Diffusion-weighted imaging of the orbit

Orbital lesions compose a heterogeneous group of pathologies that often present with non-specific imaging findings on conventional magnetic resonance imaging (MRI) sequences (T1-and T2-weighted). Accordingly, the application of diffusion MRI offers an opportunity to further distinguish between lesions along this spectrum. Diffusion-weighted imaging (DWI) represents the simplest and most frequent clinically utilised diffusion imaging technique. Recent advances in DWI techniques have extended its application to the evaluation of a wider spectrum of neurological pathology, including orbital lesions. This review details the manifestations of select orbital pathology on DWI and underscores specific situations where diffusion imaging allows for increased diagnostic sensitivity compared to more conventional MRI techniques. These examples also describe preferred management for orbital lesions identified by DWI.

Tissue proteome analysis for profiling proteins associated with lymph node metastasis in gallbladder cancer

Lymph node (LN) metastasis is the earliest sign of metastatic spread and an established predictor of poor outcome in gallbladder cancer (GBC). Patients with LN positive GBC have a significantly worse survival (median survival- 7 months) than patients with LN negative disease (median survival- ~ 23 months) in spite of standard treatment which includes extended surgery followed by chemotherapy, radiotherapy and targeted therapy. This study aims at understanding the underlying molecular processes associated with LN metastasis in GBC. Here, we used iTRAQ-based quantitative proteomic analysis using tissue cohort comprising of primary tumor of LN negative GBC (n = 3), LN positive GBC (n = 4) and non-tumor controls (Gallstone disease, n = 4), to identify proteins associated with LN metastasis. A total of 58 differentially expressed proteins (DEPs) were found to be specifically associated with LN positive GBC based on the criteria of p value ≤ 0.05, fold change ≥ 2 and unique peptides ≥ 2. These include the cytoskeleton and associated proteins such as keratin, type II cytoskeletal 7 (KRT7), keratin type I cytoskeletal 19 (KRT19), vimentin (VIM), sorcin (SRI) and nuclear proteins such as nucleophosmin Isoform 1 (NPM1), heterogeneous nuclear ribonucleoproteins A2/B1 isoform X1 (HNRNPA2B1). Some of them are reported to be involved in promoting cell invasion and metastasis. Bioinformatic analysis of the deregulated proteins in LN positive GBC using STRING database identified 'neutrophil degranulation' and 'HIF1 activation' to be among the top deregulated pathways. Western blot and IHC analysis showed a significant overexpression of KRT7 and SRI in LN positive GBC in comparison to LN negative GBC. KRT7, SRI and other proteins may be further explored for their diagnostics and therapeutic applications in LN positive GBC.

Newly Recognized CNS Tumors in the 2021 World Health Organization Classification: Imaging Overview with Histopathologic and Genetic Correlation

In 2021, the World Health Organization released an updated classification of CNS tumors. This update reflects the growing understanding of the importance of genetic alterations related to tumor pathogenesis, prognosis, and potential targeted treatments and introduces 22 newly recognized tumor types. Herein, we review these 22 newly recognized entities and emphasize their imaging appearance with correlation to histologic and genetic features.

Quantitative tissue proteome profile reveals neutrophil degranulation and remodeling of extracellular matrix proteins in early stage gallbladder cancer

Gallbladder cancer (GBC) is an aggressive malignancy of the gastrointestinal tract with a poor prognosis. It is important to understand the molecular processes associated with the pathogenesis of early stage GBC and identify proteins useful for diagnostic and therapeutic strategies. Here, we have carried out an iTRAQ-based quantitative proteomic analysis of tumor tissues from early stage GBC cases (stage I, n=7 and stage II, n=5) and non-tumor controls (n=6) from gallstone disease (GSD). We identified 357 differentially expressed proteins (DEPs) based on ≥ 2 unique peptides and ≥ 2 fold change with p value < 0.05. Pathway analysis using the STRING database showed, 'neutrophil degranulation' to be the major upregulated pathway that includes proteins such as MPO, PRTN3, S100A8, MMP9, DEFA1, AZU, and 'ECM organization' to be the major downregulated pathway that includes proteins such as COL14A1, COL1A2, COL6A1, COL6A2, COL6A3, BGN, DCN. Western blot and/or IHC analysis confirmed the elevated expression of MPO, PRTN3 and S100A8 in early stage of the disease. Based on the above results, we hypothesize that there is an increased neutrophil infiltration in tumor tissue and neutrophil degranulation leading to degradation of extracellular matrix (ECM) proteins promoting cancer cell invasion in the early stage GBC. Some of the proteins (MPO, MMP9, DEFA1) associated with 'neutrophil degranulation' showed the presence of 'signal sequence' suggesting their potential as circulatory markers for early detection of GBC. Overall, the study presents a protein dataset associated with early stage GBC.

Proteomic profiling of cell line-derived extracellular vesicles to identify candidate circulatory markers for detection of gallbladder cancer

Gallbladder cancer (GBC) is the sixth most common gastrointestinal tract cancer with a very low overall survival and poor prognosis. Profiling of cancer-derived extracellular vesicles (EVs) is an emerging strategy for identification of candidate biomarkers for the detection and prognosis of the disease. The aim of the study was to analyse the protein content from GBC cell line- derived EVs with emphasis on proteins which could be used as candidate biomarkers for the detection of GBC. NOZ and OCUG-1 cell lines were cultured and EVs were isolated from conditioned media. LC-MS/MS analysis of total EV proteins led to the identification of a total of 268 proteins in both the cell lines. Of these, 110 proteins were identified with ≥2 unique peptides with ≥2 PSMs in at least two experimental and technical replicate runs. STRING (Search Tool for the Retrieval of Interacting Genes/Proteins) database was used to perform bioinformatics analysis of 110 proteins which showed 'cell adhesion molecule binding', 'integrin binding', 'cadherin binding' among the top molecular functions and 'focal adhesion' to be among the top pathways associated with the EV proteins. A total of 42 proteins including haptoglobin (HP), pyruvate kinase (PKM), annexin A2 (ANXA2), thrombospondin 1 (THBS1), were reported to be differentially abundant in GBC tissue. Of these, 16 proteins were reported to be differentially abundant in plasma and plasma-derived EVs. We infer these proteins to be highly important to be considered as potential circulatory biomarkers for the detection of GBC. To check the validity of this hypothesis, one of the proteins, haptoglobin (HP) as a representative case, was analysed in plasma by quantitative Enzyme- linked immunosorbent assay (ELISA) and we observed its increased levels in GBC in comparison to controls (p value= 0.0063). Receiver operating characteristic (ROC) curve analysis for GBC vs controls showed an Area under the ROC Curve (AUC) of 0.8264 for HP with 22% sensitivity against 100% specificity. We propose that HP along with other candidate proteins may be further explored for their clinical application.

Role of Itolizumab in the Treatment of COVID-19 Patients, Admitted to ICU at a Tertiary Care Hospital

BACKGROUND

Clinical studies have correlated severe deterioration of COVID-19 patients due to excessive and uncontrolled production of cytokines. There is a pressing need to explore therapies, which could prevent the cytokine storm rather than terminating it.

AIMS AND OBJECTIVES

The aim of the study is to evaluate the effect of itolizumab on clinical outcomes of patients with moderate-severe COVID-19 disease admitted to ICU. The primary aim of the current study is to find out any mortality benefit in 14 days. The secondary aim is to assess the morbidity outcomes in terms of reduction in inflammatory markers and also the duration of hospital stays to assess the prognostication.

MATERIALS AND METHODS

It is a retrospective case-control study in which laboratory-confirmed COVID-19 patients admitted to ICU were taken. A total of 62 patients were recruited, 31 patients received itolizumab (cases/treatment group) and 31 patients didn't receive itolizumab (designated as controls).

RESULTS

Among the total patients recruited, 68% of the study population was male and 32% were female. A total of 12 patients expired among cases and 13 expired among controls. Overall mortality in both groups was noted to be almost similar. The control group showed mortality at lower computed tomography (CT) scores compared to the cases. There is a significant reduction in inflammatory markers, like interleukins-6 (IL-6) and D-dimer in cases compared to the control group.

CONCLUSION

In conclusion, treating patients with cytokine storms before they require intubation/mechanical ventilation is crucial to preventing deaths. Itolizumab has shown no clinical benefit in critically ill COVID-19 patients, however, timely initiation of itolizumab therapy may serve as a key therapeutic option in preventing the mortality and morbidity outcomes in moderate-severe COVID-19 patients.

Plasma-derived candidate biomarkers for detection of gallbladder carcinoma

Gallbladder carcinoma (GBC) is a major cancer of the gastrointestinal tract with poor prognosis. Reliable and affordable biomarker-based assays with high sensitivity and specificity for the detection of this cancer are a clinical need. With the aim of studying the potential of the plasma-derived extracellular vesicles (EVs), we carried out quantitative proteomic analysis of the EV proteins, using three types of controls and various stages of the disease, which led to the identification of 86 proteins with altered abundance. These include 29 proteins unique to early stage, 44 unique to the advanced stage and 13 proteins being common to both the stages. Many proteins are functionally relevant to the tumor condition or have been also known to be differentially expressed in GBC tissues. Several of them are also present in the plasma in free state. Clinical verification of three tumor-associated proteins with elevated levels in comparison to all the three control types—5′-nucleotidase isoform 2 (NT5E), aminopeptidase N (ANPEP) and neprilysin (MME) was carried out using individual plasma samples from early or advanced stage GBC. Sensitivity and specificity assessment based on receiver operating characteristic (ROC) analysis indicated a significant association of NT5E and ANPEP with advanced stage GBC and MME with early stage GBC. These and other proteins identified in the study may be potentially useful for developing new diagnostics for GBC.

Prognostic significance of tumour budding, tumour-stroma ratio and desmoplastic stromal reaction in gall bladder carcinoma

AIMS AND METHODS

The prognostic role of tumour budding (TBd) and its interaction with the stromal microenvironment has gained a lot of attention recently, but remains unexplored in gall bladder cancer (GBC). We aimed to study the interrelationship of TBd by International Tumour Budding Consensus Conference scoring system, tumour-stroma ratio (TSR) and desmoplastic stromal reaction (DSR) with the conventional clinicopathological prognostic factors, mortality and overall survival (OS) in 96 patients of operated GBC.

RESULTS

Higher age, high TNM stage, lymphovascular and perineural invasion, positive resection margins, higher TBd score, low TSR and immature DSR were significantly associated with worse OS. However, on multivariate analysis, only metastases, positive resection margins and TSR <50% proved to be independent prognostic factors. The TBd score of stroma-rich tumour group (6.40±4.69) was significantly higher than that of stroma-poor group (2.77±3.79, p≤0.001). The TBd score of immature and intermediate DSR groups was significantly higher than that of mature group (p≤0.001 and p=0.002, respectively). There was a strong interobserver agreement for TBd score, TSR and type of DSR (Cohen's Kappa=0.726 to 0.864, p≤0.001). Stroma-rich tumours were significantly associated with immature DSR and fibrotic DSR with high TSR (p≤0.001).

CONCLUSION

A high TBd, low TSR and immature DSR were significantly associated with several high-risk clinicopathological parameters and poor OS in GBC. These novel, simple, reproducible and cost-effective parameters may be included in the routine reporting checklist for GBC as additional prognostic parameters that can substratify the high-risk patients.

Segmental dilatation of ileum in a young patient presenting with anemia

Segmental dilatation of ileum (SDI) is a less known uncommon entity with a confusing clinical scenario and no definite etiopathogenesis. The preoperative diagnosis is of exclusion. However, it has an excellent prognosis after surgery. We describe a case of a young patient who presented with anemia without any overt gastrointestinal (GI) bleed. Thorough radiological examinations were needed to reach the diagnosis of SDI which was confirmed postoperatively.

Does IgG4 level evaluation in pancreatic mass play role in avoiding major surgery in uncertain presentation: A case report

A 66-year-old male presented with chief complaints of anorexia associated with mild dull, intermittent epigastric pain for 6 months. The patient was a known diabetic on oral hypoglycemic and on routine checkup was found to have deranged liver function profile. On radiology, an ill-defined hypoechoic enhancing lesion involving head, neck, and uncinate process of pancreas was noted. Whipple's pancreaticodudenectomy was done and reported as IgG4-related autoimmune pancreatitis. Later, IgG (slightly) and IgG4 were found to be markedly raised. We report this case to highlight the importance of IgG4 evaluation prior to major surgery in uncertain pancreatic mass.

Immunoproteomics approach revealed elevated autoantibody levels against ANXA1 in early stage gallbladder carcinoma

Background

Early diagnosis is important for the timely treatment of gallbladder carcinoma (GBC) patients and may lead to increased survival outcomes. Here, we have applied serological proteome analysis (SERPA), an immunoproteomics approach, for the detection of ‘tumor-associated antigens (TAAs) that elicit humoral response’ in early stage GBC patients.

Methods

Total protein from pooled tumor tissue of GBC patients (n = 7) was resolved by two-dimensional gel electrophoresis (2-DE) followed by immunoblotting using pooled blood plasma from healthy volunteers (n = 11) or gallstone disease (GSD) cases (n = 11) or early stage GBC (Stage I and II) (n = 5) or GBC stage IIIA (n = 9). 2-D gel and immunoblot images were acquired and analyzed using PDQuest software to identify immunoreactive spots in GBC cases in comparison to controls. Proteins from immunoreactive spots were identified by liquid chromatography- tandem mass spectrometric analysis (LC-MS/MS). Autoantibody levels for two of the functionally relevant proteins were investigated in individual plasma samples (52 cases and 89 controls) by dot blot assay using recombinant proteins.

Results

Image analysis using PDQuest software identified 25 protein spots with significantly high or specific immunoreactivity in GBC cases. Mass spectrometric analysis of 8 corresponding protein spots showing intense immunoreactivity (based on densitometric analysis) in early stage GBC or GBC stage IIIA cases led to the identification of 27 proteins. Some of the identified proteins include ANXA1, HSPD1, CA1, CA2, ALDOA and CTSD. Among the two proteins, namely ANXA1 and HSPD1 verified using a cohort of samples, significantly elevated autoantibody levels against ANXA1 were observed in early stage GBC cases in comparison to healthy volunteers or GSD cases (unpaired t-test, p < 0.05). Receiver operating characteristic (ROC) curve analysis for ANXA1 showed an Area under the Curve (AUC) of 0.69, with 41.7% sensitivity against a specificity of 89.9% for early stage GBC. IHC analysis for ANXA1 protein showed ‘high’ expression levels in 72% of GBC cases whereas all the controls showed ‘low’ expression levels.

Conclusions

The study suggests that the ANXA1 autoantibody levels against ANXA1 may be potentially employed for early stage detection of GBC patients. Other proteins could also be explored and verified in a large cohort of clinical samples.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12885-020-07676-6.

Fulminant amebic colitis: An unusual postoperative complication of intraabdominal malignancy

Amebiasis caused by protozoa Entamoeba histolytica (EH) is the third leading parasitic cause of human mortality. Although amebiasis is endemic in India, only about 10% of the infected individuals manifest disease. Clinical spectrum of amebiasis ranges from asymptomatic colonization to amebic colitis to hemorrhagic and fulminant colitis. Factors causing an invasive infection are not completely understood. Pathogen virulence, host immunity, and ability of the pathogen to evade host immune response play vital role in determining the disease course. Host factors such as immunocompromised states may make an individual susceptible to develop symptomatic infection. Malignancies usually result in chronic debilitation which may make the individual prone to develop invasive amebiasis with rapid progression. We report two cases of invasive amebiasis which developed a fulminant course in the immediate postoperative period after abdominal surgeries for visceral malignancies.

Prevalence of Abnormal Liver Function Tests in COVID-19 Patients at a Tertiary Care Centre

BACKGROUND AND AIM

Coronavirus disease 2019 (COVID 2019) outbreak caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is observed to cause liver dysfunction. We aimed to observe abnormal liver function tests (LFTs) in COVID-19 patients admitted in our hospital.

METHODS

It was a cross- sectional study involving 105 COVID-19 patients who were admitted in our Hospital from 03-04-2020 to 02-05-2020. The COVID-19 positivity was defined on basis of real-time PCR. Thorough clinical examination and laboratory investigations including Complete Blood Count, Renal function Tests, Liver Function Tests, Chest X-ray, ECG, etc. were done.

RESULTS

The total number of male and female patients were 64 and 41. Out of total 105 patients, 62 i.e. 59.04% had abnormal LFTs at time of admission. Out of these 62 patients, 44(70.9%) were Male and 18(29.03%) were female. Only 5(4.76%) patients had abnormal LFTs on repeat testing. Median Age of patients was 33years. Average stay of patients with Abnormal LFTs was 15 days (10-16 days) as compared to 10 days (7-11days) for patients with normal LFTs.

CONCLUSION

The prevalence of Abnormal Liver function tests in patients of COVID-19 is 59.04%. Abnormal liver functions were more in males. The average stay in hospital for COVID-19 patients with abnormal LFTs was longer than those with normal LFTs.

Current status of bone cementing and bone grafting for giant cell tumour of bone: a systemic review

INTRODUCTION

Extended intralesional curettage, together with bone grafting/cementing, is considered as a surgical treatment option for giant cell tumour of the bone. This study aimed to discover the efficacy and recurrence rate with the use of bone cement in giant cell tumour and to compare it with that of bone grafting.

MATERIAL AND METHODS

The present systemic review is derived from the publications in the past 10 years (2009-2018). A literature search was performed via PubMed, using suitable keywords and Boolean operators database ('Giant cell tumor,' 'osteoclastoma,' 'bone,' 'bone cement,' 'bone graft' and 'curettage'). A detailed statistical analysis of the data derived from the published literature was done.

RESULTS

The patients who underwent bone graft only exhibited significantly higher recurrence rates than those treated with polymethyl methacrylate only (risk ratio 1.90; 95% confidence interval 1.14, 3.16; overall effect Z = 2.488; P-value 0.012). The observational analysis was done in rest of the seven studies; three studies showed no recurrence rate. Only one study reported the highest recurrence rate of 42% and the remaining six had an overall recurrence rate of 20.4%.

CONCLUSION

The use of bone cement was associated with a statistically significantly lower recurrence rate than bone grafting in giant cell tumour of bones. We therefore recommend the use of bone cement with extensive intralesional curettage. Adjuvant therapy like electrocautery, phenol irrigation and the use of intravenous denosumab or bisphosphonates may help in decreasing the incidence of recurrence in giant cell tumour of bone.

Mucoepidermoid Carcinoma of the Gallbladder: A Case-Based Study of an Extremely Rare Tumor Highlighting the Role of Immunohistochemical Profiling

Mucoepidermoid carcinoma (MEC) is rarely reported in the hepatobiliary system. In this article, we detail the first case of MEC arising from the gallbladder, presenting in a 50-year-old male. Imaging and gross examination showed a large mass in the gallbladder fossa infiltrating the liver. This microscopically displayed the classical morphology of MEC, which was confirmed on dual immunostain for p63 and CK7 and histochemical staining for mucin. MUC and p53 immunoexpression patterns suggested a poor prognosis. The patient succumbed to the disease with liver metastasis within 6 months. The cytomorphology of the metastatic lesion is also presented. Differences in the stem cell niches in the gallbladder and the rest of the biliary tract may possibly indicate the reason for the rarity of this tumor in the gallbladder. A possibly aggressive biological behavior of the gallbladder MEC necessitates its distinction from entities like the adenosquamous carcinoma.

A Study of the Patients Suffering from Tuberculosis and Tuberculosis-diabetes Comorbidity in Revised National Tuberculosis Control Program Centers of Northern Madhya Pradesh, India

BACKGROUND

Diabetes mellitus (DM) is recognized as an important risk factor to tuberculosis (TB). India has high TB burden, along with rising DM prevalence.

AIM

This study was conducted to document the coexistence of DM and TB in persons with established TB under the Revised National Tuberculosis Control Program.

TYPE OF STUDY

This was a cross-sectional, descriptive observational study conducted at selected Directly Observed Therapy center in Gwalior North Central India.

MATERIALS AND METHODS

A total of 550 patients with confirmed diagnosis of TB and on treatment were recruited. The study participants were screened for DM and diagnoses were made on the basis of the World Health Organization criteria. Clinical parameters were compared between persons with DM and those without DM.

RESULTS

DM/TB co-morbidity was noted in 85 individuals and these made up 15.4% of the study population. The mean age was higher in DM patients with TB (43.4 ± 15.4 vs. 33.1 ± 16.2 years, P = 0.000); the mean duration of symptoms of TB with DM was more (124 ± 16.4 vs. 107.49 ± 10.3 days). Multinomial logistic regression analysis showed that increasing age, positive family history of diabetes, sedentary occupation, and presence of pulmonary TB were significantly associated with diabetes among TB patients.

CONCLUSIONS

Diabetes is an important co-morbid feature to be sought in patients with TB. This study re-echo the need to raise awareness on screening for DM in persons with TB.

A community based study to assess the validity of Indian diabetic risk score, among urban population of North Central India

Background: The prevalence of diabetes mellitus is growing rapidly worldwide and India has earned the dubious distinction of being the diabetic capital of the world and had 69.2 million (8.7%) people living with diabetes.1 Unfortunately over half of these people remain undiagnosed as diabetes. IDRS is a cost effective and simple tool for screening of undiagnosed diabetic individuals in the community. The objective of the study was to estimate prevalence of undiagnosed high risk subjects of diabetes mellitus to validate IDRS as effective tool for diagnosis of diabetes in urban areas of Gwalior City.Methods: In community based cross-sectional observational study house to house survey was conducted and face to face interview had done by predesigned questionnaire, which was based on IDRS variables for those persons of age more than 20 and not known to diabetes previously.Results: In present study 55 (8.94%) out of 615 respondents were diagnosed as a newly diabetic cases. We found that at IDRS score of ≥60 has a sensitivity of 45.5% and specificity of 88.0%.Conclusions: This study provides a use of Indian diabetes risk score for identifying undiagnosed high risk for patients with diabetes in Indian population and could make screening programmes more cost effective. 

Type 1 Tympanoplasty by Cartilage Palisade and Temporalis Fascia Technique: A Comparison

(1) To compare graft take up of type-1 tympanoplasty with cartilage palisade technique with those of type-1 tympanoplasty using autotemporalis fascia. (2) To compare hearing results of type 1 tympanoplasty with cartilage palisade technique with those of type-1 tympanoplasty using autotemporalis fascia. A prospective clinical study. It consisted of 60 patients divided into two groups of 30 patients each. After randomization 30 patients underwent type 1 tympanoplasty using cartilage palisade technique and 30 underwent type 1 tympanoplasty using autotemporalis fascia. In follow up, pure tone audiogram were carried out at 2nd, 4th and 6th month. Clinical assessment was done at 2nd 4th and 6th month. The graft uptake rate between the group 1 and group 2 are 93.33 and 90% respectively. As p value was greater than 0.05 so statistically there is no significant difference between the two group. The post operative air bone gap of the two groups were compared using student t test. The pre op mean of group 1 was 32.5 db and pre op mean of group 2 was 30.66 db. The post op mean of group 1 was 21.33, with standard deviation of 3.6984 and standard error of 0.67523. The post op mean of group 2 was 21.09 with standard deviation of 3.29 and standard error of 0.58261. t value was 0.1357. Analysis was done using student t test and p value was found to be greater than 0.05. p value is greater than 0.05 which shows that there is no statistical difference between the two groups. This study establishes the fact that hearing results after performing type 1 tympanoplasty by autotemporalis fascia when compared with type 1 tympanoplasty performed by cartilage palisade technique showed similar hearing gain and post operatively graft take up rate was also similar in two groups. The disadvantage of reducing the mechanical vibration of the tympanic membrane was overcome by the palisade reconstruction of the tympanic membrane. This study definitely emphasizes upon usage of new grafting materials in reconstruction of tympanic membrane, with similar, if not better functional results, without compromising the acoustic transfer characteristics.

Can killers be saviors?

Autoimmunity and cancer have a multifarious epidemiology. Often, it is because of an impaired genome, culminating in functional aberrations in the human system. Systemic lupus erythematosus (SLE) is a heterogeneous complex disease which ensues due to the failure of the immune system to distinguish between self and non-self antigens, thus producing autoantibodies against DNA, RNA and proteins. Cancer, the other side of the same coin, results from an excessive proliferation of cells that evade immune regulation as a result of incompetent defense by T-cells, B-cells and macrophages. Recent findings have indicated that lupus autoantibodies could be used as an effective weapon to kill cancerous cells. This is an attempt to take an account of malicious 'lupus autoantibodies' and their role in neutralizing cancerous cells which may help in enhancing the survival rate of cancer patients, hence, killers can be saviors.

Identification and Stratification of Diabetic Kidney Disease Using Serum Cystatin C and Serum Creatinine Based Estimating Equations in Type 2 Diabetes: A Comparative Analysis

BACKGROUND

Cystatin C is a low molecular weight protein produced by all nucleated human cells, with a stable production rate. Its levels are not influenced by inflammation, infections, hepatic or renal diseases, or by dietary or constitutional factors. We compared serum cystatin C and serum creatinine based predicting equations to estimate glomerular filteration rate (GFR) in type 2 diabetes mellitus, using the staging of chronic kidney disease (CKD) defined by the National Kidney Foundation. We also explored the relationship of urine albumin, GFR, serum creatinine and cystatin C concentrations.

METHODS

: A cross-sectional study was performed at a tertiary care hospital in New Delhi. Consecutive patients with type 2 diabetes mellitus above the age of 35 years were enrolled. Fasting and 2-hour-postprandial blood glucose, fasting lipid profile, lipoprotein(a), haemoglobin, microalbuminuria, glycated haemoglobin (HbA1c), liver and renal function tests were assessed. Serum levels of Cystatin C were measured using immune-turbidometric method (Dade Behring analyzer BN2). Estimated GFR (eGFR) was calculated using Cockcroft-Gault formula, Modification of Diet in Renal Disease (MDRD) and Chronic Kidney Disease-Epidemiology (CKD-EPI) Cys C formula. The three sets of eGFR were compared using repeated measure ANOVA. Linear regression analysis was performed to find the factor that affects the albumin excretion rate (AER) and e-GFR levels using all three equations.

RESULTS

We assessed 172 patients with type 2 diabetes mellitus. Mean age of the patients was 61.4 ± 9.6 years with mean duration of diabetes of 11.40 ± 7.5 years. Approximately 70% of patients had hypertension. A family history of diabetes was present in 53.4% of subjects and a history of CAD in first degree relatives in 20.9%. The prevalence of coronary artery disease was 17.4%. Albumin excretion correlated with e-GFR estimated using each of the three equations. The best correlation was seen with the CKD-EPI equation derived e-GFR. The CKD-EPI equation also identified the maximum number of patients in the normo-albuminuria group as having CKD. Albuminuria correlated with blood urea levels (p = 0.014) and serum cystatin C levels (p < 0.005).

CONCLUSION

The new cystatin C based Chronic Kidney Disease Epidemiology equation identifies more patients in early CKD and also patients with normo-albuminuric CKD compared to the creatinine based Cockcroft-Gault equation or the Modification of Diet in Renal Disease formulae.

Distribution of hepatitis B virus genotype and cancer predicting precore and basal core promoter mutations

BACKGROUND

Chronic hepatitis B (CHB) infection which is associated with an increased risk of developing liver disease including cirrhosis and hepatocellular carcinoma. Viral factors that may increase the risk for HCC development include HBV DNA level, genotypes, and naturally occurring mutations such as hepatitis B virus precore (PC) (G1896A) and basal core promoter (BCP) A1762T/G1764A double mutations. HBV genotypes and subgenotypes can significantly influence HBeAg seroconversion rates, viremia levels, mutational patterns that could significantly influence the heterogeneity in clinical manifestations and even response to antiviral therapy.

METHOD

94 CHB infected individuals with detectable serum HBV DNA levels were studied. HBsAg, HBeAg, anti-HBc IgM antibody estimations were done by ELISA. HBV DNA estimation was done. The HBV genotypes were determined by TSP-PCR and 10 samples randomly selected for DNA sequencing. PC and BCP mutations were determined by DNA sequence analysis of core region.

RESULT

Of 94 study participant samples with detectable serum HBV DNA levels, 75 were successfully genotyped and sequenced for BCP/PC region. 30/75 (40%) harbored PC and BCP mutations. The total Double mutations of BCP at A1762T/G1764A nucleotide positions, and PC mutation at G1896A nucleotide position were seen in 29.3% and 21.3%, respectively. All 75 isolates were subtype D using TSP-PCR. However, by sequencing 2/10 were subtype A, while 8 were subtype D.

CONCLUSION

Our study reinforces that D is the predominant genotype in Indian population. It reveals that Indian CHB subjects have increased prevalence of BCP & PC mutations, which possibly may lead to development of HCC.

Day care as an innovative approach in psychiatry: Analysis of Lucknow experience

CONTEXT

This article aims at demonstrating the effectiveness of day care centers in Indian setting. This is to provide impetus for an innovative approach in psychiatric practice in India.

AIMS

The aim was to narrate the experiences of a day care center being practiced in India.

SETTINGS AND DESIGN

The study provides the experiences gained in a day care center at Lucknow. The center was started in a hired building with a minimum of staff. The cost of the program is around 30,000/months.

SUBJECTS AND METHODS

The day care center has been run for nearly 5 years. During this period, 95 clients visited the center and 69 enrolled in the day care. Nearly 35 continued and 34 dropped out due to various reasons.

STATISTICAL ANALYSIS

Descriptive study.

RESULTS

There were 49 patients suffering from schizophrenia, 11 from affective disorders, and 9 patients were clubbed in the miscellaneous group. The miscellaneous group consisted of pervasive developmental disorders, slow learners, obsessive compulsive disorders (OCD) and borderline subnormality with psychosis. Most patients had a long duration of illness. The patients of schizophrenia continued in the program more often than other group. Nearly 50% of patients have obtained jobs. The exposure to day care improved the patient's social and occupational behavior. The core symptoms did not change substantially. The families were greatly empowered, and they developed a positive attitude toward illness.

CONCLUSIONS

Of the 59 patients who joined the day care program 35 could continue regularly. Among these patients, nearly 50% could take up jobs. Social and occupational behaviors improved remarkably. The families were empowered, and they developed a positive attitude toward mental illness. Such programs can be improvised with minimal costs and can be value addition in psychiatric practice. We need to develop indigenous know-how for such programs. This is a preliminary communication.

Religious/spiritual characteristics of indian and indonesian physicians and their acceptance of spirituality in health care: a cross-cultural comparison

Religious/spiritual (r/s) characteristics of physicians influence their attitude toward integrative medicine and spiritual care. Indonesia physicians collaborate with traditional, complementary, and alternative medicine (TCAM) professionals within modern healthcare system, while Indian physicians are not reported to do so. The aim of the study was to understand the r/s characteristics and their influence on Indian and Indonesian physicians' acceptance of TCAM/spirituality in modern healthcare system. An exploratory, pilot, cross-cultural, cross-sectional study, using Religion and Spirituality in Medicine, and Physician Perspectives (RSMPP) survey questionnaire, compared r/s characteristics and perspectives on integrative medicine of 169 physicians from two allopathic, Sweekar-Osmania University (Sweekar-OU), India, University of Airlanga (UNAIR), Indonesia, and a TCAM/Central Research Institute of Unani Medicine (CRIUM) institute from India. More physicians from UNAIR and CRIUM (89.1 %) described themselves as "very"/"moderately" religious, compared to 63.5 % Sweekar-OU (p = 0.0000). Greater number of (84.6 %) UNAIR physicians described themselves as "very" spiritual and also significantly high (p < 0.05) in intrinsic religiosity as compared to Sweekar-OU and TCAM physicians; 38.6 % of UNAIR and 32.6 % of CRIUM participants reported life-changing spiritual experiences in clinical settings as against 19.7 % of Sweekar-OU; 92.3 % of UNAIR, compared to CRIUM (78.3 %) and Sweekar-OU (62 %), felt comfortable attending to patients' spiritual needs, (p = 0.0001). Clinical comfort and not r/s characteristics of participants was the significant (p = 0.05) variable in full regression models, predictive of primary outcome criteria; "TCAM or r/s healing as complementary to allopathic treatment." In conclusion, mainstreaming TCAM into healthcare system may be an initial step toward both integrative medicine and also improving r/s care interventions by allopathic physicians.

Efficacy of Statins in Dyslipidemia: A Non interventional comparative study in a tertiary care hospital, Ajman, UAE

BackgroundThe reduction of serum total cholesterol and LDL-cholesterol levels varies with different statins. The objective of the present study was to compare the efficacy of Simvastatin, Atorvastatin and Rosuvastatin in the treatment of newly diagnosed dyslipidemia.Material and Methods:A prospective, non-interventional 12-week study was conducted after approval from the Ethics Committee. A total of 70 patients with newly diagnosed dyslipidemia receiving 20mg of Simvastatin, Atorvastatin or Rosuvastatin were included. The primary efficacy measure was reduction of lipid levels from the initial baseline values at the end of 12 weeks with the respective Statins. Data was analyzed using descriptive statistics, Paired -t test, and analysis of variance (ANOVA).Results:Of total 70 patients, 14 patients received Simvastatin; 40 patients received Atorvastatin and 16 patients received Rosuvastatin. Demographic and baseline clinical characteristics were similar between the three groups. Significant reduction in lipid levels (total cholesterol, and LDL) was seen within the three treatment groups (p<0.01). However, statistically significant difference in the reduction lipid levels was not observed between the three groups.Conclusion:We found no significant difference in the reduction of lipid levels between Simvastatin, Atorvastatin or Rosuvastatin patients with newly diagnosed dyslipidemia.DOI: http://dx.doi.org/10.3126/nje.v4i5.12023 Nepal Journal of Epidemiology 2014; 4(5):428-32

Indian health care professionals' attitude towards spiritual healing and its role in alleviating stigma of psychiatric services

Persons with mental illnesses in India and rest of developing world continue to consult religious/spiritual (R/S) healers or traditional, complementary and alternative medicine (TCAM) professionals prior to seeking psychiatric services that are devoid of spiritual components of care. We aim to understand TCAM and allopathic professionals' perspectives on patients' R/S needs within mental health services, cross-sectional study was conducted at five TCAM and two allopathic tertiary care hospitals in three different Indian states; 393 participants completed RSMPP, a self-administered, semi-structured survey questionnaire. Perspectives of TCAM and allopathic health professionals on role of spirituality in mental health care were compared. Substantial percentage, 43.7 % TCAM and 41.3 % allopathic, of participants believe that their patients approach R/S or TCAM practitioners for severe mental illness; 91.2 % of TCAM and 69.7 % of allopaths were satisfied with R/S healers (p = 0.0019). Furthermore, 91.1 % TCAM and 73.1 % allopaths (p = 0.000) believe that mental health stigma can be minimized by integrating with spiritual care services. Overall, 87 % of TCAM and 73 % of allopaths agreed to primary criterion variable: 'spiritual healing is beneficial and complementary to psychiatric care.' A quarter of allopaths (24.4 %) and 38 % of TCAM physicians reportedly cross-refer their grieving patients to religious/TCAM healer and psychiatrist/psychologist, respectively; on logistic regression, significant (p < 0.05) predictors were clinical interactions/references to r/s healers. Providing spiritual care within the setup of psychiatric institution will not only complement psychiatric care but also alleviate stigma against mental health services. Implications on developing spiritual care services like clinical chaplaincy are discussed.

Intra-arterial methylene blue injection into ex vivo colorectal cancer specimens improves lymph node staging accuracy: a randomized controlled trial

AIM

A randomized controlled trial was carried out to study the effect of a recently proposed technique of ex vivo intra-arterial methylene blue injection of the surgical specimen removed for colorectal cancer on lymph node harvest and staging.

METHOD

Between May 2012 and February 2013, 100 consecutive colorectal cancer resection specimens in a single institution were randomly assigned to intervention (methylene blue injection) and control (standard manual palpation technique) groups before formalin fixation. The specimen was then examined by the histopathologist for lymph nodes.

RESULTS

Both groups were similar for age, sex, site of tumour, operation and tumour stage. In the intervention group, a higher number of nodes was found [median 23 (5-92) vs. 15 (5-37), P < 0.001], with only one specimen not achieving the recommended minimum standard of 12 nodes [1/50 (2%) vs. 8/50 (16%), P = 0.014]. However, there was no upstaging effect in the intervention group [23/50 (46.0%) vs. 20/50 (40.0%); P = 0.686]. With a significantly lower number of nodes harvested in rectal cancer, the positive effect of the intervention was particularly observed in the patients who underwent preoperative neoadjuvant radiotherapy [median 30 nodes (12-57) vs. 11 (7-15); P = 0.011; proportion of cases with < 12 nodes 0/5 vs. 5/8 (62.5%), P = 0.024].

CONCLUSION

Ex vivo intra-arterial methylene blue injection increases lymph node yield and can help to reduce the number of cases with a lower-than-recommended number of nodes, particularly in patients with rectal cancer having neoadjuvant treatment. The technique is easy to perform, cheap and saves time.

Acute kidney injury and dermonecrosis after Loxosceles reclusa envenomation

Spiders of the Loxosceles species can cause dermonecrosis and acute kidney injury (AKI). Hemolysis, rhabdomyolysis and direct toxin-mediated renal damage have been postulated. There are very few reports of Loxoscelism from India. We report a case of AKI, hemolysis and a "gravitational" pattern of ulceration following the bite of the brown recluse spider (Loxosceles spp).

Perspectives of Indian traditional and allopathic professionals on religion/spirituality and its role in medicine: basis for developing an integrative medicine program

Allopathic medical professionals in developed nations have started to collaborate with traditional, complementary, and alternative medicine (TCAM) to enquire on the role of religion/spirituality (r/s) in patient care. There is scant evidence of such movement in the Indian medical community. We aim to understand the perspectives of Indian TCAM and allopathic professionals on the influence of r/s in health. Using RSMPP (Religion, Spirituality and Medicine, Physician Perspectives) questionnaire, a cross-sectional survey was conducted at seven (five TCAM and two allopathic) pre-selected tertiary care medical institutes in India. Findings of TCAM and allopathic groups were compared. Majority in both groups (75% of TCAM and 84.6% of allopathic practitioners) believed that patients' spiritual focus increases with illness. Up to 58% of TCAM and allopathic respondents report patients receiving support from their religious communities; 87% of TCAM and 73% of allopaths believed spiritual healing to be beneficial and complementary to allopathic medical care. Only 11% of allopaths, as against 40% of TCAM, had reportedly received 'formal' training in r/s. Both TCAM (81.8%) and allopathic (63.7%) professionals agree that spirituality as an academic subject merits inclusion in health education programs (p = 0.0003). Inclusion of spirituality in the health care system is a need for Indian medical professionals as well as their patients, and it could form the basis for integrating TCAM and allopathic medical systems in India.

Liver necrosis following corrosive ingestion

We describe a rare sequel of corrosive ingestion. In this patient, ingestion of a corrosive led to ischemic necrosis of the entire left lobe of the liver (segments II, III, and IV) in addition to causing full-thickness necrosis of the esophagus/stomach, infarction of the spleen, and injury to the left hemidiaphragm. Solid organ involvement following corrosive ingestion is uncommon. Although involvement of the spleen and pancreas from extension of corrosive burns from the adjacent stomach is occasionally described, involvement of the liver following corrosive ingestion has not been reported in the literature till date.

Complicated coexisting pyogenic and tuberculous otitis media affecting the temporozygomatic, infratemporal, and parotid areas: report of a rare entity

We report an unusual case in which a 28-year-old woman presented with a long-standing history of ear discharge, hearing loss, facial weakness with ipsilateral facial swelling and cellulitis, a postauricular fistula, and an abscess of the temporozygomatic, infratemporal, and parotid areas. The pus stained positive for bacteria and acid-fast bacilli, and culture was positive for Proteus vulgaris and mycobacteria. Based on these findings, a diagnosis of tuberculous otitis media with complications was made. Computed tomography showed extensive destruction of the tympanic and mastoid part of the temporal bone, as well as lytic lesions in the skull. The patient was placed on antituberculosis drug therapy. Although her facial nerve palsy and hearing loss persisted, she otherwise responded well and did not require surgery.

Mass-forming xanthogranulomatous cholecystitis masquerading as gallbladder cancer

BACKGROUND

Mass-forming xanthogranulomatous cholecystitis (XGC), an uncommon inflammatory pathology of gallbladder (GB), masquerades as gallbladder cancer (GBC) and diagnosis is often a histological surprise.

METHODS

A retrospective analysis of prospectively collected database of patients with GB mass operated between August 2009 and September 2012 was conducted to determine clinical, radiological, and intraoperative findings that might aid in the preoperative diagnosis of mass-forming XGC and ascertain their optimal management strategy.

RESULTS

Of the 566 patients with GB mass and suspected GBC, 239 were found to be inoperable on preoperative workup and 129 patients had unresectable disease on staging laparoscopy/laparotomy. Of the 198 with resectable disease, 31 were reported as XGC on final histopathology (Group A), while 167 were GBC (Group B). Of these 31 patients, six with an intraoperative suspicion of benign pathology underwent cholecystectomy with segments IVb and V resection, and frozen section histopathology. Twenty-five underwent radical cholecystectomy, with (n = 10) or without (n = 15) adjacent organ resection. In comparison, anorexia and weight loss were significantly more in Group B (p = 0.001 and <0.001). Intraoperatively, empyema and associated gallstones were more common in Group A (p = 0.011 and <0.001). On computed tomography (CT) of the abdomen, continuous mucosal line enhancement and intramural hypodense bands were significantly more in Group A (p < 0.001 and 0.025). While CT abdomen revealed one or more features suggestive of XGC in 64.5 % (20/31) of patients in Group A, 11(35.5 %) did not have any findings suggestive of XGC on imaging.

CONCLUSION

Mass-forming XGC mimics GBC, making preoperative and intraoperative distinction difficult. While imaging findings can help in suspecting XGC, definitive diagnosis require histopathological examination. Presence of typical radiological findings, however, can help in avoiding extended radical resection in selected cases.

Laparoscopic removal of a needle from the pancreas

Foreign bodies inside the pancreas are rare and usually occur after the ingestion of sharp objects like fish bone, sewing needle and toothpick. Most of the ingested foreign bodies pass spontaneously through the anus without being noticed but about 1% of them can perforate through the wall of stomach or duodenum to reach solid organs like pancreas or liver. Once inside the pancreas they can produce complications like abscess, pseudoaneurysm or pancreatits. Foreign bodies of pancreas should be removed by endoscopic or surgical methods. We hereby report our experience of successful removal one a sewing needle from pancreas.

Analysis of patients attending a private psychiatric clinic

BACKGROUND

Private psychiatric clinics provide help for the bulk of our population, but they have not been evaluated systematically. It is time that we analyze the functioning of these set-ups to improve functioning. This paper is a modest attempt to analyze one such clinic.

AIMS

To analyze the diagnostic distribution of the clients attending the clinic and to study the pattern of follow-up.

MATERIALS AND METHODS

All records from April 1(st) 1997 to 31(st) March 1999 were analyzed. This is a descriptive study.

RESULTS AND CONCLUSIONS

A total of 3077 new patients visited the clinic in this period. The male:female ratio was 54:46. Diagnostic distribution revealed the following: schizophrenia 20%, affective disorders 40%, OCD 8%, dissociative disorders 5.5% and anxiety disorders around 4.5%. The pattern of visits revealed that 50% of the patients dropped out after the first visit. Another 25% did so in next the two visits.

Prevalence of peripheral arterial disease in type 2 diabetes mellitus and its correlation with coronary artery disease and its risk factors

OBJECTIVES

Peripheral arterial disease (PAD) is one of the macrovascular complications of type 2 diabetes mellitus. Unlike other complications, it has received little attention in the Indian medical literature. There is significant difference in the reported prevalence of PAD and its associated risk factors between Indian and Western studies. In order to assess PAD in diabetics, its associated risk factors and its relationship with coronary artery disease, we conducted a hospital-based, cross-sectional study.

METHODS

Consecutive patients on regular follow up in our diabetes clinic were included. In addition to a detailed history and physical examination, anthropometric parameters like body mass index, waist circumference and waist hip ratio were measured. Relevant laboratory investigations were performed. Modified Rose questionnaire and Minnesota codes were used to diagnose coronary artery disease (CAD). Colour Doppler examination of the arteries of the lower limbs was performed. Arteries were evaluated both longitudinally and transversely. Individual ABI was obtained for each leg by dividing corresponding ankle pressure by the brachial pressure. The lower of the values obtained for the two legs was taken as the true ABI. A cut off of < 0.9 was used to define peripheral arterial disease. Predictors of PAD were assessed using univariate tests of significance. Binary logistic regression was used to identify independent predictors of CAD.

RESULTS

We studied 146 patients (79 men and 67 women; mean age 59.4 +/- 7.2 years; mean duration of diabetes 8.8 +/- 3.8 years). The prevalence of PAD was 14.4% with women having a slightly higher prevalence (14.9%), as compared to men (13.9%) (p=0.864). CAD was present in 28%. Age, duration of diabetes, smoking, systolic and diastolic blood pressures and an HbA1c >7% were significant predictors of PAD. We did not find a correlation between measures of obesity and PAD. Using binary logistic regression, older age (p=0.01), higher HbA1c levels (p=0.02), microalbuminuria (p=0.03) and deranged lipid profile (total cholesterol, HDL, triglycerides) were found to be significant predictors of CAD.

CONCLUSION

Using ankle brachial index, we found evidence of PAD in 14.3% of type 2 diabetics. Risk factors significantly associated with PAD were--higher age, longer duration of diabetes, higher systolic and diastolic blood pressure, smoking, higher HbA1c levels and CAD. The prevalence of CAD was higher in patients with PAD (52.38% vs. 24% in those without PAD; p=0.007). Thus the presence of PAD should alert the clinician to a high probability of underlying CAD.

Liver hydatid with HIV infection: an association?

Various opportunistic infections have been reported in patients with human immunodeficiency virus (HIV) infection. Although there are a few reports of echinococcal infection of the lung, spine, and brain, a hydatid cyst of the liver has never been described. In our experience of treating over 150 cases of hydatid cysts of the liver, we identified three patients with large, multifocal hydatid cysts who also had an HIV infection. The current article describes one such patient and discusses the possible host immune-parasite interaction to ascertain if HIV positivity results in increased susceptibility and severity of echinococcal infection.

Extra-adrenal phaeochromocytoma-a case report of refractory hypertension

There are at least 5% of all hypertensive patients whose blood pressure (BP) remains elevated despite adequate treatment. In these cases, the clinician is forced to search for a secondary cause of the chronic BP elevation. Certain environmental factors are known to induce resistant-hypertension. Additionally, there may be pseudo-resistance occurring or the patient may be suffering from a secondary form of hypertension such as renovascular or endocrinological hypertension (phaeochromocytoma, Cushing's syndrome, etc.). We report a case of extra-adrenal phaeochromocytoma who was on adequate antihypertensive medications but remained refractory to treatment prior to the exact diagnosis.

Stereo-selective inhibition of transient receptor potential TRPC5 cation channels by neuroactive steroids

BACKGROUND AND PURPOSE

Transient receptor potential canonical 5 (TRPC5) channels are widely expressed, including in the CNS, where they potentiate fear responses. They also contribute to other non-selective cation channels that are stimulated by G-protein-coupled receptor agonists and lipid and redox factors. Steroids are known to modulate fear and anxiety states, and we therefore investigated whether TRPC5 exhibited sensitivity to steroids.

EXPERIMENTAL APPROACH

Human TRPC5 channels were conditionally expressed in HEK293 cells and studied using intracellular Ca²⁺ measurement, whole-cell voltage-clamp and excised patch techniques. For comparison, control experiments were performed with cells lacking TRPC5 channels or expressing another TRP channel, TRPM2. Native TRPC channel activity was recorded from vascular smooth muscle cells.

KEY RESULTS

Extracellular application of pregnenolone sulphate, pregnanolone sulphate, pregnanolone, progesterone or dihydrotestosterone inhibited TRPC5 activity within 1–2 min. Dehydroepiandrosterone sulphate or 17β-oestradiol had weak inhibitory effects. Pregnenolone, and allopregnanolone, a progesterone metabolite and stereo-isomer of pregnanolone, all had no effects. Progesterone was the most potent of the steroids, especially against TRPC5 channel activity evoked by sphingosine-1-phosphate. In outside-out patch recordings, bath-applied progesterone and dihydrotestosterone had strong and reversible effects, suggesting relatively direct mechanisms of action. Progesterone inhibited native TRPC5-containing channel activity, evoked by oxidized phospholipid.

CONCLUSIONS AND IMPLICATIONS

Our data suggest that TRPC5 channels are susceptible to relatively direct and rapid stereo-selective steroid modulation, leading to channel inhibition. The study adds to growing appreciation of TRP channels as non-genomic steroid sensors.

Prevalence of non-alcoholic fatty liver disease and its correlation with coronary risk factors in patients with type 2 diabetes

OBJECTIVES

To estimate the prevalence of non-alcoholic fatty liver disease (NAFLD) by ultrasonography, and to correlate NAFLD with coronary artery disease (CAD) and coronary risk factors in a group of Indian type 2 diabetics.

METHODS

Consecutive patients of type 2 diabetes were recruited. History and physical examination were recorded. Laboratory investigations included fasting and 2-hour post-prandial blood glucose, blood urea, serum creatinine, liver function tests, lipid profile, glycated haemoglobin, microalbuminuria, and ultrasonographic measurement of carotid intimal-medial thickness (CIMT). NAFLD was diagnosed on the basis of ultrasound assessment of the liver.

RESULTS

The study group (n=124) was divided into a NAFLD group (n=71) and a non-NAFLD group (n=53). The prevalence of NAFLD was 57.2%. CAD was more prevalent in the NAFLD subgroup (60.5%) compared to the non-NAFLD subgroup (45.2%). The NAFLD subgroup had higher prevalence of hypertension, smoking, obesity (measured by BMI), central obesity (measured by waist circumference and waist hip ratio), higher HbAlc, higher triglyceride levels and lower HDL levels, and higher mean CIMT. Using binary logistic regression analysis, it was found that hypertension (p=0.013), LDL cholesterol (p=0.049), microalbuminuria (p=0.034) and NAFLD (p=0.016) were significantly correlated with CAD.

CONCLUSION

Among type 2 diabetics, NAFLD clusters with traditional coronary risk factors. It is a surrogate and fairly reliable marker of risk for CAD amongst type 2 diabetic patients. Ultrasonographically detected NAFLD is a simple, cheap, and safely assessable parameter for coronary risk stratification in type 2 diabetics.

Tuberculosis: an extremely unusual cause of orbital wall erosion

We present the case report of a 10-year-old girl who presented to us with a painless swelling involving the left infraorbital region. The swelling was diagnosed to be tubercular in origin with erosion of the zygomatic, maxillary and frontal bones constituting the inferior and lateral walls of the left orbit. The patient responded well to antitubercular chemotherapy. A discussion of the case and a literature review of causes of orbital erosion is presented.

Cis-isomerism and other chemical requirements of steroidal agonists and partial agonists acting at TRPM3 channels

BACKGROUND AND PURPOSE

The transient receptor potential melastatin-3 (TRPM3) channel forms calcium-permeable, non-selective, cationic channels that are stimulated by pregnenolone sulphate (PregS). Here, we aimed to define chemical requirements of this acute steroid action and potentially reveal novel stimulators with physiological relevance.

EXPERIMENTAL APPROACH

We used TRPM3 channels over-expressed in HEK 293 cells, with intracellular calcium measurement and whole-cell patch-clamp recording techniques.

KEY RESULTS

The stimulation of TRPM3 channels was confined to PregS and closely related steroids and not mimicked by other major classes of steroids, including progesterone. Relatively potent stimulation of TRPM3-dependent calcium entry was observed. A sulphate group positioned at ring A was important for strong stimulation but more striking was the requirement for a cis (beta) configuration of the side group, revealing previously unrecognized stereo-selectivity and supporting existence of a specific binding site. A cis-oriented side group on ring A was not the only feature necessary for high activity because loss of the double bond in ring B reduced potency and loss of the acetyl group at ring D reduced efficacy and potency. Weak steroid stimulators of TRPM3 channels inhibited effects of PregS, suggesting partial agonism. In silico screening of chemical libraries for non-steroid modulators of TRPM3 channels revealed the importance of the steroid backbone for stimulatory effects.

CONCLUSIONS AND IMPLICATIONS

Our data defined some of the chemical requirements for acute stimulation of TRPM3 channels by steroids, supporting the existence of a specific and unique steroid binding site. Epipregnanolone sulphate was identified as a novel TRPM3 channel stimulator.

Portal biliopathy: a study of 39 surgically treated patients

BACKGROUND

Portal biliopathy (PBP) denotes intra- and extrahepatic biliary duct abnormalities that occur as a result of portal hypertension and is commonly seen in extrahepatic portal vein obstruction (EHPVO). The management of symptomatic PBP is still controversial.

METHODS

Prospectively collected data for surgically managed PBP patients from 1996 to 2007 were retrospectively analysed for presentation, clinical features, imaging and the results of surgery. All patients were assessed with a view to performing decompressive shunt surgery as a first-stage procedure and biliary drainage as a second stage-procedure if required, based on evaluation at 6 weeks after shunt surgery.

RESULTS

A total of 39 patients (27 males, mean age 29.56 years) with symptomatic PBP were managed surgically. Jaundice was the most common symptom. Two patients in whom shunt surgery was unsuitable underwent a biliary drainage procedure. A total of 37 patients required a proximal splenorenal shunt as first-stage surgery. Of these, only 13 patients required second-stage surgery. Biliary drainage procedures (hepaticojejunostomy [n= 11], choledochoduodenostomy [n= 1]) were performed in 12 patients with dominant strictures and choledocholithiasis. One patient had successful endoscopic clearance of common bile duct (CBD) stones after first-stage surgery and required only cholecystectomy as a second-stage procedure. The average perioperative blood product transfusion requirement in second-stage surgery was 0.9 units and postoperative complications were minimal with no mortality. Over a mean follow-up of 32.2 months, all patients were asymptomatic. Decompressive shunt surgery alone relieved biliary obstruction in 24 of 37 patients (64.9%) and facilitated a safe second-stage biliary decompressive procedure in the remaining 13 patients (35.1%).

CONCLUSIONS

Decompressive shunt surgery alone relieves biliary obstruction in the majority of patients with symptomatic PBP and facilitates endoscopic or surgical management in patients who require second-stage management of biliary obstruction.

Homozygous null mutations in ZMPSTE24 in restrictive dermopathy: evidence of genetic heterogeneity

Restrictive dermopathy (RD) results in stillbirth or early neonatal death. RD is characterized by prematurity, intrauterine growth retardation, fixed facial expression, micrognathia, mouth in the 'o' position, rigid and tense skin with erosions and denudations and multiple joint contractures. Nearly all 25 previously reported neonates with RD had homozygous or compound heterozygous null mutations in the ZMPSTE24 gene. Here, we report three new cases of RD; all died within 3 weeks of birth. One of them had a previously reported homozygous c.1085dupT (p.Leu362PhefsX19) mutation, the second case had a novel homozygous c.1020G>A (p.Trp340X) null mutation in ZMPSTE24, but the third case, a stillborn with features of RD except for the presence of tapering rather than rounded, bulbous digits, harbored no disease-causing mutations in LMNA or ZMPSTE24. In the newborn with a novel ZMPSTE24 mutation, unique features included butterfly-shaped thoracic 5 vertebra and the bulbous appearance of the distal clavicles. Skin biopsies from both the stillborn fetus and the newborn with c.1020G>A ZMPSTE24 mutation showed absence of elastic fibers throughout the dermis. This report provides evidence of genetic heterogeneity among RD and concludes that there may be an additional locus for RD which remains to be identified.

Primary tuberculosis of nose with intracranial extension: a rare presentation

Tuberculosis continues to be a major public health problem. This disease has varying presenting features. We here present a case of primary tuberculosis of the nose with intracranial extension, a very rare presenting feature of tuberculosis.