Hydatid disease of the lung mimicking a pericardial cyst

We report a young girl who presented to us with chest discomfort and had a paracardiac mass on chest radiograph. Computerised tomographic (CT) scan of the thorax was suggestive of pericardial cyst. Hydatid serology was negative. The cyst was excised.

Sudden collapse of a young female cross country runner

The case is reported of a young previously healthy female cross country runner who collapsed on completion of a cross country run. The cause of the collapse was non-cardiogenic pulmonary oedema as a manifestation of hyponatraemic encephalopathy. The concurrent occurrence of non-cardiogenic pulmonary oedema and encephalopathy due to hyponatraemia is unusual.

Prevalence of tobacco use among school going youth in North Indian States

BACKGROUND

Tobacco use, which is the cause of several respiratory diseases, generally starts in the teens. Global Youth Tobacco Survey (GYTS) is an international initiative to investigate the tobacco use in school going youth of 13 to 15 years of age. This report describes the GYTS findings in the North Indian region.

METHODS

A two-stage cluster sample was used with selection of schools on probability proportional to enrollment size followed by systematic equal probability sampling with a random start of classes from each school. The 85-item questionnaire included 'core GYTS' and other additional questions. Data analysis was performed using EpiInfo 3.2 software and the results accounted for the complex sampling design and weighting factors in the data set.

RESULTS

The sample consisted of 9319 students out of the total eligible population of 30488 from 100 schools. The prevalence of ever-use of tobacco varied between 2.9 to 8.5% in boys and 1.5 to 9.8% in girls. The prevalence was highest in Chandigarh and lowest in Punjab. Between 16 to 46% of students were exposed to the habit of tobacco among parents or friends. There were 10 to 34% students who were passively exposed to environmental tobacco smoke.

CONCLUSION

Tobacco use is present in up to 10 percent of school going youth in the region. A majority of them had desired to quit. Tobacco control and cessation programmes therefore, remain important health issues.

Sleeping position and electrocortical activity in low birthweight infants

OBJECTIVE

To evaluate the effects of prone and supine sleeping positions on electrocortical activity during active (AS) and quiet (QS) sleep in low birthweight infants.

DESIGN

Randomised/crossover study.

SETTING

Infant Physiology Laboratory at Children's Hospital of New York.

PATIENTS

Sixty three healthy, growing, low birthweight (birth weight 795-1600 g) infants, 26-37 weeks gestational age.

INTERVENTIONS

Six hour continuous two channel electrocortical recordings, together with minute by minute behavioural state assignment, were performed. The infants were randomly assigned to prone or supine position during the first three hours, and positions were reversed during the second three hours.

OUTCOME MEASURES AND RESULTS

Fast Fourier transforms of electroencephalograms (EEGs) were performed each minute and the total EEG power (TP), spectral edge frequency (SEF), absolute (AP) and relative (RP) powers in five frequency bands (0.01-1.0 Hz, 1-4 Hz, 4-8 Hz, 8-12 Hz, 12-24 Hz) were computed. Mean values for TP, SEF, AP, and RP in the five frequency bands in the prone and supine positions during AS and QS were then compared. In the prone sleeping position, during AS, infants showed significantly lower TP, decreased AP in frequency bands 0.01-1.0 Hz, 4-8 Hz, 8-12 Hz, 12-24 Hz, increased RP in 1-4 Hz, and a decrease in SEF. Similar trends were observed during QS, although they did not reach statistical significance.

CONCLUSIONS

The prone sleeping position promotes a shift in EEG activity towards slower frequencies. These changes in electrocortical activity may be related to mechanisms associated with decreased arousal in the prone position and, in turn, increased risk of sudden infant death syndrome.

Adiponectin receptors gene expression and insulin sensitivity in non-diabetic Mexican Americans with or without a family history of Type 2 diabetes

AIMS/HYPOTHESIS

The recent discovery of two adiponectin receptors (AdipoR1 and AdipoR2) will improve our understanding of the molecular mechanisms underlying the insulin-sensitising effect of adiponectin. The aim of this study was to determine for the first time whether skeletal muscle AdipoR1 and/or AdipoR2 gene expression levels are associated with insulin resistance.

METHODS

Using RT-PCR and northern analysis we measured AdipoR1 and AdipoR2 gene expression in skeletal muscle from healthy Mexican Americans with normal glucose tolerance who had (n=8) or did not have (n=10) a family history of Type 2 diabetes.

RESULTS

Gene expression profiling indicated that the AdipoR1 and AdipoR2 isoforms are highly expressed in human skeletal muscle, unlike in mice where AdipoR2 expression was highest in the liver, and AdipoR1 was highest in skeletal muscle. In the study subjects, the expression levels of AdipoR1 (p=0.004) and AdipoR2 (p=0.04), as well as plasma adiponectin concentration (p=0.03) were lower in people with a family history of Type 2 diabetes than in those with no family history of the disease. Importantly, the expression levels of both receptors correlated positively with insulin sensitivity (r=0.64, p=0.004 and r=0.47, p=0.048 respectively).

CONCLUSIONS/INTERPRETATION

Collectively, these data indicate that both isoforms of the adiponectin receptor play a role in the insulin-sensitising effect of adiponectin.

Unconventional diagnosis of Normandy-type von Willebrand's disease in a blood donor

We report the case of a long-standing female blood donor whose blood donation was processed for cryoprecipitate. The cryoprecipitate unit was chosen at random for FVIII:C estimation as part of the quality control, and a low FVIII:C level was identified. The cause of this was subsequently shown to be the Normandy variant of type-2 von Willebrand's disease due to a homozygous Arg854Gln mutation in the von Willebrand factor gene.

Clinical and bacteriological profile of community acquired pneumonia in Shimla, Himachal Pradesh

BACKGROUND

Community acquired pneumonia (CAP) is a common clinical problem. The present study was designed to evaluate the clinical and bacteriological profile of CAP in Shimla.

METHODS

Seventy patients with community acquired pneumonia were enrolled in this study. In all the patients blood culture, sputum culture, pleural fluid culture (if available) and serological studies for the detection of Mycoplasma pneumoniae specific IgM antibodies by enzyme linked immunosorbent assay (ELISA) were done.

RESULTS

Of the 70 patients, 53 (75.6%) had an identifiable atiology with 12 patients having evidence of mixed infection. No organisms could be isolated in 17 patients inspite of using serological methods for Mycoplasma pneumoniae, invasive procedures like bronchoscopic aspirations in addition to the conventional methods like sputum culture, blood culture and pleural fluid culture. The most frequent pathogen was Streptococcus pneumoniae (n = 19; 35.8%) followed by Klebsiella pneumoniae (n = 12; 22%), Staphylococcus aureus in (n=9; 17%), Mycoplasma pneumoniae (n = 8; 15%), Escherichia Coli (n = 6; 11%), beta-haemolytic streptococci (n = 4; 7.5%) and other Gram-negative bacilli (n = 5, 9%).

CONCLUSION

Age smoking and under lying co-morbid conditions specially chronic obstructive pulmonary disease (COPD) were significantly associated with the development of CAP (p < 0.01).

Ovarian cancer and fertility medications: a critical appraisal

Ovarian cancer is the fifth most common cancer in the Western world. Infertility and nulliparity are independent risk factors for this disease. The possible link between fertility drugs and ovarian cancer remains controversial. Despite concern regarding increasing use of fertility therapy, the incidence of ovarian cancer in the Western world has remained stable for several decades. Evaluation of the literature requires assessment of the validity, importance, and applicability of the study to your particular patient. The following article demonstrates how to conduct such an assessment. The data to date do not support a causal relationship between fertility drugs and ovarian cancer. In fact, infertility therapy may confer protection for those patients who conceive. Further prospective, long-term data are needed to further delineate this relationship.

Necrotizing periorbital Fusarium infection--an emerging pathogen in immunocompetent individuals

Fungal infections of the skin and deeper tissues of the periorbital region are quite rare. We report a case of a localized, deep periorbital necrotizing Fusarium infection in an otherwise healthy, elderly lady. Since the clinical features and histopathological findings of Fusarium infection are by no means characteristic, the definitive diagnosis was achieved with the help of microbiological examination of cultured organisms. A combined medical and surgical therapy led to adequate control of infection. To conclude, localized, deep periorbital necrotizing soft tissue infection by Fusarium in an immunocompetent lady is not reported in literature. One should have a high index of suspicion for emerging fungal pathogens in the differential diagnosis of necrotizing orbital or adnexal conditions, even in an immunocompetent patient. The histologic findings of septate, branching hyphae and vascular invasion cannot distinguish Fusarium species from various other moulds such as Aspergillus species; microbiologic studies are essential for confirming the diagnosis.

Effects of quality of energy intake on growth and metabolic response of enterally fed low-birth-weight infants

Carbohydrate and fat may vary in their ability to support protein accretion and growth. If so, variations in the source of nonprotein energy might be used to therapeutic advantage in enterally fed low-birth-weight infants. To test the hypothesis that high-carbohydrate diets are more effective than isocaloric high-fat diets in promoting growth and protein accretion, low-birth-weight infants weighing 750-1600 g at birth were randomized in a double blind study to receive one of five formulas differing only in the quantity and quality of nonprotein energy. Groups 1, 2, and control received 130 kcal x kg(-1) x d(-1) with 35, 65, and 50% of the nonprotein energy as carbohydrate. Groups 3 and 4 received energy intake of 155 kcal x kg(-1) x d(-1) with 35 and 65% of the nonprotein energy as carbohydrate. Protein intake of all groups was 4 g x kg(-1) x d(-1). Growth and metabolic responses were followed weekly, and macronutrient balances including 6-h indirect calorimetry were performed biweekly. Greater rates of weight gain and nitrogen retention were observed at high-carbohydrate intake compared with high-fat intake at both gross energy intakes. Greater rates of energy storage and an increase in skinfold thickness were observed in group 4 (high-energy high-carbohydrate diet) despite higher rates of energy expenditure. These data support the hypothesis that at isocaloric intakes, carbohydrate is more effective than fat in enhancing growth and protein accretion in enterally fed low-birth-weight infants. However, a diet with high-energy and high-carbohydrate content also results in increased fat deposition.

Effects of quality of energy on substrate oxidation in enterally fed, low-birth-weight infants

BACKGROUND

Carbohydrate and fat may differ in their ability to support energy-requiring physiologic processes, such as protein synthesis and growth. If so, varying the constituents of infant formula might be therapeutically advantageous.

OBJECTIVE

We tested the hypothesis that low-birth-weight infants fed a diet containing 65% of nonprotein energy as carbohydrate oxidize relatively more carbohydrate and relatively less protein than do infants fed an isoenergetic, isonitrogenous diet containing 35% of nonprotein energy as carbohydrate.

DESIGN

Sixty-two low-birth-weight infants weighing from 750 to 1600 g at birth were assigned randomly and blindly to receive 1 of 5 formulas that differed only in the quantity and quality of nonprotein energy. Formula containing 544 kJ x kg(-1) x d(-1) with either 50%, 35%, or 65% of nonprotein energy as carbohydrate was administered to control subjects, group 1, and group 2, respectively. Groups 3 and 4 received gross energy intakes of 648 kJ x kg(-1) x d(-1) with 35% and 65% of nonprotein energy as carbohydrate. Protein intake was targeted at 4 g x kg(-1) x d(-1). Substrate oxidation was estimated from biweekly, 6-h measurements of gas exchange and 24-h urinary nitrogen excretion.

RESULTS

Carbohydrate oxidation was positively (r = 0.71, P < 0.0001) and fat oxidation was negatively (r = -0.46, P < 0.001) correlated with carbohydrate intake. Protein oxidation was negatively correlated with carbohydrate oxidation (r = -0.42, P < 0.001). Fat oxidation was not correlated with protein oxidation. Protein oxidation was less in infants receiving 65% of nonprotein energy as carbohydrate than in groups receiving 35% nonprotein energy as carbohydrate.

CONCLUSION

These data support the hypothesis that energy supplied as carbohydrate is more effective than energy supplied as fat in sparing protein oxidation in enterally fed low-birth-weight infants.

Mesenchymal chondrosarcoma of the orbit: a clinicopathological study

Extraskeletal mesenchymal chondrosarcoma of the orbit is a rare tumour and generally presents in young females. We report the clinical presentation and histopathological features of a case of orbital mesenchymal chondrosarcoma in a middle-aged man. The prognosis of this tumour is poor and though rare it should be kept in the differential diagnosis of orbital masses.

Polycystic ovary disease and the risk of pregnancy-induced hypertension

OBJECTIVE

To compare the incidence of pregnancy-induced hypertension in patients with and without polycystic ovary disease (PCOD).

STUDY DESIGN

We conducted a retrospective, case-control analysis of patients who achieved singleton pregnancies with human menopausal gonadotropin (hMG) therapy. Twenty-two PCOD patients were compared to 27 infertility patients without PCOD who were pregnant after hMG therapy. Non-PCOD patients received hMG for superovulation as part of superovulation/intrauterine insemination or in vitro fertilization/embryo transfer. PCOD patients were receiving hMG for simple ovulation induction. Pregnancy-induced hypertension was defined as late pregnancy blood pressure > 140/90 mm Hg on two readings six hours apart and return to normal blood pressure by four to six weeks postpartum.

RESULTS

There were no differences between PCOD and non-PCOD patients with reference to age, body mass index, parity or other pregnancy-induced hypertension risk factors (i.e., chronic hypertension, diabetes or chronic renal disease). Pregnant PCOD patients had a much higher incidence of pregnancy-induced hypertension, 31.8% (7/22), versus non-PCOD patients, who only had a pregnancy-induced hypertension incidence of 3.7% (1/27) (P = .016, OR = 12.1, 95% CI = 1.3-566.8).

CONCLUSION

PCOD patients are at very high risk of pregnancy-induced hypertension when pregnant after ovulation induction.

Case of the month

Each month, we will present a challenging Case of the Month for Green Journal readers, who must use their clinical acumen to arrive at the correct answer. We will also post the case each month on the Journal's web site (http://www.ajmselect.com). Several possible answers may be consistent with the case presentation; use your best judgment. Please send your answer (one per respondent) to The Green Journal at editors@amjmed.org or via Fax to (415) 447-2799. Indicate the case to which you are responding, and include your complete address. The correct answer will appear in the next issue of the Journal. The first five persons who submit correct answers will receive a free one-year subscription to the Journal. Colleagues of Drs. Kashyap in Pune, India are not eligible for this month's case. If you would like to contribute a case, please submit a brief synopsis (<250 words) to the editorial office.

Dermatofibroma of the eyelid: a case report

A 5-year-old girl presented with a large swelling measuring 50 x 35 mm in the left upper lid. The mass was firm to hard in consistency. Fine-needle aspiration showed a few spindle-shaped cells arranged in clusters. The mass was excised in toto and the histopathological examination revealed dermatofibroma, which is an extremely rare condition affecting the eyelid.

Maturational changes in heart rate and heart rate variability in low birth weight infants

To provide insight into the maturation of neural mechanisms responsible for variability in heart rate during quiet and active sleep, 6-hour continuous electrocardiographic recordings and simultaneous minute-by-minute behavioral activity state assignments were performed in 61 healthy, growing low birth weight infants. The infants weighed 795-1600 g at birth and ranged between 31-38 weeks in postconceptional age. During this age interval there was a decrease in heart rate during quiet sleep and an increase in both time domain and frequency domain measures of the variability in cardiac interbeat intervals. In quiet sleep, global variability, measured as SD of R-R intervals, increased in relation to age, as did higher frequency variability, measured as the square root of the mean of squared successive differences in R-R intervals. Developmental changes in the 0.5-2.0 Hz spectral power band of RR-interval variability, another measure of high frequency variability, paralleled the changes seen in the time domain measure. Evaluation of patterns of changes in the magnitude and direction of successive interbeat intervals provided evidence that the incidence of sustained accelerations or decelerations increased whereas the incidence of no change in consecutive RR-intervals decreased as infants matured. Among the various measures of heart rate variability, the incidence of sustained change and no change in successive interbeat intervals were most closely related to postconceptional age in both sleep states. The overall decrease in heart rate, increase in heart rate variability, and increase in the pattern of changes in interbeat interval with postconceptional age are consistent with the maturation of the autonomic cardio-regulatory activity from 31-38 weeks age.

Hypoparathyroidism unmasked by alendronate

The case of an elderly woman is reported in whom alendronate, given for osteoporosis, led to severe hypocalcaemia a few days after starting the drug treatment. This was caused by the unmasking of previously unrecognised hypoparathyroidism.