Evaluation of the hypothalamo-pituitary-adrenal axis during the post-COVID-19 period in patients treated with steroids during the illness

Objective

COVID-19 is a multisystem immunoinflammatory disorder, and the hypothalamo-pituitary-adrenal (HPA) axis may be affected by SARS-CoV-2 as well as by steroid treatment during the illness. Information on the HPA axis after recovering from COVID-19, especially in those treated with steroids, is sparse. Hence, this study was performed to evaluate the hypothalamo-pituitary-adrenal axis during the post-COVID-19 period in patients treated with steroids during the illness.

Subject and methods

This prospective study involved 60 patients aged 18-60 years who had recovered from moderate or severe COVID-19 and had received steroid treatment during the illness. The HPA axis was assessed with a low-dose (1 mcg) adrenocorticotropic hormone stimulation test at 3, 6 and 9 months in the post-COVID period.

Results

The HPA axis was suppressed in 31.66% of the patients at 3 months and 5% at 6 months; however, all patients recovered at 9 months. Cumulative steroid use during the illness was inversely correlated with stimulated cortisol at 3 months in the post-COVID period. Fatigue was present in 58.33% of the patients at 3 months and was more prevalent in those with HPA axis suppression.

Conclusion

Nearly one-third of the patients with moderate to severe COVID-19 who were treated with steroids had suppressed HPA axis at 3 months, with gradual recovery over a period of 9 months. Cumulative steroid equivalent dose, but not disease severity, was predictive of HPA axis suppression at 3 months.

Calculated plasma osmolality at hospital admission correlates well with eGFR and D-Dimer, a simple outcome predictor and guiding tool for management of severe COVID-19 patients

AIMS

To evaluate calculated total plasma osmolality as a marker of outcome prediction, fluid and metabolic balance, thrombotic risk in severe COVID-19 patients.

METHODS

Retrospective data of RT-PCR confirmed hospitalized severe COVID-19 patients (total: n = 175 patients, including diabetic subset: n = 102) were analyzed. Clinically applicable cut-offs were derived using receiver operating characteristic (ROC) curve analysis for calculated total osmolality, eGFR, and D-dimer, and their correlations were studied.

RESULTS

Among 175 severe COVID-19 patients, a significant association with mortality was seen with respect to calculated total osmolality (p < 0.001), eGFR (p < 0.001), and D-dimer (p < 0.001). In the total cohort, applicable cut-offs based on ROC curve in predicting outcome were, for total osmolality 299 mosm/kg (area under the curve (AUC)-0.773, odds ratio (OR)-1.09), eGFR 61.5 ml/min/m2 (AUC-0.789, OR-0.96), D-dimer 5.13 (AUC-0.814, OR-2.65) respectively. In diabetic subset, the cut-offs for total osmolality were 298 mosm/kg (AUC-0.794, OR-1.12), eGFR 44.9 ml/min/m2 (AUC-0.774, OR-0.96) and D-dimer 1.59 (AUC-0.769, OR-1.52) respectively.

CONCLUSIONS

Applicable cut-offs for calculated total plasma osmolality, eGFR, and D-dimer predicts clinical outcome in severe COVID-19 with and without diabetes. Correlation studies validated calculated total osmolality as a marker of the combined effect of fluid and metabolic imbalance, compromised renal function and hypercoagulability.

Integrated hydrochemical and ERT approach for seawater intrusion study in a coastal aquifer: a case study from Jafrabad Town, Gujarat State, India

Hydrochemical and geophysical approach has been adopted to evaluate the seawater intrusion (SWI) in coastal aquifers of Jafrabad Town, Gujarat State, India. Electrical Resistivity Tomography (no. 9) was carried out with spread length of 160-400 m which provided penetration depth of about 23 to 76 m. Very low resistivity zone (0-3 Ω-m range) has been observed in the ERT profiles conducted in the study area. Parameters, namely, TDS, Na, and Cl, have been considered to examine the signature of SWI. The results obtained from ionic ratios, Piper plot, and Chaddha's diagram also confirm the influence of saline water within aquifer. The very low resistivity signature is correlated with the high TDS values in the nearby wells. SWI has been observed up to 9 km from the coast, and it is observed at a depth of 20-22 m in the existing limestone mines near the coast.

Study of the Effect of Early Insulin Therapy on Inflammation and Its Correlation With Glucotoxicity in Newly Diagnosed T2DM

Diabetes is a chronic metabolic and inflammatory disorder resulting in long term vascular complications. Glucotoxicity has been proposed to aggravate inflammatory stress. In this background,effect of early insulin therapy on inflammatory markers in relation to the glycemic status could be relevant in the newly diagnosed Type 2DM patients. Clinical studies highlighting this pathophysiologic aspect are sparse. Objective: To determine the effect of early insulin therapy in newly diagnosed patients with type 2 diabetes mellitus on inflammatory markers and glucotoxicity. Methods: 40 newly diagnosed type 2 diabetes patients, attending the endocrinology OPD at a tertiary teaching hospital were enrolled in this treatment related follow up study after institutional ethical committee clearance, conducted between May 2019 to February 2020. Patients with HbA1C &gt; 8.5% to &lt;12.5% were included in the study. Metabolic (FPG, PPG, HbA1c), and inflammatory parameters (Serum IL-6, Serum TNF alpha levels) were assessed both at baseline and after 9 months of insulin treatment. A simple,conventional twice daily premixed insulin was initiated at a starting dose of insulin at 0.5 U/kg/day and the dose was titrated according to FPG and 2 hr PPG in order to maintain glycemic goals as per ADA standards. Results: The study included 40 subjects with a mean age of 43.9 years and a mean BMI of 26.46 kg/m2. At the end of 9 months of the study, mean FPG, PPG, HbA1C were significantly reduced [FPG (118.45± 24.74mg/dl), PPG (152± 25 mg/dl), HbA1c (6.67± 0.42%)] as compared to baseline [FPG, (218.4± 37.84mg/dl), PPG (307±62mg/dl), HbA1C (9.95± 1.39%) (p &lt;0.001). A statistically significant decrease in inflammatory markers like IL6, TNF alpha, from baseline to 9 months [.IL6 5.365±1.465 to 2.819±0.697 pg/ml, S.TNF alpha 36.476±16.902 to 11.274±3.712 pg/ml.] (p &lt;0.001) was observed. Correlation studies revealed at 9 months, a highly significant positive correlation between FPG, PPG and IL6 and TNF alpha levels (p&lt;0 .001), in comparison with baseline (p&lt; 0.05). However IL6 levels significantly correlated with HBA1c both at baseline and at 9 months (p&lt;0.05), whereas only a non significant positive correlation with TNF alpha was observed. Conclusion: Early Insulin treatment has beneficial effect on both Inflammation and glucotoxicity in newly diagnosed Type2 DM. Effective, simple and early insulin regimen offers a pathophysiologic based therapeutic perspective aiming at improving the natural course of diabetes.

Alpha and Beta Cell Dysfunction Improves With Effective Insulin Therapy in Treatment Naive Type 2 Diabetes - a Prospective Observational Study

Abstract: Type 2 diabetes mellitus is characterized by insulin resistance and progressive beta cell decline. Elevated glucagon levels and impaired incretin axis also contribute to the poor glycemic status. Early intensive glycemic control, reduces long-term vascular complications and may preserve β-cell function. Clinical studies of effect of early insulin therapy on combined alpha and beta cell function are lacking. Objective: To determine the effect of early insulin therapy on combined alpha and beta cell dysfunction (islet cell dysfunction) in newly diagnosed type 2 diabetes. Methods: 56 newly diagnosed type 2 diabetes patients, attending the endocrinology OPD at a tertiary teaching hospital were enrolled in this treatment related follow up study after institutional ethical committee clearance, conducted between May 2017 to December 2018. Patients with HbA1C &gt; 8.5% to &lt;12.5% (n=56) were included in the study. Metabolic (FPG, PPG, HbA1c), and Hormonal parameters (plasma glucagon levels,fasting and 2 hour mixed meal stimulated C peptide and levels) were assessed both at baseline and after 6 months of insulin treatment. Initiating dose of insulin was 0.5 U/kg/day and the dose was titrated according to FPG and 2 hr PPG in order to maintain glycemic goals as per ADA standards. Results: The study included 56 subjects with mean age of 41.24 ± 5.64 years and a mean BMI of 25.5 kg/m2. At the end of 6 months of the study, a significant reduction in the mean FPG, PPG, HbA1C were observed,[FPG (139±14.47 mg/dl), PPG (179.89 ± 19.42mg/dl),HbA1c (7.54± 0.63%)] as compared to baseline mean FPG, (216.30 ± 42.35 mg/dl),2 hour PPG (338.44 ±62.89 mg/dl), HbA1C (10.39 ± 1.56 %) (p &lt;0.001). Baseline glucagon levels were high (197.68± 49.09 pg/ml), and were significantly reduced at 6 months of insulin therapy (107.06±49.09 pg/ml).(p &lt;0.001). In comparison to the baseline a significant increase in both fasting (0.73±0.27 ng/ml) and stimulated c-peptide (1.54±1.02 ng/ml) (p&lt;0.001) levels was observed at end of the study. Conclusion: Combined alpha and beta cell (Islet) dysfunction prevails in newly diagnosed T2DM. And early insulin therapy significantly improves both these defects. The documentation of this novel beneficial effect on islet cell dysfunction in our study strengthens the concept of early insulin therapy in newly diagnosed Type 2 diabetes patients.

Evaluation of simple and cost-effective immuno- haematological markers to predict outcome in hospitalized severe COVID-19 patients, with a focus on diabetes mellitus - A retrospective study in Andhra Pradesh, India

BACKGROUND AND AIMS

COVID-19 pandemic has strained the health infrastructure globally, providing an opportunity to identify cost-effective biomarkers. We aimed to identify simple hematological prognostic markers in hospitalized severe COVID-19 patients with and without diabetes.

METHODS

Retrospective study of RT-PCR confirmed hospitalized severe COVID-19 patients (total: n = 154 patients, including diabetic subset n = 57) were analyzed. Clinically applicable cut-offs were derived using receiver operating characteristic (ROC) curve analysis for total leucocyte count (TLC), absolute neutrophil count (ANC), neutrophil lymphocyte ratio (NLR), and derived neutrophil lymphocyte ratio (dNLR) in order to prognosticate the outcome.

RESULTS

Among 154 severe COVID-19 patients, significant association with mortality was seen with respect to TLC(p < 0.001), ANC (p < 0.001), NLR(p < 0.001) and dNLR(p < 0.001). In the total cohort, applicable cut-offs based on ROC curve in predicting outcome were, for TLC 8950 cells/mm³ (area under curve (AUC)-0.764, odds ratio (OR)-7.53), ANC 7679 cells/mm³ (AUC-0.789, OR-8.14), NLR 5.13 (AUC-0.741, OR-4.77), dNLR 3.44 (AUC -0.741, OR-4.43) respectively.In diabetic subset, the cut-offs for TLC was 8950 cells/mm³ (AUC -0.762, OR-14.9), ANC 6510 cells/mm³ (AUC -0.773, OR-16.8), NLR 5.13(AUC -0.678, OR-6) and dNLR 3.25(AUC -0.685, OR-4.7) respectively.

CONCLUSIONS

In severe COVID-19 patients irrespective of diabetes, a simple, applicable total leucocyte count cut-off, 8950 cells/mm³ , together with easily derived cut-offs for ANC, NLR, dNLR may serve as cost-effective prognosticators of clinical outcome. A normal TLC may be misleading in the intensive care and the above applicable cut-off for TLC serves as an early warning tool for high-risk identification and better in-hospital management. Even with similar or lower cut-offs, diabetics had a higher mortality.

Consensus on Choice of Insulin Pen Devices in Routine Clinical Practice in India

Although insulin delivery devices are widely used by the patients, there is a paucity of published guidelines to help professionals manage their patients in insulin therapies. To provide simple and easily implementable guidelines to health care physicians on the choice of insulin delivery devices in routine clinical practice, experts in diabetes gathered together and discussed the recommendations at the National insulin Summit 2018. An ideal insulin delivery device should accurately deliver the prescribed dose of insulin and be easy to use. Recommendations are: (1) insulin should be initiated by using an insulin device if the patient seems to discontinue insulin therapy. (2) Pen devices offer accurate dosing than a syringe and vial and are associated with cost savings in the long term. (3) Switching over from syringes and vial to disposable pen devices improves adherence. (4) FlexPen^® offers better accuracy, and it requires lower dose force and injection force than SoloStar^® and KwikPen^® (5). Durable delivery pens such as NovoPen^® 4 maintain accuracy and low dose force compared with vials and syringes. (6) One pen should be used by only one patient. (7) Regular counseling on the proper use of the pen device is required regularly. This consensus-based recommendation is a useful reference tool for health care practitioners to initiate insulin therapy in patients with diabetes by using the appropriate insulin pen device.

Identification of Cystic Lesions by Secondary Screening of Familial Pancreatic Cancer (FPC) Kindreds Is Not Associated with the Stratified Risk of Cancer

OBJECTIVES

Intraductal papillary mucinous neoplasms (IPMNs) are associated with risk of pancreatic ductal adenocarcinoma (PDAC). It is unclear if an IPMN in individuals at high risk of PDAC should be considered as a positive screening result or as an incidental finding. Stratified familial pancreatic cancer (FPC) populations were used to determine if IPMN risk is linked to familial risk of PDAC.

METHODS

This is a cohort study of 321 individuals from 258 kindreds suspected of being FPC and undergoing secondary screening for PDAC through the European Registry of Hereditary Pancreatitis and Familial Pancreatic Cancer (EUROPAC). Computerised tomography, endoscopic ultrasound of the pancreas and magnetic resonance imaging were used. The risk of being a carrier of a dominant mutation predisposing to pancreatic cancer was stratified into three even categories (low, medium and high) based on: Mendelian probability, the number of PDAC cases and the number of people at risk in a kindred.

RESULTS

There was a median (interquartile range (IQR)) follow-up of 2 (0-5) years and a median (IQR) number of investigations per participant of 4 (2-6). One PDAC, two low-grade neuroendocrine tumours and 41 cystic lesions were identified, including 23 IPMN (22 branch-duct (BD)). The PDAC case occurred in the top 10% of risk, and the BD-IPMN cases were evenly distributed amongst risk categories: low (6/107), medium (10/107) and high (6/107) (P = 0.63).

CONCLUSIONS

The risk of finding BD-IPMN was independent of genetic predisposition and so they should be managed according to guidelines for incidental finding of IPMN.

Postpartum Follow-up in Women Diagnosed with Subclinical Hypothyroidism during Pregnancy

BACKGROUND

Management guidelines about the thyroid disease in pregnancy are silent about the postpartum course of new onset subclinical hypothyroidism (SCH). Hence, we analyzed the 2 years outcome of SCH diagnosed during pregnancy.

MATERIALS AND METHODS

We conducted this retrospective study using the medical records of patients with new onset SCH during pregnancy between 2010 and 2013 (n = 718). Patients who stopped their levothyroxine after delivery with a 2-year follow-up record were included. We excluded patients with known thyroid disorders and continuous use of drugs that affect the thyroid results. The patients were divided into two groups (Group 1 - euthyroid and Group 2 - hypothyroid) based on the final outcome after 2 years. The data were analyzed using appropriate statistical methods and a P < 0.05 was considered statically significant.

RESULTS

A total of 559 (77.8%) women stopped levothyroxine after delivery, and the final follow-up data were available for 467 patients only. At the end of 2 years, 384 (82.2%) remained euthyroid, and the remaining 83 (17.8%) developed hypothyroidism. SCH and overt hypothyroidism were seen in 22 and 61 patients, respectively. Group 2 patients had higher mean age (25.5 vs. 23.6 years), goiter (51 vs. 2%), initial thyroid stimulating hormone (7.9 vs. 5.1 μIU/mL), and thyroid antibody positivity (76 vs. 13%) (P < 0.001).

CONCLUSION

The majority of patients with SCH during pregnancy remain euthyroid after delivery. Advanced age, goiter, positive family history, and thyroid autoimmunity increase the future risk of hypothyroidism in patients with SCH diagnosed during pregnancy.

Improvement in subclinical cognitive dysfunction with thyroxine therapy in hypothyroidism: A study from tertiary care center

AIM

To evaluate the effect of hypothyroidism (both overt and subclinical) on cognitive function using latencies of P300 auditory evoked potentials (AEPs). P300 latency suggests that shorter latency times are related to better cognitive performance. P300 latencies were also done after thyroxine replacement to see the effect of treatment on cognitive function.

MATERIALS AND METHODS

Biochemically proven new onset cases with hypothyroidism (overt and subclinical) were enrolled into the study, AEPs of these two groups when compared with matched controls. After detailed history and physical examination, P300 potentials were recorded at two points Cz and Pz (Cz: On the midline of the head at the vertex, Pz: On the midline of the head between the vertex and occipital protuberance) using a Nicolet Viking Select neuro diagnostic system version 10.0. The study was done in electrophysiology lab in Osmania Medical College.

RESULTS

A patient characteristics of both cases and controls were comparable. The cases consisted of two groups, overt hypothyroid cases 24, mean thyroid stimulating hormone (TSH) values in them was 94, subclinical cases 21 in whom mean TSH value was 12.3. Mean P300 latencies of all cases at Cz was 342.42 ± 29.5 ms, and at Pz was 345.4 ± 30 ms. Mean P300 latencies of controls at Cz was 296.4 ± 34 ms and at Pz was 297.9 ± 33 ms (difference in P < 0.001). Mean P300 values in overt cases were 362.6 ± 32.9 ms at Cz, and at Pz it was 362.5 ± 33.9 ms. Mean P300 values in subclinical cases were 319.3 ± 30.9 ms at Cz, and at Pz it was 316.4 ± 27.9 ms. P300 values in overt cases were highly significant as compared to controls, and P300 values in the subclinical cases versus controls were also significant (P < 0.001).

CONCLUSION

P300 latency prolongation in both clinical and subclinical hypothyroid cases shows that cognitive function is affected adversely in hypothyroidism including the subclinical hypothyroid cases. Larger studies evaluating the effect of subclinical hypothyroidism on cognitive function are needed with objective means such as the AEPs P300.

An unusual combination of Klinefelter syndrome and growth hormone deficiency in a prepubertal child

Klinefelter syndrome (KS) is the most common chromosomal aneuploidy in males. It is very difficult to diagnose this disorder in childhood due to absence of significant manifestations before puberty. These patients usually present with tall stature. We report a case of KS with short stature due to growth hormone deficiency. The boy's height was below the 3rd centile with significant delay in bone age. He responded well to growth hormone injections. In view of mental subnormality karyotyping was done, which revealed KS (47XXY).

Management of large bowel obstruction with self-expanding metal stents. A multicentre retrospective study of factors determining outcome

AIM

UK cancer guidelines recommend patients with colonic obstruction due to suspected malignancy be considered for stenting with a self-expanding metal stent (SEMS). Considerable variation in practice exists due to a lack of expertise, technical difficulties and other, as yet ill-defined features. This retrospective multi-centre study aims to determine the outcome following colonic stenting for large bowel obstruction and identify factors associated with successful intervention.

METHOD

A regional programme of colonic stenting for large bowel obstruction, in five UK centres from 2005 to 2010 was evaluated for outcome including technical and clinical success, survival, complications and reoperation.

RESULTS

A SEMS was inserted in 334 patients, including 264 (79.0%) for palliation and 52 (15.6%) as a bridge to surgery. Technical success was achieved in 292 (87.4%) patients, with 46 (13.8%) experiencing a complication or technical failure. Reoperation was required in 39 (14.8%) patients stented for palliation of colorectal cancer of whom 16 (6.1%) subsequently required a colostomy. A one-stage primary anastomosis was achieved in 35 (67.3%) of the 52 patients undergoing stenting as a bridge to resection. Technical success did not vary by indication or site of obstruction (P = 0.60) but was higher for operators who had performed more than 10 procedures (OR 3.34, P = 0.001). ASA grade ≥3 predicted a worse clinical outcome (OR 0.43, P = 0.04). The through-the-scope (TTS) endoscopy technique was more successful than radiological placement alone (90.3% vs 74.8%, P < 0.001).

CONCLUSION

Experienced operators using a TTS technique achieved a better outcome for the emergency management of large bowel obstruction. Older, sicker patients and those with extracolonic and benign strictures fared less well.

The presence of a cytopathologist increases the diagnostic accuracy of endoscopic ultrasound-guided fine needle aspiration cytology for pancreatic adenocarcinoma: a meta-analysis

OBJECTIVE

A meta-analysis has not been previously performed to evaluate critically the diagnostic accuracy of endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) of solely pancreatic ductal adenocarcinoma and address factors that have an impact on variability of accuracy. The aim of this study was to determine whether the presence of a cytopathologist, variability of the reference standard and other sources of heterogeneity significantly impacts diagnostic accuracy.

METHODS

We conducted a comprehensive search to identify studies, in which the pooled sensitivity, specificity, likelihood ratios for a positive or negative test (LR+, LR-) and summary receiver-operating curves (SROC) could be determined for EUS-FNA of the pancreas for ductal adenocarcinoma using clinical follow-up, and/or surgical biopsy or excision as the reference standard.

RESULTS

We included 34 distinct studies (3644 patients) in which EUS-FNA for a solid pancreatic mass was evaluated. The pooled sensitivity and specificity for EUS-FNA for pancreatic ductal adenocarcinoma was 88.6% [95% confidence interval (CI): 87.2-89.9] and 99.3% (95% CI: 98.7-99.7), respectively. The LR+ and LR- were 33.46 (95% CI: 20.76-53.91) and 0.11 (95% CI: 0.08-0.16), respectively. The meta-regression model showed rapid on-site evaluation (ROSE) (P = 0.001) remained a significant determinant of EUS-FNA accuracy after correcting for study population number and reference standard.

CONCLUSION

EUS-FNA is an effective modality for diagnosing pancreatic ductal adencarcinoma in solid pancreatic lesions, with an increased diagnostic accuracy when using on-site cytopathology evaluation.

Functioning adrenal myelolipoma: A rare cause of hypertension

Co-occurrence of adrenal incidentaloma with hypertension calls for evaluation of endocrine causes including pheochromocytoma, Cushing's disease, and primary aldosteronism. We are reporting 40-years-old man who presented with hypertension and adrenal mass. He had elevated metanephrines, histology of resected adrenal mass revealed adrenal myelolipoma, and immuno-histochemistry was positive for chromogranin A. Both his blood pressure and urinary metanephrines returned to normal after surgery. The association of hypertension and adrenal myelolipoma may not be entirely coincidental, as it may be associated with secreting catecholamine. Literature on such an uncommon association is reviewed briefly as well.

Randomized trial comparing fanning with standard technique for endoscopic ultrasound-guided fine-needle aspiration of solid pancreatic mass lesions

BACKGROUND AND STUDY AIMS

The fanning technique for endoscopic ultrasound-guided fine-needle aspiration (EUS - FNA) involves sampling multiple areas within a lesion with each pass. The aim of this study was to compare the fanning and standard techniques for EUS - FNA of solid pancreatic masses.

PATIENTS AND METHODS

Consecutive patients with solid pancreatic mass lesions were randomized to undergo EUS - FNA using either the standard or the fanning technique. The main outcome measure was the median number of passes required to establish diagnosis. The secondary outcome measures were the diagnostic accuracy, technical failure, and complication rate of the two techniques.

RESULTS

Of 54 patients, 26 were randomized to the standard technique and 28 to the fanning technique. There was no difference in diagnostic accuracy (76.9 % vs. 96.4 %; P = 0.05), technical failure or complication rates (none in either cohort). There was a significant difference in both the number of passes required to establish diagnosis (median 1 [interquartile range 1 - 3] vs. 1 [1 - 1]; P = 0.02) and the percentage of patients in whom a diagnosis was achieved on pass one (57.7 % vs. 85.7 %; P = 0.02) between the standard and fanning groups, respectively.

CONCLUSIONS

The fanning technique of FNA was superior to the standard approach because fewer passes were required to establish the diagnosis. If these promising data are confirmed by other investigators, consideration should be given to incorporating the fanning technique into routine practice of EUS - FNA. Registered at Clinical Trials.gov (NCT 01501903).

Flexible sigmoidoscopy does not significantly increase polyp and cancer detection yield when used to supplement CT colonography

BACKGROUND AND AIMS

Flexible sigmoidoscopy (FS) increases polyp and carcinoma detection in addition to double contrast barium enema (DCBE). However, CT colonography (CTC) is now the preferred technique. Our aim was to explore whether FS increases polyp and carcinoma detection rates when used in addition to CTC.

METHODS

Patients who underwent FS and CTC between 2007 and 2009 were included and data were collected from patient records. Yields of polyp, adenoma and carcinoma detection were calculated for FS and CTC.

RESULTS

In a cohort of 294 patients, CTC detected 36 patients with carcinomas while FS detected 28. One rectal cancer not seen on CTC was diagnosed by FS. Polyps were seen by CTC in 66 and FS in 45 patients. In 5 patients FS found polyps that were not detected by CTC; 3 of which were small adenomas. FS detected extra adenomas or carcinomas in 1.36% (4/294). Adding FS to CTC neither increased the cancer nor the polyp detection yield significantly.

CONCLUSIONS

This first study investigating the use of FS in addition to CTC detected little additional pathology. The routine use of FS as a supplement to CTC for adenoma and carcinoma detection is of questionable utility.

WAP(version 2.0): an updated computing and visualization server for water molecules

By exploiting the fast-growing Internet technology, the interactive computing serverWater Analysis Package(WAP, version 2.0) has been updated with more flexible options to better understand the role of the water O atoms present in three-dimensional macromolecular (protein or nucleic acid) structures. The updated robust server facilitates the computation and visualization of water molecules from various hydration shells, interfacial water molecules and those water molecules that stabilize various secondary structural elements. It is also possible to detect the interactions of water molecules with various parts (polar atoms, nonpolar atoms, main-chain and side-chain atoms) of the protein molecule. Furthermore, a molecular graphics visualization program is interfaced to display the nature of the interactions of the water molecules. The Protein Data Bank archive interfaced with the server is updated every week; hence users get to analyse the latest structures. The computing server can be obtained from http://dicsoft2.physics.iisc.ernet.in/wap/.

Use of mobile phones by medical staff at Queen Elizabeth Hospital, Barbados: evidence for both benefit and harm

All members of medical staff, including students, were asked to participate in a self-administered questionnaire concerning patterns of mobile phone use and care. Participants' phones were cultured for micro-organisms. Healthcare professionals working in close proximity to sensitive equipment were surveyed concerning adverse events associated with mobile phones. Telephone operators were asked to monitor time elapsed as they attempted to contact medical staff by various methods. Of 266 medical staff and students at the time of the study, 116 completed questionnaires (response rate=44%). Almost all (98%) used mobile phones: 67% used their mobile phones for hospital-related matters; 47% reported using their phone while attending patients. Only 3% reported washing their hands after use and 53% reported never cleaning their phone. In total, 101 mobile phones were cultured for micro-organisms; 45% were culture-positive and 15% grew Gram-negative pathogens. The survey of staff working in close proximity to sensitive equipment revealed only one report of minor interference with life-saving equipment. Telephone operators were able to contact medical staff within 2 min most easily by mobile phone. Mobile phones were used widely by staff and were considered by most participants as a more efficient means of communication. However, microbial contamination is a risk associated with the infrequent cleaning of phones. Hospitals should develop policies to address the hygiene of mobile phones.

Abdominal tuberculosis in a district general hospital: a retrospective review of 86 cases

BACKGROUND

Abdominal tuberculosis (ATB) is a great mimic and an important cause of morbidity. Its incidence is more common in certain groups.

AIM

To review the cases of ATB in Blackburn from 1985 to 2004, with emphasis on presentation, investigation, diagnosis, treatment and follow-up.

METHODS

A retrospective cases note analysis from a prospectively compiled database.

RESULTS

Eighty-six cases of ATB were on a prospective database of all tuberculosis (TB) cases in Blackburn for 1985-2004 inclusive. Full case papers were available for 82 and partial data for the remaining four cases. Median age was 34.8 years, with an equal sex distribution. South Asians accounted for 91% of cases. The highest proportion of patients had peritoneal TB, and a considerable number (27%) had TB at multiple sites.

CONCLUSION

The diagnosis can be difficult to make because of the varied presentation, the low percentage with positive microscopy for acid-fast bacilli and the time delay of up to several weeks for a positive TB culture. The thresholds for laparoscopy and/or laparotomy for the diagnosis were therefore very low. The diagnosis could be made rapidly by these methods, and early treatment instituted. Six months short-course chemotherapy is very effective in ATB. This should be changed, if appropriate, on the basis of drug susceptibility data.

Video assisted thoracoscopic surgery at the Queen Elizabeth Hospital Barbados

Video assisted thoracoscopic surgery (VATS) is now an established technique for diagnostic and therapeutic intervention in patients with thoracic pathology at the Queen Elizabeth Hospital (QEH). This article reviews the experience with 50 patients over the period May 1996 to February 2003, looking at various factors and outcomes in an attempt to ascertain the viability of this procedure at this institution. It serves as a follow-up article to the publication of the initial experience in 1999 (1). There were 24 males and 26 females included in the study. Video assisted thoracoscopic surgery was used for diagnosis in 27 cases (54%), therapeutic indication in 17 cases (34%) and as both a diagnostic and therapeutic modality in six cases (12%). In 92% of cases, the operations were completed thoracoscopically with a conversion rate of 8%. The morbidity and mortality rates were 18% and 2% respectively. Video assisted thoracoscopic surgery is an effective tool for the treatment and investigation of selected thoracic pathology at the QEH with complications and mortality rates comparable to other institutions (2, 3).

CADB-2.0: Conformation Angles Database

The Conformation Angles Data Base (CADB) is a comprehensive, authoritative and timely knowledge base with a powerful query engine developed to facilitate the retrieval of information related to the conformational angles (main chain and side chain) of the amino-acid residues present in non-redundant (both 25 and 90%) data sets. The updated version has improved options for determining the dependency of the conformation angles of a particular residue upon the flanking residues, doublet analysis, triplet analysis and analysis of a particular protein structure. It is worth mentioning that for all options a user-friendly and convenient Java graphical user interface (GUI) has been provided to display the output on the client machine. The database is accessible at the URL http://cluster.physics.iisc.ernet.in/cadb/ or http://144.16.71.148/cadb/.

SSEP-2.0: Secondary Structural Elements of Proteins

The Secondary Structural Elements of Proteins (SSEP) database is an integrated and comprehensive knowledge base for accessing information related to all the secondary-structural elements present in non-redundant (25 and 90%) protein chains. The new version 2.0 of the database contains 2485 and 8595 protein chains from the 25 and 90% non-redundant data sets, respectively. The necessary web interfaces have been developed that enable users to visualize the three-dimensional structure of the secondary-structural element in the client machine using the free molecular-visualization program RASMOL. This source is updated at regular intervals and can be accessed through the bioinformatics web server at the URL http://cluster.physics.iisc.ernet.in/ssep or http://144.16.71.148/ssep/.

Conventional cutting vs. internal anal sphincter-preserving seton for high trans-sphincteric fistula: a prospective randomized manometric and clinical trial

BACKGROUND

Cutting setons have been used in complicated perirectal sepsis with good effect, although there is a moderately high incidence of fecal leakage after their use. The aim of this study was to compare a modified cutting seton, which repaired the internal anal sphincter muscle and re-routed the seton through the intersphincteric space, with a conventional cutting seton.

METHODS

A total of 34 patients were randomized between 1998 and 2002. They were prospectively assessed by continence score and anorectal manometry, and for anal function, clinical sepsis and fistula recurrence.

RESULTS

There was no difference in postoperative continence score, incidence of recurrent fistula or healing time between groups after a mean follow-up of 12 months. Resting anal manometric pressures and vector volumes were consistently higher with the modified seton (although not statistically significant), as was the area under the inhibitory curve during elicitation of the rectoanal inhibitory reflex across the full sphincter length. ( p<0.05).

CONCLUSION

A larger prospective study of internal anal sphincter-preserving seton use in cryptogenic high transshincteric fistula-in-ano appears justified.

An audit of upper gastrointestinal bleeding at Seremban Hospital

We retrospectively analyzed all patients presenting with upper gastrointestinal bleeding to Seremban Hospital over a one-year period. A quarter of the oesophagogastro-duodenoscopies (OGD) performed were performed as emergency for upper gastrointestinal tract bleeding. Gastric ulcers and duodenal ulcers were the two most common findings. Our results suggest that there is a male preponderance of 2:1, the Chinese were more likely to be affected and the elderly (> 60 years) were at highest risk.

Studies on the aggregation and possible channel formation in membranes of a cyclic hexapeptide, cyclo (D-Ala-L-Pro-L-Ala)2

The interaction of zwitterionic lipid DMPC and DPPC with cyclic hexapeptide, cyclo (D-Ala-L-Pro-L-Ala)2 was studied using circular dichroism (CD) and differential scanning calorimetry (DSC). Preliminary membrane conductance results showed that the peptide has a tendency to form channels inside the lipid bilayer. CD studies indicated that as the lipid/peptide (L/P) ratio (DMPC/peptide) was increased, the magnitude of the negative CD band having a lambda(max) around 200 nm decreased. At a L/P ratio of 210:1, this band disappeared completely, indicating dramatic conformational changes in the peptide on interaction with the lipid bilayer. Reduction of the phase transition temperature and the maximum heat capacity of the lipid bilayer (DPPC) for gel-to-liquid crystalline phase transition indicates a strong interaction of the peptide with the lipid bilayer.

Tolerability and efficacy of single dose albendazole, diethylcarbamazine citrate (DEC) or co-administration of albendazole with DEC in the clearance of Wuchereria bancrofti in asymptomatic microfilaraemic volunteers in Pondicherry, South India: a hospital-based study

BACKGROUND: The tolerability and efficacy of single dose albendazole (400 mg), diethylcarbamazine citrate (DEC) (6 mg/kg bodyweight) or co-administration of albendazole (400 mg) + DEC (6 mg/kg bodyweight) was studied in 54 asymptomatic Wuchereria bancrofti microfilaraemic volunteers in a double blind hospital-based clinical study. RESULTS: There was no significant difference in the overall incidence of adverse reactions between the three drug groups [42.1% (albendazole), 52.9% (DEC) and 61.1% (albendazole + DEC); P > 0.05]. The mean score of adverse reaction intensity did not differ significantly between the DEC and albendazole + DEC groups. However, the values in these two groups were significantly higher compared to that of albendazole alone [1.8 +/- 3.0 (albendazole) vs. 5.6 +/- 7.1 (DEC), 6.7 +/- 6.6 (albendazole + DEC); P < 0.05]. By day 360 post-therapy there was no significant difference between the three drug groups in relation to the clearance of microfilaria [26.3% (albendazole), 17.6% (DEC), 27.8% (albendazole + DEC)], reduction in geometric mean parasite density [94.7% (albendazole), 89.5% (DEC), 95.4% (albendazole + DEC)] or reduction in filarial antigenaemia [83% (albendazole), 87% (DEC), 75% (albendazole + DEC)]. Furthermore, there was a significant decrease in mean geometric parasite density (P < 0.05) as well as antigenaemia optical density values (P < 0.01) between pre-therapy levels and day 360 post-therapy in all three groups. CONCLUSIONS: This study has shown that single dose albendazole (400 mg) has similar efficacy in the clearance of microfilaria as that of DEC or the co-administration of the two drugs. The results strengthen the rationale of using albendazole for mass annual single dose administration for the control of transmission of lymphatic filariasis.

FT-IR microscopic characterization of normal and malignant human colonic tissues

Fourier-transform infrared spectroscopy (FT-IR) employs a unique approach to optical diagnosis of tissue pathology based on the characteristic molecular vibrational spectra of the tissue. In this study, we report infrared absorption spectra of formalin fixed, paraffin embedded normal and malignant human colonic tissues from ten different patients. Our method is based on microscopic infrared study (FT-IR-microscopy) of thin tissue specimens in parallel with normal histopathological analysis, which serves as a reference. Our results indicate that the normal colonic tissue has a stronger absorption than the cancerous type over a wide region in all ten cases. The detailed analysis showed that there is a significant decrease in carbohydrate levels, total phosphate and also possibly creatine contents for cancerous tissue in comparison to the controls. Also, RNA/DNA ratio increased in cancerous tissues relative to the normals in all the patients. The results of Linear Discriminant Analysis (LDA) showed that the normal and malignant cells could be identified with about 89% accuracy.

Novel methodology for the follow-up of acute lymphoblastic leukemia using FTIR microspectroscopy

In this report, we present a novel spectroscopic method of follow-up during chemotherapy treatment for B- and T-cell childhood leukemia patients. We isolated peripheral lymphocytes from blood drawn from patients before and after the chemotherapy and collected Microscopic FTIR (FTIR-MC) spectra of the isolated lymphocytes. Our results showed that nucleic acids content decreased in both types of patients. Changes in phospholipids and proteins level could be observed. The overall effects of drugs administered to the patients can be understood at the molecular level using FTIR-MC and these results are expected to stimulate wider applications of spectroscopy in leukemia research.

Application of FTIR microscopy for the characterization of malignancy: H-ras transfected murine fibroblasts as an example

Recently, microscopic FTIR is widely used in the field of biology and medicine. FTIR can detect biomolecular changes in the cells and tissues responsible for various disorders. In this report, we characterize the H-ras transfected fibroblasts and its normal control using microscopic FTIR. The intensity of the normal fibroblasts was higher than that of H-ras transfected fibroblasts. Our studies showed significant differences occur in the concentration of vital metabolites upon transformation. The DNA and carbohydrates level decreased in the transformed cells compared to the controls. A linear correlation could be found between the levels of carbohydrates and phosphate, while the RNA/DNA ratio varied inversely with glucose/phosphate levels.

FTIR microscopic studies on normal and H-ras oncogene transfected cultured mouse fibroblasts

Infrared absorption spectra are well known for their sensitivity to composition and three-dimensional structure of biomolecules. The biochemical changes in the sub-cellular levels developing in abnormal cells, including a majority of cancer forms, manifest themselves in different optical signatures, which can be detected by IR spectroscopy. We measured the IR absorption spectra of monolayers of cultured normal and H-ras transfected mouse fibroblasts, using a microscopic Fourier transform IR (micro-FTIR) technique. The absorption of normal cells was found to be higher than the malignant ones in the spectral range 600-3200 cm(-1). The carbohydrate and phosphate contents were higher in normal cells relative to H-ras transfected cells. An increase in the RNA/DNA ratio was observed for H-ras transfected fibroblasts, which correlates with the increased transcriptional activity expected for the cancerous cells. In part, the variation in absorbance between normal and ras transfected fibroblasts may be due to changes in the cell dimensions.

Acute myoedema: an unusual presenting manifestation of hypothyroid myopathy

We describe a patient with primary hypothyroidism due to autoimmune thyroiditis, presenting with acute myoedema and spontaneous rhabdomyolysis. During his hospital stay, he developed altered sensorium due to hypo-osmolal hyponatraemia and later developed bilateral foot drop that responded to appropriate treatment.

Spontaneous rupture of the spleen

A 10 year old boy presented to the surgical service of the Queen Elizabeth Hospital with spontaneous rupture of the spleen and was later discovered to have chronic myeloid leukaemia. He has been in haematological remission for five years followed splenectomy and alpha-interferon therapy.