaud, additional, Foster, Demetria, additional, Gascon, Evangelito, additional, Johnson, Judith, additional, Latona, Lasbert, additional, Liu, Gang, additional, Palleja, Sandra, additional, Sanjuan, Nelly, additional, Shi, Jimmy, additional, Stager, William, additional, Venkatakrishnan, Mukund, additional, Youssef-Agha, Ahmed, additional, Zhu, Julie, additional, Aertker, Leela, additional, Ankolekar, Suresh, additional, Goldberg, Lisa, additional, Rajicic, Natasa, additional, Shu, Jianfen, additional, Zou, Heng, additional, Mikhail, Magdy, additional, Dawood, Gamil, additional, Koshy, N. Mathew, additional, Mukherjee, Sandip K., additional, Abadier, Rafik, additional, Lawless, Andrea L., additional, McGuinn, William P., additional, Weintraub, Howard, additional, Rohr, Kathryn, additional, Claxton, Edmund, additional, Weiss, Robert J., additional, Klein, Terry D., additional, Nallasivan, Mani, additional, Crowley, Stephen, additional, King, Marilyn, additional, Alfieri, Anthony D., additional, Fitz-Patrick, David, additional, Loh, Irving, additional, Mayer, Nolan J., additional, Prashad, Rakesh, additional, Lederman, Samuel, additional, Weinstein, Debra, additional, Bays, Harold E., additional, Chu, Keith, additional, Maghsoudi, Alireza, additional, Thompson, Paul D., additional, Carstens, Jeff, additional, Chang, Anna, additional, Cohen, Kenneth R., additional, Dean, Julius, additional, Ellison, Howard S., additional, Erickson, Bernard, additional, Flores, Enrique A., additional, Gottlieb, Daniel W., additional, Grena, Paul, additional, Guyton, John R., additional, Jones, Peter H., additional, Joseph, John M., additional, Lepor, Norman E., additional, Lerman, Sam, additional, Matheney, Robert D., additional, Pacheco, Theodore R., additional, Russo, Michael B., additional, Rubino, John, additional, Pereira, Edward S., additional, Seals, Albert A., additional, Viera, Eduardo, additional, Steljes, Alan D., additional, Thompson, Jason, additional, Kapadia, Shaival, additional, McIvor, Michael, additional, Salazar, Jorge E., additional, Santiago, Jose O., additional, Vicari, Ralph, additional, Berk, Martin R., additional, Kaye, William A., additional, McKenzie, Marcus, additional, Podlecki, David, additional, Snyder, Brian D., additional, Nash, Stephen, additional, Herrington, David M., additional, Johnson, Wallace, additional, Lee, Joseph R., additional, Blonder, Ronald, additional, Patel, Alpa M., additional, Castello, Ramon, additional, Greco, Susan, additional, Kereiakes, Dean J., additional, Nadar, Venkatesh K., additional, Nathan, Mark, additional, Potu, Ranganatha P., additional, Sangrigoli, Robert, additional, Smalling, Richard, additional, Davis, Mitchell, additional, Braastad, Robert, additional, McCriskin, James, additional, Bodiwala, Kunal, additional, Hargrove, Joe L., additional, Graves, Mark W., additional, Emlein, George, additional, Durant, Raegan W., additional, Clower, James W., additional, Arora, Rohit, additional, Singh, Narendra, additional, Warsinger Martin, Lisa, additional, Haught, W Herbert, additional, Litt, Marc P., additional, Klein, Michael D., additional, Hoagland, Peter, additional, Goldstein, Michael, additional, Mazzella, Marco S., additional, Dunker, Daniel H., additional, Kahn, Brian H., additional, Ince, Carlos S., additional, McGrew, Frank A., additional, Lee, Jay, additional, Pan, David, additional, Khan, Salman A., additional, Elkayam, Uri, additional, Deeb, Wasim, additional, Goldberg, Anne C., additional, Brown, Christopher S., additional, Leimbach, Wayne N., additional, Backer, Thomas S., additional, Sutton, David R., additional, Gellman, Joel, additional, George, Anu R., additional, Hoffman, Alan S., additional, Kates, Mark, additional, Anand, Kishlay, additional, Bear, Robert, additional, Cavanaugh, Brendan J., additional, Reyes, Ramon G., additional, Sotolongo, Rodolfo, additional, Sabatino, Kenneth, additional, Gallagher, Kevin, additional, Sorial, Ehab, additional, Geohas, Chris, additional, Magness, Kathleen E., additional, Grunstra, Bernard P., additional, Martin, Frederik A., additional, Knapp, William S., additional, Lucas, Mel E., additional, Champlin, John J., additional, Demattia, Jason, additional, Peters, Patrick H., additional, Kirstein, Judith, additional, Randall, William J., additional, Staniloae, Cezar S., additional, Robinson, Jennifer G., additional, Adler, Alexander, additional, Case, Christopher, additional, Kaplan, Andrew J., additional, Lakin, Gregory F., additional, Goyle, Krishan K., additional, DiGiovanna, Michael J., additional, Fisher, Chester L., additional, Lillestol, Michael, additional, Robinson, Michael, additional, Perry, Robert G., additional, Levinson, Lawrence S., additional, Everhart, Brian G., additional, Madder, Robert D., additional, Martin, Earl F., additional, Martin, Earl E., additional, Alam, Imtiaz, additional, Elacion, Jose Mari L., additional, Poonawala, Robina, additional, Desta, Taddese T., additional, Robinson, Jerome A., additional, Martinez, Gilbert J., additional, Reddy, Jakkidi S., additional, Wayne, Jeffrey D., additional, Mujica Trenche, Samuel, additional, Kaplan, Westbrook I., additional, Saavedra, Rubin H., additional, DiGregorio, Michael D., additional, Bertolet, Barry D., additional, Fraser, Neil J., additional, Hart, Terence T., additional, Graf, Ronald J., additional, Jasper, David A., additional, Dunn, Michael, additional, Streja, Dan A., additional, Strobl, David J., additional, Jiang, Nan, additional, Kalen, Vicki, additional, Mascolo, Richard, additional, Samson, Mercedes B., additional, Stephens, Michael, additional, Bellard, Bret M., additional, Juarez, Mario, additional, McCarthy, Patrick J., additional, Checton, John B., additional, Stillabower, Michael, additional, Goldenberg, Edward, additional, Karim, Amin H., additional, Jaffrani, Naseem, additional, Touchon, Robert C., additional, Fruehling, Erich R., additional, Friesen, Clayton J., additional, Chaudhuri, Pradipta, additional, Morris, Frank H., additional, Broker, Robert E., additional, Patel, Rajesh J., additional, Hole, Susan, additional, Miller, Randall P., additional, Miranda, Francisco G., additional, Dar, Sadia, additional, Gentry, Shawn N., additional, Hermany, Paul, additional, Treasure, Charles B., additional, Trevino, Miguel E., additional, Acosta, Raimundo, additional, Japour, Anthony, additional, Durr, Samuel J., additional, Wang, Thomas, additional, Ganda, Om P., additional, Krichmar, Perry, additional, Arter, James L., additional, Jacoby, Douglas, additional, Schwartz, Michael A., additional, Al-Karadsheh, Amer, additional, Gencheff, Nelson E., additional, Pasquini, John A., additional, Dunbar, Richard, additional, Kohnstamm, Sarah, additional, Lozano, Hector F., additional, Welty, Francine K., additional, Pitts, Thomas L., additional, Zehnder, Brian, additional, El Hafi, Salah, additional, King, Mark A., additional, Ghitis, Arnold, additional, Bahu, Marwan M., additional, Ranjbaran Jahromi, Hooman, additional, Caputo, Ronald P., additional, Busch, Robert S., additional, Shapiro, Michael D., additional, Zavaro, Suhail, additional, Daudjee, Munib, additional, Jacobs, Shahram, additional, Shah, Vipul B., additional, Rubalcava, Frank, additional, Alhaddad, Mohsin T., additional, Lui, Henry, additional, Rajan, Raj T., additional, Saba, Fadi E., additional, Gunapooti, Mahendra Pai N, additional, Kayembe, Tshiswaka B., additional, Jennings, Timothy, additional, Strzinek, Robert A., additional, Shanik, Michael H., additional, Singh, Pradeep K., additional, Kennedy, Alastair C., additional, Rubenstein, Howard, additional, Manshadi, Ramin, additional, Ladner, Joanne, additional, Kakish, Lily, additional, Kakish, Ashley, additional, Little, Amy L., additional, Gerber, Jaime, additional, Hinchion, Nancy J., additional, Guarino, Janet, additional, Raychok, Denise, additional, Budzinski, Susan, additional, Kelley-Garvin, Kathleen, additional, Beckord, April, additional, Schlinder, Jessica, additional, Schwartzbard, Arthur, additional, Cobos, Stanley, additional, Freeman, Deborah, additional, Abisalih, David, additional, McCann, Dervilla, additional, Guy, Kylie, additional, Chase, Jennifer, additional, Samuelson, Stacey, additional, Cassidy, Madeline, additional, Tardif, Marissa, additional, Smith, Jaime, additional, Sprout, Brenna, additional, Riedeman, Nanette, additional, Goza, Julie, additional, Johnson, Lori, additional, Kraske, Chad, additional, Hastings, Sheila, additional, Dutka, Chris, additional, Smith, Stephanie, additional, McCabe, Toni, additional, Maloney, Kathleen, additional, Alfieri, Paul, additional, Hosemane, Vinay, additional, Syravanh, Chanhsamone, additional, Pau, Cindy, additional, Limcoiloc, April, additional, Carreira, Tabitha, additional, Kurosawa, Taryn S., additional, Krumian, Razmig, additional, Preston, Krista, additional, Nashed, Ashraf, additional, Schneidman-Fernandez, Daria, additional, Patterson, Jack, additional, Tsakonas, John, additional, Esaki, Jennifer, additional, Sprafka, Lynn, additional, Patel, Porous, additional, Mitchell, Brian, additional, Ross, Erin M., additional, Miller, Donna, additional, Prashad, Akash, additional, Feyler, Kristina M., additional, Juarbe, Natasha, additional, Herrera, Sandra, additional, Keiran, Sarah M., additional, Whitehead, Becky, additional, Asher, Whitney, additional, Hobbs, Coury, additional, Elie, Abbey, additional, Brooks, Jean, additional, Zaleski, Amanda L., additional, Foxen, Brenda, additional, Lapke, Barb, additional, Wright, Philippa, additional, Pavol, Bristol, additional, Carangi, Gwen, additional, Turner, Marla, additional, Sanders, Katharine W., additional, Delamar, Rikita S., additional, Wilson, Virginia L., additional, Harvel, Sarah M., additional, Cartledge, Alison M., additional, Bailey, Kaitlyn R., additional, Mahon, Kathleen, additional, Schuchard, Timothy, additional, Humbert, Jen, additional, Hanson, Mark C., additional, Cecil, Michael P., additional, Abraham, James S., additional, Benedict, Lorie, additional, Slayton, Claudia, additional, Burnett, Curtis S., additional, Ono-Lim, Rachel W., additional, Budzinski, Sharon, additional, Khan, Shubi A., additional, Goss, Sharon, additional, Techmanski, Terry, additional, Valliani, Farida, additional, Joseph, Rimla, additional, Flores, Edith, additional, Contreras, Laurn, additional, Aguillon, Ana, additional, Silvia, Carrie-Ann, additional, Martin, Maria, additional, Kerut, Edmund K., additional, Levenson, Leslie W., additional, Glade, Louis B., additional, Cospolich, Brian J., additional, Stein, Maureen W., additional, LaGuardia, Stephen P., additional, Sonza, Thelma L., additional, Fife, Tracy M., additional, Forschler, Melissa, additional, Watts, Jasmyne, additional, Fritsch, Judy, additional, Futchko, Emese, additional, Utech, Sarah, additional, Baker, Scott B., additional, Roura, Miguel F., additional, Segel, Scott A., additional, Magee, James S., additional, Jackson, Cathy, additional, Goldfaden, Rebecca F., additional, Quas, Liudmila, additional, Ortiz, Elizabeth C., additional, Simpson, Michael, additional, Foster, Robert, additional, Brian, Christopher, additional, Trimm, James, additional, Bailey, Michael, additional, Snoddy, Brian, additional, Reeder, Van, additional, Wilkinson, Rachel, additional, Settle, Harold, additional, Massey, Cynthia, additional, Maiola, Angela, additional, Hall, Michele, additional, Hall, Shelly, additional, Hall, Wanda, additional, Xenakis, Mark, additional, Barrett, Janet, additional, Campanile, Giovanni, additional, Anthou, David, additional, Neill, Susan F., additional, Karas, Steven, additional, Polanco, Enrique, additional, Schechtman, Norberto, additional, Tischner, Grace, additional, Warren, Kay, additional, St Cyr, Cynthia, additional, Kuczinski, Menna, additional, Alexander, Latrina, additional, Ibarra, Maricruz, additional, Horowitz, Barry S., additional, Steinsapir, Jaime, additional, Mangual-Coughlin, Jeanette, additional, Mooney, Brittany, additional, Vasquez, Precilia, additional, Rodkey, Kathleen, additional, Biberstein, Alexandria, additional, Ignacio, Christine, additional, Robinson, Irina, additional, Hibberd, Marcia, additional, Hoffman, Lisa B., additional, Murak, Daniel J., additional, Varavenkataraman, Raghupathy, additional, Ohlson Elliott, Theresa M., additional, Cunningham, Linda A., additional, Palmerton, Heather L., additional, Poole, Sheri, additional, Moore, Jeannine, additional, Wallace, Helene, additional, Chandler, Ted, additional, Riley, Robert, additional, Dawood, Farah, additional, Azeem, Amir, additional, Cammarata, Michael, additional, Owen, Ashleigh, additional, Aggarwal, Shivani, additional, Qureshi, Waqas, additional, Almahmoud, Mohamed, additional, Oseni, Abdullahi, additional, Leigh, Adam, additional, Barnes, Erin, additional, Pflum, Adam, additional, Aladin, Amer, additional, Blinson, Karen, additional, Wayne, Vickie, additional, Doomy, Lynda, additional, Wall, Michele, additional, Bitterman, Valerie, additional, Young, Cindi, additional, Grice, Rachel, additional, Poliakova, Lioubov, additional, Davalos, Jorge, additional, Rosenbaum, David, additional, Boulware, Mark, additional, Mazzola, Heather, additional, Strader, J. Russell, additional, Linsky, Russell, additional, Schwartz, David, additional, Graf, Elizabeth, additional, Gneiting, Alicia, additional, Palmblad, Melissa, additional, Donlin, Ashley, additional, Ensminger, Emily, additional, Garcia, Hillary, additional, Robinson, Dawn, additional, Tran, Carolyn, additional, Jacqmein, Jeffrey, additional, Bartilucci, Darlene, additional, Koren, Michael, additional, Maluchnik, Barbara, additional, Parks, Melissa, additional, Miller, Jennifer, additional, DeFosse, Cynthia, additional, Knouse, Albert B., additional, Delancey, Amy, additional, Chin, Stephanie, additional, Stephens, Thomas, additional, Sohal, Mag, additional, Ingram, Juana, additional, Kumar, Swarooparani, additional, Foley, Heather, additional, Smith, Nina, additional, McKinney, Vera, additional, Schwarz, Linda, additional, Moore, Judith, additional, Anderson, Hildreth Vernon, additional, Sdringola-Maranga, Stefano, additional, Denktas, Ali, additional, Turrentine, Elizabeth, additional, Patterson, Rhonda, additional, Marshall, John, additional, Tolar, Terri, additional, Patrick, Donna, additional, Schwartzkopf, Pamela, additional, Fletcher, Anthony M., additional, Harris, Frances R., additional, Clements, Sherry, additional, Brown, Tiffany, additional, Smith, William, additional, Baehl, Stacey J., additional, Fluty, Robin, additional, VanHamersveld, Daniel, additional, Breen, Dennis, additional, Bender, Nancy, additional, Stafford, Beverly, additional, Washington, Tamika, additional, Pike, Margaret N., additional, Stich, Mark A., additional, Jawad, Evyan, additional, Nadeem, Amin, additional, Nyland, Jill, additional, Hamer, Rhonda, additional, Calhoun, Kendra, additional, Mall, Charlotte, additional, Cadogan, Samuel, additional, Raynes, Kati, additional, Katz, Richard, additional, Marshall, Lorraine, additional, Abbas, Rashida, additional, Dinerman, Jay L., additional, Hartley, John T., additional, Lamb, Beth, additional, Eskridge, Lisa, additional, Raymond, Donna, additional, Clemmer, Kristy, additional, Fine, Denise M., additional, Beardsley, Paula, additional, Werner, Janet, additional, Mahan, Bette, additional, VanTol, Courtney, additional, Herman, Robert, additional, Raiser-Vignola, Christine, additional, McShan, Felicia, additional, Neill, Stefanie A., additional, Blick, David R., additional, Liston, Michael J., additional, Nelson, Denetta K., additional, Dorrell, Sandra K., additional, Wyman, Patricia, additional, Quraishi, Ambereen, additional, Ferro, Fernando, additional, Morris, Frank, additional, Coombs, Vicki J., additional, Mains, Autumn M., additional, Campbell, Austin A., additional, Phelps, Jeanne, additional, Geary, Cheryl A., additional, Sheridan, Ellen G., additional, Downing, Jean M., additional, Swatkowski, Arie, additional, Redden, Tish, additional, Dragutsky, Brian, additional, Thomas, Susan, additional, Mitchell, Candace, additional, Barker, Diana, additional, Turcotte, Elanie, additional, Segerson, Deborah, additional, Guy, Jill, additional, De La Mora, Karena, additional, Hong, Jennifer, additional, Do, Dennis, additional, Norris, Rose, additional, Khan, Faisal, additional, Montero, Hector, additional, Kelly-White, Stacy, additional, Cleland, Alan, additional, Alcalde-Crawford, Rosalyn, additional, Morgan, Melissa, additional, Sarabu, Brijmohan, additional, Minor, Megan, additional, Kamat, Shweta, additional, Estes, Stephanie M., additional, Harless, Nancee, additional, Disney, Alicia, additional, Pagano, Jodi L., additional, Alford, Chad M., additional, Bedwell, Noel W., additional, Hardy, Warren D., additional, DeAndrade, Kevin, additional, Elmore, Jessica G., additional, Auerbach, Eric, additional, Haney, Anthony W., additional, Brooks, Miriam H., additional, Torres, Jose, additional, Roper, Lois, additional, Backer, Terry, additional, Backer, Katie, additional, Evans, John G., additional, Silva, Ricardo A., additional, Dajani, Lorraine H., additional, Yousif, Veronica, additional, Ross, Tammy, additional, Roy, Sion K., additional, Oudiz, Ronald, additional, Hamal, Sajad, additional, Flores, Ferdinand, additional, Leahy, Amor, additional, Ayer, Debra, additional, George, Swapna, additional, Stewart, Chrisi Carine, additional, Orellana, Elvira, additional, Boccalandro, Cristina, additional, Rangel, Mary, additional, Hennings, Suzanne, additional, Vanselow, Carl, additional, Victor, Teri, additional, Birdwell, Darlene, additional, Haas, Paul, additional, Sandoval, Anthony, additional, Ciavarella, Gina, additional, Saglam, Caroline, additional, Bird, Amy, additional, Beck, Keith, additional, Poliquin, Brian, additional, Dominguez, David, additional, Tenorio, Brittany, additional, Perkins, Harvonya, additional, San Roman, Esther, additional, Bransford, Paris, additional, Lowrance, Christy, additional, Broussard, Marcy, additional, Ellis, Mary, additional, Skiles, Bobbi, additional, Hamilton, Jessica, additional, Hall, Kathryn, additional, Olvera, Diego, additional, Hartwell, Julee A., additional, Sorial, Nevien, additional, Rickman, Mary, additional, Berman, Kevin, additional, Mehta, Nirav, additional, Laborin, Annie, additional, Rothenberger, Rodger, additional, Beauvilliers, Sarah, additional, Morrell, Kathy, additional, Schachter, Michael P., additional, Perkins, Cindy L., additional, Gordon, Elizabeth A., additional, Lauer, Jennifer, additional, Bichsel, Kim, additional, Oliver, Kelly, additional, Mellor, Leslie J., additional, Demattia, Candice, additional, Schomburg, Jennifer, additional, Moreno, Yenniffer, additional, Mansur-Garza, Eduardo, additional, Rippstein, Lena, additional, Chacon, Lorie, additional, Pena, Andrea, additional, King, Michelle, additional, Richardson, Susan, additional, Jessop, Annette, additional, Tucker, Nicole, additional, Royer, Whitney, additional, Templeton, Gilbert, additional, Moell, Ann, additional, Weller, Christine, additional, Botts, Melissa J., additional, Hollon, Gretel, additional, Homberg-Pinassi, Elsa, additional, Forest, Paula, additional, Abhulhak, Aref Bin, additional, Chun-Furlong, Devona, additional, Harrington, Deborah, additional, Harlynn, Emily, additional, Schmitt, Marjorie, additional, Shelsky, Constance, additional, Feldick, Patricia, additional, Cherrico, Mary, additional, Jagle, Courtney, additional, Warnecke, Nicholas, additional, Myer, Debra, additional, Ruder, Deanna J., additional, Underwood, Albina, additional, Rauba, Alan, additional, Carr, George, additional, Oberhaus, Barbara, additional, Vanderfeltz, Jessica, additional, Stucky-Heil, Mary Jo, additional, Gibson, Dale R., additional, Fuentes, Vonnie, additional, Talbot, Kimberly L., additional, Simon, William C., additional, Grimes, Katlyn J., additional, Wheeler, Christina R., additional, Shultz, Cassaundra, additional, Metcalf, Rhonda A., additional, Hill, Jennifer L., additional, Oliver, Michelle R., additional, Ahmad, Basharat, additional, Azeem, Fouzal, additional, Rahim, Abdul, additional, Freeman, George H., additional, Bloch, Dawn, additional, Freeman, Heather, additional, Brown, Jamie, additional, Rosbach, Sarah, additional, Melander, Pamela, additional, Taralson, Nick, additional, Liu, Alex, additional, Harms, Katlyn, additional, Michale, Mahfouz, additional, Lopez, Jose, additional, Revoredo, Maria, additional, Edevane, Shari, additional, Shawley, Sarah, additional, Jackson, Timothy L., additional, Oliver, Michael J., additional, DeSalle, Dina, additional, Matlock, Patricia J., additional, Beraun, Ionna M., additional, Hendrix, Heather, additional, Bromley, Garrett, additional, Niemerski, Ashley, additional, Teran, Gabby, additional, Guerrero, Sonia, additional, Marvi, Murtaza, additional, Palanpurwala, Zehra, additional, Torres, Andrea, additional, Gloyd, Patty, additional, Conger, Michelle, additional, Laurent, Aziz, additional, Nayor, Olia, additional, Villanueva, Catalina S., additional, Khambati, Munira, additional, Mumford, Tabetha J., additional, Castillo, Melanie J., additional, Desta, Taddese, additional, Robinson, Jerome, additional, Woods, La Shawn, additional, Bahri, Anita, additional, Herrera, Nancy, additional, Casaclang, Cecilia, additional, Unger, Jeffrey R., additional, Martinez, Geraldine, additional, Moon, Mia K., additional, Mohaupt, Stephen M., additional, Sandoval, Larry, additional, Valenzuela, Louisito, additional, Ramirez, Victora, additional, Mata, Nelly, additional, Avila, Veronica, additional, Patino, Marisol, additional, Montano-Pereira, Cynthia, additional, Barnett, Omar, additional, Webster, William M., additional, Christensen, Lorraine M., additional, Bofman, Leighna, additional, Livingston, Melanie, additional, Adams, Stacey, additional, Hobbs, Joseph, additional, Koskela, Leesa, additional, Katz, Mia, additional, Mujica-Trenche, Samuel, additional, Cala, Franklin, additional, Rana, Noreen T., additional, Scarlett, Jennifer, additional, Cala Anaya, Milagros, additional, Jones, Marsha R., additional, Hollis, Kelly D., additional, Roth, Debbie, additional, Eads, Kristin, additional, Watts, Tina, additional, Perkins, Judy, additional, Arnold, Alice, additional, Ginsberg, Daniel C., additional, Quinn, Denise, additional, Cureton, Nicole, additional, Fittingoff, David B., additional, Iqbal, Mohammed I., additional, White, Stephen R., additional, Sisneros, Edith, additional, Ducca, Michelle, additional, Streja, David, additional, Campos, Danny, additional, Boak, Jennifer L., additional, Amir, Farzeen, additional, Anderson, Felice, additional, Kmetzo, James J., additional, Bongarzone, Mary O., additional, Scott, Dawn, additional, De Leon, Mary Grace, additional, Buda, Cynthia, additional, Graettinger, William, additional, Alex, Michelle, additional, Hess, Erika, additional, Govoni, James, additional, Bartel, Melissa, additional, Monchamp, Travis L., additional, Roach, Julie S., additional, Gibson, Sara, additional, Allfrey, Amy M., additional, Timpy, Kristen, additional, Bott, Kathy, additional, Soucy, Karin A., additional, Willis, Jean, additional, Valerio, Cecilia A., additional, Chunduri, Anusha, additional, Coker, Rebecca, additional, Vidrine, Nicole, additional, Thompson, Ellen A., additional, Studeny, Mark A., additional, Marcum, Melissa K., additional, Monway, Tammy S., additional, Kosmicki, Douglas L., additional, Kelley, Melissa J., additional, Godfrey, Corey M., additional, Krenk, Susan L., additional, Holcomb, Randy R., additional, Baehr, Deb K., additional, Trauernicht, Mary K., additional, Rowland Lowry, David, additional, Bondy Herts, Betty, additional, Phelps, Jeanne E, additional, Downing, Jean-Marie, additional, Gamer Dignon, Carol, additional, Cockrill, Elisabeth S., additional, Chapla, Pravinchandra G., additional, Fera, Diane, additional, Chang, Margaret, additional, Fredette, Patricia, additional, Ashby, Tamie, additional, Bergin, Renee, additional, Stearns, Zebediah A., additional, Ware, David B., additional, Boudreaux, Rachael M., additional, Rodriguez, Joanna, additional, McKenzie, Robert, additional, Huber, Amanda, additional, Sommers, Rebecca, additional, Rowe, Heather, additional, McLallen, Stacy, additional, Haynes, Michale, additional, Adamson, Ashley, additional, Henderson, Janice, additional, McClure, Lori, additional, Harris, Beverly A., additional, Ference, Laura, additional, Meissner-Dengler, Sue, additional, Treasure, Lisa, additional, Nicely, Doreen, additional, Light, Timothy L., additional, Osborn, Tracey A., additional, Mai, Kimberly J., additional, Vivas, Pablo, additional, Rios, Jose, additional, Rodriguez, Dunia, additional, DeRaad, Roger, additional, Walder, James, additional, Bailon, Oscar, additional, Hockett, Denice, additional, Anderson, Debbie, additional, McIntosh, Kelli, additional, Odegard, Amber, additional, Shepherd, Andrew, additional, Seifert, Mary, additional, Kelley, Laurence, additional, Shetty, Rajendra, additional, Castine, Michael, additional, Brill, David, additional, Fisher, Gregory, additional, Richmond, Nicole, additional, Gray, Kathleen, additional, Miller, Patricia, additional, Coneys, Charlene, additional, Chanza, Yarixa, additional, Sumoza, Monica, additional, Caudill, Victoria M., additional, Harris, Kelly D., additional, Manion, Courtney A., additional, Lineberger-Moore, Melody J., additional, Wolfe, Julie J., additional, Rosen, Barbara J., additional, DiVito, Patricia, additional, Moffat, Janet L., additional, Michaelis, Christina, additional, Koshy, Prashant, additional, Perea, Diana, additional, Al Yacoub, Ghaith, additional, Sadeghi, Stephanie, additional, LeGalley, Thomas D., additional, Evonich, Rudolph F., additional, Jean, William J., additional, Friesen, Gary M., additional, Pap, John M., additional, Pesola, David A., additional, Cowan, Mark D., additional, Dosh, Kristofer M., additional, Larson, Dianna, additional, Price, Adele M., additional, Nease, Jodi A., additional, Anderson, Jane E., additional, Piggott, Lori A., additional, Iwaoka, Robert, additional, Sharkey, Kevin, additional, McMillan, Edward, additional, Lowder, Laurie, additional, Morgan, Latisha, additional, Davis, Kyle, additional, Caldwell, Tara, additional, Breglio, Erica, additional, Summers, Jasmine, additional, Poulimas, Rachel, additional, Zahid, Muhammad, additional, Syed, Hamid, additional, Escobar, Maria, additional, Levy, Jacob, additional, Warsi, Rahma, additional, Ma, Carol, additional, Cen, Puxiao, additional, Cawthon, Kimberly A., additional, Barnes, Delores B., additional, Allen, Deanna G., additional, Warrington, Margaret L., additional, Stastny, Carol R., additional, Michaels, Robin J., additional, Saleh, Mohamad, additional, Sorin, John, additional, Rathod, Sunny, additional, Juett, Urakay, additional, Spencer, Steven, additional, Keval, Aziza, additional, McBride, Jill, additional, Young, Shane, additional, Baxter, Catherine, additional, Rasmussen, Carol, additional, Coxe, Shari L., additional, Campos, Luis, additional, Tavackoli, Shahin, additional, Beckham, Diana, additional, Sanchez, Darlynee, additional, Basrai, Karanjit, additional, Helms, Dorian, additional, Clinton, Erica, additional, Smith, Kasie, additional, Cusnir, Henry, additional, Klaus Clark, Mary, additional, Cherukuri, Madhavagopal V., additional, Scarfaru, Ameta, additional, Nash, Stephen D., additional, Grimm, Loretta C., additional, Grace, Anna, additional, McElheran, Kylie, additional, Subasic, Dino, additional, Buhay, Zedrick, additional, Litvinoff, Janet, additional, Shah, Deepak, additional, Cervantes, Shannon, additional, Usher, Freda, additional, Yasser, Farra, additional, Trusevich, Theodore, additional, Garcia, Ronnie L., additional, Wyatt, Jamison, additional, Bose, Rahul, additional, Miska, Holllilyn, additional, Spivey, Traci, additional, Wren, Amy B., additional, Vance, Katie E., additional, Holman, Lani L., additional, Gibbons, Pam, additional, Eby, Elaine, additional, Shepard, Sandra, additional, Charoenthongtrakul, Soratree, additional, Snodgrass, Brett, additional, Nazem, Mohammed, additional, Keteenburg, Shelly, additional, Murthy, Prathima, additional, Prater, Frederic, additional, Rumfelt, Ashley, additional, Eizensmits, Christina, additional, Iannuzzi, Lisa, additional, Patel, Pourus R., additional, Bergamino, Clellia, additional, McFeaters, Elizabeth, additional, Rizk, Botros, additional, Pflaum, Emiljia, additional, Kalish, Danny, additional, Ambatali, Rex, additional, Ameli, Mona, additional, Sanguinetti, Delaina, additional, Vaidya, Rakesh, additional, Broeders, Martinus A.W., additional, Henrikus, Dorman, additional, Kuijper, Adrianus F.M., additional, Al-Windy, Nadea, additional, Magro, Michael, additional, Hamraoui, Karim, additional, Aksoy, Ismail, additional, Vermeiren, Guy L.J., additional, Roeters van Lennep, H.W.O., additional, Hoedemaker, Gerard, additional, Remmen, Johannes Jacobus, additional, Bogaard, Kjell, additional, van der Heijden, Dirk, additional, Knufman, Nicole MJ, additional, Frederiks, Joost, additional, Louwerenburg, Johannes Willem, additional, van Rossum, Piet, additional, Milhous, Johannes, additional, van der Meer, Peter, additional, van der Weerdt, Arno, additional, Breedveld, Rob, additional, Keijzers, Mitran, additional, Hermans, Walter, additional, van de Wal, Ruud, additional, Zwart, Peter A.G., additional, van der Linden, Marc M.J.M., additional, Zwiers, Gerardus, additional, Boswijk, Dirk J., additional, Geert Tans, Jan, additional, van Eck, Jacob, additional, Hessen, Maarten V., additional, Hamer, Barnabas J.B., additional, Zoet-Nugteren, Stieneke, additional, Theunissen, Lucien, additional, van Beek, E.A., additional, Nijmeijer, Remco, additional, Nierop, Pieter R., additional, Linssen, Gerard, additional, Swart, H.P., additional, Lenderink, Timo, additional, Bartels, Gerard L., additional, den Hartog, Frank, additional, Berg van den, Brian J., additional, van Kempen, Wouter, additional, Kentgens, Susanne, additional, Rojas Lingan, Gloria M., additional, Peeters, Martinus M., additional, Keterberg, Hilligje, additional, Nierman, Melchior, additional, den Hollander, Annemieke K., additional, Hoogendijk, Jacqueline, additional, Voors-Pette, Christine, additional, Kose, Vicdan, additional, Viergever, Peter, additional, Yena, Larysa, additional, Syvolap, Viktor, additional, Kopytsya, Mykola P., additional, Barna, Olga, additional, Panina, Svitlana S., additional, Lutai, Mykhailo I., additional, Shershnyova, Oxana V., additional, Luzkiv, Iryna, additional, Bula, Larysa S., additional, Zotov, Sergii, additional, Vyjhovaniuk, Ivan, additional, Lysunets, Olena, additional, Koshlia, Volodymyr I., additional, Sydor, Nataliya, additional, Vayda, Myroslava F., additional, Ushakov, Olexiy, additional, Rishko, Mykola, additional, Shcherbak, Viktor P., additional, Svyshchenko, Yevgeniya, additional, Tseluyko, Vira, additional, Yagensky, Andriy, additional, Zolotaikina, Viktoriia I., additional, Godlevska, Olga, additional, Ivanova, Larysa, additional, Koval, Olena, additional, Mitchenko, Olena I., additional, Kardash, Galyna Y., additional, Rudyk, Yurii S., additional, Stanislavchuk, Mykola, additional, Ivanovych Volkov, Volodymyr, additional, Karlinskaya, Olena G., additional, Tykhonova, Susanna A., additional, Vatutin, Nikolay, additional, Smirnova, Ganna, additional, Kovalenko, Volodymyr M., additional, Lizogub, Viktor, additional, Sebov, Denys, additional, Dyadyk, Oleksandr, additional, Andrievskaya, Svetlana, additional, Krasko, Mykola P., additional, Parkhomenko, Alexander N., additional, Horbach, Lidiya, additional, Kupnovytska, Iryna G., additional, Pertseva, Tetyana, additional, Karpenko, Oleksandr, additional, Reshotko, Dmytro, additional, Zhurba, Svitlana V., additional, Rudenko, Leonid, additional, Yu Zharinova, Viktoriia, additional, Shatylo, Valerii B., additional, Karpenko, Yuriy I., additional, Orynchak, Mariya A., additional, Kameneva, Tatiana R., additional, Zherlitsina, Elena, additional, Alpenidze, Diana N., additional, Arutyunov, Grigoriy P., additional, Baranova, Elena, additional, Bart, Boris, additional, Belenkiy, Dmitriy I., additional, Boldueva, Svetlana A., additional, Demchenko, Elena A., additional, Eltishcheva, Vera V., additional, Gofman, Alexander M., additional, Goloshchekin, Boris M., additional, Gennadyevich Gordeev, Ivan, additional, Gratsianskiy, Nikolay, additional, Kamalov, Gadel, additional, Khasanov, Niyaz R., additional, Kholina, Irina M., additional, Kobalava, Zhanna D., additional, Kobeleva, Elena V., additional, Konradi, Alexandra O., additional, Kostenko, Victor A., additional, Dmitrievich Kuimov, Andrey, additional, Ermakova, Polina Y., additional, Malyutina, Sofia K., additional, Panov, Alexey V., additional, Polezhaeva, Natalia V., additional, Reshetko, Olga, additional, Shilkina, Nataliya P., additional, Shustov, Sergey B., additional, Smolyarchuk, Elena A., additional, Stryuk, Raisa I., additional, Yurievnar Solovieva, Elena, additional, Susekov, Andrey V., additional, Vezikova, Natalia, additional, Ivanova, Svetlana N., additional, Petrov, Alexander A., additional, Konstantinov, Vladimir O., additional, Agafina, Alina S., additional, Gurevich, Victor, additional, Zrazhevskiy, Konstantin N., additional, Supryadkina, Tatiana V., additional, Perepech, Nikita B., additional, Arkhipovskiy, Vadim L., additional, Yu Butko, Dmitry, additional, Zobenko, Irina A., additional, Orlikova, Olga V., additional, Mordovin, Viktor, additional, Barbarash, Olga L., additional, Lebedeva, Anastasiya, additional, Nosov, Vladimir, additional, Averkov, Oleg V., additional, Pavlikova, Elena P., additional, Karpov, Yuri B., additional, Lvovna Giorgadze, Marina, additional, Khrustalev, Oleg A., additional, Arkhipov, Mikhail, additional, Raskina, Tatiana A., additional, Shilko, Julia V., additional, Samoilova, Yulia, additional, Kosmacheva, Elena D., additional, Nedogoda, Sergey V., additional, Coetzee, Kathleen, additional, Burgess, Lesley J., additional, Theron, F.C.R., additional, Ebrahim, Iftikhar O., additional, Haasbroek, Gerbrand A., additional, Pretorius, Maria, additional, Trokis, Julien S., additional, Urbach, Dorothea V., additional, Abelson, Mark J., additional, Horak, Adrian R., additional, Badat, Aysha E., additional, Makotoko, Ellen M., additional, Du Toit Theron, Hendrik, additional, Ramlachan, Padaruth, additional, Corbett, Clive H., additional, Mitha, Ismail H., additional, Nortje, Hendrik F.M., additional, Jansen van Rensburg, Dirkie J., additional, Sebastian, Peter J., additional, Bester, F.C.J., additional, van Zyl, Louis J., additional, Rayner, Brian L., additional, Błach, Elżbieta, additional, Dąbrowska, Magda, additional, Kania, Grzegorz, additional, Kelm-Warchol, Agata E., additional, Kinasz, Leszek P., additional, Korecki, Janusz, additional, Kruk, Mariusz, additional, Laskowska-Derlaga, Ewa, additional, Madej, Andrzej, additional, Saminski, Krzysztof, additional, Wasilewska, Katarzyna, additional, Szymkowiak, Katarzyna, additional, Wojciechowska, Małgorzata, additional, Piorowska, Natalia, additional, Dyczek, Andrzej, additional, Abhaichand, Rajpal K., additional, Byrapaneni, Ramesh B., additional, Hattur, Basavanagowdappa, additional, Bhaskara Rao, Malipeddi, additional, Ghaisas, Nitin, additional, Shankar Kadam, Sujit, additional, Gupta, Jugal B., additional, Jayadev, Santhosh M., additional, Kothiwale, V.A., additional, Mathur, Atul, additional, Bhaskar, Vijay, additional, Aluri, Ravi K., additional, Ponangi, Udaya P., additional, Sarna, Mukesh K., additional, Sathe, Sunil, additional, Sharma, Manish K., additional, Singh Sawhney, Jilendra Pal, additional, Keshavamurthy, Chakrabhavi B., additional, Srinivas, Arun, additional, Thacker, Hemant P., additional, Sharda, A., additional, Joseph, Johny, additional, Dwivedi, Sunil, additional, Mohan, Viswanathan, additional, Premchand, Rajendra K., additional, Bedard, Jacques, additional, Bergeron, Jean, additional, Collette, Ronald, additional, Crowley, David, additional, Dumas, Richard, additional, Henein, Sam, additional, Moran, Geoff, additional, O’Mahony, William F., additional, O’Mahony, Michael, additional, Chan, Sammy, additional, Sherman, Mark H., additional, Wong, Graham C., additional, Carlson, Brian D., additional, Gupta, Milan K., additional, Borts, David, additional, Peterson, Sean R., additional, Chilvers, Martyn, additional, Kelly, Allan J., additional, Gregoire, Jean C., additional, Kouz, Simon, additional, Rodés Cabau, Josep, additional, Andor, Minodora, additional, Cinteza, Mircea, additional, Ciudin, Radu, additional, Cojan, Radu I., additional, Darabont, Roxana O., additional, Dumitrascu, Dan-Lucian, additional, Fierbinteanu-Braticievici, Carmen, additional, Fruntelata, Ana Gabriela, additional, Militaru, Constantin, additional, Minescu, Bogdon E., additional, Luminita Serban, Doina, additional, Mitu, Florin, additional, Nastase Melicovici, Dorel, additional, Petrascu, Ovidiu, additional, Pirvu, Octavian M., additional, Podoleanu, Cristian, additional, Pop, Calin, additional, Stanescu-Cioranu, Rodica-Valentina V., additional, Tase, Adrian, additional, Voiculet, Cristina, additional, Aroney, Constantine N., additional, Dart, Anthony M., additional, Davis, Timothy, additional, Kostner, Karam, additional, O’Neal, David N., additional, Purnell, Peter W., additional, Singh, Bhuwanendu B., additional, Sullivan, David R., additional, Thompson, Peter, additional, Watts, Gerald F., additional, Blenkhorn, Adam F., additional, Amerena, John V., additional, Samie, Rafeeq, additional, Hendriks, Randall, additional, Proietto, Joseph, additional, Petrovsky, Nikolai, additional, Whelan, Alan, additional, Colquhoun, David, additional, Scott, Russell S., additional, Young, Simon C., additional, Pegg, Tammy, additional, Wilson, Samuel JS, additional, Hamer, Andrew W., additional, Luke, Richard A., additional, Hart, Hamish H., additional, Devlin, Gerard P., additional, Wilkins, Gerard T., additional, Ternouth, Ian F., additional, Nandra, Samraj, additional, Loeprich, Bruno S., additional, McGrath, Nicole, additional, Tie, Stuart L., additional, Bos, Rob J., additional, Wils, Alexandra, additional, Jacobs, Tamara, additional, Badings, Erik A., additional, Ebels-Tuinbeek, Lillian A., additional, Scholten, Mayke L., additional, Bayraktar-Verver, Esther, additional, Zweers, Debby, additional, Schiks, Manoek, additional, Kalkman, Carolien, additional, Tiemes, Tineke, additional, Mulderij, Jeanette, additional, Dabrowska, Katarzyna, additional, Wijnakker, Wilma, additional, Van de Loo, Riny, additional, de Graauw, Jeanne, additional, Reijnierse, Giny, additional, van der Zeijst, Mirjam, additional, Scholten, Mariska, additional, Hofmeijer, Henk R., additional, van Dijk-van der Zanden, Antoinette, additional, van Belle, Dineke J., additional, Van Es, Jan, additional, Van Buchem, Gera, additional, Zijda, Wendy, additional, Verheij, Harald, additional, Oldenhof-Janssen, Linnea, additional, Bader, Martina, additional, Löwik, Marije, additional, Stuij, Sandra, additional, Vantrimpont, Pascal, additional, van Aken, Krista, additional, Hamilton, Karen, additional, Blömer, Han, additional, van Laerhoven, Gabriela, additional, Tukkie, Raymond, additional, Janssen, Maarten, additional, Verdel, Gerard, additional, Funke Küpper, Jon, additional, van Vlies, Bob, additional, Kalkman, Caroline, additional, Vooges, Joke, additional, Vermaas, Marinella, additional, Langenberg, Rachel, additional, Haenen, Niek, additional, Smeets, Frans, additional, Scheepmaker, Arko, additional, Grosfeld, Marcel, additional, Van Lieshout, Ilvy, additional, van den Berg, Marleen, additional, Wittekoek, Marian, additional, Mol, Petra, additional, Stapel, Antionette, additional, Sierevogel, Margaretha, additional, van der Ven, Nancy, additional, Berkelmans, Annemiek, additional, Viergever, Eric, additional, Kramer, Hanneke, additional, Engelen, Wilma, additional, Houwelingen, Karen V., additional, Wildbergh, Thierry X., additional, Mosterd, Arend, additional, Hobé-Rap, Coriet, additional, van Doorn, Marjan, additional, Bunschoten, Petra, additional, Freericks, Michel, additional, Emans, Mireille, additional, Den Boer-Penning, Petra, additional, Verlek, Els, additional, Freericks, Christine, additional, de Nooijer, Cornelis, additional, Welten, Christina, additional, Groenenberg, Ingrid, additional, van der Horst, Claudia, additional, Vonk, Esther, additional, Tjeerdsma, Geert, additional, Jochemsen, Gerard M., additional, van Daalen, Corinne, additional, Danse, Ingrid Y., additional, Kuipers, Lucy, additional, Pieterse, Anke, additional, Oomen, Antonius, additional, de Waard, Daan, additional, Jan Flu, Willem, additional, Kromhout, Zusan, additional, Van der Bij, Petra, additional, Feld, Rob, additional, Hessels-Linnemeijer, Brigitta, additional, Lardinois, Rob, additional, Posma, Jan L., additional, Aukema-Wouda, Zwanette R., additional, Hendriks-van Woerden, Marjolijn, additional, van Wijk, Desiree, additional, Beelen, Driek P., additional, Hendriks, Ingrid H., additional, Jonker, Jan J., additional, Schipperen, Stefanie, additional, Köse, Vicdan, additional, Rojas, Gloria, additional, Goedhart, Linda, additional, van Meurs, Hanneke, additional, Rijssemus, Jacqueline, additional, Swinkels-Diepenmaat, Lindy, additional, de Louw-Jansen, Marloes, additional, Bierens-Peters, Dominique, additional, van Kempen, Willem W., additional, Wittekoek, Marianne E., additional, Agous, Irmaina, additional, Schenk, Geert, additional, Wittekoek, Janneke, additional, Cox, Kevin, additional, Julia, Deborah F., additional, Jonker, Jan J.C., additional, Janssen, Roel, additional, Nierman, Melchor, additional, Katerberg, Hilligje, additional, van der Haar, Irene, additional, Van Kempen, Willem W., additional, van Mesdag, Taco, additional, Alvarez Costa, Leyda M., additional, Schensema, Manon, additional, Zweekhorst, Salomé, additional, Font Julia, Deborah, additional, Hanewinckel, Lauri, additional, Olsthoorn, Joyce, additional, Berends, Johan C., additional, van der Spek, Arie C., additional, van der Berg, Roy, additional, Timmermann, Rob J., additional, Boerema, Ingrid, additional, Mudruk, Iryna, additional, Khrystoforova, Anna, additional, Kyselov, Serhii, additional, Hilova, Yaroslava V., additional, Logoida, Pavlo, additional, Sanina, Nataliia A., additional, Golikova, Ilona P., additional, Nemchyna, Olena O., additional, Isaichikov, Ivan I., additional, Potapova, Olga B., additional, Gura, Iurii V., additional, Berestetska, Larysa, additional, Kulianda, Olena O., additional, Tantsura, Oleksandr, additional, Kulbachuk, Oleksandr S., additional, Petsentiy, Volodymyr, additional, Biskub, Ihor, additional, Handych, Tetyana, additional, Lagkuti, Oleg, additional, Gagarina, Alyna, additional, Chendey, Taras, additional, Bilonko, Oksana F., additional, Matova, Olena, additional, Bezrodna, Larysa, additional, Yarynkina, Olena, additional, Ovdiienko, Tetiana, additional, Randchenko, Volodymyr, additional, Mospan, Maryna, additional, Butko, Olena, additional, Romanenko, Olga, additional, Pavelko, Mykhailo, additional, Sichkaruk, Iryna, additional, Lazareva, Svitlana O., additional, Kudryk, Olena A., additional, Koltsun, Inessa M., additional, Magdalits, Tetiana, additional, Zadorozhniy, Sergei, additional, Kompaniiets, Kira, additional, Ivanov, Andrii, additional, Romanenko, Sergiy, additional, Kaplan, Pavlo, additional, Romanov, Vadym Y., additional, Mykytyuk, Oksana P., additional, Zaitseva, Nataliia S., additional, Pyvovar, Sergiy N., additional, Burdeuna, Lyudmyla, additional, Serdobinska, Emerita, additional, Shevchenko, Tatiana I., additional, Ivanytskyi, Igor I., additional, Khyzhnyak, Olena V., additional, Kalinkina, Nataliya, additional, Keting, Olena, additional, Sklyanna, Olena, additional, Kashanska, Olga, additional, Shevelok, Anna, additional, Khristichenko, Marina, additional, Titov, Ievgenii Y., additional, Oleksander, Danilenko O., additional, Polenova, Nataliia S., additional, Altunina, Nataliia, additional, Kororaieva, Viktoriia, additional, Zborovskiy, Stanislav, additional, Kholopov, Leonid, additional, Suliman, Iurii, additional, Lukashenko, Lanna, additional, Shvaykin, Stanislav, additional, Glavatskiy, Olexandr M., additional, Sychov, Roman O., additional, Kulynych, Roman L., additional, Skarzhevskyi, Oleksandr A., additional, Dovgan, Nataliia V., additional, Horbach, Marta, additional, Cherkasova, Olga, additional, Tyshchenko, Iryna, additional, Todoriuk, Liudmyla, additional, Kizim, Svitlana, additional, Brodi, Nataliia, additional, Ivanko, Oleksandr, additional, Garbarchuk, Olga, additional, Alieksieieva, Liudmyla, additional, Shandra, Tetiana L., additional, Beregova, Olena, additional, Bodretska, Larisa An, additional, Naskalova, Svitlana S., additional, Antoniuk-Shcheglova, Ivanna A., additional, Bondarenko, Olena V., additional, Andreeva, Natalia G., additional, Vakalyuk, Iryna I., additional, Chovganyuk, Olha S., additional, Artemenko, Nataliya R., additional, Maltsev, Kiril A., additional, Kalishevich, Natalia, additional, Kondratyeva, Natalia G., additional, Nikitina, Svetlana A., additional, Martjanova, Maria V., additional, Sokolova, Anna V., additional, Dragunov, Dmitrii O., additional, Kolesnik, Olga, additional, Larina, Vera, additional, Tsygankova, Oxana V., additional, Ivanova, Maria, additional, Karpov, Illia A., additional, Aronova, Elena M., additional, Vedernikova, Ekaterina S., additional, Lubinskaya, Ekaterina I., additional, Burak, Taras Y., additional, Skichko, Sergey I., additional, Rasulev, Farhad, additional, Soldatova, Ekaterina B., additional, Fenin, Alexander L., additional, Laptev, Ilya I., additional, Luchinkina, Elena E., additional, Akatov, Alexandr, additional, Polenova, Natalia V., additional, Slavina, Natalia N., additional, Korovnika, Irina N., additional, Yu Prochorova, Marina, additional, Shakirova, Regina, additional, Andreicheva, Elena N., additional, Krasnova, Olga A., additional, Lobzhanidze, Tinatin V., additional, Dmitrova, Tatiana B., additional, Stakhiv, Viktoriya V., additional, Pechatnikova, Maria I., additional, Panova, Alexandra V., additional, Tipikina, Maria Y., additional, Rotar, Oxana P., additional, Bokovin, Nikolay A., additional, Karabalieva, Saule K., additional, Tumarov, Farid Y., additional, Vasileva, Elena V., additional, Gennadevna Lozhkina, Natalya, additional, Filippova, Ekaterina V., additional, Sharkaeva, Alisa I., additional, Filippova Deilik, Ekanerina V., additional, Yu Tolkacheva, Natalia, additional, Domracheva, Elena N., additional, Ryabikov, Andrey N., additional, Abesadze, Inga T., additional, Alugishvili, Marianna Z., additional, Nikolaeva, Elena P., additional, Smirnova, Nadezda V., additional, Rodionova, Valentina I., additional, Dolovstaya, Polina V., additional, Yunonin, Igor E., additional, Kadin, Sergey V., additional, Sveklina, Tatyana S., additional, Bushmanova, Anna V., additional, Barkova, Elena L., additional, Gomova, Irina S., additional, Brytkova, Yana V., additional, Ivanova, Tatiana B., additional, Zubareva, Marina Y., additional, Skopets, Inga, additional, Galashevskaya, Lybov A., additional, Butinskaya, Emilia D., additional, Gusarova, Olga G., additional, Kalishevich, Natalia B., additional, Pavlova, Yana R., additional, Serebrenitskaya, Marianna P, additional, Grygorieva, Vitalina F., additional, Kuchaeva, Gulnara R., additional, Vasileva, Inna A., additional, Ospanova, Gulnara I., additional, Vahrusheva, Yulia V., additional, Semenova, Irina A., additional, Mikhailova, Irina E.E., additional, Kvasova, Olga O., additional, Shurygina, Valeria D., additional, Rivin, Alexey E., additional, Savelyev, Alexey O., additional, Savelyev, Alexey A., additional, Milyaeva, Olesya O., additional, Lapshina, Nadezhda N., additional, Lantsova, Ninel A., additional, Alexandrov, Pavel V., additional, Orlikov, Evgeniy A., additional, Falkovskaya, Alla, additional, Ripp, Tatiana, additional, Triss, Sergei, additional, Pekarskiy, Stanislav, additional, Ekaterina, Sitkova, additional, Zhuravleva, Evgeniya N., additional, Perova, Olga, additional, Kovaleva, Galina, additional, Koroleva, Liubov, additional, Mishchenko, Lydia, additional, Garshin, Boris P., additional, Kutuzova, Svetlana A., additional, Provotorova, Lyudmila I., additional, Zadvorny, Igor P., additional, Okhapkina, Olga V., additional, Khrustalev, Anatoly O., additional, Suvorova, Tatiana, additional, Shaf, Elena S., additional, Vershinina, Varvara A., additional, Kozulin, Andrey A., additional, Oleynik, Oxana A., additional, Martynova, Irina Y., additional, Kizhvatova, Natalia V., additional, Salasyuk, Alla S., additional, Tsoma, Vera V., additional, Ledyaeva, Alla A., additional, Chumachek, Elena V., additional, Blignaut, S.C., additional, Alexander, Tersia Y., additional, Du Plessis, Chano, additional, Govender, Thirumani, additional, Du Toit, Samatha M., additional, Motala, Leya, additional, Gassiep, Areesh, additional, Naude (Smit), Christina, additional, Terblanche, Marli, additional, Snoer (Kruger), Marlien, additional, Pillay, Berenice, additional, Basson, De Vries, additional, Theron, Marisa E., additional, Fouche, Bianca, additional, Coetzee, Mareli E., additional, Odendall, Pieter, additional, Van Wijk, Frederik H., additional, Conradie, Anna-Mari, additional, Van der Westhuizen, Trudie, additional, Tredoux, Carine, additional, Mookdam, Mohamed S., additional, Van der Merwe, Andie J., additional, Snyman, Karin, additional, Smal, Gerda, additional, De Jager, Yvonne, additional, Mabin, Thomas A., additional, King, Annusca, additional, Henley, Lindy L., additional, Zwane, Brenda M., additional, Robinson, Jane, additional, Karsten, Marinda, additional, Page, Andonia M., additional, Nsabiyumva, Valerie, additional, Krahenbuhl, Charmaine, additional, Patel, Jaiprakash D., additional, Motala, Yunus E., additional, Dawood, Ayesha, additional, Koza, Nondumiso B., additional, Peters, Lenore M.S., additional, Ramlachan, Shavashni, additional, Bodenstein, Wilhelm J., additional, Roux, Pierre, additional, Fouche, Lizelle, additional, Boshoff, Cecilia M., additional, Mitha, Haroon M., additional, Khan, Fathima, additional, Cyster, Henry P., additional, Cyster, Helen, additional, Wessels, E. C., additional, Jacobs, Florence J., additional, Sebastian, Melanie A., additional, Sebastian, Deborah A., additional, Mahomed, Nadia, additional, Immink, Ignatius P., additional, Cotzee, Celia, additional, Cronje, Tanja, additional, Roscher, Madele, additional, Le Roux, Maria, additional, Trinder, Yvonne A., additional, Wnętrzak-Michalska, Renata, additional, Piszczek, Magdalena, additional, Piela, Andrzej, additional, Czernecka, Ewa, additional, Knychas, Dorota, additional, Walczak, Alina, additional, Gładysz, Izabella, additional, Filas, Katarzyna, additional, Kiluk, Ewelina, additional, Świgło, Krzysztof, additional, Jędrzejczyk, Iwona, additional, Łuczyńska, Kamila, additional, Tymendorf, Katarzyna, additional, Piesiewicz, Wojciech, additional, Kinasz, Wojciech L., additional, Samborski, Stefan, additional, Bartuś, Ilona, additional, Latocha Korecka, Gramzyna, additional, Gulaj, Ewa, additional, Sopa, Jolanta, additional, Derlaga, Bogusław, additional, Baisiak, Marcin, additional, Kowalisko, Allicia, additional, Stainszewska-Marasazlek, Edyta, additional, Szafran, Bartosz, additional, Swiatkiewicz, Malgorzata, additional, Racewicz, Artur, additional, Grycel, Sławomir, additional, Supronik, Jerzy, additional, Walendziuk, Sylwia, additional, Tarantowicz, Magdalena, additional, Stasiak, Agata, additional, Sidorowicz-Białynicka, Anna, additional, Dwojak, Marek, additional, Jaźwińska-Tarnawska, Ewa, additional, Kupczyk, Katarzyna, additional, Martowska, Kamila, additional, Kulon, Kamila, additional, Gajda, Katarzyna, additional, Wilson, Bivin, additional, Velusamy, Krithika, additional, Sadhiq, Swaidha S., additional, Siddeshi, Bhavani, additional, Bhanukumar, M., additional, Srivatsav, Abhishek, additional, Ramesh, Madhan, additional, Harsha Chalasani, Sri, additional, Johnson, Mini, additional, Gopu, Prashanth, additional, George, Jeesa, additional, Reddy, Sowmya, additional, Thara Eleena, Swetha Tessy, additional, Rao Kodem, Damodara, additional, Nakkella, Haritha N., additional, Kumari Mandula, Padma, additional, Kumar Vuriya, Anjan, additional, Rajana, Syamala, additional, Kale, Aruna, additional, Rajeev, Tiwari, additional, Jain, Raina, additional, Jain, Vipin, additional, Mandayam Adhyapak, Srilakshmi, additional, Sheeba, Lumin, additional, C R, Uma, additional, R, Ramya, additional, Kulkarni, Aditya V., additional, Ganachari, M.S., additional, Sambrekar, Ruma, additional, Bilal, Mohammad, additional, Chakravarthy, Kalyan, additional, Badhavath, Ravi, additional, Kumar, Sravan, additional, Simhadri, Meenakshi, additional, Salamuddin, Farooque, additional, Prasad, Venkat, additional, Dwivedi, Vivek, additional, Sarna, Sudha, additional, Arora, Tilak, additional, Chawla, Deepak, additional, Sathe, Archana, additional, Gayatree, Chaware, additional, Nanda, Ajeet, additional, Avtar, Ram, additional, Sharma, Jyoti, additional, P S, Vaibhavi, additional, D, Sasirekha, additional, Kobbajji, Deepthi, additional, Ningappa, Ramya, additional, Shree, Shwetha, additional, K, Chandrashekar, additional, M R, Nandini, additional, S, Sowjanya, additional, I G, Devika, additional, N, Yashaswini, additional, G, Sonika, additional, L, Rathna, additional, R, Priyanka, additional, Shrimanker, Rupal J., additional, Vinutha Reddy, Lakshmi, additional, Sumathi, K., additional, Devi, Babitha, additional, Naik, Bina N., additional, Manjunath, Rohini, additional, Ashok, Rajeshwari, additional, Kunjumon, Tony V., additional, Thomas, Jesline, additional, Samdhani, Shaik, additional, Selvam, Kasthuri, additional, Subramani, Poongothai, additional, Parthasarathy, Nandakumar, additional, Bohra, Nirmal K., additional, Gatla, Anvesh K., additional, Horbatuk, Cheryl, additional, Sills, Julie, additional, Davey, E B., additional, Paramonczyk, Liz, additional, Racanelli, Olga, additional, Strybosch, Sandy, additional, Belanger, Andre, additional, Palardy, Jean, additional, Schiffrin, Alicia, additional, Gauthier, Sylvie, additional, Kalyniuk, Norman, additional, Whatley, Shawn D., additional, Lappala, Heather, additional, Patel, Grishma, additional, Reeve, Matthew, additional, Moran, Catherine, additional, Everitt, Jody, additional, Ferrari, Teresa, additional, Bouffard, Christine, additional, Frohlich, Jirir, additional, Francis, Gordon, additional, Mancini, John, additional, Bondy, Gregory, additional, DeAngelis, Debbie, additional, Fulton, Patricia, additional, Blank, David W., additional, Lombardo, Angela, additional, Roy, Mylène, additional, Chow, Jackie, additional, Fox, Hyman, additional, Grootendorst, William J., additional, Hutchinson, Angela, additional, Chan, Sharon M., additional, Fitzgerald, Christie, additional, Wilkins, Lynn, additional, Raymond, Rebecca L., additional, Reyes, Arlene, additional, Marc André, Lavoie, additional, Fortin, Denis, additional, Ouimet, Hélène, additional, Tôn-Nu, Thanh-Thao, additional, Dussureault, Martine, additional, Blain, Marie-Hélène, additional, Roy, Madeleine, additional, Kopajko, Nathalie, additional, Fleury, Chantal, additional, Maheux, Karine, additional, Ciobotaru, Gabriela Valentina, additional, Constantinescu, Maria C., additional, Gherghinescu, Carmen-Lucia, additional, Avram, Ana-Maria, additional, Manitiu, Ioan, additional, Sinpetrean, Aura, additional, Pop, Lucian, additional, Lupu, Delia, additional, Usvat, Radu, additional, Petrisor, Ana, additional, Dumitru, Nicoleta, additional, Moruju, Camelia, additional, Gheorghita, Adelina, additional, Mitu, Magda V., additional, Macarie, Cosmin, additional, Pop, Ana Maria, additional, Diaconu, Maria-Catalina, additional, Grancea, Iulia, additional, Cosma, Mihaela, additional, Crisan, Mihaela, additional, Herron, Elizabeth, additional, Nestel, Paul, additional, Kay, Sally B., additional, Carter, Kaye S., additional, Badshah, Imran, additional, Makepeace, Ashley, additional, Drinkwater, Jocelyn, additional, England, Michelle, additional, Rafei, Azette, additional, Patterson, Kylie, additional, Jenkins, Alicia, additional, McAuley, Sybil, additional, Kent, Sue M., additional, Vibert, Joy E., additional, Perrett, Leonie, additional, David, Thomas, additional, Kaye, Samantha L., additional, O’Connor, Monika, additional, Perera, Nimalie J., additional, Lai, Nicole T., additional, Kearins, Kerry A., additional, Dicamillo, Christinia, additional, Anderson, Heather, additional, Ferguson, Louise, additional, Radtke, Sharon D., additional, Thamarappillil, Charles T., additional, Boys, Janice M., additional, Long, Anita K., additional, Shanahan, Toni, additional, Nyguyen, Michael, additional, Forrest, Nicole, additional, Tulloch, Gill, additional, Greenwell, Della, additional, Price, Sarah L., additional, Tint, Aye N., additional, Sumithran, Priya K., additional, Debreceni, Tamara L., additional, Walker, Lisa, additional, Caruana, Mary, additional, Edwards, Kira, additional, Stathopoulos, Maria, additional, Haywood, Cilla, additional, Sajkov, Dimitar, additional, Pringle, Sharen, additional, Tabner, Anne, additional, Bartolay, Kathrina, additional, Abeyratne, Chamindi, additional, Bragg, Kylie, additional, Mulhern, Patrick, additional, Purnell, Peter, additional, Williams, Lyn, additional, Hamlyn, Jane, additional, Connelly, Aurelia, additional, Hoffman, Jan, additional, Bailey, Samantha, additional, Kerr, Jane, additional, Morrison, Zarnia, additional, Maeder, Sarah, additional, McEwan, Roberta, additional, Kunasekera, Prasanna, additional, McGregor, Patrice, additional, Young, Jo, additional, Berry, Sharon, additional, Cutfield, Rick, additional, Choe, Michelle, additional, McNamara, Catherine, additional, Shergill, Narrinder K., additional, Crone, Petra, additional, Williams, Miles G., additional, Dyson, Keith, additional, Schmid, Diana H., additional, Doak, Audrey C., additional, Spooner, Melissa, additional, Edwards, Colin, additional, Turner, Anne, additional, McAnnalley, Grainne M., additional, Fisher, Raewyn A., additional, Hamilton, Fraser B., additional, Friedlander, Denis H., additional, Kirk, Melissa R., additional, Scales, Jayne E., additional, McLelland, Marguerite A., additional, Dalman, Neelam A., additional, Vickers, Cathy E., additional, Jackson, Carolyn, additional, Coleman, Wendy, additional, Garden, Phillip I., additional, and Arnold, Wendy F., additional

Published
2021
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23. Effect of a Collaborative Care Model on Anxiety Symptoms Among Patients with Depression and Diabetes in India: The INDEPENDENT Randomized Clinical Trial

Author

Nikhil Tandon, Viswanathan Mohan, Lydia Chwastiak, Christopher G. Kemp, Aravind Sosale, Mohammed K. Ali, Rajesh Sagar, Ranjit Mohan Anjana, Deepa Rao, K.M.V. Narayan, Gumpeny R. Sridhar, Shivani A. Patel, Leslie Johnson, Subramani Poongothai, and Karl M F Emmert-Fees

Subjects
medicine.medical_specialty, Primary Health Care, business.industry, Depression, Collaborative Care, India, Anxiety, medicine.disease, Article, law.invention, Psychiatry and Mental health, Randomized controlled trial, Diabetes Mellitus, Type 2, law, Diabetes mellitus, Medicine, Humans, medicine.symptom, business, Psychiatry, Depression (differential diagnoses), Diabetes, Integrated Care
Abstract

Objective: We assessed the impact of a collaborative care intervention on anxiety symptoms among participants in India with comorbid depression, poorly controlled diabetes, and moderate to severe anxiety symptoms. Method: We analyzed data from a randomized controlled trial conducted at four diabetes clinics in India. Participants received either collaborative care or usual care. We included only participants who scored ⩾10 on the Generalized Anxiety Disorder-7 (GAD-7) at baseline. We estimated the effect of the intervention on clinically significant reduction in anxiety symptoms; we considered several potential baseline moderators and mediation by anti-depressant use. Results: One hundred and seventy-two participants scored 10 or above on the GAD-7 at baseline. Collaborative care participants were more likely than control participants to achieve a clinically significant reduction in anxiety symptoms at 6 and 12 months (65.7% vs. 41.4% at 12 months, p = 0.002); these differences were not sustained at 18 or 24 months. There was little evidence of moderation by participant characteristics at baseline, and effects were not mediated by anti-depressant use. Conclusions: Collaborative care for the treatment of depression and type 2 diabetes can lead to clinically significant reductions in anxiety symptoms among patients with anxiety. Effects were notable during the active intervention period but not over the year post-intervention.

Published
2021

25. Comparison of Glycemic Excursion Using Flash Continuous Glucose Monitoring in Patients with Type 2 Diabetes Mellitus Before and After Treatment with Voglibose

Author

Ulagamathesan Venkatesan, Selvam Kasthuri, Jayvel Selvakumar, Viswanathan Mohan, Pokal Prasanna Kumar Gupta, Ranjit Mohan Anjana, Sengottuvel Kayalvizhi, Syed Tariq, Evangelin Honey, Subramani Poongothai, and Subramaniam Muthukumar

Subjects
Adult, Blood Glucose, medicine.medical_specialty, α-Glucosidase inhibitor, Endocrinology, Diabetes and Metabolism, 030209 endocrinology & metabolism, Type 2 diabetes, Postprandial hyperglycemia, 03 medical and health sciences, Flash glucose monitoring, 0302 clinical medicine, Endocrinology, Diabetes mellitus, Internal medicine, Voglibose, FreeStyle Libre ProFlash, Medicine, Humans, Hypoglycemic Agents, In patient, 030212 general & internal medicine, Prospective Studies, Glycemic variability, Type-2 diabetes mellitus, Glycemic, Glycated Hemoglobin, business.industry, Continuous glucose monitoring, Blood Glucose Self-Monitoring, Type 2 Diabetes Mellitus, Original Articles, medicine.disease, Medical Laboratory Technology, Glucose, Diabetes Mellitus, Type 2, Cardiology, business, After treatment, Inositol, medicine.drug
Abstract

Purpose: To determine the effect of Voglibose add-on therapy on daily glycemic excursions (using FreeStyle® Libre Pro™, a Flash glucose monitoring system) in Indian patients with type 2 diabetes mellitus (T2DM) receiving a stable dose of metformin (Met) or metformin+sulfonylurea (Met+SU). Patients and Methods: T2DM patients with glycosylated hemoglobin (HbA1c) ≥7.0% and at least two postprandial excursions ≥140 mg/dL (within 2 h of meal) during the screening phase (visit 1/day −14 ± 2) were enrolled in this prospective, multicenter interventional study. The patients were randomized at visit 2 (day 0 ± 2) to receive Voglibose 0.2 or 0.3 mg tablets (BID/TID) as add-on therapy to Met and Met+SU. All the patients were followed at day 14 ± 2 (visit 3), month 3 ± 14 days (visit 4), 14 weeks (i.e., visit 4 + 14 days) ±2 days (visit 5), and month 6 ± 14 days (visit 6). Continuous glucose monitoring was performed to study glycemic excursions at visits 2, 3, and 5. The study outcomes were: change in average number of glycemic excursions per day, percent time spent in glucose fluctuations, mean Postprandial glucose (PPG), Fasting plasma glucose (FPG), day and night time mean glucose levels from baseline to day 14 and week 14; change in mean amplitude of glycemic excursion (MAGE) from baseline to 14 weeks; and mean HbA1c level at 3 and 6 months. Results: Out of 110 patients enrolled, 101 patients (91.8%) (Met+SU+Voglibose: 73 and Met+Voglibose: 28) completed the study. There was a significant decrease in average number of glycemic excursions per day from baseline to day 14 in the Met+Sul+Voglibose group and to week 14 in the Met+Voglibose group. There was also a significant reduction in percent time spent above target glucose range from baseline to day 14 in both treatment groups and to week 14 in the Met+SU+Voglibose group. A significant reduction in mean PPG area under the curve, day and night time mean glucose levels, and mean FPG levels from baseline to day 14 was reported in both treatment groups. A significant reduction in night time glucose, and average MAGE and HbA1c levels was reported from baseline to week 14 in the Met+Voglibose group and the Met+SU+Voglibose group, respectively. At 6 months, body weight, glucose levels, cholesterol, low-density lipoprotein-cholesterol, and HbA1c were significantly lower, especially in the Met+SU+Voglibose arm. Conclusion: Voglibose was useful in reducing glycemic variability and improving glycemic control in Asian Indian adults with T2DM. (CTRI/2018/04/013074)

Published
2020

26. A systematic review protocol for estimation of the prevalence of depression using diagnostic instruments in the elderly population in India, 2000-2019

Author

Deepti Dabar, Shiv Dutt Gupta, Mohan, Subramani Poongothai, Prateek Behera, Surama Manjari Behera, Manju Pilania, Yadav, and Mohan Bairwa

Subjects
Gerontology, Protocol (science), Funnel plot, Critical appraisal, Systematic review, business.industry, education, Medicine, CINAHL, PsycINFO, Publication bias, business, Cohort study
Abstract

IntroductionDepression is a common mental disorder in the elderly population, which significantly impacts their quality of life. However, correct estimates of its magnitude are not available in the elderly in India. The present systematic review and meta-analysis would attempt to estimate the prevalence of depression using diagnostic instruments among elderly persons aged 60 years and above.Methods and analysisSearches will be performed in PubMed, Scopus, Embase, Web of Science, CINAHL, and PsycINFO. Community-based cross-sectional and cohort studies (2001 – 9/2019) reporting the prevalence of depression in the elderly; using diagnostic instruments will be included. Studies conducted among chronic disease patients, in-hospital patients, and special groups such as with disaster-stricken populations, and studies reporting the only 1 or 2 subcategories of depression, will be excluded. Disagreements in study selection and data abstraction will be resolved by consensus and arbitration by a third reviewer. AXIS critical appraisal tool will be used for quality assessment of individual studies. Findings of eligible studies will be pooled using fixed-effects or random-effects meta-analysis whichever is appropriate. Heterogeneity between studies will be examined by Cochran’s Q test and quantified by I2statistic. A cumulative meta-analysis will be used to detect temporal trends in the prevalence of depression and the effect of poor-quality studies on the pooled estimate. Publication bias will be assessed by visual inspection of funnel plots and the Egger test.Ethics and disseminationNo ethical approval will be needed because it will be a systematic review. Data from previously published studies will be retrieved and analyzed. Findings will be disseminated through a peer-reviewed publication in a scientific journal and conferences.PROSPEROregistration number CRD42019138453.Strengths and limitations of this studyIt is a first-ever systematic review of depression prevalence in India based on diagnostic instruments only.Meta-analytic techniques such as cumulative meta-analysis, leave-one-out (jack-knife estimation) meta-analysis, and meta-regression will enrich the analysis and provide the estimate of prevalence nearer to the population estimate.A comprehensive synthesis of all available depression prevalence data in India using a standardized risk of bias tool.The protocol adheres to Preferred Reporting Items for Systematic Reviews and Meta-Analyses Protocols guidelines.Heterogeneity in methodologies, such as diagnostic criteria, study duration, sampling design, and study locations may limit comparison across studies.

Published
2020
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27. Diet Intake and Patterns in Adults With and Without Depression in South Asia

Author

Lydia Chwastiak, Garima Rautela, Dorairaj Prabhakaran, Mohammed K. Ali, Masood Kadir, K.M. Venkat Narayan, Nida I. Shaikh, Subramani Poongothai, Nikhil Tandon, Anjana Ranjit Mohan, Viswanathan Mohan, and Karla I. Galaviz

Subjects
Nutrition and Dietetics, South asia, business.industry, Dietary Patterns, Environmental health, Dietary intake, Medicine (miscellaneous), Medicine, business, Depression (differential diagnoses), Food Science
Abstract

OBJECTIVES: To compare dietary intake and patterns among adults with and without depression in South Asia. METHODS: Baseline survey data from the 2015–16 Centre for cArdiometabolic Risk Reduction in South-Asia study, representative of three urban South Asian cities (n = 13 588), were analyzed. Non-pregnant adults ≥ 20 years completed interviewer-administered surveys including a semi-quantitative Food Frequency Questionnaire (FFQ) and Patient Health Questionnaire-9 (PHQ-9) to assess depression. Participants were categorized as having moderate/severe depression (PHQ-9 = 10–27), mild depression (PHQ-9 = 5–9), and no depression (PHQ-9 = 0–4). FFQ data were transformed into daily food (g/d) and beverage (ml/d) intake. Among adults with and without depression, we compared differences in socio-demographic characteristics and daily food and nutrient intake (energy and macronutrients and their distributions) using Students t tests and chi-sq tests and determined diet patterns using exploratory factor analysis. RESULTS: Overall,16% (95% CI 14.7, 17.5) had mild depression and 6% (95% CI 5.1, 7.1) had moderate/severe depression. Compared with adults with no or mild depression, adults with moderate/severe depression had lower intake of energy (2196 ± 804 [no] vs. 2408 ± 852 [mild] vs. 2751 ± 902 [moderate/severe] kcal/d), carbohydrates (284 ± 102 vs. 318 ± 117 vs. 366 ± 125 g/d)), protein (77 ± 35 vs. 81 ± 36 vs. 87 ± 33g/d)), fat (81 ± 36 vs. 88 ± 37 vs. 101 ± 39 g/d), and all food groups except meat (41 ± 83 vs. 41 ± 97 vs. 28 ± 73 g/d) and poultry (132 ± 146 vs. 107 ± 143 vs. 76 ± 113 g/d). Across groups, diets comprised 51–53% carbohydrates, 12–14% protein, and 32–33% fat. Four distinct diet patterns were seen among adults without depression (traditional, modern, non-vegetarian, vegetarian), with mild depression (traditional, western, vegetarian, non-vegetarian), and with moderate/severe depression (traditional, energy-dense, western, non-vegetarian). CONCLUSIONS: Diets of South Asian adults with depression were poorer in quality and quantity than those without depression. Efforts are needed to better study the direction of these associations and ways to improve diets of South Asians. FUNDING SOURCES: NHLBHI, NIH, Oxford Health Alliance Vision 2020 of the UnitedHealth Group, Fogarty International Center and the Eunice Kennedy Shriver NIDDK, NIH and the Emory Global Health Institute.

Published
2021

28. Altered circulatory levels of miR-128, BDNF, cortisol and shortened telomeres in patients with type 2 diabetes and depression

Author

Paramasivam Prabu, Ranjit Mohan Anjana, C. S. Shanthirani, Subramani Poongothai, Viswanathan Mohan, and Muthuswamy Balasubramanyam

Subjects
Adult, Male, medicine.medical_specialty, Hydrocortisone, Endocrinology, Diabetes and Metabolism, India, 030209 endocrinology & metabolism, Type 2 diabetes, 030204 cardiovascular system & hematology, Cardiovascular System, 03 medical and health sciences, chemistry.chemical_compound, 0302 clinical medicine, Endocrinology, Insulin resistance, Neurotrophic factors, Internal medicine, Diabetes mellitus, Epidemiology, Internal Medicine, medicine, Humans, Telomere Shortening, Cholesterol, business.industry, Depression, Brain-Derived Neurotrophic Factor, Confounding, General Medicine, Middle Aged, medicine.disease, MicroRNAs, chemistry, Diabetes Mellitus, Type 2, Case-Control Studies, Circulatory system, Female, Insulin Resistance, business, Biomarkers
Abstract

Several studies have reported the role of biomarkers either in diabetes or depression. The present study is aimed at profiling the circulating levels of miR-128, brain-derived neurotrophic factor (BDNF), cortisol and telomere length in patients with type 2 diabetes with and without depression compared to individuals with normal glucose tolerance. Study subjects (n = 160) were recruited from an ongoing epidemiological study in southern India. Non-diabetic and diabetic individuals were diagnosed as per the World Health Organization criteria. Depression score was derived using PHQ-12 questionnaire. Real-time quantitative PCR and ELISA methodologies were used to quantify the biomarkers. Circulatory levels of miR-128 and cortisol were significantly (p

Published
2019

29. Prevalence of depression among the elderly (60 years and above) population in India, 1997–2016: a systematic review and meta-analysis

Author

Hitesh Khurana, Mohan Bairwa, Priyamadhaba Behera, Vikas Yadav, Subramani Poongothai, Manju Pilania, Viswanathan Mohan, Girish Chandra Baniya, and Shiv Dutt Gupta

Subjects
medicine.medical_specialty, Funnel plot, Population, India, 030209 endocrinology & metabolism, 03 medical and health sciences, 0302 clinical medicine, Elderly, Epidemiology, medicine, Prevalence, Humans, 030212 general & internal medicine, education, Depression (differential diagnoses), Aged, education.field_of_study, business.industry, Depression, lcsh:Public aspects of medicine, Public Health, Environmental and Occupational Health, lcsh:RA1-1270, Publication bias, Middle Aged, Meta-analysis, Sample size determination, Systematic review, Biostatistics, business, Demography, Research Article
Abstract

Background There is lack of information on the magnitude of depression among elderly population in India. This systematic review and meta-analysis aimed to estimate the prevalence of depression among elderly population in India. Methods PubMed, Scopus, Web of Science, Embase, PsycINFO, IndMed, and Google Scholar were searched to identify articles reported community-based prevalence of depression among elderly population using screening tools. This study included the articles published during the years 1997 to 2016. Studies conducted in the special population groups, hospitals, reported only a subcategory of depression, and not specified the screening tool were excluded. Data were extracted from published reports and any missing information was requested from authors. Estimates were pooled using random-effects meta-analyses. Subgroup and sensitivity analysis were performed. The publication bias was evaluated by using Egger’s test and visual inspection of the symmetry in funnel plots. Results Fifty-one studies from 16 States of India were included as 56 datasets, which estimated the prevalence of depression among Indian elderly population as 34.4% (95% CI: 29.3–39.7). In sub-group analysis, the pooled prevalence was higher among females, rural populations, and in the eastern part of the country. Studies using non-probability sampling, and GDS and CES-D screening tool showed higher prevalence. Exclusion of the studies with sample size less than 100 and low-quality studies (score

Published
2019

30. Effect of a Collaborative Care Model on Depressive Symptoms and Glycated Hemoglobin, Blood Pressure, and Serum Cholesterol Among Patients With Depression and Diabetes in India

Author

Madhu Kosuri, Radha Shankar, Karl M F Emmert-Fees, Nikhil Tandon, Rajesh Sagar, Aravind Sosale, Mohammed K. Ali, Shivani A. Patel, Bhavana Sosale, Ranjit Mohan Anjana, Lydia Chwastiak, Viswanathan Mohan, K.M. Venkat Narayan, Deepa Rao, Subramani Poongothai, and Gumpeny R. Sridhar

Subjects
Adult, Male, medicine.medical_specialty, India, Collaborative Care, Blood Pressure, Type 2 diabetes, 01 natural sciences, law.invention, 03 medical and health sciences, chemistry.chemical_compound, 0302 clinical medicine, Randomized controlled trial, law, Internal medicine, Health care, medicine, Humans, 030212 general & internal medicine, Cooperative Behavior, 0101 mathematics, Developing Countries, Stroke, Depression (differential diagnoses), Original Investigation, Aged, Glycated Hemoglobin, Patient Care Team, Depression, business.industry, Self-Management, 010102 general mathematics, Cholesterol, LDL, General Medicine, Middle Aged, medicine.disease, Hemoglobin A, Diabetes Mellitus, Type 2, Socioeconomic Factors, chemistry, Female, Glycated hemoglobin, business
Abstract

IMPORTANCE: Mental health comorbidities are increasing worldwide and worsen outcomes for people with diabetes, especially when care is fragmented. OBJECTIVE: To assess whether collaborative care vs usual care lowers depressive symptoms and improves cardiometabolic indices among adults with diabetes and depression. DESIGN, SETTING, AND PARTICIPANTS: Parallel, open-label, pragmatic randomized clinical trial conducted at 4 socioeconomically diverse clinics in India that recruited patients with type 2 diabetes; a Patient Health Questionnaire-9 score of at least 10 (range, 0-27); and hemoglobin A(1c) (HbA(1c)) of at least 8%, systolic blood pressure (SBP) of at least 140 mm Hg, or low-density lipoprotein (LDL) cholesterol of at least 130 mg/dL. The first patient was enrolled on March 9, 2015, and the last was enrolled on May 31, 2016; the final follow-up visit was July 14, 2018. INTERVENTIONS: Patients randomized to the intervention group (n = 196) received 12 months of self-management support from nonphysician care coordinators, decision support electronic health records facilitating physician treatment adjustments, and specialist case reviews; they were followed up for an additional 12 months without intervention. Patients in the control group (n = 208) received usual care over 24 months. MAIN OUTCOMES AND MEASURES: The primary outcome was the between-group difference in the percentage of patients at 24 months who had at least a 50% reduction in Symptom Checklist Depression Scale (SCL-20) scores (range, 0-4; higher scores indicate worse symptoms) and a reduction of at least 0.5 percentage points in HbA(1c), 5 mm Hg in SBP, or 10 mg/dL in LDL cholesterol. Prespecified secondary outcomes were percentage of patients at 12 and 24 months who met treatment targets (HbA(1c)

Published
2020

31. Estimation of the prevalence of depression using diagnostic instruments in the elderly population in India, 2000–2019: a systematic review protocol

Author

Manju Pilania, Mohan Bairwa, Viswanathan Mohan, Prateek Behera, Deepti Dabar, Vikas Yadav, Shiv Dutt Gupta, Surama Manjari Behera, and Subramani Poongothai

Subjects
Funnel plot, medicine.medical_specialty, Epidemiology, education, prevalence, India, CINAHL, PsycINFO, elderly, Quality of life (healthcare), systematic review, medicine, Humans, Depression (differential diagnoses), Aged, Psychiatric Status Rating Scales, Depression, business.industry, General Medicine, Publication bias, Critical appraisal, Family medicine, Quality of Life, business, diagnostic tool, Cohort study
Abstract

IntroductionDepression is a common mental disorder in the elderly population, which significantly impacts their quality of life. However, correct estimates of its magnitude are not available in the elderly in India. The present systematic review and meta-analysis would attempt to estimate the prevalence of depression using diagnostic instruments among elderly persons aged 60 years and above.Methods and analysisSearches will be performed in PubMed, Scopus, Embase, Web of Science, CINAHL and PsycINFO. Community-based cross-sectional and cohort studies (2001 to September 2019) reporting the prevalence of depression in the elderly, using diagnostic instruments will be included. Studies conducted among chronic disease patients, in-hospital patients and special groups such as with disaster-stricken populations, and studies reporting the only one or two subcategories of depression, will be excluded. Disagreements in study selection and data abstraction will be resolved by consensus and arbitration by a third reviewer. AXIS critical appraisal tool will be used for quality assessment of individual studies. Findings of eligible studies will be pooled using fixed-effects or random-effects meta-analysis whichever is appropriate. Heterogeneity between studies will be examined by Cochran’s Q test and quantified by I² statistic. A cumulative meta-analysis will be used to detect temporal trends in the prevalence of depression and the effect of poor-quality studies on the pooled estimate. Publication bias will be assessed by visual inspection of funnel plots and the Egger test.Ethics and disseminationNo ethical approval will be needed because it will be a systematic review. Data from previously published studies will be retrieved and analysed. Findings will be disseminated through a peer-reviewed publication in a scientific journal and conferences.PROSPERO registration numberCRD42019138453.

Published
2020

32. Strategies adopted in conduct of clinical trials amidst coronavirus disease-2019 (COVID-19)

Author

Kannikan Viswanathan, Kulasegaran Karkuzhali, Ramasamy Aarthy, Balasundaram Bhavani Sundari, Ravi Pavitha, Abdul Ali Tameem Nisha, Mohamed Althab Begum, Jagannathan Ramesh, Ranjit Mohan Anjana, Rajkumar Marappan, Subramani Poongothai, Boopathi Hemalatha, Selvam Kasthuri, and Mahalakshmi Ravisankar

Subjects
clinical trials, medicine.medical_specialty, lcsh:RC648-665, Coronavirus disease 2019 (COVID-19), Approved Protocol, business.industry, challenges, lcsh:Diseases of the endocrine glands. Clinical endocrinology, Clinical trial, Food and drug administration, Investigational product, covid-19, Family medicine, Pandemic, Agency (sociology), medicine, General Earth and Planetary Sciences, Adverse effect, business, General Environmental Science
Abstract

The conduct of clinical trials is crucial to all research stakeholders and very challenging to the investigators, study teams, and participants during (coronavirus disease-2019) COVID-19 pandemic. The main challenges include difficulties in maintaining complete adherence to approved protocol, regulatory provisions applicable guidelines, recruitment of subjects, protection of rights, safety and well-being of trial subjects (participants), is of paramount importance. The CDSCO (Central Drugs Standard Control Organization), EMA (European Medicines Agency), and FDA (Food and Drug Administration) have come out with the guidelines on the management of clinical trials during the COVID-19. This article describes the process of conducting clinical trials at Department of Clinical Trials at Madras Diabetes Research Foundation (MDRF), Chennai, during the COVID-19 pandemic. Effective strategies taken at our site include compliance with scheduled visits of subjects, laboratory testing (investigations), administration of investigational product(s), assessment of safety and efficacy parameters, reporting of SAEs (serious adverse event). These strategies could be a useful reference to investigators, doctors, and research staff across hospital sites in India and elsewhere.

Published
2020

33. Input of stakeholders on reducing depressive symptoms and improving diabetes outcomes in India: Formative work for the INDEPENDENT Study

Author

Deepa, Rao, Lauren, Lipira, Shuba, Kumar, Rani, Mohanraj, Subramani, Poongothai, Nikhil, Tandon, G R, Sridhar, Wayne, Katon, Km Venkat, Narayan, Lydia, Chwastiak, Viswanathan, Mohan, and Mohammed K, Ali

Subjects
Article
Abstract

Depression and diabetes are highly comorbid, adversely affecting treatment adherence and resulting in poor outcomes. To improve treatment and outcomes for people dually-affected by diabetes and depression in India, we aimed to develop and test an integrated care model. In the formative phase of this INtegrated DEPrEssioN and Diabetes TreatmENT (INDEPENDENT) study, we sought stakeholder perspectives to inform culturally-sensitive adaptations of the intervention.At our Delhi, Chennai, and Vishakhapatnam sites, we conducted focus groups for patients with diabetes and depression and interviewed healthcare workers, family members, and patients. These key informants were asked about experiences with diabetes and depression and for feedback on intervention materials. Data were analyzed using a grounded theory approach.Three major themes emerged that have bearing on adaptation of the proposed intervention: importance of family assistance, concerns regarding patient/family understanding of diabetes, and feedback regarding the proposed intervention (e.g. adequate time needed for implementation; training program and intervention should address stigma).Based on our findings, the following components would add value when incorporated into the intervention: 1) engaging families in the treatment process, 2) clear/simple written information, 3) clear non-jargon verbal explanations, and 4) coaching to help patients cope with stigma.

Published
2017

34. Epidemiology of Depression and its Relationship to Diabetes in India

Author

Subramani, Poongothai, Ranjit Mohan, Anjana, Shankar, Radha, Balasundaram Bhavani, Sundari, Coimbatore Subramanyam, Shanthi Rani, and Viswanathan, Mohan

Subjects
Diabetes Complications, Diabetes Mellitus, Type 2, Depression, Prevalence, Humans, India
Abstract

Depression is one of the most common chronic mental illnesses globally and in India. It has been reported that depression is twice as common in individuals with type 2 diabetes. The prevalence of both depression and type 2 diabetes are rapidly increasing. This article reviews the prevalence of depression in the general population as well as in patients with type 2 diabetes and its complications with special reference to recent data from India. It also makes a case for screening for depression in diabetes clinics and integrating depression treatment with diabetes care in order to make the treatment more wholistic.

Published
2017

35. Oral pancreatic enzyme therapy in the control of diabetes mellitus in tropical calculous pancreatitis

Author

C. S. Pitchumoni, Viswanathan Mohan, and Subramani Poongothai

Subjects
Adult, Blood Glucose, Male, medicine.medical_specialty, Abdominal pain, Pancreatic disease, Administration, Oral, Gastroenterology, Calculi, Diabetes Complications, Endocrinology, Diabetes mellitus, Internal medicine, medicine, Humans, business.industry, Glucagon secretion, medicine.disease, Steatorrhea, Postprandial, Pancreatitis, Oncology, Pancreatin, Female, Liver function, medicine.symptom, business, Blood Chemical Analysis
Abstract

Pancreatic enzyme supplementation therapy conducted during a 6 mo period produces better control of diabetes, improvement in nutrition, and overall improvement in quality of life in patients with tropical calculous pancreatitis.Tropical calculous pancreatitis is characterized by abdominal pain, pancreatic calculi, and diabetes. The diabetes in insulin resistant. The brittle diabetes may be owing to defective glucagon secretion and erratic absorption of nutrients.Patients with tropical calculous pancreatitis with diabetes and chronic pancreatitis were studied for fasting and postprandial plasma glucose, glycosylated hemoglobin, serum cholesterol, triglycerides, and calcium, liver function, and plasma C-peptide. All patients were given Creon and evaluated for quality of life.Clinical parameters of the patients showed considerable improvement at the end of the trial. Abdominal pain, steatorrhea, and sense of well being improved. There was a significant reduction in postprandial plasma glucose and glycosylated hemoglobin.

Published
1998

36. Input of stakeholders on reducing depressive symptoms and improving diabetes outcomes in India: Formative work for the INtegrated DEPrEssioN and Diabetes TreatmENT study

Author

Lauren Lipira, Viswanathan Mohan, Nikhil Tandon, K.M.V. Narayan, Subramani Poongothai, Lydia Chwastiak, Mohammed K. Ali, Wayne Katon, Rani Mohanraj, Gumpeny R. Sridhar, Deepa Rao, and Shuba Kumar

Subjects
diabetes, lcsh:Specialties of internal medicine, Depression, business.industry, Stigma (botany), 030209 endocrinology & metabolism, Context (language use), General Medicine, South Asia, Coaching, Focus group, Grounded theory, Integrated care, Formative assessment, 03 medical and health sciences, 0302 clinical medicine, lcsh:RC581-951, Intervention (counseling), Medicine, 030212 general & internal medicine, business, integrated care models, Clinical psychology
Abstract

Context: Depression and diabetes are highly comorbid, adversely affecting treatment adherence, and resulting in poor outcomes. To improve treatment and outcomes for people dually affected by diabetes and depression in India, we aimed to develop and test an integrated care model. Aims: In the formative phase of this INtegrated DEPrEssioN and Diabetes TreatmENT (INDEPENDENT) study, we sought stakeholder perspectives to inform culturally-sensitive adaptations of the intervention. Settings and Design: At our Delhi, Chennai, and Visakhapatnam sites, we conducted focus groups for patients with diabetes and depression and interviewed health-care workers, family members, and patients. Subjects and Methods: Key informants were asked about experiences with diabetes and depression and for feedback on intervention materials. Analysis: Qualitative data were analyzed using a grounded theory approach. Results: Three major themes emerged that have bearing on adaptation of the proposed intervention: importance of family assistance, concerns regarding patient/family understanding of diabetes, and feedback regarding the proposed intervention (e.g., adequate time needed for implementation; training program, and intervention should address stigma). Conclusions: Based on our findings, the following components would add value when incorporated into the intervention: (1) engaging families in the treatment process, (2) clear/simple written information, (3) clear nonjargon verbal explanations, and (4) coaching to help patients cope with stigma.

Published
2016

37. Noninvasive type 2 diabetes screening: clinical evaluation of SCOUT DS in an Asian Indian cohort

Author

Muthuswamy Balasubramanyam, Rajendra Pradeepa, C S Shanthi Rani, Viswanathan Mohan, Nathaniel Matter, Mohan Deepa, Ranjit Mohan Anjana, Subramani Poongothai, and Bhaskaran S. Regin

Subjects
Blood Glucose, Male, medicine.medical_specialty, endocrine system diseases, Endocrinology, Diabetes and Metabolism, Urology, India, Type 2 diabetes, Sensitivity and Specificity, White People, Impaired glucose tolerance, Endocrinology, Diabetes mellitus, medicine, Humans, Mass Screening, False Positive Reactions, Skin, Glucose tolerance test, Framingham Risk Score, medicine.diagnostic_test, business.industry, Area under the curve, nutritional and metabolic diseases, Reproducibility of Results, Fasting, Glucose Tolerance Test, Middle Aged, medicine.disease, Surgery, Medical Laboratory Technology, Spectrometry, Fluorescence, Diabetes Mellitus, Type 2, ROC Curve, Cohort, Arm, Female, business, Clinical evaluation
Abstract

This study evaluated the noninvasive, point-of-care diabetes screening device, Scout DS (VeraLight Inc., Albuquerque, NM) (SCOUT), in a native Asian Indian cohort.SCOUT is a tabletop, skin fluorescence spectrometer that reports a risk score following a 3-4-min noninvasive measurement of a subject's left volar forearm. SCOUT, fasting plasma glucose (FPG), and hemoglobin A(1c) (A1C) were compared for detection of abnormal glucose tolerance (AGT) in a cohort of 256 subjects without previous diagnosis of diabetes or impaired glucose tolerance in Chennai, India. After an overnight fast, a 75-g, 2-h oral glucose tolerance test was administered, and AGT was defined as a plasma glucose value ≥ 140 mg/dL (7.8 mmol/dL). Sensitivity, false-positive rate (FPR), and receiver-operating characteristics area under the curve for AGT detection were computed for SCOUT, FPG, and A1C. Intra-day reproducibility of SCOUT was assessed.SCOUT, FPG, and A1C (at respective thresholds of 50, 110 mg/dL, and 5.7%) exhibited sensitivities of 87%, 32%, and 86%, respectively, and FPR of 52%, 3%, and 58%, respectively. For the 177 subjects receiving a valid SCOUT Diabetes Score on both measurement attempts, the coefficient of variation was 5.8%, and the Pearson correlation was 0.91. A SCOUT score could be obtained on 91% of subjects after two attempts.The performance of SCOUT is similar to that of A1C, whereas FPG had a much lower sensitivity. SCOUT is an effective tool for AGT screening in Asian Indians.

Published
2012

38. Association of depression with complications of type 2 diabetes--the Chennai Urban Rural Epidemiology Study (CURES- 102)

Author

Subramani, Poongothai, Ranjit Mohan, Anjana, Rajendra, Pradeepa, Anbazhagan, Ganesan, Ranjit, Unnikrishnan, Mohan, Rema, and Viswanathan, Mohan

Subjects
Adult, Male, Peripheral Vascular Diseases, Urban Population, Depression, India, Blood Pressure, Coronary Artery Disease, Glucose Tolerance Test, Middle Aged, Diabetes Complications, Electrocardiography, Epidemiologic Studies, Logistic Models, Diabetes Mellitus, Type 2, Risk Factors, Population Surveillance, Surveys and Questionnaires, Prevalence, Humans, Female
Abstract

The aim of the study was to assess the relationship between depression and diabetic complications among urban south Indian type 2 diabetic subjects [T2DM].T2DM subjects [n = 847] were recruited from the Chennai Urban Rural Epidemiology Study [CURES], a population based study in Chennai (formerly Madras) in South India. A previously validated depression questionnaire [PHQ-12 item] was administered. Four field stereo retinal colour photography was done and diabetic retinopathy [DR] was classified according to the Early Treatment Diabetic Retinopathy Study grading system. Neuropathy was diagnosed if the vibratory perception threshold of the right great toe, measured by biothesiometry, wasor = 20. Nephropathy was diagnosed if urinary albumin excretion wasor = 300 microg/mg creatinine. Peripheral vascular disease [PVD] was diagnosed if an ankle-brachial index was0.9. Coronary artery disease [CAD] was diagnosed based on a past history of documented myocardial infarction and/or electrocardiographic evidence of Q wave and/or ST segment changes.Of the 847 T2DM studied, 198 (23.4%) were found have depression. The prevalence of depression was significantly higher among diabetic subjects with DR (35.0% vs 21.1%, p0.001), neuropathy (28.4% vs 15.9%, p = 0.023), nephropathy (35.6% vs 24.5%, p = 0.04) and PVD (48.0% vs 27.4%, p0.001) as compared to subjects without these complications. DR, neuropathy, nephropathy, and PVD were associated with depression even after adjusting for age, gender, duration of diabetes and glycated haemoglobin. DR (Odds ratio [OR] = 2.19, Confidence interval [CI]:1.45-3.51, p0.001) was associated with depression even after adjusting for neuropathy and nephropathy. There was also a significant association between depression and neuropathy, after adjusting for retinopathy and nephropathy (OR = 2.07, CI: 1.41-3.04, p0.001). There was a significant association of depression with nephropathy but this was lost (OR = 1.71, CI: 0.87-3.35, p = 0.119) after adjustment for retinopathy. PVD (OR = 3.52, CI: 1.94-6.40, p0.001) remained significantly associated with depression even after adjusting for CAD. However, there was no significant association of depression with CAD (OR = 0.73, CI: 0.42 -1.27, p = 0.264).Among Asian Indians, the prevalence of depression is higher in T2DM subjects with retinopathy, neuropathy, nephropathy and PVD compared to those without the respective complications.

Published
2012

39. Prevalence of depression in relation to glucose intolerance in urban south Indians--the Chennai Urban Rural Epidemiology Study (CURES-76)

Author

Rajendra Pradeepa, Ranjit Mohan Anjana, Viswanathan Mohan, Subramani Poongothai, Anbazaghan Ganesan, and Nandan Umapathy

Subjects
Gerontology, Adult, Blood Glucose, Male, medicine.medical_specialty, Urban Population, Endocrinology, Diabetes and Metabolism, India, Fasting glucose, Endocrinology, Internal medicine, Diabetes mellitus, Surveys and Questionnaires, Epidemiology, Glucose Intolerance, medicine, Prevalence, Humans, South indians, Depression (differential diagnoses), Response rate (survey), business.industry, Depression, Middle Aged, medicine.disease, Impaired fasting glucose, Medical Laboratory Technology, Newly diagnosed diabetes, Logistic Models, Female, business
Abstract

This study investigated the association between depression and glucose intolerance in urban residents of southern India.Subjects were recruited from the Chennai Urban Rural Epidemiology Study, carried out on a representative sample of 26,001 subjects recruited from Chennai city in southern India. Subjects with known diabetes were excluded (n = 1,498). Of the remaining 24,503 subjects, fasting capillary blood glucose (FBG) estimation were available for 23,787 subjects (response rate, 97.1%) in whom depression was assessed using a validated instrument, the Patient Health Questionnaire-12. Subjects with FBG values ≥126 mg/dL were termed as subjects with newly diagnosed diabetes (NDD), those with values between 100 and 125 mg/dL as having impaired fasting glucose (IFG), and those with100 mg/dL as having normal fasting glucose (NFG).The overall prevalence of depression was 14.3% (3391 of 23,787 subjects), and an increasing prevalence of depression was seen with increasing grades of glucose intolerance: NFG (13.1%), IFG (15.7%), and NDD (19.7%) (trend χ(2) = 57.1, P 0.001). The prevalence of depression was higher in females at all grades of glucose intolerance. Risk for depression was higher among NDD subjects compared to NFG subjects (odds ratio = 1.12, 95% confidence interval 1.03-1.22, P = 0.01) and IFG subjects (odds ratio 1.21, 95% confidence interval 1.02-1.44, P = 0.03) and also for IFG compared to NFG subjects (odds ratio = 1.12, 95% confidence interval 1.02-1.21, P = 0.01) after adjusting for age, gender, body mass index, hypertension, and socioeconomic status.The prevalence of depression increases with increasing grades of glucose intolerance and is highest among those with diabetes.

Published
2010

40. A Single-Center, Open, Comparative Study of the Effect of Using Self-Monitoring of Blood Glucose to Guide Therapy on Preclinical Atherosclerotic Markers in Type 2 Diabetic Subjects

Author

Anandakumar Amutha, Christopher G. Parkin, R. Ravikumar, Subramani Poongothai, Viswanathan Mohan, Santhamma Sowmya, and Kulasegaran Karkhuzali

Subjects
Adult, Blood Glucose, Male, medicine.medical_specialty, Evening, endocrine system diseases, Adolescent, Endocrinology, Diabetes and Metabolism, Biomedical Engineering, Bioengineering, Young Adult, Internal medicine, Diabetes mellitus, Blood Glucose Self-Monitoring, Internal Medicine, Clinical endpoint, Medicine, Humans, Hypoglycemic Agents, Prospective Studies, Prospective cohort study, Aged, Glycated Hemoglobin, business.industry, nutritional and metabolic diseases, Type 2 Diabetes Mellitus, Original Articles, Fasting, Middle Aged, medicine.disease, Atherosclerosis, Postprandial Period, Metformin, Surgery, Postprandial, Carotid Arteries, Sulfonylurea Compounds, Diabetes Mellitus, Type 2, Disease Progression, Patient Compliance, Female, business, Biomarkers, medicine.drug
Abstract

Background: The aim of our study was to determine the effect of treatment based on preprandial and postprandial self-monitoring of blood glucose (SMBG) on the progression of carotid intima-medial thickness (CIMT) in noninsulin-treated type 2 diabetes mellitus (T2DM) subjects. Methods: In this 18-month prospective trial, we recruited subjects 18–70 years of age, treated with metformin and sulfonylurea, with a standardized hemoglobin A1c (HbA1c) level ⩽9.0%. Subjects were randomized to use of fasting/preprandial (FP) SMBG results to adjust evening medication or use of postprandial (PP) SMBG results to adjust morning medication. The primary end point was change in CIMT; change in HbA1c was a secondary end point. Results: Of the 300 subjects randomized, 280 (140 in each group) completed all biochemical tests and CIMT analysis. Carotid intima-medial thickness was reduced significantly in PP subjects from 0.78 (±0.15) mm to 0.73 (±0.14) mm ( p < 0.005), but no significant CIMT reduction was seen in FP subjects. A significant reduction in HbA1c was also seen in the PP group ( p < 0.005) but not in the FP group 1 ( p = 0.165). significant improvements in body mass index ( p = 0.038), waist circumference ( p < 0.001), systolic blood pressure ( p = 0.008), and serum cholesterol ( p = 0.02) were also seen in PP subjects but not in FP subjects. Conclusion: Use of postprandial SMBG data to adjust therapy was associated with a significant regression of carotid intima-medial thickening and a reduction in HbA1c in T2DM, whereas no significant improvement in these parameters was seen in subjects who used fasting/preprandial SMBG data for therapy adjustment.

Published
2010

41. Prevalence of depression in a large urban South Indian population--the Chennai Urban Rural Epidemiology Study (CURES-70)

Author

Anbhazhagan Ganesan, Subramani Poongothai, Rajendra Pradeepa, and Viswanathan Mohan

Subjects
Gerontology, Adult, Male, Rural Population, medicine.medical_specialty, Urban Population, Age adjustment, Population, Prevalence, Public Health and Epidemiology, lcsh:Medicine, India, Rural Health, Surveys and Questionnaires, Epidemiology, Odds Ratio, Medicine, Humans, lcsh:Science, education, Socioeconomic status, Depression (differential diagnoses), education.field_of_study, Multidisciplinary, business.industry, Depression, lcsh:R, Urban Health, Odds ratio, Middle Aged, Mental Health/Psychology, Patient Health Questionnaire, Social Class, Regression Analysis, lcsh:Q, Female, Public Health and Epidemiology/Epidemiology, business, Demography, Research Article
Abstract

Background In India there are very few population based data on prevalence of depression. The aim of the study was to determine the prevalence of depression in an urban south Indian population. Methods and Findings Subjects were recruited from the Chennai Urban Rural Epidemiology Study (CURES), involving 26,001 subjects randomly recruited from 46 of the 155 corporation wards of Chennai (formerly Madras) city in South India. 25,455 subjects participated in this study (response rate 97.9%). Depression was assessed using a self-reported and previously validated instrument, the Patient Health Questionnaire (PHQ) – 12. Age adjustment was made according to the 2001 census of India. The overall prevalence of depression was 15.1% (age-adjusted, 15.9%) and was higher in females (females 16.3% vs. males 13.9%, p

Published
2009

42. Association of depression with common carotid artery intima media thickness and augmentation index in a large Urban South Indian population- The Chennai Urban Rural Epidemiology Study (CURES - 138)

Author

Viswanathan Mohan, R. Pradeepa, Jayagopi Surendar, Subramani Poongothai, and Karunakaran Indulekha

Subjects
medicine.medical_specialty, Endocrinology, Diabetes and Metabolism, augmentation index, lcsh:Diseases of the endocrine glands. Clinical endocrinology, South Asians, Endocrinology, Right Common Carotid Artery, Internal medicine, medicine.artery, medicine, intima media thickness, Asian Indians, Common carotid artery, lcsh:RC799-869, Depression (differential diagnoses), lcsh:RC648-665, diabetes, business.industry, Odds ratio, Confidence interval, Surgery, Patient Health Questionnaire, Intima-media thickness, depression, lcsh:Diseases of the digestive system. Gastroenterology, Original Article, atherosclerosis, business, Body mass index
Abstract

AIM: The aim of the study was to assess the relationship of depression with carotid intima media thickness and augmentation index in Asian Indians. Research Design and Methods : For this study, 1505 subjects were randomly selected from a population based study conducted in Chennai, South India. Right common carotid artery intima medial thickness [IMT] was determined using high-resolution B-mode ultrasonography. Augmentation index [AI] was measured using the Sphygmocor apparatus. Depressive symptoms were assessed using a previously validated instrument, the Patient Health Questionnaire -12 (PHQ -12). Results : Of the 1505 subjects included in this study, depressive symptoms were present in 16.6% (n = 250) of the subjects. The mean IMT and AI values among subjects with depression were significantly higher than those without depression [0.83 ± 0.43 mm vs 0.73 ± 0.12 mm, P < 0.001] and IMT was higher in females with depression while AI was higher in males with depression. However, both IMT and AI were higher among those with depression in both genders. In multiple logistic regression model, depressive symptoms were associated with IMT even after adjusting for age, gender, body mass index, fasting plasma glucose, serum cholesterol and hypertension (Odds ratio [OR] =2.17, 95% Confidence intervals [CI]:1.01- 4.63, P = 0.047) but in the case of AI, the significance was lost in the adjusted model (OR = 1.01, 95% CI: 0.991-1.02, P = 0.445). Conclusion: Among Asian Indians, presence of depressive symptoms was associated with carotid intima media thickness and Augmentation index, even after adjusting for potential confounders.

Published
2015

43. Why are clinical trials necessary in India?

Author

Viswanathan Mohan, Mohan Damodaran Nair, Ranjit Unnikrishnan, Subramani Poongothai, and Jeyakumar Balasubramanian

Subjects
lcsh:R5-920, Opinion, medicine.medical_specialty, good clinical practice, Traditional medicine, business.industry, Clinical study design, lcsh:R, Alternative medicine, lcsh:Medicine, India, General Medicine, Public relations, Clinical trial, Clinical trials, Good clinical practice, Medicine, lcsh:Medicine (General), business
Abstract

Clinical trials are emerging as an important activity in India as it is an essential component of the drug discovery and development program to which India is committed. The only robust way to evaluate a new medicine is by doing properly designed clinical trials. In addition to advancing science, clinical trials offer myriad benefits to the participants. The recent hue that created in India about clinical trials is probably an exaggeration of facts. However, these points to the need for ensuring proper compliance with the regulatory norms and proper training of concerned personnel in good clinical practice (GCP). This will ensure that India continues to reap the benefits of clinical trials and also become a world leader in this field.

Published
2014

44. Clinical profile of lean NIDDM in South India

Author

Paul Zimmet, Eesh Bhatia, Viswanathan Mohan, Raj Deepa, G. Premalatha, R. Vijayaprabha, Mohan Rema, Subramani Poongothai, and Ian R. Mackay

Subjects
Blood Glucose, Male, endocrine system diseases, Endocrinology, Diabetes and Metabolism, medicine.medical_treatment, Myocardial Infarction, Myocardial Ischemia, Blood Pressure, Body Mass Index, Cohort Studies, chemistry.chemical_compound, Endocrinology, Diabetic Neuropathies, Diastole, Insulin, C-Peptide, C-peptide, Glutamate Decarboxylase, Smoking, General Medicine, Fasting, Middle Aged, Postprandial Period, Cholesterol, Cohort, Female, hormones, hormone substitutes, and hormone antagonists, Cohort study, Adult, endocrine system, medicine.medical_specialty, Systole, India, Nephropathy, Islets of Langerhans, Internal medicine, Diabetes mellitus, Internal Medicine, medicine, Diabetes Mellitus, Humans, Hypoglycemic Agents, Obesity, Triglycerides, Autoantibodies, Glycated Hemoglobin, Diabetic Retinopathy, Dose-Response Relationship, Drug, business.industry, Body Weight, nutritional and metabolic diseases, medicine.disease, chemistry, Diabetes Mellitus, Type 2, business, Body mass index, Diabetic Angiopathies
Abstract

The majority (> 80%) of patients with non insulin dependent diabetes mellitus (NIDDM) present in Europe and America are obese. In developing countries like India, most NIDDM (> 60%) are non-obese and many are actually lean with a body mass index (BMI) of < 18.5 and are referred to as 'lean NIDDM'. This paper compares the clinical profile of a cohort of 347 lean NIDDM, with a group of 6274 NIDDM of ideal body weight (IBW) and 3252 obese NIDDM attending a diabetes centre at Madras in South India. The lean NIDDM who constituted 3.5% of all NIDDM patients seen at our centre, had more severe diabetes and an increased prevalence of retinopathy (both background and proliferative), nephropathy and neuropathy. Although a larger percentage of the lean NIDDM patients were treated with insulin, 47% of the males and 53% of the females were still on oral hypoglycaemic agents even after a mean duration of diabetes of 9.2 +/- 8.1 years. Studies of GAD antibodies, islet cell antibodies (ICA) and fasting and stimulated C-peptide estimations done in a small subgroup of the lean NIDDM showed that they were distinct from IDDM patients. More studies are needed on metabolic, hormonal and immunological profile of lean NIDDM seen in developing countries like India.

Published
1998

45. Effect of Spironolactone and Amiloride on Thiazolidinedione-Induced Fluid Retention in South Indian Patients with Type 2 Diabetes

Author

Viswanathan, Vijay, primary, Mohan, Viswanathan, additional, Subramani, Poongothai, additional, Parthasarathy, Nandakumar, additional, Subramaniyam, Gayathri, additional, Manoharan, Deepa, additional, Sundaramoorthy, Chandru, additional, Gnudi, Luigi, additional, Karalliedde, Janaka, additional, and Viberti, Giancarlo, additional

Published
2013
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46. Effect of essentiale in diabetic subjects with Non - Alcoholic fatty liver

Author

T Sangeetha, Raj Deepa, Viswanathan Mohan, K Karkuzhali, Subramani Poongothai, Sharadha Gopalakrishnan, G Saravanan, and G Siva Prakash

Subjects
medicine.medical_specialty, business.industry, Endocrinology, Diabetes and Metabolism, Fatty liver, Non alcoholic, Essentiale, medicine.disease, Gastroenterology, Clinical trial, chemistry.chemical_compound, Endocrinology, chemistry, Internal medicine, Diabetes mellitus, Internal Medicine, Medicine, Liver function, Alanine aminotransferase, business, After treatment
Abstract

Nonalcoholic fatty liver (NAFL) has been reported to be common among subjects with diabetes. However, there are not much therapeutic options for NAFL. In this open labeled clinical trial we studied the effect of Essentiale in diabetic subjects with NAFL. Twenty-eight type 2 diabetic patients attending the out-patient division of M.V. Diabetes Specialities Centre, Chennai and satisfying the inclusion criteria were recruited for the study. High resolution B mode ultrasonography was carried out for diagnosis of NAFL. Liver function markers [Alanine aminotransferase (ALT), Aspartate aminotransferase (AST) and Gamma Glutamyl transferase (GGT)] were measured. 22 out of the 28 patients (78.5%) were available for follow up. The mean age of the study subjects was 41±8 years and 50% were males. A significant reduction in all the liver enzymes were observed after Essentiale treatment (baseline vs. six months after treatment: ALT: 54.5± 29.6 IU/L vs. 37.1±18.7 IU/L, p< 0.05, AST: 38.0±18.0 IU/L vs. 27.6±12.4 IU/L, p< 0.05, GGT: 38.7±27.5 IU/L vs. 29.6±13.8 IU/L, p< 0.05). Ultrasound studies revealed that the hepatic echotexture improved after Essentiale treatment in 12/22 (54.5%) of the study subjects, while there was no change in 9/22 (40.9%), and it worsened in only one patient (4.5%). The study results suggest that Essentiale protects and improves liver function in diabetic subjects with NAFL. Prospective, blinded clinical trials are required to confirm these findings.

Published
2005

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