A practical evidence-based approach to management of type 2 diabetes in children and young people (CYP): UK consensus

BACKGROUND

Type 2 diabetes in young people is an aggressive disease with a greater risk of complications leading to increased morbidity and mortality during the most productive years of life. Prevalence in the UK and globally is rising yet experience in managing this condition is limited. There are no consensus guidelines in the UK for the assessment and management of paediatric type 2 diabetes.

METHODS

Multidisciplinary professionals from The Association of Children's Diabetes Clinicians (ACDC) and the National Type 2 Diabetes Working Group reviewed the evidence base and made recommendations using the Grading Of Recommendations, Assessment, Development and Evaluation (GRADE) methodology.

RESULTS AND DISCUSSION

Young people with type 2 diabetes should be managed within a paediatric diabetes team with close working with adult diabetes specialists, primary care and other paediatric specialties. Diagnosis of diabetes type can be challenging with many overlapping features. Diabetes antibodies may be needed to aid diagnosis. Co-morbidities and complications are frequently present at diagnosis and should be managed holistically. Lifestyle change and metformin are the mainstay of early treatment, with some needing additional basal insulin. GLP1 agonists should be used as second-line agents once early ketosis and symptoms are controlled. Glycaemic control improves microvascular but not cardiovascular risk. Reduction in excess adiposity, smoking prevention, increased physical activity and reduction of hypertension and dyslipidaemia are essential to reduce major adverse cardiovascular events.

CONCLUSIONS

This evidence-based guideline aims to provide a practical approach in managing this condition in the UK.

Peripheral nervous system manifestations of MOG antibody associated disease

Recent studies have reported the involvement of peripheral nervous system (PNS) in association with MOG-IgG, including isolated neuropathies. In this retrospective study we characterized the PNS involvement in MOG antibody associated disease (MOGAD). Six out of 215 MOGAD patients had PNS involvement (all polyradiculopathy) that occurred concurrently with a CNS demyelinating episode. We also demonstrated MOG expression in healthy human controls' proximal nerve root. Nine patients with true-positive MOG-IgG1 had PNS involvement temporally unrelated to a CNS demyelinating event. All these patients had an alternate etiology of PNS involvement. Isolated peripheral neuropathy is not a feature of MOGAD, but inflammatory nerve root involvement can occur concurrently with CNS demyelinating events.

Usefulness of Diagnostic Ultrasound for Detection of Common Shoulder Abnormalities Prior to MRI

Shoulder pain is a common musculoskeletal pain in the general population and results in significant disability, quality of life impairment and financial burden to the health care system. This cross-sectional study was carried out among purposively selected 61 adult patients with shoulder pain and or limited range of motion in the Department of Radiology and Imaging, Mymensingh Medical College Hospital, Mymensingh, Bangladesh from September 2018 to August 2020 to determine the usefulness of USG in detection of common shoulder abnormalities, as an initial imaging modality using MRI as reference standard. The majority of the patients 25(40.98%) were in age group of 51-60 years with mean age of 52.98±10.85 years. In the dectection of rotator cuff pathology, the overall sensitivity, specificity and accuracy of USG for any complete tear were 100.0% each, for any partial tear were 79.71%, 96.57% and 91.80%, for any rotator cuff tear were 83.33%, 96.25% and 91.80%, and for any tendinosis were 90.48%, 99.37% and 96.31% respectively. The sensitivity, specificity and accuracy of USG were 88.23%, 92.59% & 90.16% for long head of biceps tendon sheath effusion, 100.0% each for long head of biceps tendon dislocation, 71.11%, 87.50% and 75.41% for glenohumeral joint effusion, and 58.06%, 96.67% and 77.05% for bursal effusion respectively. From this study, it is concluded that high resolution USG showed high sensitivity, specificity and accuracy compared to MRI in detecting common shoulder abnormalities, and could be considered as the first line imaging modality in the evaluation of shoulder pain.

Nerve Conduction Differences in a Large Clinical Population: The Role of Age and Sex

BACKGROUND

The normal limits of nerve conduction studies are commonly determined by testing healthy subjects. However, in comprehensive real-life nerve conduction electrodiagnostic (EDX) evaluations, multiple nerves are tested, including normal nerves, for purposes of comparison with abnormal ones.

OBJECTIVE

This study aims to evaluate the average values of normal nerve conduction studies in a large population and examined the influence of age and sex.

METHODS

EDX parameters were extracted from an electronic database of studies performed from May 2016 to February 2022. Established normal values were used to determine the classification of a nerve study as normal.

RESULTS

We identified 10,648 EDX reports with 5077 normally interpreted nerve conduction studies (47.6%) of which 57% (n = 2890) were for females. The median age of studies with no abnormalities was 45.1 years (range < 1 to 92) overall and 42.5 years (range: 0.16 -89.5 years) for males and 47.5 years (range:<1 -91.7) for females. Correlations between age and amplitude, latency, and velocity (p < 0.001) were observed in most nerves. Amplitude correlated negatively with age in adults in all nerves with a mean of -0.44 (range: -0.24 to -0.62). However, in the pediatric population (age < 18 years), amplitude as well as velocity increased significantly with age. In the adult cohort, sex differences were noted, where females had higher mean sensory nerve action potentials in ulnar, median, and radial evaluations (p < 0.001). In older patients (aged > 70 years) with normally interpreted EDX studies (845 records of 528 patients), sural responses were present in 97%.

CONCLUSIONS

This real-life study confirms that advanced aging is associated with decreased nerve conduction amplitudes, increased latency, and the slowing of conduction velocity. The findings also indicate higher sensory amplitudes and conduction velocities in females. Sural nerve responses were identified in most adults over age 70.

Clinical and Haematological Findings in Dengue Fever

From 2000 onwards dengue fever has been occurring at regular intervals in Bangladesh. Ultrasonography is a useful diagnostic procedure. This study was done, keeping this background in mind. Objective of this study was to identify the role of ultrasonography as a useful tool in early diagnosis of dengue haemorrhagic fever. This was a cross-sectional descriptive type of observational study. Results of ultrasonography, haematogy an immunology were observed in 2004 and 2019 in 32 patients on each occasion. In 2004 out of 32 patients 29 had positive ultrsonographic findings supported by corresponding haematological and immunological findings. In 2019 ultrsonography was done in three out of thirty two patients, all three had had positive ultra sonographic findings which were supported by haematological and immunological findings. Dengue fever has serious complications like plasma leakage which manifest in the form of ascites, pleural effusion, thick gallbladder wall etc. If such complications can be detected at an early stage many lives can be saved.

Population-Based Epidemiology Study of Paraneoplastic Neurologic Syndromes

OBJECTIVES

Population-based epidemiologic data for paraneoplastic neurologic syndromes (PNSs) in the United States are lacking. Our objective was to evaluate the incidence, prevalence, and associated morbidity of PNS.

METHODS

We performed a population-based epidemiology study in Olmsted County, Minnesota, with patients identified between January 1, 1987, and December 31, 2018, using the medical records linkage system of the Rochester Epidemiology Project (REP) who met the definite/probable 2021 PNS criteria and 2004 PNS criteria. Patients with dermatomyositis and myasthenia gravis with underlying tumors were included. Age- and sex-specific population counts were obtained from REP resources for January 1, 2014 (prevalence denominator) and annually for 1987-2018 (incidence denominator). Morbidity was estimated using disability-adjusted life years (DALYs; years lived with disability [YLD] plus years of life lost [YLL]).

RESULTS

There were 28 patients with PNS identified (50% female) residing in Olmsted County, Minnesota, with median age at diagnosis of 54.5 (IQR 46.5-69.0) years. All patients had a cancer diagnosis, and 18 (64%) patients were neural autoantibody positive including antineuronal nuclear autoantibody type 1 (ANNA-1/anti-Hu; n = 1), ANNA-2/anti-Ri (n = 1), muscle-type acetylcholine receptor (AChR; n = 6), Purkinje cell cytoplasmic antibody type 1 (PCA-1/anti-Yo; n = 1), kelch-like protein 11 (KLH11; n = 3), collapsin response mediator protein 5 (CRMP-5/anti-CV2; n = 2), α-amino-3-hydroxy-5-methyl-4-isoxazole propionic acid receptor (n = 1), neurofilament light chain (n = 1), leucine zipper 4 (LUZP4; n = 1), and unclassified neural antibodies (n = 1). PNS incidence was 0.6/100,000 person-years and increased over time from 0.4/100,000 person-years (1987-2002) to 0.8/100,000 person-years (2003-2018) (p = 0.06). Prevalence was 5.4/100,000 people. The median follow-up period after PNS diagnosis was 3.1 years (IQR, 1.1-9.9 years). Total disability-adjusted life years (DALYs) for 28 patients with PNS were 472.7 years, based on total years of life lost (YLL) for patients dying between 1987 and 2018 (n = 15) of 445.3 years plus years lived with disability (YLD) 27.4 years.

DISCUSSION

PNSs are rare neurologic disorders but are associated with severe morbidity and mortality. The estimated number of prevalent PNS cases in the United States is 17,099, and predicted DALY for all US PNS cases is 292,393 years. Their apparent increasing rate of detection is attributable to increasing physician awareness and availability of serologic testing.

Incidence and Prevalence of Immune-mediated Necrotizing Myopathy in Adults in Olmsted County, Minnesota

INTRODUCTION/AIMS

Immune-mediated necrotizing myopathy (IMNM) is considered a rare subtype of the immune-mediated myopathies, but its incidence and prevalence are unknown. This study aimed to determine the incidence and prevalence of IMNM in the adults in Olmsted County, Minnesota.

METHODS

We identified adult patients with IMNM defined by the 2016 European Neuromuscular Centre diagnostic criteria among Olmsted County, Minnesota, residents over a 20-year period RESULTS: Seven patients fulfilled the inclusion criteria. Six patients were tested for IMNM antibodies: 4 were anti 3-Hydroxy-3-Methylglutaryl-CoA Reductase (HMGCR)-positive, 1 was anti-signal recognition particle (SRP)-positive and 1 was seronegative. The incidence of IMNM during 2010-2019 was 8.3 per million person-years. The prevalence of IMNM in 2010 was 1.85 per 100,000 people ≥50 years. Median age at symptom onset was 64 years (range: 52-86) and median time from symptom onset to diagnosis was 3 months (range <1-156). Statin use among anti-HMGCR IMNM patients, but not the entire IMNM cohort, was higher than in controls (P=0.024). Two IMNM patients developed cancers. The incidence of malignancy in IMNM was not higher than that of the general population. Treatment outcome was favorable in all patients except for 1 with delayed treatment and one with insufficient therapy. Among 3 deceased patients, 1 died from cancer while 2 died from IMNM-related cardiorespiratory complications.

DISCUSSION

IMNM is a rare disease. Its prevalence is one tenth that of inclusion body myositis in Olmsted County, Minnesota. IMNM patients in our cohort were not at higher risk for developing cancer.

Neurofascin-155 Immunoglobulin Subtypes: Clinicopathologic Associations and Neurologic Outcomes

BACKGROUND AND OBJECTIVE

Multiple studies highlighting diagnostic utility of neurofascin 155 (NF155)-IgG4 in chronic demyelinating inflammatory polyradiculoneuropathy (CIDP) have been published. However, few studies comprehensively address the long-term outcomes, or clinical utility of NF155-IgM or NF155-IgG, in the absence of NF155-IgG4. In this study we evaluate phenotypic and histopathological specificity, and differences in outcomes between these NF155 antibody isotypes or IgG subclasses. We also compare NF155-IgG4 seropositive cases to other seropositive demyelinating neuropathies.

METHODS

In this study, neuropathy patient sera seen at Mayo Clinic were tested for NF155-IgG4, NF155-IgG and NF155-IgM autoantibodies. Demographic and clinical data of all seropositive cases were reviewed.

RESULTS

We identified 32 NF155 patients (25 NF155-IgG positive [20 NF155-IgG4 positive], 7 NF155-IgM seropositive). NF155-IgG4 seropositive patients clinically presented with distal more than proximal muscle weakness, positive sensory symptoms (prickling, asymmetric paresthesia, neuropathic pain) and gait ataxia. Cranial nerve involvement (11/20, 55%) and papilledema (4/12, 33%) occurred in many. Electrodiagnostic testing (EDX) demonstrated demyelinating polyradiculoneuropathy (19/20, 95%). Autonomic involvement occurred in 45% (n=9, median CASS score 3.5, range 1-7). Nerve biopsies from the NF155-IgG4 patients (n=11) demonstrated grouped segmental demyelination (50%), myelin reduplication (45%) and paranodal swellings (50%). Most patients needed 2^nd and 3^rd line immunosuppression but had favorable long-term outcomes (n=18). Among 14 patients with serial EDX over 2 years, all except one demonstrated improvement after treatment. NF155-IgG positive NF155-IgG4 negative (NF155-IgG positive) and NF155-IgM positive patients were phenotypically different from NF155-IgG4 seropositive patients. Sensory ataxia, neuropathic pain, cerebellar dysfunction and root/plexus MRI abnormalities were significantly more common in NF155-IgG4 positive compared to MAG-IgM neuropathy. Chronic immune sensory polyradiculopathy (CISP)/CISP-plus phenotype was more common among Contactin-1 neuropathies compared to NF155-IgG4 positive cases. NF155-IgG4 positive cases responded favorably to immunotherapy compared to MAG-IgM seropositive cases with distal acquired demyelinating symmetric neuropathy (p<0.001) and had better long-term clinical outcomes compared to contactin-1 IgG (p=0.04).

DISCUSSION

We report long-term follow-up and clinical outcome of NF155-IgG4 patients. NF155-IgG4 but not IgM or IgG patients have unique clinical-electrodiagnostic signature. We demonstrate NF155-IgG4 positive patients, unlike classical CIDP with neuropathic pain and dysautonomia common at presentation. Long-term outcomes were favorable.

CLASSIFICATION OF EVIDENCE

This study provides Class III evidence that NF155-IgG4 seropositive patients, compared to typical CIDP patients, present with distal more than proximal muscle weakness, positive sensory symptoms, and gait ataxia.

Prevalence of disorders in preweaned dairy calves from 731 dairies in Germany: A cross-sectional study

The objective of this cross-sectional study was to determine the prevalence of disorders in preweaned calves in 3 regions in Germany, exemplary for structural diversity in dairy farming. A farm visit was performed on a single occasion on 731 dairy farms in the northern, eastern, and southern regions of Germany between December 2016 and July 2019. Farms differed in herd size, geographical location, and management. In the northern region, the farms had a median of 90 milking cows and were often run as full-time family businesses, partly with external workers. The eastern region tended to have larger farms (a median of 251 milking cows), which were often large-scale agricultural enterprises with employees. In the southern region, the farms had a median of 39 milking cows and were often traditional family businesses, some of these being part-time businesses. Clinical examinations were performed on 14,164 preweaned dairy calves (median 12 calves per farm) by trained veterinarians. A complete data set was available for 13,656 calves. Almost half (42.0%) of the evaluated calves were classified as being affected by at least 1 of the common calf disorders. Omphalitis (O, 20.9%; n = 2,876) and diarrhea (D, 18.5%; n = 2,670) were the most frequently recorded diagnoses, whereas respiratory diseases (RD) were observed to a lesser extent (8.7%; n = 1,100). A striking feature was the fact that 7.1% (n = 987) of the calves were affected by more than 1 disorder at the same time (multimorbidity, M). The following combinations of disorders were frequently observed: O and D (n = 596), O and RD (n = 164), and D and RD (n = 140). Disorders such as O and D, as well as M, were predominantly observed in calves aged 2 wk. A gradual increase in the frequency of RD was observed with age. For all disorders except RD, male calves were more often affected than females. Omphalitis was predominantly diagnosed in the summer months, whereas RD, D, and M were more common in the fall. We detected several statistically significant differences in the prevalence of clinical signs and disorders in preweaned dairy calves between the 3 exemplary regions. The prevalence of RD was higher in the south (10.8%) than in the north (8.2%) and east (7.4%). In the north (33.2%), O was observed more frequently than in the other regions (east: 18.9%; south: 10.5%), whereas D was found less frequently in the north (13.8%) than in the east (21.6%) and south (20.0%).

Ranolazine-induced lipid storage myopathy presenting with respiratory failure and head drop

Ranolazine is an anti-ischemic drug often used along with statins in patients with ischemic heart disease. Ranolazine-induced proximal myopathy or rhabdomyolysis have been rarely reported, but toxic effects of statins could not be completely ruled out in those cases. We report a 68-year-old man with ranolazine-induced myopathy who presented with respiratory insufficiency and head drop. Creatine kinase level was normal. The Patient continued to worsen despite statin cessation but markedly improved after stopping ranolazine. Muscle biopsy showed excessive lipid accumulation predominantly in type 1 myofibers. The precise mechanism of toxicity is not clear. Treating physicians should be aware of this rare but potentially debilitating adverse effect of ranolazine. Prognosis is good upon discontinuation of the offending drug.

Expanding the Spectrum of Chronic Immune Sensory Polyradiculopathy: CISP-Plus

Objective

Sensory loss with normal nerve conduction studies (NCS) from focal sensory root inflammatory demyelination is characteristic of chronic immune sensory polyradiculopathy (CISP). However, nonpure cases involving motor and distal sensory nerves exist (CISP-plus). We hypothesize that CISP-plus and CISP are fundamentally part of the same syndrome through comparison of clinical, neurophysiologic, and pathologic features.

Methods

CISP-plus (primary dorsal root with lesser motor and sensory nerve involvement) and CISP cases were retrospectively analyzed (1986–2019).

Results

We identified 44 CISP-plus and 28 CISP cases (n = 72) with 86% (38/44) of patients with CISP-plus and 79% (22/28) of patients with CISP experiencing imbalance. On examination, large fiber sensory loss was present in 98% (43/44) of patients with CISP-plus and 96% (27/28) of patients with CISP. Gait ataxia was evident in 93% (41/44) of patients with CISP-plus and 79% (22/28) of patients with CISP. Mild distal weakness was common in CISP-plus (75%, 33/44). NCS showed mild abnormalities in all patients with CISP-plus and were normal (by definition) in all patients with CISP. Elevated CSF protein, slowing of somatosensory evoked potentials, and MRI root enhancement occurred in most CISP-plus and CISP cases. Eleven CISP-plus nerve biopsies showed loss of large myelinated fibers and onion-bulb formations, most prominent in rootlet biopsies. Immunotherapy resulted in marked improvement of gait ataxia in 84% (27/32) of patients with CISP-plus and 93% (13/14) of patients with CISP with return to normal neurologic examination in half (25/46).

Conclusion

The recognition of CISP-plus expands the spectrum of CIDP by combining CISP-plus (predominant sensory polyradiculopathy with mild motor and sensory nerve involvement) with pure CISP (focal sensory polyradiculopathy) together as proximal sensory CIDP.

Paraneoplastic neurological syndrome: an evolving story

Paraneoplastic neurological syndrome (PNS) comprises a group of neurological disorders that result from a misguided immune response to the nervous system triggered by a distant tumor. These disorders frequently manifest before the diagnosis of the underlying neoplasm. Since the first reported case in 1888 by Oppenheim, the knowledge in this area has evolved rapidly. Several classic PNS have been described, such as limbic encephalitis, paraneoplastic cerebellar degeneration, encephalomyelitis, opsoclonus-myoclonus, sensory neuronopathy, Lambert-Eaton Myasthenic syndrome, and chronic gastrointestinal dysmotility. It is now recognized that PNS can have varied nonclassical manifestations that extend beyond the traditional syndromic descriptions. Multiple onconeural antibodies with high specificity for certain tumor types and neurological phenotypes have been discovered over the past 3 decades. Increasing use of immune checkpoint inhibitors (ICIs) has led to increased recognition of neurologic ICI-related adverse events. Some of these resemble PNS. In this article, we review the clinical, oncologic, and immunopathogenic associations of PNS.

Chloroquine and Hydroxychloroquine Myopathy: Clinical Spectrum and Treatment Outcomes

Chloroquine (CQ) and hydroxychloroquine (HCQ) have been associated with muscle toxicity, mostly described as a proximal myopathy with evidence of lysosomal dysfunction on muscle biopsy. In this retrospective study, we aimed to define the clinical phenotype, laboratory features, and treatment outcomes of CQ/HCQ myopathy, as well as the safety profile of these drugs. We identified 13 patients seen between 2000 and 2019, with a median age at presentation of 66 years (range 53–89); 11 were females. At onset of symptoms, patients were on CQ or HCQ for a minimum of 6 months and up to 21 years. Diagnosis was often delayed by a median of 6 months (range 3–48). At presentation, 13 patients reported limb weakness, with five requiring assistance in walking. Ten reported dysphagia, often severe, resulting in marked weight loss or aspiration pneumonia. Nine reported respiratory symptoms, which were multifactorial in four, and four reported severe neck weakness. Myopathy clinical phenotype showed predominant involvement of one or more of the following: proximal limb muscle weakness (12 patients), dysphagia (9), axial weakness (4), and respiratory failure (5). Eleven patients had a cardiac evaluation showing prolonged QT interval in 10 and CQ/HCQ cardiomyopathy (CMP) in four. Ten out of 12 patients markedly improved after discontinuing the medication, but most were left with some residual weakness. Eleven patients had a muscle biopsy showing a myopathy with rimmed vacuoles and marked acid phosphatase reactivity. Nine had elevated creatine kinase level up to 1,199 U/L. Twelve patients had an electromyography (EMG), which showed myopathic motor unit potentials with fibrillation potentials in 11 and myotonic discharges in 3. Higher cumulative dose and longer exposure duration were associated with more severe disability and more common cardiac and swallow involvement, indicating a cumulative dose effect. Herein, we demonstrate that long-term exposure to CQ and HCQ may result in a myopathy with a wide spectrum of clinical presentation and predilection for swallowing, respiratory, and cardiac muscles, often with marked associated morbidity. Once accurately diagnosed and the drug is discontinued, patients usually improve but often fail to return to baseline.

Anti-cN1A antibodies do not correlate with specific clinical, electromyographic, or pathological findings in sporadic inclusion body myositis

BACKGROUND

Anti-cytosolic 5'-nucleotidase 1A (cN1A) antibodies are commonly detected in patients with sporadic inclusion body myositis (sIBM). However, their pathogenic role has not been established. Moreover, efforts toward identifying sIBM distinct clinicopathologic characteristics associated with these antibodies have yielded conflicting results.

METHODS

We first searched for patients, seen in our clinics, tested for anti-cN1A antibodies between December 2015 and December 2019. We identified 92 patients who were diagnosed with sIBM, according to the 2011 ENMC or Griggs et al criteria. Thereafter, we reviewed and compared the clinical and investigational findings of these patients in relation to their antibody status.

RESULTS

Anti-cN1A antibodies were present in 47/92 (51%) patients with sIBM. Comparison of seropositive and seronegative cohorts yielded no significant difference in clinical features, including facial weakness, oropharyngeal and respiratory involvement, or disease severity. The antibody titer did not correlate with the clinical phenotype, CK value, or presence of myotonic discharges on EMG. Anti-cN1A antibody positive patients appeared to have more frequent auto-aggressive inflammation on muscle biopsy but not as an isolated myopathological feature.

CONCLUSIONS

Our study showed that anti-cN1A antibody positive and negative sIBM patients have similar clinical features and disease severity. Anti-cN1A antibodies in our sIBM cohort did not correlate with any studied clinical or laboratory parameter and, therefore, were of limited value in the patient's assessment.

Improving accuracy of myasthenia gravis autoantibody testing by reflex algorithm

OBJECTIVE

To improve myasthenia gravis (MG) autoantibody testing.

METHODS

MG serologic tests with confirmatory or refuting clinical-electrodiagnostic (EDX) testing and cancer evaluations were reviewed over 4 years (2012-2015). All patients had acetylcholine receptor-binding (AChR-Bi), modulating (AChR-Mo), and striational (STR) autoantibody testing, and negatives reflexed to muscle-specific kinase (MuSK). Thymoma and cancer occurrences were correlated with STR and reflexed glutamic acid decarboxylase 65 (GAD65), ganglionic acetylcholine receptor (α3), collapsin response mediating protein-5, and voltage-gated potassium channel complex autoantibodies.

RESULTS

Of 433 samples tested, 133 (31%) met clinical-EDX criteria for MG. Best sensitivity (90%) occurred at AChR-Bi >0.02 nmol/L, leaving 14 negative (6 ocular MG, 7 generalized MG, 1 MuSK MG) with specificity 90% (31 false-positives). Using AChR-Mo antibodies (>20% loss), specificity was better (92%, 24 false-positives), but sensitivity dropped (85%). Specificity improved (95%) by testing AChR-Mo when AChR-Bi are positive, resulting in 45% reduction of false-positives (31-17), maintaining AChR-Bi 90% sensitivity. Cutoff values recommended by area under the curve analysis did not outperform this approach. AChR-Bi and AChR-Mo values were significantly higher in true-positives. CT evaluations in 121 MG samples revealed 16 thymomas. Historical or subsequent cancers occurred in 22. STR and reflexed autoantibodies were not more common in MG with thymoma or other cancers. Full-body CT (n = 34) was performed in those with STR and reflex autoantibody positivity, but without additional cancers found.

CONCLUSION

Accuracy of MG serologic testing is improved by reflexing AChR-Bi-positive cases to AChR-Mo. STR and other reflexed cancer evaluation autoantibodies did not provide value beyond standard CT chest imaging at the time of MG diagnosis. Diagnostic certainty is informed by AChR-Bi and AChR-Mo with higher values increasing specificity.

Relation of Hepatic Venous Doppler Sonography and Portal Flowmetry in Determination of Severity of Esophageal Varices in Liver Cirrhosis

Cirrhotic patients have hepatic vein waveform abnormalities (HVWA). Both Doppler ultrasonography of hepatic venous wave form (HVWF) and portal Doppler flowmetry (PDF) can non invasively recognize hepatic vein wave form abnormalities and determine severity of esophageal varices. Here we applied cross sectional study and found out the relation between HVWF and PDF and duration of the study from July 2016 to June 2017 in a tertiary Medical College Hospital, Bangladesh. 49 purposively taken diagnosed, hospital admitted, cirrhotic patients were included. Face to face interview and reviewing of records were the source of data and it was analyzed by SPSS windows version-12 software programs. At first, local ethical committee approved the study protocol, p<0.05 was statistically significant and 95% was confidence interval. Esophagogastroduodenoscopy is the gold standard for the diagnosis of esophageal varices. Alternative diagnostic investigations would be either HVWF or PDF. HVWF were normal triphasic. Abnormal biphasic and monophasic PDF consisted of the maximum values of portal flow velocity, portal vein flow volume, diameter of the portal vein, and congestion index. Small and large varices were the easiest form of endoscopic grading of esophageal varices. No clinical or echocardiographic feature of right sided heart failure had found in any patient. Both HVWF and PDF can certainly demonstrate the presence of varices but only HVWF detected severity of esophageal varices - monophasic wave (60.47%) in Doppler USG which signified (<0.05) large varices (67.44%) in endoscopy and in biphasic wave (31.53%) in Doppler USG which signified small varices (32.66%) in endoscopy. Patients who developed varices had portal vein diameter (PVD) and congestion index (CI) were higher (p<0.02) and portal vein velocity (PVV) was lower (p<0.05) than whom did not develop varices, but severity of varices could not be detected. Portal vein flow volume (PVFV) did not signify the presence or severity of varices. Moderately positive correlation (correlation co-efficient was 0.0064) was found between Doppler USG of HVWF and esophagogastroduodenoscopic in severity detection varices. In determination of severity of esophageal varices in patients with liver cirrhosis Hepatic venous Doppler sonography plays more vital role than PDF.

Transmigrated and Impacted Upper 2nd Premolar Associated with Dentigerous Cyst

A male patient about 45 years old came to my private clinic "The Dental Aid", Dhanmondi, Dhaka, Bangladesh last year (February 2016) with the complaint of pain at right palatal premolar region. On clinical examination we found the absence of upper left 2nd premolar from the series of dentition but on the right side premolars are present. The oral mucosa was intact and normal in color. There was no caries, dental pocket or any other pathology in the teeth of both jaws. On palpation we found soft area on the right palatal side at the premolar area. We took intraoral peri-apical radiograph and found impacted left 2nd premolar whose crown was encircled by radiolucent area at the palatal side. Here, we present a rare case of transmigrated and impacted left 2nd maxillary premolar associated with dentigerous cyst. The cyst was successfully treated under general anaesthesia by enucleation along with extraction of the involved maxillary transposed and impacted left second premolar.

A Type 1 Diabetes Genetic Risk Score Predicts Progression of Islet Autoimmunity and Development of Type 1 Diabetes in Individuals at Risk

OBJECTIVE

We tested the ability of a type 1 diabetes (T1D) genetic risk score (GRS) to predict progression of islet autoimmunity and T1D in at-risk individuals.

RESEARCH DESIGN AND METHODS

We studied the 1,244 TrialNet Pathway to Prevention study participants (T1D patients' relatives without diabetes and with one or more positive autoantibodies) who were genotyped with Illumina ImmunoChip (median [range] age at initial autoantibody determination 11.1 years [1.2-51.8], 48% male, 80.5% non-Hispanic white, median follow-up 5.4 years). Of 291 participants with a single positive autoantibody at screening, 157 converted to multiple autoantibody positivity and 55 developed diabetes. Of 953 participants with multiple positive autoantibodies at screening, 419 developed diabetes. We calculated the T1D GRS from 30 T1D-associated single nucleotide polymorphisms. We used multivariable Cox regression models, time-dependent receiver operating characteristic curves, and area under the curve (AUC) measures to evaluate prognostic utility of T1D GRS, age, sex, Diabetes Prevention Trial-Type 1 (DPT-1) Risk Score, positive autoantibody number or type, HLA DR3/DR4-DQ8 status, and race/ethnicity. We used recursive partitioning analyses to identify cut points in continuous variables.

RESULTS

Higher T1D GRS significantly increased the rate of progression to T1D adjusting for DPT-1 Risk Score, age, number of positive autoantibodies, sex, and ethnicity (hazard ratio [HR] 1.29 for a 0.05 increase, 95% CI 1.06-1.6; P = 0.011). Progression to T1D was best predicted by a combined model with GRS, number of positive autoantibodies, DPT-1 Risk Score, and age (7-year time-integrated AUC = 0.79, 5-year AUC = 0.73). Higher GRS was significantly associated with increased progression rate from single to multiple positive autoantibodies after adjusting for age, autoantibody type, ethnicity, and sex (HR 2.27 for GRS >0.295, 95% CI 1.47-3.51; P = 0.0002).

CONCLUSIONS

The T1D GRS independently predicts progression to T1D and improves prediction along T1D stages in autoantibody-positive relatives.

Magnetic Resonance Imaging in Evaluation of Sinonasal Masses with Histopathological Correlation

Sinonasal mass is the abnormal growth of tissue from nasal cavity and mucosa of the paranasal sinuses. The growth may be benign or malignant. The benign lesion grows slowly and does not metastasize. The malignant lesion grows rapidly and metastasizes early. The aim of this study is to evaluate and diagnose the various types of sinonasal masses with MRI and its correlation with histopathological findings. This cross sectional descriptive study was carried out for a period of 02 years, from July 2015 to June 2017. The patients were selected from the ENT outpatient department and from the department Radiology & Imaging of Mymensingh Medical College Hospital, Mymensingh, Bangladesh who were reported as case of sinonasal masses. Thirty three (33) patients (17 males and 16 females) with sinonasal masses were included after fulfilling exclusion & inclusion criteria which was confirmed by proper clinical examination & were subjected to MRI and histopathological examination. The age range was 11 to 85 years. The nasal cavity was the most commonly involved site with sinonasal malignancies (were 4 cases, 12.12%) followed by the maxillary sinuses (were 2 cases, 6.06%). The least commonly affected site was the frontal sinuses (was 1 case, 3.03%). Histopathological findings shows benign sinonasal tumors were present in 25 cases. The most common benign lesion was sinonasal polyposis 10 cases (30.30%), followed by inverted papilloma 6 cases (18.18%) & juvenile nasopharyngeal angiofibroma 6 cases (18.18%), adenoma 02 cases (6.06%), and one case was rhinosporidiosis (3.03%). Malignant sinonasal tumors were present in 8 cases. Most common malignant tumors were nasopharyngeal carcinoma in 4 cases (12.12%), adenoid cystic carcinoma in 3 cases (9.09%) and non-Hodgkin lymphoma was present in 01 case (3.03%). MRI report shows benign masses in 23 cases of which nasopharyngeal polyposis was 10(30.30%), inverted papilloma 6(18.18%), juvenile angiofibroma 4(12.12%), adenoma 02(6.06%) & rhinosporidiosis 1(3.03%). Among 10 malignant tumors nasopharyngeal carcinoma were 6(18.18%), adenoid cystic carcinoma 3(9.09%) & non-Hodgkin lymphoma 1(3.03%). MRI findings of malignant sinonasal masses revealed that sensitivity 87.5%, specificity 40.0%, positive predictive value (PPV) 70% & negative predictive value 66%. Statistically significant association was observed between histopathology & MRI findings, p value was 0.305. Statistically significant association was found between histopathology & MRI findings.

Detection of Ovarian Tumor by Color Doppler Ultrasonography and CA-125

Ovarian cancer is the most frequent cause of death from all gynaecological malignancies because of its insidious onset, vague symptoms and late presentation. This cross-sectional study was carried out on purposively selected 43 patients with suspected ovarian tumor in the Department of Radiology and Imaging in collaboration with the Department of Gynaecology and Obstetrics and Department of Pathology, Mymensingh Medical College Hospital, Bangladesh from January 2015 to December 2016 to assess the diagnostic performance of color Doppler ultrasonography and CA-125 in a combination described as Novel Index in detection of ovarian tumor. Highest number of patients of ovarian tumor 10(23.26%) were in age group 35 to 44 years and 45 to 54 years with a mean of 37.72±15.65 years with a range of 8-70 years. Histopathology findings revealed 19(44.18%) benign tumors and 24(55.82%) malignant tumors. Sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV) and accuracy of Resistance Index (RI) in diagnosis of ovarian tumor were 91.67%, 89.47%, 91.67%, 89.47% and 90.69% respectively. Sensitivity, specificity, PPV, NPV and accuracy of serum CA-125 were 83.33%, 89.47%, 90.90%, 80.95% and 86.04% respectively. Sensitivity, specificity, PPV, NPV and accuracy of Novel index were 95.83%, 89.47%, 92.00%, 94.44% and 93.02% respectively. Novel index showed better diagnostic performance. Based on the current study it is concluded that the combination of color Doppler ultrasonography and serum CA-125 can be useful for diagnosis of ovarian tumor.

Baseline study and risk analysis of landfill leachate - Current state-of-the-science of computer aided approaches

For the successful completion of a risk analysis process, its foundation (i.e. a baseline study) has to be well established. For this purpose, a baseline study needs to be more integrated than ever, particularly when environmental legislation is increasingly becoming stringent and integrated. This research investigates and concludes that no clear evidence of computer models for baseline study has been found in a whole-system and integrated format, which risk assessors could readily and effectively use to underpin risk analyses holistically and yet specifically for landfill leachate. This is established on the basis of investigation of software packages that are particularly closely related to landfills. Holistic baseline study is also defined along with its implications and in the context of risk assessment of landfill leachate. The study also indicates a number of factors and features that need to be added to baseline study in order to render it more integrated thereby enhancing risk analyses for landfill leachate.

Prevalence and Visual Outcomes of Cataract Surgery in Rural South India: A Cross-Sectional Study

PURPOSE

To determine the prevalence of cataract surgery and postoperative vision-related outcomes, especially with respect to sex, socioeconomic status (SES) and site of first contact with eye care, in a rural area of South India.

METHODS

In a population-based cross-sectional survey of 5530 individuals aged 50 years or older from 10 villages selected by cluster sampling, individuals who had undergone cataract surgery in one or both eyes were identified. Consenting participants were administered a questionnaire, underwent vision assessment and ophthalmic examination. Outcomes were classified as good if visual acuity of the operated eye was 6/18 or better, fair if worse than 6/18 but better than or equal to 6/60, and poor if worse than 6/60.

RESULTS

Prevalence of cataract surgery in this age group (771 persons) was 13.9% (95% confidence interval, CI, 13.0-14.9%). In the 1112 eyes of 749 persons studied, at presentation, 53.1% (95% CI 50.1-56.1%) of operated eyes had good, 38.1% (95% CI 35.2-41.0%) had fair, and 8.8% (95% CI 7.1-10.5%) had poor outcomes. With pinhole, 75.2% (95% CI 72.6-77.8%) had good, 17.2% (95% CI 14.9-19.5%) had fair, and 7.4% (95% CI 5.8-9.0%) had poor outcomes. In 76.3% of eyes with fair and poor presenting outcomes we detected an avoidable cause for the suboptimal visual acuity. Place of surgery and duration since surgery of 3 years or more were risk factors for blindness, while SES, sex and site of first eye care contact were not.

CONCLUSION

The high prevalence of avoidable causes of visual impairment in this rural setting indicates the scope for preventive strategies.

Autophagy and Mammalian Viruses: Roles in Immune Response, Viral Replication, and Beyond

Autophagy is an important cellular catabolic process conserved from yeast to man. Double-membrane vesicles deliver their cargo to the lysosome for degradation. Hence, autophagy is one of the key mechanisms mammalian cells deploy to rid themselves of intracellular pathogens including viruses. However, autophagy serves many more functions during viral infection. First, it regulates the immune response through selective degradation of immune components, thus preventing possibly harmful overactivation and inflammation. Additionally, it delivers virus-derived antigens to antigen-loading compartments for presentation to T lymphocytes. Second, it might take an active part in the viral life cycle by, eg, facilitating its release from cells. Lastly, in the constant arms race between host and virus, autophagy is often hijacked by viruses and manipulated to their own advantage. In this review, we will highlight key steps during viral infection in which autophagy plays a role. We have selected some exemplary viruses and will describe the molecular mechanisms behind their intricate relationship with the autophagic machinery, a result of host-pathogen coevolution.

UK service level audit of insulin pump therapy in paediatrics

AIM

To conduct an audit of insulin pump therapy in the UK after the issue of guidelines for the use of continuous subcutaneous insulin infusion by NICE in 2008 (Technology Appraisal 151).

METHODS

All centres in the UK, providing pump services to children and young people were invited to participate in an online audit. Audit metrics were aligned to NICE Technology Appraisal 151 and an electronic data collection tool was used.

RESULTS

Of the 176 UK centres identified as providing pump services, 166 (94.3%) participated in the study. A total of 5094 children and young people were identified as using continuous subcutaneous insulin infusion (19% of all paediatric patients with Type 1 diabetes), with a median (range) of 16.9 (0.67-69.4)% per centre. Units had a median of 0.58 consultant sessions, 0.43 full-time equivalent diabetic specialist nurses, and 0.1 full-time equivalent dieticians delivering the pump service. The majority of this time was not formally funded. Families could access 24-h clinical and technical support (83% units), although the delivery varied between consultant, diabetic specialist nurse and company representatives. Only 53% of units ran, or accessed, structured education programmes for continuous subcutaneous insulin infusion use. Most units (86%) allowed continuous subcutaneous insulin infusion use for paediatric inpatients, but only 56% had written guidelines for this scenario. Nine percent of units had encountered funding refusal for a patient fulfilling NICE (Technology Appraisal 151) criteria.

CONCLUSION

The number of children and young people on continuous subcutaneous insulin infusion therapy is consistent with numbers estimated by NICE. There is a worrying lack of funded healthcare professional time. The audit also identified gaps in the provision of structured education and absence of written inpatient guidelines.

The U.K. service level audit of insulin pump therapy in adults

AIMS

The National Institute for Health and Clinical Excellence (NICE) published guidelines for the use of continuous subcutaneous insulin infusion in 2008 (technology appraisal 151). The first U.K.-wide insulin pump audit took place in 2012 with the aim of determining adherence to the guidance issued in NICE technology appraisal 151. The results of the adult service level audit are reported here.

METHODS

All centres providing continuous subcutaneous insulin infusion services to adults with diabetes in the U.K. were invited to participate. Audit metrics were aligned to technology appraisal 151. Data entry took place online using a DiabetesE formatted data collection tool.

RESULTS

One hundred and eighty-three centres were identified as delivering adult continuous subcutaneous insulin infusion services in the U.K., of which 178 (97.3%) participated in the audit. At the time of the audit, 13 428 adults were using insulin pump therapy, giving an estimated prevalence of use of 6%. Ninety-three per cent of centres did not report any barriers in obtaining funding for patients who fulfilled NICE criteria. The mean number of consultant programmed activities dedicated to continuous subcutaneous insulin infusion services was 0.96 (range 0-8), mean whole-time equivalent diabetes specialist nurses was 0.62 (range 0-3) and mean whole-time equivalent dietitian services was 0.3 (range 0-2), of which 39, 61 and 60%, respectively, were not formally funded.

CONCLUSIONS

The prevalence of continuous subcutaneous insulin infusion use in the U.K. falls well below the expectation of NICE (15-20%) and that of other European countries (> 15%) and the U.S.A. (40%). This may be attributable, in part, to lack of healthcare professional time needed for identification and training of new pump therapy users.

Profile of levodopa-induced dyskinesia in patients of Parkinson's disease: a record based study

OBJECTIVES

Levodopa-induced dyskinesia (LID) is one of the most disabling complications of long-term pharmacotherapy of Parkinson's disease (PD). The objective of our study was to examine the clinical profile and determinants of severity of LID in Indian PD patients on levodopa therapy.

METHODS

Retrospective analysis of records of PD patients with LID was performed. All patients were on levodopa and carbidopa combination. Records of subjects with complete information about disease profile, drug intake, and dyskinesia were analyzed. Characterization of LID was based on responses to part IV of unified Parkinson's disease rating scale (UPDRS).

RESULTS

Records of 42 patients (M∶F  =  4·6∶1) were analyzed. The median Hoehn and Yahr (H&Y) stage was 2·5 while median duration of levodopa therapy was 6·16 years (range: 1·91-14·58). Early morning dystonia was reported by 97·6% of the patients. Patients treated with ≧2 concomitant PD medication reported a significantly lower median UPDRS IV A score compared to patients treated with <2 number of concomitant drugs. A trend toward a lower UPDRS IV A score was associated with use of dopamine agonists (DA). Patients with H&Y score ≧3 had a significantly higher median total UPDRS IV A score than patients with H&Y score <3.

DISCUSSION

Early morning dystonia might be more common among Indian patients of LID. Use of a higher number of concomitant PD medications alongside levodopa is associated with a reduced severity of dyskinesia, even on prolonged use. Levodopa-induced dyskinesia is not only a drug-related phenomenon but the stage of PD itself also affects the dyskinesia severity.

General practitioners' knowledge of whiplash guidelines improved with online education

OBJECTIVE

The primary objective of this study was to evaluate the effect of an online education program used to implement the Australian (New South Wales) whiplash guidelines with general practitioners (GP). The secondary aim was to identify factors associated with learning.

METHODS

An online educational and evaluation activity was developed to reflect the key messages for GP from the Australian whiplash guidelines. The educational activity was hosted on the Royal Australian College of General Practitioners' website (www.gplearning.com.au) for a period of 3 years. Participants were recruited through advertisement and media releases. Participants completed a baseline evaluation of their knowledge, participated in the interactive educational activity and completed a post-knowledge questionnaire. The primary outcome was change in professional knowledge, predictors of learning were computed using linear regression.

RESULTS

Two hundred and fifteen GP participated. Knowledge significantly improved between baseline and post-knowledge questionnaire scores (P < 0.00001). A total of 57.2% of participants improved their knowledge by more than 20%, indicating a large effect. Low baseline knowledge predicted learning, accounting for 71% of the variance.

CONCLUSIONS

Online education of GP significantly improved their knowledge in relation to guidelines for whiplash. Those with low baseline knowledge improved their knowledge the most, suggesting that implementation strategies should be targeted at this group.

Literature review of baseline study for risk analysis - the landfill leachate case

There is growing awareness and public concern about environmental impacts of waste management and disposal. Environmental policy instruments have been strengthened and associated governmental programmes have increased in recent years, resulting in high level strategies for waste management. Risk assessment is now an essential tool in the prioritisation of environmental and human health protection. However, regulators need to compare the full range of risks on a sound and consistent basis. Comparing risks from such diverse sources poses a significant challenge, and traditional hazard and risk assessments are no longer sufficient. Consideration now needs to be given to a much wider range of factors if risk assessment is to be used as an aid to more integrated decision-making process. For this purpose, baseline study - the foundation of risk assessment - can play a crucial role. To date limited research has been conducted on the need, parameters, requirements, and constituents of baseline study particularly in the context of how, why, and what information is to be collated in order to render risk assessments more appropriately integrated and complete. To establish the 'state-of-the-art' of baseline study, this paper comprehensively reviews the literature regarding environmental risk assessment in general terms, and then proceeds to review work that is specifically related to landfills and landfill leachate, thereby identifying knowledge gaps and shortfall areas. This review concludes that a holistic baseline study procedure for waste disposal sites, which risk assessors could use for carrying out risk analyses specifically for landfill leachate, does not as yet exist.