Protein energey malnutrition and skeletal muscle wasting in childhood acute lymphoblastic lukemia

OBJECTIVE

To determine the nutritional status and the extent of skeletal muscle wasting in children with acute lymphoblastic leukemia (ALL) at the time of diagnosis and after induction chemotherapy.

DESIGN

Prospective observational study.

SETTING

Tertiary care teaching hospital.

METHODS

25 new cases of ALL underwent somatometric measurements and ultrasonographic evaluation of skeletal muscle and subcutaneous fat at initial presentation and after completion of induction therapy.

RESULTS

Malnutrition (weight for age < 80percnt) was evident in 13 cases (52percnt), but cumulative incidence of malnutrition (weight for age < 80percnt, weight for height < 90percnt, height for age < 95percnt, skin fold thickness < 5th centile, midarm muscle circumference < 5th centile) was 88percnt. Nine children lost weight during induction (range: 0.2 to 5.8 kg; means +/- SD: 1.9 plusmn 1.8 kg). All these cases had a complicated course during induction chemotherapy. Fourteen children (56percnt) had skeletal muscle wasting during induction chemotherapy. All those children who had lost weight also had skeletal muscle wasting. Subcutaneous fat, in contrast increased in 24 cases (96percnt).

CONCLUSION

Malnutrition exists in a significant proportion of children with ALL. If induction chemotherapy is complicated, children lose significant weight and have significant muscle wasting. Increase in subcutaneous fat occurs in almost all children, which is probably a consequence of therapy with oral steroids

Assessment of malnutrition in alcoholic and non alcoholic cirrhotics

OBJECTIVE

To study the nutritional status in patients with chronic liver disease using anthropometric techniques.

METHODS

A total of 60 cirrhotic patients (30 Alcoholic (AC), 30 Non-alcoholic (NAC) and 30 control (CO) subjects were studied. Nutritional status was assessed using anthropometric measurements such as stature, body weight, body mass index, (BMI), skinfold thickness measurements and mid upper arm muscle circumference. Serum protein, serum albumin and globulin were measured.

RESULTS

The skinfold thicknesses were significantly lower in NAC group of patients. In contrast the AC group of patients showed significantly lower mid upper arm muscle circumference values. Both groups of cirrhotic patients showed significantly lower total serum protein and serum albumin levels.

CONCLUSION

Body fat is relatively more affected in NAC group of patients and muscle mass is more affected in AC group of patients.

The distribution, determinants, and clinical correlates of vertebral osteophytosis: a population based survey

OBJECTIVE

Vertebral osteophytes are a characteristic feature of intervertebral disc degeneration. There are, however, few population data concerning the occurrence of and clinico-biological correlates of vertebral osteophytes in both the dorsal and lumbar spine. Our purpose was to determine the frequency and distribution of anterior osteophytes in the thoracic and lumbar spine, and their relationship with both various putative risk factors, including physical activity and obesity, and self-reported back pain.

METHODS

Men and women aged 50 years and over were recruited from primary care based registers in 5 UK centers. They were invited to attend for an interviewer administered lifestyle questionnaire, assessment of height and weight, and lateral spinal radiographs. Lateral spinal radiographs were evaluated by a single observer for the presence of osteophytes from T4 to L5 using a semiquantitative score (grade): 0 = none, 1 = doubtful, 2 = mild, 3 = moderate, 4 = severe. Based on these data 2 summary statistics were derived: the maximum osteophyte grade at any vertebral level (MAX), and the sum of the osteophyte grades at the individual vertebral levels (TOT).

RESULTS

In total, 681 women, mean age 63.3 years, and 499 men, mean age 63.7 years, were studied; 84% of men and 74% of women had at least one vertebral level with a grade 1 or higher osteophyte. Both the sum of the individual grades (TOT) and the proportion of subjects with MAX > or =2 were greater in men than in women in both the dorsal and lumbar spine, and both increased with age. The pattern of spinal involvement was similar in the sexes, with osteophytes occurring most frequently at T9-10 and L3. Increasing body mass index was associated with more frequent osteophytes at both dorsal and lumbar spine, although the relationship was stronger at the dorsal spine. Heavy physical activity, particularly in young adult life, was associated with osteophytosis in men. Self-reported back pain, both ever and in the past year, was linked with lumbar osteophytes in men.

CONCLUSION

The distribution within the spine in our study and the relationship with heavy physical activity points to mechanical factors being important in pathogenesis of vertebral osteophytosis. Prospective studies are needed to explore the types of physical activity that increase susceptibility to vertebral osteophytosis. In men, osteophytes affecting the lumbar spine are associated with back pain.

Longitudinal growth of arm circumference in Punjabi infants

OBJECTIVE

To study distance and velocity growth pattern of mid-upper-arm-circumference in Punjabi infants.

DESIGN

Longitudinal, monthly follow up.

SETTING

Growth clinic and homes of subjects.

SAMPLE

One hundred and fifty four (Male 86, Female 68) Punjabi infants weighing more than 2.5 kg at birth with gestation over 37 weeks.

METHODS

Every subject was measured for mid-upper-arm circumference between 1 to 12 months of age at one monthly intervals by the same investigator with a time tolerance of 3 days on the day of measurement.

RESULTS

Mid upper arm circumference showed rapid increase between 1 to 6 months whereafter, gain became slower during second half of infancy. It had grown by 34.9% in male and 40.2% in female infants between 1 to 12 months. Sex differences favoring male infants were statistically significant between 1 to 4 months. Monthly growth rates for arm-circumference depicted vascillatory pattern.

CONCLUSION

The values presented for arm circumference may be used as reference base to monitor growth of children during infancy.

Retro-peritoneal cystic lymphangioma in association with fetal hydantoin syndrome

Antiepileptic drugs are known to be teratogenic. Use of phenytoin during pregnancy can cause various congenital malformations leading to 'fetal hydantoin syndrome'. One such case reported is unique in the sense that it occurred with retroperitoneal cystic lymphangioma, itself a rare condition. Such an association is not described elsewhere.

Respiratory rates of Indian infants under 2 months of age

There are few data from developing countries, including India, on the normal range of the respiratory rate (RR) recorded by observation. To determine the normal range of RR in infants up to 8 weeks of age and to define tachypnoea, we studied 100 healthy infants, 50 of normal birthweight and 50 of low birthweight) at 1, 2, 4, 6 and 8 weeks of age. The RR was recorded by observation and auscultation simultaneously for 60 seconds on each visit when the baby was either asleep or awake and content. The median RRs ranged between 42 and 43 breaths/min in infants of normal birthweight and 40 and 44 breaths/min. in low birthweight infants. Inter-age variability up to 8 weeks of age was very slight and statistically insignificant. Only 2-10% of the infants at any given age had a RR > or = 60/min. At all ages, RR by observation was higher than that by auscultation (p < 0.001). Neither birthweight nor gender significantly influenced the RR. When awake, infants had significantly higher RRs than when asleep. The RR extrapolated from a 15-second breath count was significantly lower (p < 0.05-0.01), whereas results from 30-second counts were similar to 60-second counts. Our data endorse the use of a RR > or = 60 breaths/min. counted for 1 minute as a cut-off to define tachypnoea in infants < 2 months of age.

Mortality associated with vertebral deformity in men and women: results from the European Prospective Osteoporosis Study (EPOS)

Clinically apparent vertebral deformities are associated with reduced survival. The majority of subjects with radiographic vertebral deformity do not, however, come to medical attention. The aim of this study was to determine the association between radiographic vertebral deformity and subsequent mortality. The subjects who took part in the analysis were recruited for participation in a multicentre population-based survey of vertebral osteoporosis in Europe. Men and women aged 50 years and over were invited to attend for an interviewer-administered questionnaire and lateral spinal radiographs. Radiographs were evaluated morphometrically and vertebral deformity defined according to established criteria. The participants have been followed by annual postal questionnaire--the European Prospective Osteoporosis Study (EPOS). Information concerning the vital status of participants was available from 6480 subjects, aged 50-79 years, from 14 of the participating centres. One hundred and eighty-nine deaths (56 women and 133 men) occurred during a total of 14,380 person-years of follow-up (median 2.3 years). In women, after age adjustment, there was a modest excess mortality in those with, compared with those without, vertebral deformity: rate ratio (RR) = 1.9 (95% confidence interval (CI) 1.0,3.4). In men, the excess risk was smaller and non-significant RR = 1.3 (95% CI 0.9,2.0). After further adjusting for smoking, alcohol consumption, previous hip fracture, general health, body mass index and steroid use, the excess risk was reduced and non-significant in both sexes: women, RR = 1.6 (95% CI 0.9,3.0); men RR = 1.2 (95% CI 0.7,1.8). Radiographic vertebral deformity is associated with a modest excess mortality, particularly in women. Part of this excess can be explained by an association with other adverse health and lifestyle factors linked to mortality.

Effect of a gluten free diet on osteopenia in adults with newly diagnosed coeliac disease

BACKGROUND/AIMS

Calcium and vitamin D malabsorption in coeliac disease predispose to skeletal demineralisation. This study aimed to determine bone mineral density in patients studied in the first year after diagnosis of coeliac disease, and to detect changes in bone mineral density over the subsequent year.

METHODS

Lumbar spine and femoral neck bone mineral density was measured in 21 adults with coeliac disease, diagnosed and started on a gluten free diet during the preceding year, with dual energy x ray absorptiometry and repeated after 12 months.

RESULTS

Bone mineral density was significantly lower in patients than in paired controls (matched for age and sex), at lumbar spine (0.819 g/cm2 compared with 1.021 g/cm2, p < 0.001 Wilcoxon signed rank test) and femoral neck (0.663 g/cm2 compared with 0.794 g/cm2, p < 0.001). Repeat measurement after 12 months demonstrated that patients had a significant gain in bone mineral density at lumbar spine (16.6%/year), and femoral neck (15.5%/year, p < 0.002, Wilcoxon signed rank test at both sites), whereas no significant change in bone mineral density was detected in controls.

CONCLUSIONS

Treatment of coeliac disease with a gluten free diet is associated with a significant increase in bone mineral density, although patients still had lower bone mineral density than controls.

Percentile curves for body-mass index of Punjabi infants

OBJECTIVE

To study percentile distance growth pattern of Body Mass Index (BMI) of Punjabi male and female infants.

DESIGN

Longitudinal.

SETTING

Growth Clinic.

SUBJECTS

154 Punjabi infants (Male 86; Female 68), aged birth-12 months.

FOLLOW-UP

Nude body weight and crownheel length of all babies at birth and whereafter, were measured at monthly age intervals with time tolerance to +/-3 days by the same investigator upto 12 months of life.

RESULTS

Mean (+/- SD) values for BMI measured 12.2 +/- 1.40 kg/m2 and 16.5 +/- 1.40 kg/m2 at birth and 12 months, respectively in male infants. The corresponding figures for female infants were 12.5 +/- 1.60 kg/ m2 and 16.5 +/- 1.50 kg/m2. A rapid increase in BMI values amongst infants of both sexes between birth to about six months followed by flattening of curves upto 12 months of age indicates an age dependent nature of BMI during first half of infancy in comparison to latter half during which these demonstrated stable trend. These findings are in contrast to those of the western infants who showed a regular increase in BMI throughout the first year of life. Sex differences were not significant at majority of the age levels.

CONCLUSIONS

Percentile grids presented for BMI represent a normal, healthy and well-nourished infant population which can be used to assess the adiposity status of infants of the two sexes during the first year of life.

Coexisting polyostotic fibrous dysplasia and Paget's disease

The following case report describes a patient who is known to have both fibrous dysplasia and Paget's disease, and traces his history over more than 50 years. The similarities and differences between the two conditions and their relative importance at the various stages of the history are discussed.

Osteoporosis in treated adult coeliac disease

Forty five women and 10 men with coeliac disease diagnosed in adult life, who were already on a gluten free diet, had serial bone mineral density measurements at the lumbar spine and femoral neck over 12 months. Osteoporosis, defined as a bone mineral density (BMD) < or = 2 SD below the normal peak bone mass was found in 50% of male and 47% of female coeliac patients. Patients with a BMD < or = 2 SD below age and sex matched normal subjects, had a significantly lower body mass index (21.3 kg.m-2 compared with 25.2 kg.m-2, p < 0.02 Wilcoxon rank sum test) and lower average daily calcium intake (860 mg/day compared with 1054 mg/day, p < 0.05 Wilcoxon rank sum test) than patients with normal bone mineral density. In postmenopausal women with coeliac disease there was a strong correlation between the age at menopause and BMD at both the lumbar spine (r = 0.681, p < 0.01, Spearman's rank correlation) and femoral neck (r = 0.632, p < 0.01). No overall loss of bone was shown over the 12 months of follow up, and relative to the reference population there was a significant improvement in BMD at the lumbar spine in women (p < 0.025, paired t test) and at the femoral neck in men (p < 0.05, paired t test). There was a significant negative correlation between the annual percentage change in BMD at the lumbar spine and the duration of gluten free diet (r = -0.429, p<0.01, Spearman's rank correlation), with the largest gain in BMD in patients with most recently diagnosed coeliac disease. Osteoporosis was shown in 47% of patients with treated adult coeliac disease. Recognised risk factors for osteoporosis in the general population including low body mass index, dietary calcium intake, and early menopause are particularly important in coeliac disease. Treatment of coeliac disease with a gluten free diet probably protects against further bone loss, and in the early stages is associated with a gain in bone mineral density.

Bone mineral density in nonsteroid treated early rheumatoid arthritis

OBJECTIVES

To determine whether significant reduction in bone mass is detectable in early disease in patients with rheumatoid arthritis (RA) and to examine the possible influences of disease activity and physical disability on bone mineral density (BMD) of the lumbar spine (LS) and femoral neck (FN).

METHODS

LS and FN BMD values were measured and Z scores determined in a cross-sectional study of 104 patients with RA of less than five years duration. BMD values were also compared between a subgroup of 64 patients and a normal control group matched for age, sex, menopausal status and body mass. BMD values and Z scores were correlated with disease activity, measured by the Stoke Index, disability, measured by HAQ score, and disease duration.

RESULTS

Premenopausal female patients with RA had significantly reduced mean FN Z scores (-0.62, 95% CI -0.30 to -0.94) which correlated with HAQ scores (Rs 0.358, p = 0.05) and age (Rs 0.397, p = 0.03). There were no significant changes of BMD in males or postmenopausal females. Disease duration and disease activity did not correlate with BMD changes.

CONCLUSION

BMD is reduced in premenopausal female patients with early RA possibly related to the attainment of peak bone mass. No significant reduction of BMD was found in males or postmenopausal females with early disease. Physical disability but not disease activity appears to play a role in the reduction of FN bone mass.

Longitudinal bone mineral density changes in early rheumatoid arthritis

A prospective longitudinal study of patients with early RA was performed to examine the influence of disease duration, disease activity and physical activity on bone loss. Sixty-seven patients with non-steroid treated RA of less than 5 yr duration, including 16 patients with disease duration less than 6 months, had BMD measurements of the femoral neck and the lumbar spine over a 12-month period using dual energy X-ray absorptiometry. The BMD changes were compared with values from 72 control patients and were also correlated with serial measurements of disease activity (measured by the Stoke Index) and disability [measured by the Health Assessment Questionnaire (HAQ) score], at 3-monthly intervals over the 12-month period. No significant differences in BMD changes were found between RA patients and controls overall. Patients with disease duration of less than 6 months had significantly greater loss of BMD at the femoral neck (-3.9%, S.E.M. 1.5) than the remainder of the cohort (-0.2%, S.E.M. 0.7) (P = 0.02) and controls (-0.8%, S.E.M. 0.6). Lumbar spine BMD changes correlated with the initial Stoke Index (Rs-0.373, P = 0.01) but not mean Stoke Indices. There was no correlation of BMD changes with age or HAQ scores. These findings suggest that significant bone loss occurs within the first few months of disease in patients with RA.

A safer and more effective treatment regimen for eclampsia

In a prospective controlled trial 91 consecutive women with eclampsia were randomly allocated either to a magnesium sulphate and nifedipine regime or to a lytic cocktail and nifedipine group. The type and severity of disease, details of labour and delivery, and the maternal and perinatal outcomes and complications related to the 2 treatment regimens were compared. Recurrence of fits, aspiration pneumonia and sudden hypotension were significantly reduced when patients were treated with the new magnesium sulphate and nifedipine regimen compared with the lytic cocktail plus nifedipine regimen. No patient treated with the new regimen died or had respiratory depression; in the other group there were 2 maternal deaths plus 1 case of severe hypoxic brain damage. No difference was observed in duration of labour or mode of delivery. Perinatal mortality was significantly lower in the magnesium sulphate plus nifedipine treated group. The synergistic action of magnesium sulphate and nifedipine in the dosage employed in this study may be used to reduce maternal and perinatal mortality and morbidity in women with eclampsia.

Co-existence of oblique pinnae and congenital heart disease

The paper reports a syndrome in which oblique placement of one or both the pinnae on face was found to co-exist with congenital anomalies of heart like VSD, PDA and Tetralogy of Fallot, etc. Although clinically discernible in 90% of the subjects, objective evidence of obliquity of pinna was documented by photogrammetry. The values for the ear inclination in subjects categorized clinically as normally placed pinna were 7.9 degrees +/- 3.39 degrees with range 2 degrees-17 degrees. In contrast, subject where the pinna was clinically categorized as oblique had mean AEI 16.5 degrees +/- 5.81 degrees with a range 5 degrees-33 degrees. Eighteen of the 20 subjects with oblique pinna were demonstrated to have some congenital anomaly of heart as indicated by clinical and echocardiographic examination. In contrast, in subjects with normally placed pinna only 3 out of 34 possessed clinical heart defects. Presence of oblique pinna indicates a thorough search for undetected heart defects.

A reappraisal of steroid-induced osteoporosis

The anti-inflammatory and immunosuppressive effects of corticosteroids were first recognized by Hench and colleagues in 1949. It soon became apparent that supraphysiological doses were associated with numerous side effects, particularly osteoporosis and skeletal failure. In spite of this, the pathogenesis of steroid osteoporosis remains unclear and its prevention and treatment controversial.

Idiopathic polymyositis complicated by arthritis and mesangial proliferative glomerulonephritis: case report and review of the literature

A 56-yr-old male developed a systemic illness while receiving cyclical oral etidronate therapy for idiopathic osteoporosis. The illness, characterized by fever, proximal myopathy and inflammatory synovitis, was associated with interstitial lung disease and mesangial proliferative glomerulonephritis. Elevated plasma creatine phosphokinase level and inflammatory muscle biopsy findings confirmed a diagnosis of polymyositis (PM). Antibodies to Jo-1 were also detected. A review of the literature reveals that mesangial proliferation is the commonest glomerular lesion and suggests a possible association between arthritis and glomerulonephritis in PM. The prognosis of this renal lesion appears to be good, although only limited data is available.

Osteoporosis in rheumatoid arthritis

Osteoporosis is recognised as a common complication of rheumatoid arthritis, with two characteristic patterns--juxta-articular and generalized bone loss. Increasingly sophisticated means of measuring bone turnover and identifying inflammatory mediators which affect bone resorption have enhanced our understanding of the disease process. The aetiology is multifactorial, involving disease-specific and general factors, but the relative importance of the various risks remains uncertain. The evidence for a protective role for oestrogens and the detrimental effect of low dose corticosteroids will be discussed. Biochemical assessment of bone loss lacks sensitivity and specificity, but the rapid improvement in radiological techniques for measuring bone mineral density have improved our ability to diagnose and assess disease progression. The diagnosis and treatment of specific risk factors, such as testosterone or vitamin D deficiency, may be helpful in a few patients, but the ultimate aim must be the early diagnosis and prevention of this potentially catastrophic complication.

Percentile growth charts for head circumference in Punjabi infants

Percentile growth charts for head circumference of Punjabi infants (male 86 and female 68) measured serially at monthly intervals during the first year of life are presented. Besides, constancy of sample size and strict adherence to time tolerance limit of +/- 3 days, on the day of monthly measurements other factors considered responsible for the natural smooth course of the percentile grids are highlighted. The presented data would enable easy detection of infants with abnormal course of head growth.

Nail-patella syndrome associated with mixed crystal deposition arthropathy

This report describes a case of nail-patella syndrome in a woman with a strong family history who presented with effusions in her shoulder and knees. Microscopic examination of the shoulder fluid suggested the presence of calcium pyrophosphate dihydrate (CPPD) crystals, and examination of the knee fluid suggested both hydroxyapatite (HAP) and CPPD crystals. To our knowledge, the coexistence of these two conditions has not been reported in the past. Moreover, it brings up a new element regarding the inflammatory origin of the nail-patella syndrome.