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Biomedical subjects

R Guleria

Publications and source records attributed to R Guleria.

At least 19 recordsLinked to original sources
PubMed2006

Retinoic acid receptors and tissue-transglutaminase mediate short-term effect of retinoic acid on migration and invasion of neuroblastoma SH-SY5Y cells.

Long-term treatment with all trans-retinoic acid (RA) induces neuronal differentiation and apoptosis. However, the effect of short-term RA treatment on cell proliferation, migration and invasion of neuroblastoma cell lines (SH-SY5Y and IMR-32) remains unclear. RA induces expression of tissue-transglutaminase (TGase) and promotes migration and invasion after 24 h of treatment in SH-SY5Y cells, but not in IMR-32 cells. RA receptor (RAR) agonist (4-(E-2-[5,6,7,8-tetrahydro-5,5,8,8-tetramethyl-2-naphthalenyl]-1-propenyl) benzoic acid) and RAR/retinoid X receptor (RXR) agonist (9-cis-RA) promote expression of TGase, migration and invasion of SH-SY5Y cells, while RXR agonist has no significant effect. RAR antagonist blocks RA effect on migration and invasion, indicating that RAR receptors are required. Retinoid receptors are expressed and activated by RA in both cell lines. However, only transient activation of RAR is observed in IMR-32 cells. These findings suggest that different responses observed in SH-SY5Y and IMR-32 cells could be due to differential activation of retinoid receptors. Overexpression of TGase has no effect on migration or invasion, while overexpression of antisense TGase blocks RA-induced migration and invasion, indicating that other molecules along with TGase mediate RA effects. In addition to the long-term effects of RA that are coupled with cell differentiation, short-term effects involve migration and invasion of neuroblastoma SH-SY5Y cells.

Alitretinoin↗
PubMed2006

Quality of life in newly diagnosed patients with lung cancer in a developing country: is it important?

There are no data regarding quality of life (QoL) assessments in lung cancer in developing countries like India. Quality of life was evaluated in 76 newly diagnosed lung cancer patients by using the World Health Organization Quality of Life questionnaire in Hindi (WHOQoL-Bref) (men 87%). The mean age was 55 years (SD = 10). Cough, dyspnoea, chest pain and haemoptysis were present in 83%, 72%, 66% and 43% of patients respectively. The median duration of symptoms was 5.9 months (range 1-13). Eighty-nine per cent had non-small cell lung cancer. The median pack-years smoked was 23 (range 0.5-88). Most patients (53%) had a Karnofsky's Performance Status (KPS) of 70 and 83% had stage III or IV disease. Quality of life did not correlate with age, gender, presence or duration of symptoms, histological type, stage of disease or degree of smoking. The physical and psychological domains of QoL correlated significantly with the KPS (P = 0.001 and P = 0.01 respectively). Patients with a KPS of 80 had better physical (P < 0.001), psychological (P < 0.01) and social (P < 0.05) QoL than those with a KPS of 70. In conclusion, patients with lung cancer in a developing country like India have an unsatisfactory QoL. The Karnofsky's Performance Scale is a simple and reliable surrogate marker for assessing QoL in these patients. Larger multi-centric studies may help in providing a more comprehensive evaluation of the effect of various demographic and clinical variables on QoL in this setting.

Carcinoma, Non-Small-Cell Lung↗
PubMed2005

The effect of renal transplantation on pulmonary function and respiratory muscle strength in patients with end-stage renal disease.

Pulmonary function and respiratory muscle strength was assessed in 29 hemodialysis patients who underwent successful renal transplantation. These tests were performed 7 days prior to transplantation, 30 days following transplantation, and 90 days posttransplantation. Patients with end-stage renal disease showed dyspnea, a restrictive defect in pulmonary function, respiratory muscle weakness, and hypoxia. Following transplantation the dyspnea improved and mechanical indices of respiratory muscle function and lung volume improved. In conclusion transplantation resulted in a significant improvement in lung and respiratory muscle function.

Blood Gas Analysis↗
PubMed2004

High prevalence of insulin resistance in postpubertal Asian Indian children is associated with adverse truncal body fat patterning, abdominal adiposity and excess body fat.

OBJECTIVE: The objectives were to study the relationships of insulin resistance with generalized and abdominal obesity, and body fat patterning in urban postpubertal Asian Indian children. DESIGN: Cross-sectional, population-based epidemiological study. SUBJECTS: In all, 250 (155 males and 95 females) healthy urban postpubertal children. MEASUREMENTS: Anthropometric profile, percentage of body fat (%BF), fasting serum insulin, and lipoprotein profile. RESULTS: Fasting insulin correlated significantly with body mass index (BMI), %BF, waist circumference (WC), central and peripheral skinfold thicknesses and sum of four skinfold thicknesses (Sigma 4SF) in both sexes, and with systolic blood pressure and waist-to hip circumference ratio (W-HR) in males only. Consistent increase in fasting insulin was noted with increasing values of central skinfold thickness at each tertile of peripheral skinfold thickness, WC, and %BF. Central skinfold thickness correlated with fasting insulin even after adjusting for WC, W-HR, and %BF. The odds ratios (OR) (95% CI) of hyperinsulinemia (fasting insulin concentrations in the highest quartile) were 4.7 (2.4-9.4) in overweight subjects, 8 (4.1-15.5) with high %BF, 6.4 (3.2-12.9) with high WC, 3.7 (1.9-7.3) with high W-HR, 6.8 (3.3-13.9) with high triceps skinfold thickness, 8 (4.1-15.7) with high subscapular skinfold thickness, and 10.1 (5-20.5) with high Sigma 4SF. In step-wise multiple logistic regression analysis, %BF [OR (95% CI): 3.2 (1.4-7.8)] and Sigma 4SF [OR (95% CI): 4.5 (1.8-11.3)] were independent predictors of hyperinsulinemia, similar to insulin resistance assessed by HOMA (homeostatic model of assessment) in the study. CONCLUSION: A high prevalence of insulin resistance in postpubertal urban Asian Indian children was associated with excess body fat, abdominal adiposity, and excess truncal subcutaneous fat. Primary prevention strategies for coronary heart disease and diabetes mellitus in Asian Indians should focus on the abnormal body composition profile in childhood.

Abdomen↗
PubMed2004

Pulmonary functions in patients with type 2 diabetes mellitus & correlation with anthropometry & microvascular complications.

BACKGROUND & OBJECTIVES: The purpose of this study was to evaluate pulmonary functions including respiratory muscle strength in patients with type 2 diabetes mellitus (T2DM) and to determine their correlations with anthropometric profile, glycaemic control, and microangiopathic diabetic complications. METHODS: Twenty nine patients with T2DM and 11 healthy control subjects were divided into the following three groups; (i) T2DM patients with any or a combination of microangiopathy(ies) (retinopathy, nephropathy, and peripheral neuropathy) (group 1, n=12); (ii) T2DM patients without any complications (group 2, n = 17); and (iii) a healthy control group (group 3, n=11). All patients were assessed with anthropometry, glycosylated haemoglobin (HbA1C), and lipid profile. Pulmonary functions were measured by spirometry. Pulmonary diffusion capacity for carbon monoxide (DLco) was measured by the steady state method. The presence of diabetic nephropathy was determined by 24 h protein excretion. RESULTS: A significant reduction of DLco was observed in group 1 (P<0.001), as compared to the other groups. There were no differences among the three groups for other pulmonary functions; forced vital capacity, forced expired volume in one second, peak expiratory flow rate, and maximal static inspiratory and expiratory pressures. Significant correlations were observed between DLco and the following parameters in group 1; HbA1c (r=0.62, P<0.05), total cholesterol level (r = -0.44, P<0.05) and creatinine clearance (r=0.42, P<0.05). INTERPRETATION & CONCLUSION: The present study shows that the impairment of pulmonary diffusion capacity for carbon monoxide was common in T2DM Asian Indian patients having microangiopathy. Pathophysiologically, it could be related to glycaemic control or dyslipidaemia. Correlation of % BF with DLCo needs to be explored further.

Adult↗
PubMed2004

Bronchoscopy in adults at a tertiary care centre: indications and complications.

Fibreoptic bronchoscopy (FOB) helps in visualisation of the endobronchial tree. Fibreoptic bronchoscopies were done in 429 cases between January 1999 and January 2000 [322 men (75.1%) and 107 women (24.9%)]. Patients were between 12 and 89 years of age (mean+/- SD = 49 +/- 15.1 years). Of which, 196 (45.7%) had lung cancer and 233 (54.4%) had non-malignant disease [Tuberculosis (TB) 26, miliary TB 16, non-resolving pneumonia 29, atypical pneumonia 10, bronchiectasis 11, aspergillosis 12, sarcoidosis 17, interstitial lung disease (ILD) 20, haemoptysis with normal chest x-ray 13 and miscellaneous 79]. In this series of 429 patients a significant number of patients (n = 127) presented with fever (38 malignant and 89 non-malignant disease, p < 0.0001), 137 had haemoptysis (74 malignant and 63 non-malignant disease, p < 0.01), 89 had chest pain (61 malignant and 28 non-malignant disease, p < 0.0001) and 29 patients presented with complaint of anorexia (21 malignant and 8 non-malignant disease, p < 0.003). High prevalence of lung lesions in the right upper lobe [10.4% (43 of 411)] and left main bronchus [12% (49 of 411)] was observed. Left upper lobe showed 8.7% (36 patients) lesions and right middle lobe showed 5.5% (23 patients) lesions. In 143 (34.8%) patients, FOB findings were normal. Out of 407 patients, FOB was suggestive of necrotic/nodular growth in 159 patients (39.1%), infiltrative growth in 8 patients (1.9%), and extrinsic compression was found in 39 patients (9.6%). In 143 patients (35.2%) no endobronchial growth was seen. Bronchial biopsy (BB) was performed in 162 (37.8%) patients, transbronchial lung biopsy in 56 patients (13.1%), bronchial washing for cytology in 350 patients (81.5%), bronchial washing for AFB in 302 patients (70.3%), bronchial washing for culture in 67 patients (15.6%), bronchial washing for fungus in 64 patients (14.9%) and Pneumocystis carinii infection was looked for in 6 patients (1.4%). Postbronchoscopy complications were recorded as follows: Early termination of FOB due to decreased O2 saturation in 10 cases (2.4%), postbiopsy bleeding in 5 cases (1.2%), post FOB fever in 5 cases (1.2%), chest pain in 7 patients (1.7%) and pneumothorax occurred in 2 patients (0.5%). FOB performed in outpatient setting is a useful and safe modality. Most patients in whom FOB was done in the present setup had suspected lung cancer. No major complications were encountered.

Adolescent↗
PubMed2004

Laser bronchoscopy--current status.

The majority of patients with lung cancer have advanced disease with severe endobronchial symptoms such as cough, dyspnea, and hemoptysis for which palliation is required. Laser resection of endobronchial lesions located in the trachea, mainstem or proximal lower lobe bronchi provides significant and rapid improvement in the patient's symptoms. Neodymium:yttrium-aluminium-garnet (Nd:YAG) laser is gaining popularity due to efficient photocoagulation, good penetration and excellent hemostasis. Complications are rare and can be minimized by following standardized techniques and safety guidelines. Laser resection is equally effective with the rigid and flexible bronchoscope. The future may see combinations of laser with other palliative modalities to improve the chances of a symptom-free life for lung cancer patients.

Bronchoscopes↗
PubMed2003

Feasibility and safety of day care laparoscopic cholecystectomy in a developing country.

BACKGROUND: Although day care laparoscopic cholecystectomy (DCLC) has been shown to be safe in centres with adequate infrastructure for day care surgery, its feasibility and safety in developing countries has never been studied. Because of differences in the quality of health care delivery, western guidelines for day care surgery cannot be universally applied to developing countries. PATIENTS AND METHODS: Patients less than 65 years who were graded I and II on the American Society of Anesthesiologists physical status score, irrespective of their educational status, living within 20 km, and willing to make their own arrangements for a return to hospital in case of problems were selected for DCLC. Follow up was done by patients calling the hospital the morning after surgery. RESULTS: 50% of the eligibility criteria were new; 313/383 patients were suitable for DCLC. The commonest cause for rejection was that the patient lived out of the defined area (50%). Altogether 92% were discharged within eight hours of surgery. The reasons for failure to discharge were the presence of abdominal drains in four (2%), nausea and vomiting in nine (3%), and conversion to open surgery in five (2%). Ten patients (3%) were readmitted; of these only two (<1%) had complications needing re-exploration. Analysis of results showed that the inclusion and discharge criteria were valid and that the readmission and complication rates as well as the ease and accuracy of follow up were comparable to published data. DCLC reduced waiting times and increased patient turnover and may have a positive impact on resident training. CONCLUSIONS: DCLC is safe, feasible, and has potential benefits for health care delivery in developing countries. Each surgical service needs to develop their own guidelines based on local patient demography.

Adolescent↗
PubMed2003

Effect of inhalation of salbutamol, beclomethasone dipropionate & ipratropium bromide on mucociliary clearance in some patients with chronic stable bronchial asthma.

BACKGROUND & OBJECTIVES: Asthma is now regarded as an inflammatory disease and bronchial inflammation may disrupt mucociliary function. Inhaled drugs may act by improving mucociliary function. The aim of the study was to investigate the effect of salbutamol, ipratropium bromide and beclomethasone on mucociliary clearance in patients with chronic stable asthma and to compare the efficacy of these drugs on mucociliary clearance. METHODS: Ten patients with chronic stable asthma were enrolled in the study, but two patients did not complete the study. Patients with bronchial asthma were chosen on clinical grounds. (99m)Tc phytate radioaerosol generated through a nebulizer, was given to each patient on four days. After each administration the radioactivity over the thorax was constantly measured in sequential frame mode for 120 min. Radioactivity in the thorax was also measured after 24 h. A base-line pulmonary function test with reversibility was obtained. Salbutamol, ipratropium bromide, beclomethasone dipropionate and placebo inhalation were given randomly to each patient on four days. RESULTS: The mean age of patients (n = 8) was 36 +/- 9.3 yr and mean duration of symptoms was 5 +/- 6.6 yr. There was no visual impression that mucociliary clearance was enhanced with any of the drugs. The time activity curves did not show any visually recognisable change in slope. In only one patient the curve tended to show a steeper slope with ipratropium inhalation. In the rest of the patients the curves showed no difference at all with medication when compared with placebo. All the quantitative indices analyzed by two-way ANOVA at the end of one and two hours were comparable for the three test drugs and placebo. None of the three test drugs demonstrated statistically significant mucociliary clearance effect compared with placebo. However, the temporal difference in airways clearance efficiency (ACE) was significant with beclomethasone and ipratropium bromide. INTERPRETATION & CONCLUSION: Inhalation of any of the three drugs tested did not produce any immediate improvement in mucociliary clearance as compared to placebo in patients with stable bronchial asthma suggesting the need for further studies using higher doses of drugs for longer duration in a large sample.

Administration, Inhalation↗
PubMed2003

Receiver operating characteristics curve analysis of body fat & body mass index in dyslipidaemic Asian Indians.

BACKGROUND & OBJECTIVES: Optimal limit of body mass index (BMI) for Asian Indians remains to be defined. In this study, we describe the anthropometric and lipid profiles and determine the appropriate cut-offs of BMI for defining obesity in dyslipidaemic patients. METHODS: Correlations were carried out between lipid profile and anthropometric variables in 217 dyslipidaemic Asian Indians and the data were compared to those of 123 healthy historical controls. Receiver operating characteristics (ROC) curve analysis was carried out to determine the appropriate cut-offs of BMI for defining obesity taking the percentage of body fat (% BF) as the standard. RESULTS: Dyslipidaemic patients had high waist-hip ratio (W-HR) and percentage of BF. The prevalence of obesity as measured by percentage of BF was significantly (P < 0.05) higher as compared to obesity defined by the BMI cut-off. W-HR was the most important independent predictor (odds ratio: 2.8; 95% CI: 1.02-7.83) of atherogenic dyslipidaemia on multivariate logistic regression analysis. On ROC curve analysis the suggested appropriate cut-offs of BMI were; males 24.0 kg/m2 (sensitivity, 74.7%, and specificity, 79.7%), and females 23.0 kg/m2 (sensitivity, 85.7% and specificity, 62.5%). According to the suggested lower limits of BMI, an additional 15 per cent dyslipidaemic patients will be diagnosed as obese. INTERPRETATION & CONCLUSION: The observations in dyslipidaemic Asian Indians suggest high prevalence rates of generalized and abdominal obesity, and that high values of W-HR alone predisposes to atherogenic dyslipidaemia. Further, obesity may be optimally defined by a lower cut-off of BMI. The revised criteria for the BMI-based diagnosis of obesity will lead to a more rational management of dyslipidaemia in Asian Indians.

Adolescent↗
PubMed2003

Evaluation of quantitative buffy coat (QBC) assay and polymerase chain reaction (PCR) for diagnosis of malaria.

A prospective study was undertaken to compare the Polymerase Chain Reaction (PCR) and Quantitative Buffy Coat (QBC) assay with conventional Giemsa technique for diagnosis of malaria. A total of 104 samples were taken for the purpose. They comprised of fever cases suggestive of malaria (n=74) and control group, fever cases other than malaria (n=30). Peripheral blood smears were prepared by Giemsa staining and QBC assay was performed as per standard protocol. From the stored blood samples, parasite DNA was extracted and PCR was performed using P. falciparum and P. vivax specific sets of primers. The QBC assay was 100% in agreement with the Giemsa stain. Specificity of the PCR detection of P. falciparum parasites was 100%. However, sensitivity for detection of P. falciparum and P. vivax by PCR was 64.28% and 82.35% respectively. In mixed cases of malaria (n=2), PCR results were in 100% agreement with that of Giemsa. The lower sensitivity of PCR for P. falciparum could probably be due to inaccessibility of target DNA, presence of PCR inhibitors in samples and parasite strain variations.

Animals↗
PubMed2002

Central fatigue of the diaphragm and quadriceps during incremental loading.

Anecdotal observations suggest that low frequency fatigue, as judged by a fall in twitch tension, is more difficult to achieve in the diaphragm than nonrespiratory muscle but this hypothesis has not previously been directly tested. We studied 7 subjects by performing incremental repetitive contraction loading protocols of the diaphragm and quadriceps. We measured twitch transdiaphragmatic pressure (Tw Pdi) and twitch quadriceps tension (Tw Q) during both muscle contraction and relaxation phases during the run. Unpotentiated and potentiated Tw Pdi and Tw Q were measured before and at 20, 40, and 60 minutes after the run. During the run, greater activation of the quadriceps was achieved; for example, at 70% of maximal voluntary effort the interpolated Tw Q was 12.5% of the relaxation phase Tw Q (implying activation of 87.5%) compared with 29.4% (i.e., 70.6% activation) for the diaphragm (p = 0.05). A significantly greater fall in Tw Q than Tw Pdi was observed (unpotentiated Tw Pdi at 20 minutes 94% baseline versus Tw Q 59% baseline, p = 0.007). Low frequency fatigue in humans is more difficult to generate in the diaphragm than in the quadriceps muscle due in part to reduced central activation.

Adult↗
PubMed2001

A comparative study of telomerase activity in sputum, bronchial washing and biopsy specimens of lung cancer.

The potential of telomerase, the ribonucleoprotein enzyme, as a non-invasive screening marker was studied in pre-bronchoscopy sputum (S), bronchial washings (W) and bronchoscopic biopsy (B) samples from individuals under evaluation for lung cancer. Out of the 52 cases studied, 42 were clinically suspected primary lung cancer patients and 10 had pulmonary disorders but had no clinical evidence of lung cancer. Fifteen (39.5%) S samples, 24 (63.1%) W samples and 32 (84.2%) B samples, which were cytologically/histopathologically positive were also positive for telomerase activity. Interestingly, 16 (42%) S samples, 20 (52.6%) W samples and 20 (52.6%) B samples, initially reported cytologically/histopathologically negative, showed detectable telomerase activity. Lung cancer was finally confirmed in these cases by repeat cytology/histopathology. However, telomerase activity was detected in 31 (81.6%) S, 26 (68.4%) W and 33 (86.8%) B samples of suspected lung cancer patients. Telomerase activity was negative in S, W, and B of four of the suspected cases, which ultimately turned out to be negative for lung cancer. Cytopathology/histopathology alone (including repeat attempts) identified 15 (39.5%) cases of sputum, 24 (63.1%) cases of bronchial washings and 32 (84.2%) bronchoscopic biopsy samples. Out of 10 controls, low telomerase activity was detected in only one (10%) of the bronchial washings, which later turned out to be due to large number of inflammatory cells. Telomerase activity assay of sputum carried sensitivity, specificity and diagnostic accuracy of 81.6, 100 and 86.5%, respectively, while that for bronchial washing was 68.4, 100 and 76.9%, respectively, and for bronchoscopic biopsy samples was 86.8, 100 and 88.1%, respectively. A positive correlation (P<0.01) was seen between age and telomerase activity in sputum, bronchial washing and biopsy samples but no significant correlation was seen between sex and telomerase activity or duration of smoking and telomerase activity. A significant positive correlation was observed between staging and telomerase activity in sputum (P<0.01), bronchial washing (P<0.01) and biopsy samples (P<0.01). Our findings indicate that telomerase is a specific marker for malignant lung disease and can complement cytology/histopathology in the diagnosis of lung cancer. Sputum telomerase assay holds the potential for early and non-invasive diagnosis of lung cancer.

Adult↗
PubMed2000

Comparative yield of different respiratory samples for diagnosis of Pneumocystis carinii infections in HIV-seropositive and seronegative individuals in India.

Respiratory specimens were prospectively examined for Pneumocystis carinii from 53 patients. The majority of specimens were comprised of expectorated sputum, induced sputum, broncho-alveolar lavage (BAL), and tracheal aspirates. In only four patients Pneumocystis carinii (P. carinii) was detected. All the samples were produced by broncho-alveolar lavage. Candida spp and Aspergillus spp were also identified in a small number of patients. Acid-fast-bacilli were not detected in any of the cases under study. There were no sex-related differences in distribution. The present prospective study was undertaken in order to determine P. carinii infections in human immunodeficiency virus (HIV) seropositive and seronegative individuals. Expectorated sputum samples were probably the major limiting factor in low positivity for detection of P. carinii and study of BAL specimens would be more useful for better results.

AIDS-Related Opportunistic Infections↗
PubMed1999

Haemoptysis in patients with a normal chest radiograph: bronchoscopy-CT correlation.

The exact role of fibre-optic bronchoscopy (FOB) and CT of the chest in the diagnosis of patients presenting with haemoptysis and a normal or non-localizing chest radiograph has not been clearly defined. A study was designed to evaluate 50 patients presenting with haemoptysis and a normal or non-localizing chest radiograph using FOB and high-resolution computed tomography (HRCT). A definitive diagnosis was established in 17 (34%) patients. The aetiologies included bronchiectasis (24%), bronchial adenoma (6%), tuberculosis (2%) and bronchitis (2%). The diagnosis was made by HRCT in 15 (30%) patients, while FOB was diagnostic in five (10%) patients. The diagnosis was made by HRCT and FOB in all patients with focal airway abnormalities. Therefore, HRCT effectively delineated abnormalities of both the central and peripheral airways. It is concluded that CT should be obtained prior to FOB in all patients presenting with haemoptysis and a normal or non-localizing chest radiograph.

Adenoma↗
PubMed1999

Portal systemic shunting of insulin does not lead to insulin resistance in patients with extrahepatic portal vein obstruction.

There is no clear relation between portal systemic shunting, reduced hepatic insulin extraction leading to an increased systemic delivery of insulin, and, resultant peripheral hyperinsulinemia and insulin resistance. Extrahepatic portal vein obstruction is a natural human model of portal systemic shunting with essentially normal liver function. To investigate the role of portal systemic shunting of insulin in creating systemic hyperinsulinemia and insulin resistance, we studied nine subjects with portal systemic shunting and nine controls matched for age (+/- 2 years), body weight (+/- 2 kg) and height (+/- 5 cm). We carried out an oral glucose tolerance test and hyperinsulinemic euglycemic clamp study at insulin infusion rate of 40 mU/m2/ min. Comparable (p = 0.61) basal insulin concentrations in the two groups (Mean (SE): 21.0 (3.98) vs. 24.1 (4.28) mU/L) demonstrated a lack of hyperinsulinemia in the presence of portal systemic shunting. The lower (p = 0.03) insulin area under curve on oral glucose tolerance test in presence of portal systemic shunting (7.40 (0.95) vs. 10.83 (1.15) U/L-min) indicated that lower extraction of insulin by the liver leads to a lower requirements in the periphery. The coefficient of variation for plasma glucose between 60 and 120 min of the clamps was 4.44 (0.55)%. Comparable (p = 0.82) M-values (6.21 (0.67) vs. 6.38 (0.45) mg/kg/min) in the two groups proved a lack of significant insulin resistance in the presence of portal systemic shunting. We conclude that isolated portal systemic shunting leads to neither hyperinsulinemia nor insulin resistance.

Adult↗