P6378Characteristics of hypertensive iron ore miners with oral glucocorticoid induced diabetes mellitus and compromised lung function

Introduction

Oral glucocorticoids are efficacious agents for treating respiratory diseases, with high risk to induce metabolic diseases including diabetes and hypertension

Purpose

To analyse the hypertensive patient population from the rural setting on ongoing glucocorticoid treatment and diagnosed as diabetic due to the extensive chronic methylprednisolone equivalent glucocorticoid dose of more than 4 mg/day for at least 3 months for treatment of respiratory ailments due to occupational hazard

Methods

We diagnosed the identified and analysed a subset of patients from the Redi iron ore miners (n=25,500), who were newly diagnosed diabetics (n=1100) and with associated systemic hypertension (systolic BP >140 mmHg, diastolic BP > than 90 mmHg). Patients diagnosed as Oral Glucocorticoid Induced Diabetes Mellitus (GIDM) and hypertensives (n=847; 572 males and 275 females) were characterised on metabolic parameters. t-test was utilised for statistical analysis

Results

We observed a high incidence of GIDM (4.31%) with a high rate of hypertension (77%, 847/1100). Mean SBP was 150 mmHg (SD ± 9.9, 95% CI 147–152), mean DBP was 90 mmHg (SD ± 8.9, 95% CI 88–92). BMI in GIDM with hypertension (GIDM-H) group was similar to GIDM group (26 kg/m2) (Table), with relatively older age in GIDM–H (53 vs 51 years). The glycemic parameters were relatively more deranged in GIDM-H group. There was significant correlation for a high propensity of relatively younger <50 years (n=506) and near normal weight people with BMI <26 kg/m2 (n=594) to develop GIDM (p=0.006)

Metabolic Parameters GIDM Vs GIDM-H Mean ±SD, min, max, 95% CI GIDM (n=1100) GIDM with Hypertension (n=847) Age (yrs) 51 (SD ±14, 95% CI 48–54) 53 (SD ±13, 95% CI 50–56) HbA1c (%) 7.1 (SD ±0.62, 95% CI 7–7.3), 7.2 (SD ±0.60, 95% CI 7.1–7.3) BMI (kg/m2) 26 (SD ±3.6, 95% CI 25–27) 26 (SD ±3.4, 95% CI 25–27) Fasting Plasma Glucose (mg/dl) 146 (SD ±49, 95% CI 136–155) 149 (SD ±48, 95% CI 138–160) Post Prandial Glucose (mg/dl) 207 (SD ±74, 95% CI 192 - 221) 212 (SD ±74, 95% CI 195–228)

Conclusions

The high rates of hypertension in patients with GIDM is an alarmingly problem which has pronounced harmful comorbid implications, especially in younger, economically productive population in limited resource setting. The health care professionals need to be educated to limit use of glucocorticoids to inhalational therapy with minimal systemic effects. Specific pathophysiological approach to address the steroid induced insulin resistance, strategies to reduce cardiovascular risk and damage, makes treatment of hypertension and GIDM difficult, which calls for action to limit the mining activities and mitigate risk of chronic complications

Determination of Lycopene in Dietary Supplements and Raw Materials by High-Performance Liquid Chromatography: Collaborative Study

A collaborative study was conducted to evaluate the interlaboratory performance of an LC method for lycopene in dietary supplements and the raw materials commonly used in their manufacture. Twelve laboratories from six countries agreed to participate in the study. Results from 10 laboratories were received and are reported. Five dietary supplements, including both tablets and a softgel capsule with a lycopene content ranging from 25 g to 25 mg per unit, and three raw materials, including gelatin-based beadlets, vegetarian beadlets, and a suspension in oil ranging from 5 to 20 lycopene, were analyzed as blind duplicates. In addition to the commercial products, two positive controls and a negative control were included in the study. For the raw materials studied, the repeatability relative standard deviations (RSDr) ranged from 1.49 to 5.13 for total lycopene, and the reproducibility relative standard deviations (RSDR) ranged from 3.84 to 9.21 with HorRat values from 1.23 to 3.24. For finished products, the RSDr ranged from 1.31 to 4.62, RSDR from 4.28 to 10.5, and HorRat values from 0.79 to 2.07. Corresponding values for all-trans-lycopene were significantly higher. It is recommended that the method be considered for Official First Action for all-trans- and total lycopene in finished products and raw materials.

FTO gene variants are strongly associated with type 2 diabetes in South Asian Indians

AIMS AND HYPOTHESIS

Variants of the FTO (fat mass and obesity associated) gene are associated with obesity and type 2 diabetes in white Europeans, but these associations are not consistent in Asians. A recent study in Asian Indian Sikhs showed an association with type 2 diabetes that did not seem to be mediated through BMI. We studied the association of FTO variants with type 2 diabetes and measures of obesity in South Asian Indians in Pune.

METHODS

We genotyped, by sequencing, two single nucleotide polymorphisms, rs9939609 and rs7191344, in the FTO gene in 1,453 type 2 diabetes patients and 1,361 controls from Pune, Western India and a further 961 population-based individuals from Mysore, South India.

RESULTS

We observed a strong association of the minor allele A at rs9939609 with type 2 diabetes (OR per allele 1.26; 95% CI 1.13-1.40; p = 3 x 10(-5)). The variant was also associated with BMI but this association appeared to be weaker (0.06 SDs; 95% CI 0.01-0.10) than the previously reported effect in Europeans (0.10 SDs; 95% CI 0.09-0.12; heterogeneity p = 0.06). Unlike in the Europeans, the association with type 2 diabetes remained significant after adjusting for BMI (OR per allele for type 2 diabetes 1.21; 95% CI 1.06-1.37; p = 4.0 x 10(-3)), and also for waist circumference and other anthropometric variables.

CONCLUSIONS

Our study replicates the strong association of FTO variants with type 2 diabetes and similar to the study in North Indians Sikhs, shows that this association may not be entirely mediated through BMI. This could imply underlying differences between Indians and Europeans in the mechanisms linking body size with type 2 diabetes.

Characteristics of gestational diabetic mothers and their babies in an Indian diabetes clinic

AIMS AND OBJECTIVES

To compare clinical and metabolic features of mothers with gestational diabetes (GDM) and their offspring with those in non-diabetic pregnancies at the King Edward Memorial Hospital, Pune, India.

MATERIALS AND METHODS

Antenatal information was obtained from hospital records. GDM was diagnosed by 75 g OGTT (Oral Glucose Tolerance Test) in clinically high-risk women. Anthropometric measurements of mother and the babies were recorded within 24h of delivery and a maternal blood sample collected for hematological and biochemical measurements.

RESULTS

Between the period Jan 1998 to December 2003,265 women with gestational diabetes were treated in our Unit. Forty nine percent had first-degree relatives with diabetes. Compared to non-diabetic mothers (n=215) GDM mothers were older (29.0 vs. 26.0y, p<0.001), more obese (body mass index- BMI 26.0 vs. 22.0 kg/m2, p<0.001), centrally obese (Waist hip ratio-WHR 0.89 vs 0.86, p<0.001), adipose (sum of 4 skinfolds 98.4 vs. 61.4 mm, p<0.001) and had higher blood pressure (127/80 vs. 122/70 mmHg, p<0.001). GDM mothers had higher concentrations of plasma triglycerides (195.0 vs. 153.0 mg/dl, p<0.01); blood hemoglobin (11.7 vs 10.9 g/dl, p<0.001) and higher platelet count but lower concentration of HDL cholesterol and albumin. Sixty percent GDM mothers and 34% of non-diabetic mothers were delivered by caesarean-section, 23% of GDM mothers delivered pre term (<37 wk). Despite the smaller gestation, babies of GDM mothers were heavier (BW 2950.0 vs. 2824.0g, p<0.001, adjusted for gender), longer (48.9 vs. 48.0 cm, p<0.01) and more adipose (sum of 2 skinfolds 10.5 vs. 8.5 mm). Only 5% of babies born to GDM mothers weighed > 4000 g but 30% were >90th centile of birth weight of babies born to non-diabetic mothers. Babies of GDM mothers suffered higher neonatal morbidity.

CONCLUSIONS

GDM mothers in urban India are more obese and more adipose than non-diabetic mothers, frequently have a family history of diabetes and show metabolic features of insulin resistance syndrome, suggesting high cardiovascular risk. Neonates of GDM mothers are heavier, longer and more adipose than those born to non-diabetic mothers, and suffer higher neonatal morbidity.

Hypertrophic cardiomyopathy: an autopsy analysis of 14 cases

BACKGROUND

Hypertrophic cardiomyopathy (HCM) is one of the less common forms of primary cardiomyopathies. There is little data available on HCM in Indian literature.

AIMS

To assess the incidence and analyse the clinicopathological features of HCM.

SETTINGS

Analysis of data of 15 years from a tertiary care centre.

METHODS AND MATERIAL

The clinical and pathological data in fourteen cases of HCM with respect to their gross and microscopic features and clinical presentation were reviewed.

RESULTS

Incidence of HCM amongst the autopsied primary cardiomyopathies (N = 101) was 13.9% (n=14). Males were affected more. Common presenting symptoms were exertional dyspnoea, angina and palpitations. Concentric and asymmetric hypertrophy was equally seen. Obliterative small vessel disease was noted in 50% of the cases. Although significant myofibre disarray (>5%) was seen in all fourteen cases, it could be demonstrated in only 40- 50% of an average of twenty sections studied. Type IA myofibre disarray was the commonest. Six of the fourteen patients died suddenly. Cardiac failure was the commonest cause of death.

CONCLUSIONS

Myofibre disarray is a highly sensitive and specific marker for HCM only when considered in a quantitative rather than a qualitative fashion. In this context, the rationale for performing endomyocardial biopsy is to rule out mimics of HCM.

Subvalvular left ventricular aneurysms

Subvalvular left ventricular aneurysms can be subaortic or submitral with variable etiology. This is a retrospective study of 19 subvalvular aneurysms seen in 16 cases. There were 12 isolated subaortic aneurysms, 3 isolated submitral aneurysms, and in 1 case with multiple subaortic and submitral aneurysms. Subaortic aneurysms were associated with infective endocarditis, while there seems to be a strong association between submitral aneurysms and tuberculosis. Five cases of subvalvular aneurysm has associated aneurysm sinus of Valsalva-this association suggests a congenital weakness in the attachment of aortic and mitral annuli to the underlying myocardium. Cardio Pathol 2000;9:267-271

Pneumocystis carinii pneumonia in human immunodeficiency virus infected patients in Bombay: diagnosed by bronchoalveolar lavage cytology and transbronchial lung biopsy

We report Pneumocystis carinii pneumonia (PCP) diagnosed by bronchoalveolar lavage cytology and transbronchial lung biopsy in three out of five human immunodeficiency virus (HIV) positive adult patients presenting with interstitial pneumonitis. One of these patients was serologically positive for HIV at the time of presentation and the remaining two patients were detected to be HIV positive on follow up after the diagnosis had been established. All the three patients were treated with co-trimoxazole. One patient recovered and was discharged; another patient improved with treatment but died after jugular vein cannulation and the third patient succumbed to cryptosporidial diarrhoea. The remaining two patients with non-specific interstitial pneumonitis treated with prednisolone and bronchodilators were recovered and were discharged from the hospital.

Coronary artery-intramyocardial sinusoid communication in a case of pulmonary atresia with intact ventricular septum

Intramyocardial sinusoid--coronary artery fistulous communications are well established channels in pulmonary atresia with intact ventricular septum. Angiographically flow can be demonstrated from the right ventricular cavity into the coronary arteries. We have histologically demonstrated such a communication in a case of pulmonary atresia with intact septum.

Effective hemodialysis and hemofiltration driven by an extracorporeal membrane oxygenation pump in infants with hyperammonemia

Two infants with urea cycle disorders had life-threatening hyperammonemia within the first 5 days of life. Both patients were small for dates, poorly oxygenated, and hemodynamically unstable. We employed a combination of extracorporeal oxygenation and hemodialysis to provide high-flow filtration in a controlled system to rapidly detoxify both patients.

Balloon mitral valvotomy: an autopsy study

The autopsy findings in 20 patients who died following percutaneous balloon mitral valvotomy are reported. The procedure was attempted in 508 patients. In 17 of the 20 patients, balloon mitral valvotomy was attempted as a salvage procedure. Ten patients died in the immediate post valvotomy period (within 24 h), seven died within a week and three between 1 to 3 months. In 13 patients, the balloon valvotomy successfully opened out one or both commissures. Interatrial septostomy defects created by the transeptal catheter could be identified in 19 of 20 heart specimens. The size of the defects ranged from small (5 mm) openings to large (15 mm) defects especially with double balloon. Marked mitral valvar thickening with nodular calcification was observed in 16 cases. Significant complications leading to mortality included cardiac tamponade (five cases) due to left ventricle apical perforation (3/5 cases). Mitral valve damage in the form of leaflet tears, chordal rupture and long splits in five cases resulted in significant mitral regurgitation. The leaflet tears resulted in detachment of part of the leaflet from the annulus. A late complication noted was infective endocarditis. Associated pulmonary tuberculosis, chronic obstructive pulmonary disease, respiratory infections and multivalvar diseases also contributed to mortality.

Syndrome myxoma: a report of 2 cases

Cardiac myxomas are fascinating tumours because of the protean manifestations associated with them. The complex association of cardiac myxomas, with cutaneous lesions and endocrine overactivity has been recognized. We report two such interesting cases.

Isolated left-sided intracardiac fungal mass

A left-sided fungal (Candidial) intracardiac mass was found at autopsy in a 38-day premature infant with hydrops foetalis. Such a manifestation of systemic candidiasis has not been reported previously.

Persistent truncus arteriosus--an autopsy study of 16 cases

Sixteen specimens of heart with persistent truncus arteriosus were studied to evaluate the anatomic features. Using the Collet and Edwards classification, type I truncus arteriosus was the most frequent (62.5%). Using Van Praagh's classification type A1 was the most common (43.7%). There were two cases which could not be classified according to the Collet and Edwards classification. The truncal valve was tricuspid in 75% of the cases and bicuspid in the remaining 25%. In all 6 cases with interruption of the aorta, the truncal valve was committed to the right ventricle. The ventricular septal defect was subtruncal in all except 1 case. There was variation in the thickness of the posterior limb of the septal band and the ventriculo-infundibular fold. Absence of the ventriculo-infundibular fold in 3 cases led to truncal tricuspid continuity. Right-sided aortic arch and interruption of the aorta were frequently associated arch anomalies.

Direct extension of bronchogenic carcinoma through pulmonary veins into the left atrium mimicking left atrial myxoma

Direct extention of bronchogenic carcinoma via pulmonary veins into the left atrium is rare. We describe two such cases, one which presented as a left atrial mass with pulmonary edema, and another which was detected at autopsy.

Ultrastructural changes in the hippocampal CA1 region following transient cerebral ischemia: evidence against programmed cell death

The ultrastructural changes in the pyramidal neurons of the CA1 region of the hippocampus were studied 6 h, 24 h, 48 h, and 72 h following a transient 10 min period of cerebral ischemia induced by common carotid occlusion combined with hypotension. The pyramidal neurons showed delayed neuronal death (DND), i.e. at 24 h and 48 h postischemia few structural alterations were noted in the light microscope, while at 72 h extensive neuronal degeneration was apparent. The most prominent early ultrastructural changes were polysome disaggregation, and the appearance of electron-dense fluffy dark material associated with tubular saccules. Mitochondria and nuclear elements appeared intact until frank neuronal degeneration. The dark material accumulated with extended periods of recirculation in soma and in the main trunks of proximal dendrites, often beneath the plasma membrane, less frequently in the distal dendrites and seldom in spines. Protein synthesis inhibitors (anisomycin, cycloheximide) and an RNA synthesis inhibitor (actinomycin D), administered by intrahippocampal injections or subcutaneously, did not mitigate neuronal damage. Therefore, DND is probably not apoptosis or a form of programmed cell death. We propose that the dark material accumulating in the postischemic period represents protein complexes, possibly aggregates of proteins or internalized plasma membrane fragments, which may disrupt vital cellular structure and functions, leading to cell death.

The bicuspid aortic valve--an autopsy study

Congenital Bicuspid Aortic Valve is a common congenital anomaly. We studied 48 cases of bicuspid aortic valve seen over a period of 20 years. 18 cases were associated with other congenital anomalies, patent ductus arteriosus being the most frequent. 30 were isolated lesions. The morphology of the cusps and position of raphe were noted. Calcification and infective endocarditis were frequently noted in the isolated forms of Bicuspid Aortic Valve. Coronary arteries were dissected in 32 cases to determine the dominance.

Single ventricle (morphologic study of 21 cases)

The morphological characters of 21 cases of single ventricle which constituted 1.63% of cases of congenital heart disease were studied. The single ventricular chamber with left ventricular characters was seen in 11 cases. In 8 of these, the great vessels were transposed with aorta arising from outlet chamber (SLL-7:SDD-1). Except in one case where there was common A-V valve, two A-V valve, two A-V valves entered the main chamber with some abnormality of A-V valves in all the cases. Bulbo-ventricular foramen was obstructive in 6 cases with resultant hypoplasia of aorta. Aortic arch anomalies were present in 5 of these. Valvular pulmonary stenosis was present in two. In 3 cases with normally related great vessels (SDS), bulbo-ventricular foramen was obstructive in two with hypoplastic pulmonary artery. Abnormalities of A-V valves were similar to the previous group. The incidence of single right ventricle was high in this series (47%). In half the cases, there was associated asplenia syndrome. This group in general showed common atrium with exception of one case, common A-V canal, both great vessels arising from same outflow with atrophic conal septum. Anomalies of pulmonary veins were common. The subsets observed were ADD-3, ADL-1, AL single trunk-1. In the remaining cases without asplenia, both A-V valves were present though some abnormalities were present in all. Systemic and pulmonary venous anomalies were rare. The subsets observed were SLL-3, SDL-1, SDD-1.(ABSTRACT TRUNCATED AT 250 WORDS)

Congenital aneurysms of the sinus of Valsalva with dissection into the interventricular septum

Four cases of congenital aneurysm of sinus of Valsalva (CASV) with rupture and dissection into the intraventricular septum are described. Their incidence (26.6%) in 15 consecutive cases of CASV is unusually high. Only one of these showed secondary rupture into the left ventricle. If these aneurysms remain unruptured, their diagnosis during life is difficult as in the case of other unruptured aneurysms of CASV. The occurrence of conduction abnormalities in young patients should be one of the indications, and 2-D echocardiography would help to arrive at a definite diagnosis and aid in the institution of appropriate surgical treatment.