Are metabolic syndrome, obstructive sleep apnoea & syndrome Z sequential?--a hypothesis

BACKGROUND & OBJECTIVES

The metabolic syndrome (MS) is a risk factor for development of cardiovascular disease and is closely associated with obstructive sleep apnoea (OSA). Co-occurrence of both OSA and MS is called syndrome Z. It has been hypothesized that the OSA may be a manifestation of MS. We collected data on polysomnography (PSG) and biochemical investigations on middle aged urban Indians during a community based study in South Delhi while studying prevalence of obstructive sleep apnoea and analysed to find out the ages at which the OSA, MS and syndrome Z exist in these subjects.

METHODS

A 2-stage, cross-sectional, population-based study in subjects of either gender between 30-65 yr of age in 4 different socio-economic zones of the South Delhi, India, was performed earlier (from April 2005 through June 2007). In-hospital, supervised PSG studies were performed and biochemical investigations for the MS using National Cholesterol Education Programmme Adult Treatment Panel (NCEP ATP) III criteria were carried out. In this communication, the data were further analysed to estimate the prevalences of MS alone, OSA alone and syndrome Z and average ages of 3 conditions.

RESULTS

Three hundred and fifty one subjects had satisfactory PSG studies. The MS alone was present in 105 [29.9%; (95% CI 25.1-34.7)] while OSA alone was present in 24 [6.8%; (95% CI 4.2-9.5)] subjects and the syndrome Z was present in 70 [19.9%; (95% CI 15.8-24.1)] subjects. Median ages of normal subjects, and subjects with MS, OSA and syndrome Z were 40, 43, 43 and 47 yr respectively. Minimum ages of normal subjects, and subjects with MS, OSA and syndrome Z were 30, 30, 32 and 32 yr respectively.

INTERPRETATION & CONCLUSIONS

When body mass index (BMI) was normal, the increasing median ages of these conditions indicated that the MS may be the first event followed by OSA and eventually syndrome Z develops. With BMI >25 or >30 no clear-cut difference was noted, indicating that the BMI itself could have an independent role in MS, OSA and syndrome Z.

VEGF expression as a prognostic marker in osteosarcoma

BACKGROUND

The vascular endothelial growth factor (VEGF) pathway is the key regulator of angiogenesis. In osteosarcoma baseline VEGF is of proven prognostic value but prognostic potential of post-NACT VEGF expression is largely unexplored.

PROCEDURE

Treatment naive patients with osteosarcoma were subjected to initial staging workup followed by three cycles of neoadjuvant chemotherapy (NACT) and surgery; resected tumors were assessed for histological necrosis by Huvos grading. Initial biopsy and resected tumor specimens post-NACT were examined for VEGF expression by immunohistochemistry. Positive VEGF expression was considered when intensive positive staining was observed in >10% of the tumor cells. VEGF expression at baseline was compared with grade of tumor; pre-NACT and post-NACT VEGF expression were compared with histological necrosis. Receiver operating characteristic curves were generated to assess best threshold and predictability.

RESULTS

A total of 31 patients were recruited with median age of 17 years (range 5-66 years); male/female ratio was 25:6; 23 patients (74%) were non-metastatic. At baseline, there was 90% concordance between positive VEGF expression and higher histological grade (28/31); baseline VEGF expression did not correlate well with stage and histological necrosis. Twenty-one (67%) were poor and 10 (33%) were good histologic responders; post-NACT VEGF expression as well as VEGF change following NACT significantly correlated with histological necrosis.

CONCLUSION

Positive VEGF expression in surviving tumor cells post-NACT in resected tumors appears to be an important negative prognostic factor in osteosarcoma which may help future therapies to be identified according to the angiogenic potential of the disease.

Can human papillomavirus DNA testing of self-collected vaginal samples compare with physician-collected cervical samples and cytology for cervical cancer screening in developing countries?

BACKGROUND

To determine human papillomavirus (HPV) types by polymerase chain reaction (PCR)-reverse line blot assay and examine the concordance between HPV by Hybrid Capture 2 (HC2) and PCR on self-collected vaginal and physician-collected cervical samples and cytology.

METHODS

This was a cross-sectional study of 546 sexually active women aged > or =30 years with persistent vaginal discharge, intermenstrual or postcoital bleeding or an unhealthy cervix. Participants self-collected vaginal samples (HPV-S) and physicians collected cervical samples for conventional Pap smear and HPV DNA (HPV-P) testing and performed colposcopy, with directed biopsy, if indicated. HPV testing and genotyping was done by HC2 and PCR reverse line blot assay. Concordance between HC2 and PCR results of self- and physician-collected samples was determined using a Kappa statistic (kappa) and Chi-square test.

RESULTS

Complete data were available for 512 sets with 98% of women providing a satisfactory self-sample. PCR detected oncogenic HPV in 12.3% of self- and 13.0% of physician-collected samples. Overall, there was 93.8% agreement between physician-collected and self-samples (kappa=76.31%, 95% confidence interval [CI]: 64.97-82.29%, p=0.04)-complete concordance in 473 cases (57 positive, 416 negative), partial concordance in seven pairs and discordance in 32 pairs. The sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) of self-sampling for detection of cervical intraepithelial neoplasia (CIN)2+ disease were 82.5%, 93.6%, 52.4% and 98.4%, respectively; for physician-sampling they were 87.5%, 93.2%, 52.2% and 98.9%, respectively; and for cytology they were 77.5%, 87.3%, 34.1% and 97.9%, respectively. Concordance between HC2 and PCR was 90.9% for self-samples (kappa=63.7%, 95% CI: 55.2-72.2%) and 95.3% for physician-collected samples (kappa=80.4%, 95% CI: 71.8-89.0%).

CONCLUSIONS

Self-HPV sampling compares favourably with physician-sampling and cytology. A rapid, affordable, HPV self-test kit can be used as the primary method of cervical cancer screening in low-resource situations.

Predisposition to vitamin D deficiency osteomalacia and rickets in females is linked to their 25(OH)D and calcium intake rather than vitamin D receptor gene polymorphism

BACKGROUND

Osteomalacia (OSM) and rickets are widely prevalent in developing countries especially in females. The factors associated with such predisposition are not known.

OBJECTIVES

To identify nutritional, endocrine and genetic factors related to calcium and vitamin D metabolism that are associated with OSM/rickets in females.

SUBJECTS AND METHODS

We studied 98 patients with OSM or rickets and their relatives including male and female sibs and parents (n = 221) for the presence of biochemical OSM {low serum 25-hydroxyvitamin D [25(OH)D], raised intact PTH (iPTH) and raised alkaline phosphatase} and associated nutritional and genetic factors. Polymerase chain reaction restriction fragment length polymorphism (PCR-RFLP) was used for genotyping vitamin D receptor (VDR) (BsmI and FokI) and PTH gene (BstBI and DraII) single nucleotide polymorphisms (SNPs) in 74 families. The differences in the factors associated with calcium and vitamin D among the different groups were analysed by analysis of variance (ANOVA). Logistic regression analysis and the transmission disequilibrium test (TDT) were carried out to assess association between nutritional and genetic factors, and the disease, respectively.

RESULTS

Most of the patients were female (91.8%). The mean serum 25(OH)D level of the female patients was comparable to that of the female sibs (14.4 +/- 5.7 vs. 18.3 +/- 9.7 nmol/l). The frequency of biochemical OSM was fivefold higher in female than in male sibs (24.4%vs. 4.9%). Female sibs also had significantly lower 25(OH)D, dietary calcium intake and sunshine exposure than male sibs. The frequency of biochemical OSM was comparable between mothers and fathers. The odds of biochemical OSM in the family members was reduced by 11% per 15-min daily sunshine exposure [odds ratio (OR) = 0.89, 95% confidence interval (CI) = 0.81-0.98, P = 0.02] and decreased by 20% per 100 mg dietary calcium intake (OR = 0.80, 95% CI = 0.67-0.96, P = 0.02). VDR/PTH gene SNPs showed no association with OSM/rickets on TDT analysis.

CONCLUSION

Among the immediate family members of patients with OSM/rickets, female sibs have features of biochemical OSM in up to 24.4%. Female sibs, unlike male sibs, share with patients features of markedly low serum 25(OH)D levels, poor dietary calcium intake and poor exposure to sunshine. Genetic factors such as VDR and PTH gene SNPs were not associated with OSM/rickets.

Visual format for detection of Mycobacterium tuberculosis and M. bovis in clinical samples using molecular beacons

A real-time polymerase chain reaction (PCR) assay for the direct identification of Mycobacterium tuberculosis and M. bovis using molecular beacons was developed. The assay was modified for use in regular thermal cyclers. Molecular beacons that were specific for M. tuberculosis (Tb-B) and M. bovis (Bo-B) were designed. The fluorescence of the target PCR product-molecular beacon probe complex was detected visually using a transilluminator. The results were then compared with those of conventional multiplex PCR (CM-PCR) assays and biochemical identification. The detection limit of Tb-B and Bo-B beacons was 500 fg and 50 fg by the visual format and real-time PCR assay, respectively, compared with 5 pg by CM-PCR assay. Pulmonary and extrapulmonary samples were examined. The agreement between culture and the two assays was very good in sputum samples and fair in extrapulmonary samples. The agreement between clinical diagnoses with the two assays was moderate in extrapulmonary samples. There was very good agreement between CM-PCR and visual format assays for all samples used in the study. Concordance in the identification of isolates by the visual, CM-PCR assay, and biochemical identification was seen. Hence, the use of molecular beacon detection of M. tuberculosis and M. bovis in clinical samples is feasible by setting up two asymmetric PCRs concurrently. The assay is sensitive, specific, simple to interpret, and takes less than 3 hours to complete.

Efficacy of L-ornithine L-aspartate in acute liver failure: a double-blind, randomized, placebo-controlled study

BACKGROUND & AIMS

In acute liver failure (ALF), high blood ammonia levels have been documented that correlate with mortality and complications. L-ornithine L-aspartate (LOLA) reduces ammonia levels by increasing hepatic ammonia disposal and its peripheral metabolism. Present study evaluated efficacy and ammonia lowering effect of LOLA in ALF.

METHODS

This study was placebo-controlled and blinded. We randomized 201 patients with ALF between January 2005 and October 2007 to either placebo or LOLA infusions (30 g daily) for 3 days. Arterial ammonia was measured at baseline and daily for 6 days. The primary end point was improvement in survival. The study followed CONSORT guidelines and was registered at the ClinicalTrials.gov (Identifier: NCT00470314).

RESULTS

There was no reduction in mortality with LOLA treatment (mortality: 33.3% in placebo and 42.4% in LOLA; relative risk of death 1.27; 95% CI: 0.88-1.85; P = .204). By multivariate analysis, ammonia levels were an independent predictor of survival. There was significant decrease in ammonia levels in both groups with time (P < .001), but the levels of ammonia between the randomized groups at any time point, either during the 72 hours of LOLA infusion or during the follow-up were similar (P = .492). There was no difference between the 2 groups in the improvement in encephalopathy grade (P = .418), consciousness recovery time (P = .347), survival time (P = .612), or complications like seizures (P = .058) and renal failure (P = .615). The fetal outcome was also similar (P = .172). No adverse drug effect was noted.

CONCLUSIONS

LOLA infusion did not lower the ammonia or improved survival in ALF.

Structural and functional abnormalities in lungs in patients with achalasia

Dilatation and oesophageal body aperistalsis in achalasia can lead to stasis which in turn can induce repeated microaspiration. It is therefore conceivable that patients with achalasia may also have abnormalities in lungs secondary to repeated episodes of microaspiration. There is a lack of systematic study on involvement of lungs in patients with achalasia. Thirty patients with achalasia underwent pulmonary function tests (spirometry, and carbon mono-oxide diffusion capacity) and high resolution computerized tomography (HRCT) of the chest. The mean age of patients and mean duration of disease were 33.5 +/- 10.9 years and 28.1 +/- 27.3 months respectively. Regurgitation was present in 22 (73.3%) of them. Respiratory symptoms in them were dry cough in 17 (56.6%), and chest pain in 18 (60%). The oesophagus was dilated in 26 (86.6%) and 13 (43.3%) had residue in oesophagus. Sixteen (53.3%) patients had either anatomical changes as seen on HRCT or functional changes as observed on pulmonary function tests. Of those with functional abnormalities, five (16.6%) and one (3.3%) had restrictive and obstructive airways disease respectively. While evidence of tracheo-bronchial compression by dilated oesophagus was present in eight (26.6%), 10 (33.3%) patients had parenchymal lung disease [nodular opacities in five (16.6%), ground glass appearance six (20%), patchy pulmonary fibrosis five (16.6%), air trapping two (6.6%), consolidation and bronchiectasis one (3.3%) each]. There was a significant association between presence of regurgitation and dilatation of oesophagus (P = 0.032). More than half (53.3%) of patients with achalasia have structural and/or functional abnormalities in lungs.

Validation of CRIB II for prediction of mortality in premature babies

OBJECTIVE

Validation of Clinical Risk Index for Babies (CRIB II) score in predicting the neonatal mortality in preterm neonates < or = 32 weeks gestational age.

DESIGN

Prospective cohort study.

SETTING

Tertiary care neonatal unit.

SUBJECTS

86 consecutively born preterm neonates with gestational age < or = 32 weeks.

METHODS

The five variables related to CRIB II were recorded within the first hour of admission for data analysis. The receiver operating characteristics (ROC) curve was used to check the accuracy of the mortality prediction. HL Goodness of fit test was used to see the discrepancy between observed and expected outcomes.

RESULTS

A total of 86 neonates (males 59.6% mean birthweight: 1228 +/- 398 grams; mean gestational age: 28.3 +/- 2.4 weeks) were enrolled in the study, of which 17 (19.8%) left hospital against medical advice (LAMA) before reaching the study end point. Among 69 neonates completing the study, 24 (34.8%) had adverse outcome during hospital stay and 45 (65.2%) had favorable outcome. CRIB II correctly predicted adverse outcome in 90.3% (Hosmer Lemeshow goodness of fit test P=0.6). Area under curve (AUC) for CRIB II was 0.9032. In intention to treat analysis with LAMA cases included as survivors, the mortality prediction was 87%. If these were included as having died then mortality prediction was 83.1%.

CONCLUSION

The CRIB II score was found to be a good predictive instrument for mortality in preterm infants < or = 32 weeks gestation.

A randomized controlled trial (RCT) comparing best supportive care (BSC), 5-FU plus folinic acid (FUFA) and, gemcitabine plus oxaliplatin (Gem-Ox) in management of unresectable gallbladder cancer (GBC)

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Background: GBC is common in females residing in the northern part of India. Surgery is the only curative treatment. Unfortunately most patients present in advance and unresectable stage (median survival 3–4 months). Chemotherapy regimens for GBC are not yet standardized. Studies are few and mostly retrospective with small sample size and usually combine heterogeneous malignancies. Adequately powered RCT are not available. This was rationale to undertake study. Methods: It was single center, open label, three armed RCT. Ethical clearance was taken. Planned sample size was 81 to have type I & type II error probabilities of 0.05 & 0.2 respectively. Primary end point was to compare OS in unresectable GBC between BSC vs. FUFA vs. Gem-Ox arms. Secondary end points were to compare PFS in three arms and toxicity analysis of chemotherapy arms. Inclusion criteria were: proven unresectable GBC, performance state ≤2, adequate bone marrow reserve and normal biochemical profile (bilirubin≤3 mg % & liver enzymes within 5 times of upper limit). Patients in BSC group received symptomatic treatment without anticancer therapy. In FUFA group, weekly bolus doses of 5-FU (425mg/m2) plus Folinic acid (20 mg/m2) were given for a maximum of 30 weeks. In Gem-Ox group patients received gemcitabine (900 mg/m2) plus oxaliplatin (80 mg/m2) days 1 and 8 q3 weekly till maximum of 6 cycles. Results: Eighty one patients were randomized (BSC=27, FUFA=28, Gem-Ox=26). Median OS in BSC, FUFA and gem- Ox arms was 4.5 (CI 0.2–8.8), 5.3 (CI 3–6.2) and 9.3 (CI 5–14) months respectively (p= 0.039)). Median PFS was 2.8 (CI 1.8–3.8), 3.5 (CI 3.2–3.8) and 8.5 (CI 5.7–11.3) months in BSC, FUFA and Gem-Ox arm respectively (p= 0.0001). Chemotherapy arms were generally well tolerated. There was no difference in grade 3/4 toxicities in FUFA and Gem-Ox arm except for deranged liver function test, which was more in Gem-Ox arm (p=0.04). There was no toxic death. Conclusions: Probably this is the first RCT confirming efficacy of chemotherapy (Gem-Ox) compared to BSC in improving OS and PFS in unresectable GBC. Both chemotherapy arms were well tolerated.

No significant financial relationships to disclose.

Role of MRI in osteosarcoma for chemotherapy response evaluation and prediction: Correlation with histological necrosis

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Background:Histologic necrosis (HN), the current gold standard for response evaluation in osteosarcoma (OS), is accessible only after neoadjuvant chemotherapy (NACT) and may get affected by confounding factors. Thus, it would be useful to have surrogate markers of response evaluation and prognostication using magnetic resonance imaging (MRI) to individualize therapy. Method:Thirty-one treatment naïve OS patients received 3 cycles of NACT followed by surgery during 2006–2008. All patients underwent baseline and post-NACT conventional(C), diffusion-weighted (DW) and dynamic contrast enhanced (DCE) MRI. Taking ‘Huvos grading’ (good response >/= 90% HN) as reference standard, various parameters of MRI were compared with it. Tumor considered as ellipsoidal; volume (V), average tumor plane (ATP) and relative(r)-ATP (ATP/body surface area) were calculated using standard formula for ellipse. Receiver operating characteristic curves were generated to assess the best threshold and predictability. Sensitivity and specificity were calculated along with 95% confidence limits. After deriving thresholds for each parameter in univariable analysis, multivariable analysis was carried out. Results: Both pre-and post NACT, absolute and relative size parameters were well correlated with HN, though post NACT change in parameters did not. Apparent diffusion coefficient (ADC), either pre-and post NACT measurements or change following chemotherapy were not correlating well. However, on adjusting for volume, significant correlation was found. Thus, we could derive a new parameter diffusion per unit volume (DV= ADC /V). Change in shape of time intensity curve did not show significant correlation. Conclusions: In OS, NACT response can be assessed and predicted by conventional and DW- MRI early in the disease course which correlates well with HN. DV seems to be a sensitive substitute for response evaluation. For DCE-MRI, more sophisticated models in future studies might be useful. [Table: see text]

No significant financial relationships to disclose.

A study of the prevalence and type of anemia in lymphoid malignancies

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Background: Anemia is a common and serious problem in patients with lymphoid malignancy. Hence there was need to analyze the prevalence of anemia in our patient population and evaluate its cause for optimal management. Methods: Newly diagnosed patients of lymphoid malignancy- non Hodgkins lymphoma (NHL), Hodgkins lymphoma (HL), and chronic lymphocytic leukemia (CLL) aged more than 15 years without renal failure and who had not received blood transfusion, iron, folic acid or vitamin B complex in the last 2 weeks were analyzed. 316 patients were screened for the prevalence of anemia. Of the anemic patients (hemoglobin <11gm/dl), 46 were studied for the type of anemia. These patients underwent the following investigations -complete hemogram with RBC indices, hematocrit, reticulocyte count, peripheral blood smear (PBS) examination, direct Coombs test (DCT), bone marrow (BM) aspiration and biopsy, S. iron (SI), S. ferritin (SF), total iron binding capacity (TIBC), percentage saturation (psat), S. Vitamin B12 and Folic acid levels. Anemia was categorized as due to either autoimmune hemolytic anemia (AIHA)-DCT positive with evidence of hemolysis on PBS, B12 and folate deficiency (<200 pgm/ml and < 4ngm/ml respectively), iron deficiency anemia (IDA)- psat <20% and SF315μgm/dl, anemia of chronic disease (ACD)-psat200μgm/L, a combination of IDA and ACD -psat <20%, SF -30–200 with TIBC ≤315 μgm/dl. Results: The prevalence of anemia in patients with lymphoid malignancy was 42.41% (134 /316, 95% CI-36.96% -47.85%). It was multifactorial in 39.13% (18/46) patients. ACD was the most common cause of anemia present in 71.74% (33/46) patients. This was followed by nutritional anemia (iron,B12 and folate deficiency) in 47.83% (22/46) and AIHA in 10.87% (5/46) of patients. Conclusions: Although anemia of chronic disease is the most common cause of anemia in patients with lymphoid malignancy, it is multifactorial in a large number of patients and hence it is important to rule out other causes of anemia like nutritional and AIHA in these patients.

No significant financial relationships to disclose.

Prevalence and risk factors of obstructive sleep apnea among middle-aged urban Indians: a community-based study

BACKGROUND

The epidemiology of obstructive sleep apnea (OSA) and obstructive sleep apnea syndrome (OSAS) is not well studied among Indians. We sought to determine the prevalence and risk factors of OSA in a middle-aged urban Indian population.

METHODS

We conducted a two-stage, cross-sectional, community-based study in four different socioeconomic zones of the South Delhi district, India, from April 2005 to June 2007. In stage 1, subjects of either gender aged 30-65 yrs were administered a questionnaire by door-to-door survey using systematic random sampling. Subjects that responded were classified as habitual and non-habitual snorers. In stage 2, all the habitual and 10% of randomly selected non-habitual snorers were invited for overnight polysomnographic study.

RESULTS

Of the 2860 subjects approached, 2505 (88%) completed stage 1. Habitual snoring was present in 452 (18%) subjects. In stage 2, OSA defined as apnea-hypopnea index 5 was observed in 94 (32.4%) of 290 habitual snorers and 3 (4%) of 75 non-habitual snorers. Estimated population prevalence of OSA and OSAS was 9.3% (95% CI 8.2-10.5%) and 2.8% (2.1-3.4%) respectively. On multivariable analysis, male gender (adjusted odds ratio 3.8 [1.7-4.9]), body-mass index 25 kg/m(2) (4.1 [2.0-8.3]), and abdominal obesity (2.2 [1.9-5.3]) were independently associated with the presence of OSA. A linear trend was observed in the prevalence of OSA across the socioeconomic strata.

CONCLUSIONS

OSA is a significant public health problem in the middle-aged Indian population across the socioeconomic spectrum. OSA is associated with some of the well known risk factors for cardiovascular disease.

Refractive status at birth: its relation to newborn physical parameters at birth and gestational age

BACKGROUND

Refractive status at birth is related to gestational age. Preterm babies have myopia which decreases as gestational age increases and term babies are known to be hypermetropic. This study looked at the correlation of refractive status with birth weight in term and preterm babies, and with physical indicators of intra-uterine growth such as the head circumference and length of the baby at birth.

METHODS

All babies delivered at St. Stephens Hospital and admitted in the nursery were eligible for the study. Refraction was performed within the first week of life. 0.8% tropicamide with 0.5% phenylephrine was used to achieve cycloplegia and paralysis of accommodation. 599 newborn babies participated in the study. Data pertaining to the right eye is utilized for all the analyses except that for anisometropia where the two eyes were compared. Growth parameters were measured soon after birth. Simple linear regression analysis was performed to see the association of refractive status, (mean spherical equivalent (MSE), astigmatism and anisometropia) with each of the study variables, namely gestation, length, weight and head circumference. Subsequently, multiple linear regression was carried out to identify the independent predictors for each of the outcome parameters.

RESULTS

Simple linear regression showed a significant relation between all 4 study variables and refractive error but in multiple regression only gestational age and weight were related to refractive error. The partial correlation of weight with MSE adjusted for gestation was 0.28 and that of gestation with MSE adjusted for weight was 0.10. Birth weight had a higher correlation to MSE than gestational age.

CONCLUSION

This is the first study to look at refractive error against all these growth parameters, in preterm and term babies at birth. It would appear from this study that birth weight rather than gestation should be used as criteria for screening for refractive error, especially in developing countries where the incidence of intrauterine malnutrition is higher.

HBV genotypes in India: do they influence disease severity?

AIMS

Association of HBV genotypes (especially A and D) with severity of liver disease is controversial. We studied the influence of HBV genotypes on liver disease severity among Indian patients.

METHODS

We selected 247 HBV infected patients (42 acute hepatitis, 87 carriers, 44 chronic hepatitis B [CHB], 35 liver cirrhosis [LC] and 40 hepatocellular carcinoma [HCC]). Genotyping of stored sera was performed using genotype-specific enzyme-linked immunosorbent assay (ELISA) and restriction fragment length polymorphism (RFLP). The distribution of genotypes in disease states of differing clinical, histological and biochemical severity were compared.

RESULTS

The most common genotype was D (162/237, 68.3%), followed by A (61, 25.7%) and C (14, 5.9%). The distribution of HBV genotypes between patients with acute hepatitis and CHB (carriers + CHB + LC + HCC), or between carriers and disease states (CHB + LC + HCC), or between mild chronic infection (carriers + CHB) and complications of chronic HBV infection (LC + HCC) was similar. Eighty-seven patients had liver biopsy; the median histological activity index (HAI) and fibrosis stage at baseline were similar between genotype groups (four [1-9] genotype A [n = 28]), three (2-4) genotype C (n = 4) and four (1-10) genotype D (n = 55); P = 0.33 for HAI score; (0.5 [0-6] genotype A, 0.5 [0-4] genotype C and 1 [0-6] genotype D; P = 0.92 for fibrosis stage). The response to therapy was similar between the genotypes.

CONCLUSION

Clinical, histological severity and therapeutic responses are similar among patients with HBV genotypes A and D.

Prevalence and pattern of cardiac autonomic dysfunction in newly detected type 2 diabetes mellitus

Cardiac autonomic functions were assessed in 145 consecutive recently detected type 2 diabetics. Ninety-nine healthy persons served as controls. Criteria for normalcy were, heart rate variation during deep breathing >or=15 beats/min, deep breathing expiratory to inspiratory R-R ratio >or=1.21, Valsalva ratio >or=1.21, sustained handgrip test >or=16 mm of mercury, cold pressor test >or=10, BP response to standing <or=10mm of mercury and 30:15 R-R ratio on standing >or=1.04. An abnormal test was defined as the above parameters being <10 beats/min, <1.21, <1.21, <or=10mm of mercury, <10, >or=30 mm of mercury and <or=1.0, respectively. A borderline test was defined as, heart rate variation during deep breathing 11-14, sustained handgrip test 11-15 mm of mercury, BP response to standing 11-29 mm of mercury and 30:15 R-R ratio on standing 1.01-1.03. Parasympathetic dysfunction was found in 44.2% and sympathetic dysfunction in 51.9% diabetics. Among healthy controls, these figures were 11.9% and 22.1%, respectively. Cardiac autonomic function was normal in 7.8% patients and 32.5% healthy controls.

Comparison of gliclazide with insulin as initial treatment modality in newly diagnosed type 2 diabetes

AIM

This study was designed to compare effectiveness and remission rate between gliclazide and insulin as initial treatment in newly diagnosed, drug-naive patients with type 2 diabetes.

METHODS

Newly diagnosed, drug-naive subjects with type 2 diabetes having mean fasting blood glucose >200 mg/dL were enrolled into either of two groups (gliclazide or insulin). The former received gliclazide modified-release 60 mg daily, while the insulin group received 16 units of premixed insulin as two divided doses along with medical nutrition therapy. Premeal blood glucose was monitored, and the dose was adjusted accordingly. Glycosylated hemoglobin (HbA1c), lipid profile, and postmeal C-peptide were estimated at baseline and 6 months. Remission was defined as euglycemia off drug for a minimum duration of 1 month.

RESULTS

Baseline and 6-month blood glucose, HbA1c, and lipid profile were comparable between groups. Blood glucose levels normalized in 2-6 weeks in both groups. At 6 months, one of 30 (3.33%) in the gliclazide group and 24 of 30 (80%) in the insulin group were in remission. Ten of 16 (62.5%) in the insulin group and one of 20 (.5%) in the gliclazide group continued to maintain euglycemia off all pharmacological treatment at 12 months. At 6 months, C-peptide increased in the insulin group (3.21+/-1.61 ng/mL at baseline vs. 5.82+/-2.23 ng/mL at 6 months), while it remained unchanged in the gliclazide group (3.4+/-1.87 ng/mL at baseline vs. 3.82+/-1.78 ng/mL at 6 months) (P=0.0003).

CONCLUSIONS

Comparable glycemic control could be achieved with both insulin and oral hypoglycemic agent in newly diagnosed type 2 diabetes subjects. Insulin treatment exceeded gliclazide in the remission (drug-free) rate.

Incidence of hepatocellular carcinoma among Indian patients with cirrhosis of liver: an experience from a tertiary care center in northern India

BACKGROUND/AIM

Despite bearing the main burden of HCC, prospective studies from developing countries are lacking. This prospective observational study was designed to estimate the incidence of HCC among Indian patients with hepatic cirrhosis.

METHODS

Between April 2001 and November 2004, we enrolled 301 patients with liver cirrhosis. Patients found to be free of HCC using baseline abdominal ultrasound, triple-phase computed tomography (TPCT) and serum alpha-fetoprotein (AFP) levels were followed up prospectively for detection of HCC using ultrasound and AFP every 6 months, and TPCT annually.

RESULTS

Among the 194 patients (mean age [SD] 45.1 [+/-13.1] years; male:female 6.1:1.0) followed up, 154 had Child's A and 40 had Child's B disease. The causes of cirrhosis were: hepatitis B-71 (36.6%), hepatitis C-54 (27.8%), dual infection with hepatitis B and C-12 (6.2%) and others including autoimmune, alcoholic and cryptogenic cirrhosis 57 (29.4%). During a cumulative follow up period of 563.4 person-years, 9 cases of HCC were detected, with an incidence rate of 1.60 per 100 person-years.

CONCLUSION

In our study, the incidence of HCC among patients with liver cirrhosis was intermediate, being lower than that in Japan but higher than that reported from Europe.

Role of immune activation in CD4+ T-cell depletion in HIV-1 infected Indian patients

OBJECTIVES

The correlation of immune activation with CD4(+) depletion and HIV-1 disease progression has been evidenced by several studies involving mainly clade B virus. However, this needs to be investigated in developing countries such as India predominately infected with clade C virus.

MATERIALS AND METHODS

In a cross-sectional study of 68 antiretroviral treatment naïve, HIV-1 infected Indian patients, we studied the association between CD4(+) T cells, plasma HIV-1 RNA levels, and immune activation markers using unadjusted and adjusted correlative analyses.

RESULTS

Significant negative correlations of higher magnitude were observed between the CD4(+) T cell percentages and plasma HIV-1 RNA levels in the study population when adjusted for the effects of immune activation markers. However, the negative association of CD4(+) T cells with immune activation markers remained unaffected when controlled for the effects of plasma HIV-1 RNA levels.

CONCLUSIONS

Our results support the important role of immune activation in CD4(+) T cell depletion and disease progression during untreated HIV-1 infection.

Economic evaluation of a surveillance program of hepatocellular carcinoma (HCC) in India

PURPOSE

Surveillance of patients of cirrhosis of liver is practiced for early detection of HCC. No data from any developing country on cost-effectiveness of such a program are available.

METHODS

Economic evaluation of HCC surveillance was embedded in a prospective study undertaken to estimate the incidence of HCC in 194 cirrhotics. The protocol consisted of 6 monthly abdominal ultrasound (US) and serum alphafetoprotein (AFP) estimation, and yearly triple phase CT. Cost was estimated from the hospital and patient perspectives. Cost-effectiveness ratios for detecting a case of HCC were estimated. Modeling was done to estimate cost effectiveness with different combinations of diagnostic tests.

RESULTS

Cost-effectiveness ratios of HCC surveillance program per HCC case detected were estimated as US$ 280 from the hospital perspective. From patient perspective, these were US$ 9,965 for outstation and US$ 2,808 for local patients. Cost-effectiveness ratio for direct medical cost per case of HCC detected by 6 monthly US and AFP, the EASL protocol, was estimated to be US$ 1,510 in the private sector.

CONCLUSION

The cost of HCC surveillance program is exorbitant for India (gross national income per capita US$ 620) and possibly other low/middle income countries.

Missing girls in India: infanticide, feticide and made-to-order pregnancies? Insights from hospital-based sex-ratio-at-birth over the last century

BACKGROUND

There are 44 million missing women in India. Gender bias; neglect of girls, infanticides and feticides are responsible. The sex ratio at birth can be used to examine the influence of antenatal sex selection on the sex ratio.

MATERIALS AND METHODS

Records from 321,991 deliveries at one hospital over 11 decades were utilized. The middle year in each decade was taken as representative of the decade. Data from 33,524 deliveries were then analyzed. Data for each decade was combined with that of previous decades and compared to the data of subsequent decades to look for any change in the trend. Sex ratio in the second children against sex of the first child was studied separately.

RESULTS

The mean sex ratio for the 110 years examined was 910 girls to 1000 boys (95% CI; 891 to 930). The sex ratio dropped significantly from 935 (CI: 905 to 967) before 1979, to 892 (CI: 868 to 918) after 1980 (P = 0.04). The sex ratio in the second child was significantly lower if the first child was a girl [716 (CI: 672 to 762] (P<0.001). On the other hand, there was an excess of girls born to mothers whose first child was boy [1140 girls per 1000 boys (CI: 1072 to 1212 P<0.001)].

CONCLUSIONS

The sex ratio fell significantly after 1980 when ultra sound machines for antenatal sex determination became available. The sex ratio in second children if the first was a girl was even lower. Sex selective abortions after antenatal sex determination are thus implicated. However data on second children especially the excess of girls born to mothers who have a previous boy seen in the decade before the advent of antenatal ultra sound machines, suggests that other means of sex selection are also used.

Presence of spondyloarthropathy and its clinical profile in patients with hypoparathyroidism

BACKGROUND

Though spondyloarthropathy has been described in patients with sporadic idiopathic hypoparathyroidism (SIH), the clinical profile is not known.

OBJECTIVES

To describe the clinical profile including radiological features of spondyloarthropathy and prevalence of HLA-B27 allele in patients with hypoparathyroidism, and to identify any differences from ankylosing spondylitis.

SUBJECTS AND METHODS

Clinical characteristics and radiographs of pelvis and spine were assessed in 40 consecutive patients with SIH. Radiographs were assessed by radiologist (RS) and rheumatologist (RG) for the features of spondyloarthropathy including sacroiliitis, syndesmophytes and hip joint calcification, and so on. HLA-B27 genotyping was carried out in patients with SIH, and 195 healthy controls using duplex PCR. Fourteen control radiographs were from age-matched normal individuals.

RESULTS

Three patients with SIH had clinically overt spondyloarthropathy which closely resembled ankylosing spondylitis. Fourteen (eight females and six males) of the 40 patients with SIH showed radiological changes including syndesmophytes in lower dorsal or dorso-lumbar spine (n = 6), sacroiliitis and new bone formation at the acetabular rim of the hip joint (n = 10). Though all six patients demonstrating syndesmophytes had new bone formation at hip, sacroiliitis was seen in only three of them. None of the 14 controls had syndesmophytes, sacroiliitis or hip joint calcification. The mean (SD) duration of illness (15.4 +/- 8.7 vs. 6.5 +/- 5.9 years, P < 0.01), BMI (24.1 +/- 5.2 vs. 20.8 +/- 3.7 kg/m(2), P = 0.04) and frequency of basal ganglia calcification was higher (100%vs. 57.7%, P < 0.01) in patients who showed changes of spondyloarthropathy in comparison to those without these changes. On multiple logistic regression analysis, only duration of hypoparathyroid illness was associated with spondyloarthropathy with an odds ratio of 1.17 (95% CI = 1.05-1.30, P < 0.01) per year increase in the duration. The mean age, serum total calcium, inorganic phosphorus and serum intact PTH (iPTH) levels were not significantly different between SIH patients with and without spondyloarthropathy. The frequency of HLA-B27 allele was comparable between SIH and the control groups.

CONCLUSIONS

Thus, spondyloarthropathy is a distinct clinical entity in patients with SIH. Its salient clinical features include presence of syndesmophytes at the thoracic or thoraco-lumbar spine, mild sacroiliitis, calcification at the acetabular margin of hip, preserved bone density, equal distribution in both sexes and lack of HLA-B27 association. Presence of spondyloarthropathy, like basal ganglia calcification, is associated with longer duration of hypoparathyroidism. It is important to differentiate hypoparathyroid-related spondyloarthropathy from ankylosing spondylitis because the management for the two disorders is different.