"FISHed" out the diagnosis: A case of DiGeorge syndrome

Our patient presented with congenital heart disease (CHD: Tetralogy of Fallot), hypocalcemia, hypoparathyroidism, and facial dysmorphisms. Suspecting DiGeorge syndrome (DGS), a fluorescence in situ hybridization (FISH) analysis for 22q11.2 deletion was made. The child had a hemizygous deletion in the 22q11.2 region, diagnostic of DGS. Unfortunately, the patient succumbed to the heart disease. DGS is the most common microdeletion syndrome, and probably underrecognized due to the varied manifestations. This case stresses the importance of a detailed physical examination and a high index of suspicion for diagnosing this genetic condition. Timely diagnosis can help manage and monitor these patients better and also offer prenatal diagnosis in the next pregnancy.

DNA damage-induced ephrin-B2 reverse signaling promotes chemoresistance and drives EMT in colorectal carcinoma harboring mutant p53

Mutation in the TP53 gene positively correlates with increased incidence of chemoresistance in different cancers. In this study, we investigated the mechanism of chemoresistance and epithelial-to-mesenchymal transition (EMT) in colorectal cancer involving the gain-of-function (GOF) mutant p53/ephrin-B2 signaling axis. Bioinformatic analysis of the NCI-60 data set and subsequent hub prediction identified EFNB2 as a possible GOF mutant p53 target gene, responsible for chemoresistance. We show that the mutant p53-NF-Y complex transcriptionally upregulates EFNB2 expression in response to DNA damage. Moreover, the acetylated form of mutant p53 protein is recruited on the EFNB2 promoter and positively regulates its expression in conjunction with coactivator p300. In vitro cell line and in vivo nude mice data show that EFNB2 silencing restores chemosensitivity in mutant p53-harboring tumors. In addition, we observed high expression of EFNB2 in patients having neoadjuvant non-responder colorectal carcinoma compared with those having responder version of the disease. In the course of deciphering the drug resistance mechanism, we also show that ephrin-B2 reverse signaling induces ABCG2 expression after drug treatment that involves JNK-c-Jun signaling in mutant p53 cells. Moreover, 5-fluorouracil-induced ephrin-B2 reverse signaling promotes tumorigenesis through the Src-ERK pathway, and drives EMT via the Src-FAK pathway. We thus conclude that targeting ephrin-B2 might enhance the therapeutic potential of DNA-damaging chemotherapeutic agents in mutant p53-bearing human tumors.

A case-control study on insulin resistance, metabolic co-variates & prediction score in non-alcoholic fatty liver disease

BACKGROUND & OBJECTIVE

Asian Indians have a high prevalence of insulin resistance and the metabolic syndrome. Currently, non-alcoholic fatty liver disease (NAFLD) is considered to be an integral part of the metabolic syndrome with insulin resistance as a central pathogenic factor. We studied anthropometric parameters, insulin resistance and metabolic co-variates in subjects with NAFLD as compared to those without NAFLD, and also developed a prediction score for NAFLD.

METHODS

Thirty nine subjects with NAFLD and 82 controls were selected for the study after ultrasonography of 121 consecutive apparently healthy subjects. Anthropometric profile [body mass index (BMI), waist circumference (WC) etc,], lipid profile, hepatic aminotransferases, fasting blood glucose (FBG), insulin were recorded and value of homeostasis model assessment of insulin resistance (HOMA-IR) was analysed. Step-wise logistic regression analysis and area under the receiver operator curve (aROC) were analysed to arrive at a prediction score.

RESULTS

Overall, prevalence of NAFLD was 32.2 per cent and prevalence of metabolic syndrome was seen in 41 per cent among cases and 19.5 per cent in controls (P<0.01). Subjects with NAFLD had significantly higher values of BMI, WC, hip circumference, FBG, fasting insulin, total cholesterol and serum triglycerides. Step-wise logistic regression analysis showed odds ratio (OR) and 95 per cent confidence interval (CI) for BMI [ 4.3 (1.6, 11.3)], FBG [5.5 (1.5, 19.8)] and fasting insulin [ 2.4 (1.0, 5.8)] as independent predictors of NAFLD. The prediction score for NAFLD was; 1 (fasting insulin) +1.6 (BMI) + 1.9 (FBG) (sensitivity of 84.6%, specificity of 51.2% and aROC 76%).

INTERPRETATION & CONCLUSION

In this study, presence of NAFLD indicated close relationship with multiple features of metabolic syndrome. The prediction score developed could be used as a screening tool to predict NAFLD among Asian Indians in north India.

Is there a role for lengthening flexor hallucis and flexor digitorum longus tendons in surgery for club foot?: a preliminary report

Most cases of club foot (congenital talipes equinovarus) respond to non-operative treatment but resistant cases may need surgery. It is broadly accepted that lengthening of tendo Achillis, the tendon of tibialis posterior and capsulotomy of the ankle and subtalar joints are necessary during surgical release, but there is no consensus as to whether lengthening of the tendons of flexor hallucis longus and flexor digitorum longus is required. We randomised 13 children with severe bilateral club foot deformities to undergo lengthening of the flexor hallucis longus and flexor digitorum longus tendons on one side and simple decompression on the other. We found no difference in the deformities of the toes between the lengthened and non-lengthened sides at a mean follow-up of four years (2 to 6). We conclude that routine lengthening of the tendons of flexor hallucis longus and flexor digitorum longus during soft-tissue surgery for resistant club foot is not necessary.

Knowledge, attitude and practice of complementary and alternative medicines for diabetes

OBJECTIVES

To investigate the current status of knowledge, attitude and practice of patients with diabetes relating to complementary and alternative medicine (CAM) in an Indian community, and to determine perceptions about the use of CAM and factors influencing knowledge and usage.

SETTING

Endocrine clinic of Swaroop Rani, Nehru Hospital, Allahabad, India.

STUDY DESIGN

Hospital-based cross-sectional study.

PARTICIPANTS

Patients with diabetes attending the clinic for the first time.

SAMPLE SIZE

A sample of 493 study participants selected by systematic sampling from a population of 6094 patients with diabetes.

STUDY VARIABLES

Age, socio-economic status, educational status, religion, family history of disease, knowledge and practice of CAM, reasons for using CAM, method of use and perceived relief.

STATISTICAL ANALYSIS

Normal test of proportions, chi(2) test, Kolomogorov-Smirnov test.

RESULTS

Awareness of CAM among patients was high (71%). High prevalence of CAM use was found (67.7%) among all participants, and 95% among participants aware of CAM, mostly using 'naturopathy' (97.3% among users). No significant gap (P>0.10) between knowledge and practice in different categories was observed. Desire for quick and additional relief was the most common perceived reason for using CAM (86.8%). Higher levels of education and socio-economic status were significant positive correlates of CAM use. Knowledge of CAM was gained mainly from friends and neighbours. About 30% of users adopted CAM without allopathic treatment earlier. Only 42.2% of users perceived some relief by using CAM. Lowering of blood sugar was the most common perceived relief. CAM, along with diet control and exercise, resulted in maximum degree of satisfaction (61.9%) experienced by users. No relief was experienced by 53.6% of users of 'naturopathy'.

CONCLUSIONS AND SUGGESTIONS

Use of CAM in diabetes is highly prevalent despite high levels of disappointment after its use. In this study, we suggest the need for health education relating to CAM and self-care in diabetes. Use of CAM should be explored with patients before clinical decisions are made.

The burden of diabetes and impaired glucose tolerance in India using the WHO 1999 criteria: prevalence of diabetes in India study (PODIS)

This random multistage cross-sectional population survey was undertaken to determine the prevalence of diabetes mellitus (DM) and impaired glucose tolerance (IGT) in subjects aged 25 years and above in India. The study was carried out in 77 centers (40 urban and 37 rural). 18363 (9008 males and 9355 females) subjects were studied. 10617 (5379 males and 5238 females) were from urban areas and 7746 (3629 males and 4117 females) from rural areas. Blood samples were taken after a fast of 10-12 h and 2 h after 75 g of oral glucose. Subjects were categorized as having IGT or DM using the World Health Organisation (WHO) (1999) criteria. The standardized prevalence rate for DM in the total Indian, urban and rural populations was 4.3, 5.9 and 2.7%, respectively. The corresponding IGT rates in the three populations was 5.2, 6.3 and 3.7%, respectively. The urban prevalence of DM and IGT was significantly greater than in the rural population (P < 0.001 in both instances). The prevalence of DM was significantly, more than that of IGT (P < 0.001) within both the rural and urban populations. Type 2 diabetes is a major health problem is India.

Comparing the ADA 1997 and the WHO 1999 criteria: Prevalence of Diabetes in India Study

This random multistage cross-sectional population survey was undertaken to determine the prevalence of type 2 diabetes mellitus (DM) in subjects aged 25 years and above in India. The study was carried out in 77 centres (42 urban and 35 rural) to reflect the size and heterogeneity of the Indian population. 18,363 (9008 male and 9355 female) subjects were studied. 10,617 (5379 males and 5238 females) were from urban areas and 7746 (3629 males and 4117 females) from rural areas. Blood samples were taken after a fast of 10-12 and 2 h after 75 g of oral glucose. Subjects were categorized as having impaired fasting glycemia (IFG) or DM using the 1997 ADA or having impaired glucose tolerance (IGT) or DM using the 1999 WHO criteria. The age- and gender-standardized prevalence rate for DM using the ADA criteria was 3.6% whilst that using the WHO criteria was 4.3% (P < 0.001). The respective standardized prevalence of DM, using the two criteria was, 4.7 and 5.6%, respectively (P < 0.001) in the urban Indian population and 2.0 and 2.7% (P < 0.02) in the rural Indian population. Using the WHO criteria, 581 subjects were newly diagnosed whilst the ADA criteria newly diagnosed 437 subjects. The respective numbers for the urban population were 425 and 323, and for the rural population were 146 and 114, respectively. The ADA criteria could diagnose 75.2, 76.0 and 73.0% of the subjects who had DM as per the WHO criteria. Of 739 Indian subjects who had IFG, 106 (14.3%) were diagnosed as having DM by the WHO criteria whilst 505 (68.3%) had values compatible with a diagnosis of IGT. Of the 536 urban subjects with IFG, 74 (13.8%) had DM and 350 (65.3%) had IGT using the WHO criteria. Of the 302 rural subjects with IFG, 32 (15.8%) had DM and 155 (76.3%) had IGT using the WHO criteria. 505 (49.9%) of 1012 Indian subjects with IGT as per the WHO criteria had IFG. 350 (47.7%) of 733 urban subjects and 155 (55.5%) of 279 rural subjects with IGT had values compatible with IFG as per the ADA criteria. Type 2 diabetes is a major health problem is India. The use of the ADA criteria would underestimate the prevalence of DM by not diagnosing subjects showing a poor response to a glucose challenge. This along with the discrepancies between subjects showing IGF or IGT could be a challenge to any prevention program.

The burden of diabetes and impaired fasting glucose in India using the ADA 1997 criteria: prevalence of diabetes in India study (PODIS)

This random multistage cross sectional population survey was undertaken to determine the prevalence of diabetes mellitus (DM) and impaired fasting glycemia/glucose (IFG) in subjects aged 25 years and above in India. The study was carried out in 108 centers (49 urban and 59 rural) to reflect the size and heterogeneity of the Indian population. 41,270 (20,534 males and 20,736 females) subjects were studied. 21,516 (10,865 males and 10,651 females) were from urban areas and 19,754 (9669 males and 10,085 females) from rural areas. Blood samples were taken after a fast of 10-12h and the subjects were categorized as having IFG or DM using the 1997 American Diabetes Association criteria. The age and gender standardized prevalence rate for DM and IFG in the total Indian population was 3.3 and 3.6% respectively (P < 0.001). The standardized prevalence of DM and IFG in urban areas was significantly higher than that for the rural population (urban DM prevalence 4.6% versus rural DM prevalence 1.9%, P < 0.001; urban IFG prevalence 4.8% versus rural IFG prevalence 2.5%, P < 0.001). There was no statistically significant difference in the prevalence between DM (4.6%) and IFG (4.8%) in the urban population. The rural prevalence of IFG (2.5%) was significantly (P <0.001) more than the rural prevalence of DM (1.9%). Type 2 diabetes is a major health problem is India.

Systemic lupus erythematosus and gouty arthritis: an uncommon association

OBJECTIVE

To examine the frequency of gouty arthritis in patients with systemic lupus erythematosus (SLE) and elucidate the clinical factors that predispose to this occurrence.

METHODS

A chart review of in-patients (1989-2001) and out-patients (1999-2001) with ICD9 billing codes for gouty arthritis/tophaceous gout and SLE was performed. Twenty-six patients were identified. Patients meeting American College of Rheumatism criteria for SLE and crystal-proven gout or a self-limited inflammatory arthritis felt to be crystal-induced (i.e. definite gout) were included.

RESULTS

Ten patients were identified. Their mean age was 46.5 yr; 80% were African-American and 70% were women. Nine of the ten had lupus nephritis and four had undergone renal transplantation. An acute worsening of renal function unrelated to lupus activity preceded almost all gout flares. Lupus activity at the time of the first gout attack as measured by the Systemic Lupus Activity Measure (SLAM) was low. Eight patients were on prednisone (mean dose 8 mg/day) for their SLE at the time the attack of gout occurred.

CONCLUSIONS

Gouty arthritis is uncommon in SLE; it occurs primarily in patients with long-standing SLE and nephritis. Worsening renal function usually preceded gout attacks, but SLE disease activity was minimal. Crystal-induced arthritis should be included in the differential diagnosis of a lupus patient presenting with acute inflammatory arthritis because the long-term treatment of the two conditions differs substantially.

Augmentation of non-specific immunity in mice by gold preparations used in traditional systems of medicine

BACKGROUND & OBJECTIVES

Gold preparations are highly valued in Indian systems of medicine and extensively used for tonic and rejuvenating properties. This study was aimed to evaluate the effects of Ayurvedic gold preparation Swarna Bhasma (SB) and Unani preparation Kushta Tila Kalan (KTK) on non-specific immunity in mice. A gold-containing drug auranofin (AN) used in modern medicine was studied for comparison.

METHODS

Male mice were administered with the incremental doses of these drugs orally for 10 days. Parameters of study included body weight, organ weight, peritoneal exudate cell (PEC) counts and phagocytic activity of PEC.

RESULTS

Both test drugs (KTK and SB) significantly (P < 0.001) increased counts of peritoneal macrophages and stimulated phagocytic index of macrophages. AN elicited a suppressive action on these parameters.

INTERPRETATION & CONCLUSION

Traditional preparations of gold exhibited immunostimulant activity on macrophage functions in contrast to immunosuppressive effects of AN. This is an interesting observation and gives a rational basis to the claims of efficacy and safety of gold when used in calcined forms.

Polyamines as biomarkers for plant regeneration capacity: improvement of regeneration by modulation of polyamine metabolism in different genotypes of indica rice

The importance of cellular polyamine (PA) levels and the ratio of putrescine (Put) to spermidine (Spd) for plant regeneration ability via somatic embryogenesis in several commercially grown indica rice varieties is reported here. The genotypes namely NDR-624, IR-20, IR-36, BJ-1 (having Put:Spd ratio approximately 2.3) showed superior plant regeneration while KL, PB-1 and TN-1 (having Put:Spd ratio approximately 3.8) showed moderate plant regeneration ability. The genotypes namely HS, Bindli, DV-85, ACB-72, IR-64 and IR-72 (having Put:Spd ratio approximately 5.0) showed poor plant regeneration ability. In contrast KH-7 (Put:Spd ratio approximately 10.0) showed no response at all. Favorable modification of cellular PA titers and their Put:Spd ratio by the addition of exogenous PAs (Put, Spd) or their biosynthesis inhibitor, difluoromethylarginine (DFMA) led to the induction/promotion of plant regeneration in poorly responding genotypes. These results showed a close relationship between cellular PA levels and their Put:Spd ratio with in vitro morphogenetic capacity in indica rice and suggest that the cellular PAs and Put:Spd ratios are important determinants (biomarkers) of plant regeneration ability in indica rice, and the improvement/induction of plant regeneration in morphogenetically poor and recalcitrant species could be achieved by modulating PA metabolism.

Serial renal biopsy in systemic lupus erythematosus

OBJECTIVE

To examine the role of sequential renal biopsies in patients with systemic lupus erythematosus (SLE), with regard to indications, morphologic change over time, and the clinical utility of repeat biopsies.

METHODS

Patients with repeat renal biopsies were identified from the University of Toronto Lupus Clinic Database and their biopsies were reviewed blindly by a committee, using the WHO classification as well as activity and chronicity indices. Reasons for obtaining biopsy were documented, and therapeutic decisions following repeat biopsy were tabulated.

RESULTS

Fifty-seven patients (49 F/9 M) had at least 2 renal biopsies between 1970 and 1994. The mean interval between biopsies was 4.2 years. The major reason for obtaining the first biopsy was disease diagnosis (32/57), while the majority of repeat biopsies were performed to discern the cause of increasing proteinuria (45/57). A comparison of the WHO classification of initial and repeat biopsies showed evolution to another class in 23 instances, but more commonly a change within a class was seen. A decrease in proliferative lesions (classes III and IV and subsets of V) was noted on repeat biopsies. The chronicity index increased significantly (p = 0.0001) and the activity index decreased (p = 0.064) between biopsies. Seventy-seven percent of patients had a change in treatment based on biopsy results.

CONCLUSION

The major reason for repeat renal biopsy in patients with SLE was proteinuria. Renal morphology in patients with SLE can change with time, particularly in terms of chronicity and activity features. Repeat biopsies in patients with SLE appear to have clinical utility.

Influence of education and occupation on knowledge about diabetes control

BACKGROUND

A global epidemic of diabetes has been predicted during the first quarter of the twenty-first century, with a substantial increase in its prevalence in India. Good management of diabetes is a necessary step towards its control and blood glucose testing forms an integral part of this. This study was undertaken to assess the importance of education and occupation in relation to knowledge about good control of diabetes.

METHODS

Perception patterns regarding methods for testing blood glucose and metabolic control were assessed by the direct interview method in 793 patients with type 2 diabetes. Patients' knowledge levels were compared for different educational and occupational categories using the Normal test (z-test) and the Student's t-test.

RESULTS

The difference between the mean ages of men and women diabetics was not significant (p > 0.1). It was found that 46.7% of the subjects were aware of the importance of blood glucose testing. Awareness regarding the importance of microalbuminuria, lipid profile and glycosylated haemoglobin was observed in 24.1%, 15.5% and 7.6% of patients, respectively. A positive impact of education on overall knowledge levels was observed. However, no definite relationship was found between knowledge and occupation.

CONCLUSION

There was a total lack of knowledge regarding self-care of diabetes in all educational and occupational categories (including patients who were qualified doctors). This calls for an urgent need to create greater public awareness. This study may serve as a guideline for developing an educational package for different subsections of the community.

Disseminated tuberculosis causing bilateral adrenal enlargement and Addison's disease

The clinical features and computed tomography imaging of a patient with acute adrenal failure following disseminated tuberculosis is described.