Outcomes of patients with elevated pulmonary artery systolic pressure on echocardiography due to chronic lung diseases

BACKGROUND

Pulmonary hypertension is associated with increased mortality, and lung diseases are the second most common cause of pulmonary hypertension. We aimed to evaluate the prognostic value of echocardiography in low-middle income countries where right heart catheterization is difficult to perform.

METHODS

This retrospective chart review study included adult patients hospitalized from June 2012 to May 2021, with a pulmonary artery systolic pressure (PASP) of ≥35 mmHg on echocardiography. The control arm consisted of patients with similar lung diseases who did not have an elevated PASP.

RESULTS

The study and control arm consisted of 128 patients each, with both groups having similar lung diseases. Obesity hypoventilation syndrome was the most common etiology of elevated PASP (28.1 %), followed by pulmonary embolism (20.3 %). The overall 1-year mortality of the study cohort, after diagnosis of elevated PASP, was 20.3 %. The control cohort with normal PASP had a 1-year mortality of 4.7 %. In the study cohort, patients with bronchiectasis had the highest cause-specific 1-year mortality (45.5 %). In the normal PASP cohort, the highest cause-specific 1-year mortality was observed in patients with interstitial lung disease (13.0 %). One-year hospital readmission was observed in 46.9 % and 33.6 % of patients in the study and control arms, respectively. On multivariate analysis, increased odds of 1-year mortality were observed in patients with elevated PASP, patients with 1-year hospital readmission, and in patients with interstitial lung disease or bronchiectasis.

CONCLUSION

Elevated PASP on echocardiography may be a prognostic factor for mortality in patients with chronic lung diseases.

Therapeutic enhancing potential of piracetam with diethylstilbestrol in prevention of grand-mal seizures in rats: inhibition of PI3K/Akt/mTOR signaling pathway and IL-1β, IL-6, TNF-α cytokines levels

OBJECTIVE

Epilepsy, a neurodegenerative disorder, continues to throw challenges in the therapeutic management. The current study sought to ascertain if the therapeutic interactions between piracetam and diethylstilbestrol may prevent grand-mal seizures in rats.

MATERIALS AND METHODS

Piracetam (PIR; 10 and 20 mg/kg) and diethylstilbestrol (DES; 10 and 20 mg/kg) alone as a low-dose combination were administered to rats for 14 days. The electroshock (MES; 180 mA, 220 V for 0.20 s) was delivered via auricular electrodes on the last day of treatment and rats were monitored for convulsive behavior. To elucidate the mechanism, hippocampal mechanistic target of rapamycin (mTOR) and interleukin (IL)-1β, IL-6 and tumor necrotic factor-alpha (TNF-α) levels were quantified. Hippocampal histopathology was conducted to study the neuroprotective effect of drug/s. In vitro studies and in silico studies were conducted in parallel.

RESULTS

To our surprise, the low dose of the combination regimen of PIR (10 mg/kg) and DES (10 mg/kg) unfolded synergistic anti-seizure potential, with brimming neuroprotective properties. The mechanism could be related to a significant reduction in the levels of hippocampal mTOR and proinflammatory cytokines. The docking scores revealed higher affinities for phosphatidylinositol 3-kinase (PI3K) in co-bound complex, and when docking DES first, while better affinities for protein kinase B (Akt) were revealed when docking PIR first (both drugs bind cooperatively as well). This indicated that the entire PI3K/Akt/mTOR signaling pathway is intercepted by the said combination. In addition, the % of cell viability of HEK-293 cells [pre-exposed to pentylenetetrazol (PTZ)] was increased by 327.29% compared to PTZ-treated cells (toxic control; 85.16%).

CONCLUSIONS

We are the first to report the promising efficacy of the combination (PIR 10 mg/kg + DES 10 mg/kg) to restrain seizures and epileptogenic changes induced by electroshock by a novel mechanism involving inhibiting the PI3K/Akt/mTOR signaling.

Clinical Risk Factors for Death in Patients With Empyema and Active Malignancy

Background Pleural infection is a common clinical problem resulting in prolonged hospitalization and increased mortality. In patients with active malignancy, management decisions are based on the need for further immunosuppressive therapies, the ability to tolerate surgery, and consideration of the limited life expectancy. Identifying patients at risk for death or poor outcomes is very important as it will guide care. Study design and methods This is a retrospective cohort study of all patients with active malignancy and empyema. The primary outcome was time to death from empyema at three months. The secondary outcome was surgery at 30 days. Standard Cox regression model and cause-specific hazard regression model were used to analyze the data. Results A total of 202 patients with active malignancy and empyema were included. The overall mortality rate at three months was 32.7%. On multivariable analysis, female gender and higher urea were associated with an increased risk of death from empyema at three months. The area under the curve (AUC) of the model was 0.70. The risk factors for surgery at 30 days included the presence of frank pus and postsurgical empyema. The AUC of the model was 0.76. Interpretation Patients with active malignancy and empyema have a high probability of death. In our model, the risk factors for death from empyema included female gender and higher urea.

Mobile Cone-Beam CT-Assisted Bronchoscopy for Peripheral Lung Lesions

Peripheral bronchoscopy with the use of thin/ultrathin bronchoscopes and radial-probe endobronchial ultrasound (RP-EBUS) has been associated with a fair diagnostic yield. Mobile cone-beam CT (m-CBCT) could potentially improve the performance of these readily available technologies. We retrospectively reviewed the records of patients undergoing bronchoscopy for peripheral lung lesions with thin/ultrathin scope, RP-EBUS, and m-CBCT guidance. We studied the performance (diagnostic yield and sensitivity for malignancy) and safety (complications, radiation exposure) of this combined approach. A total of 51 patients were studied. The mean target size was 2.6 cm (SD, 1.3 cm) and the mean distance to the pleura was 1.5 cm (SD, 1.4 cm). The diagnostic yield was 78.4% (95 CI, 67.1-89.7%), and the sensitivity for malignancy was 77.4% (95 CI, 62.7-92.1%). The only complication was one pneumothorax. The median fluoroscopy time was 11.2 min (range, 2.9-42.1) and the median number of CT spins was 1 (range, 1-5). The mean Dose Area Product from the total exposure was 41.92 Gy·cm² (SD, 11.35 Gy·cm²). Mobile CBCT guidance may increase the performance of thin/ultrathin bronchoscopy for peripheral lung lesions in a safe manner. Further prospective studies are needed to corroborate these findings.

Spontaneous large volume hemothorax managed with a small-bore chest tube

A 67-year-old male with metastatic lung cancer presented with acute shortness of breath and increasing oxygen requirements. He had a decreasing hemoglobin for which he required red blood cell transfusions. His chest X-ray showed near complete white-out of the left lung. Bedside ultrasound (Handheld Sonostar C4PL) showed a large pleural effusion with swirling echogenic material suggestive of plankton sign. The pleural effusion was aspirated and showed frank blood, after which a small-bore chest tube (SBCT) was inserted. A total of 3200 mL of blood was drained with the SBCT. There was complete clearance of the pleural space, and no further blood product transfusions were needed. This case highlights that conservative management can be considered in patients with spontaneous hemothorax due to metastatic disease.

Ventilatory Strategy to Prevent Atelectasis During Bronchoscopy Under General Anesthesia: A Multicenter Randomized Controlled Trial (Ventilatory Strategy to Prevent Atelectasis -VESPA- Trial)

BACKGROUND

Atelectasis negatively influences peripheral bronchoscopy, increasing CT scan-body divergence, obscuring targets, and creating false-positive radial-probe endobronchial ultrasound (RP-EBUS) images.

RESEARCH QUESTION

Can a ventilatory strategy reduce the incidence of atelectasis during bronchoscopy under general anesthesia?

STUDY DESIGN AND METHODS

Randomized controlled study (1:1) in which patients undergoing bronchoscopy were randomized to receive standard ventilation (laryngeal mask airway, 100% Fio2, zero positive end-expiratory pressure [PEEP]) vs a ventilatory strategy to prevent atelectasis (VESPA) with endotracheal intubation followed by a recruitment maneuver, Fio2 titration (< 100%), and PEEP of 8 to 10 cm H2O. All patients underwent chest CT imaging and a survey for atelectasis with RP-EBUS bilaterally on bronchial segments 6, 9, and 10 after artificial airway insertion (time 1) and 20 to 30 min later (time 2). Chest CT scans were reviewed by a blinded chest radiologist. RP-EBUS images were assessed by three independent, blinded readers. The primary end point was the proportion of patients with any atelectasis (either unilateral or bilateral) at time 2 according to chest CT scan findings.

RESULTS

Seventy-six patients were analyzed, 38 in each group. The proportion of patients with any atelectasis according to chest CT scan at time 2 was 84.2% (95% CI, 72.6%-95.8%) in the control group and 28.9% (95% CI, 15.4%-45.9%) in the VESPA group (P < .0001). The proportion of patients with bilateral atelectasis at time 2 was 71.1% (95% CI, 56.6%-85.5%) in the control group and 7.9% (95% CI, 1.7%-21.4%) in the VESPA group (P < .0001). At time 2, 3.84 ± 1.67 (mean ± SD) bronchial segments in the control group vs 1.21 ± 1.63 in the VESPA group were deemed atelectatic (P < .0001). No differences were found in the rate of complications.

INTERPRETATION

VESPA significantly reduced the incidence of atelectasis, was well tolerated, and showed a sustained effect over time despite bronchoscopic nodal staging maneuvers. VESPA should be considered for bronchoscopy when atelectasis is to be avoided.

TRIAL REGISTRY

ClinicalTrials.gov; No.: NCT04311723; URL: www.

CLINICALTRIALS

gov.

Dietary carbohydrate influences the colocalization pattern of Glucagon-like Peptide-1 with neurotensin in the chicken ileum

Glucagon-like peptide (GLP)-1 colocalizes with neurotensin (NT) in the same enteroendocrine cells (EECs) of the chicken ileum. The present study was designed to clarify the influence of dietary carbohydrate (CHO) on the colocalization pattern of GLP-1 with NT in the chicken distal ileum. Male White Leghorn chickens at 6 weeks of age (n = 15) were divided into three groups, a control and two experimental (low-CHO and CHO-free), with five chickens in each, and fed control or experimental diets for 7 d. Distal ileum was collected from each bird as a tissue sample and subjected to double immunofluorescence staining to detect GLP-1 and NT. Three types of EEC, GLP-1+/NT+, GLP-1+/NT- and GLP-1-/NT+, were demonstrated in the chicken ileum. GLP-1+/NT+ cells in the control group had a spindle-like shape with a long cytoplasmic process, but those in the experimental groups were round and lacked a cytoplasmic process. The ratio of GLP-1+/NT+ cells was significantly decreased in the two experimental groups compared with that in the control group. The ratio of GLP-1+/NT+ cells was significantly lower than those of GLP-1+/NT- and GLP-1-/NT+ cells in the two experimental groups. Most cells that were immunoreactive for GLP-1 and NT antisera lacked signals of proglucagon (PG) and NT precursor (NTP) mRNA in the experimental groups. The number of EECs expressing PG and NTP mRNA signals showed tendencies for decreases with a reduction of dietary CHO level. These findings suggest that dietary CHO could be a significant regulator of the pattern of colocalization pattern of GLP-1 with NT in the chicken ileum.

Giant Cell Arteritis as an Uncommon Cause of Chronic Cough: A Case Report

Patient: Female, 27-year-old

Final Diagnosis: Giant cell arteritis

Symptoms: Cough

Medication:—

Clinical Procedure: —

Specialty: Pulmonology

Safety and incidence of complications associated with bronchoscopy in an obese population

INTRODUCTION

The safety of bronchoscopy in obese patients and those with obstructive sleep apnea (OSA) is unclear. Our objective was to evaluate the incidence of complications during bronchoscopy under moderate sedation in obese patients and to assess the impact of OSA, body mass index (BMI), and duration of the procedure.

METHODS

We performed a retrospective study in adult patients undergoing bronchoscopy from January 2010 to August 2019. All patients with BMI > 30 kg/m² were included. Logistic regression analyses were used to identify the factors associated with all-complications and respiratory complications.

RESULTS

A total of 345 obese patients were identified. The average BMI in our cohort was 35.3 ± 5.1 kg/m² . During the pre-procedure risk assessment, 165 (47.8%) patients were labelled as "suspected OSA." The most common doses of sedation given during the bronchoscopies were fentanyl 50 mcg (34.5%) and midazolam 3 mg (33.6%). The incidence of major complications was 0.6% and minor complications were 41.2%. Minor respiratory (22.9%) and cardiac (26.4%) complications were common. No deaths occurred due to bronchoscopy. Factors that were associated with increased respiratory complications were female gender, suspected OSA, and bronchoscopy duration 20-30 minutes and bronchoscopy duration greater than 1 hour.

CONCLUSION

Bronchoscopy under moderate sedation performed in obese patients is safe; however, increased risk may exist with females, increased procedure time, and suspected OSA.

Pediatric size phlebotomy tubes and transfusions in adult critically ill patients: a pilot randomized controlled trial

Background

Transfusion of red blood cells (RBC) is common, can have adverse effects, and is a costly and limited resource. Interventions that reduce iatrogenic blood losses could reduce transfusions. The objectives of this pilot trial were to assess the feasibility (acceptability of the intervention and suitability of eligibility criteria) and potential effectiveness of pediatric size phlebotomy tubes in adult critically ill patients.

Methods

We conducted a pilot, randomized controlled trial in the medical intensive care unit (ICU) of a university-affiliated, tertiary care referral hospital from November 2017 to September 2018. A total of 200 patients with hemoglobin of at least 7 g/dL and without bleeding were randomized to pediatric or adult size phlebotomy tubes. Stratification was according to baseline hemoglobin (7-9.49 g/dL, 9.5-11.99 g/dL, and 12 g/dL or greater). Acceptability was measured via the number of blood test recollections and the number of patients that discontinued the use of pediatric tubes. The suitability of patient eligibility criteria was determined by identifying baseline characteristics associated with RBC transfusions. Potential effectiveness was estimated from the time to RBC transfusion or to hemoglobin level below 7 g/dL.

Results

The use of pediatric tubes was acceptable as patients experienced a low number of tests recollections (on average 1 every 57 days), and none of the participants discontinued their use. The baseline hemoglobin category was the only factor that appeared to be independently associated with RBC transfusions. A total of 6 patients (6%) in the pediatric tube group and 11 patients (11%) in the adult tube group (hazard ratio, 0.69; 95% CI, 0.25 to 1.9) received an RBC transfusion or reached hemoglobin below 7 g/dL. Almost all of these patients (16 of 17 participants) had baseline hemoglobin of 7-9.49 g/dL.

Conclusions

This pilot study suggests that pediatric phlebotomy tubes are acceptable to patients and can therefore be used in adult ICU patients. A future study should focus on patients with hemoglobin levels below 9.5 g/dL, as these patients have a high risk of transfusions. This intervention has the potential of being successful in selected patients. A definitive trial is warranted.

Trial registration

ClinicalTrials.gov, NCT03286465. Retrospectively registered on September 18, 2017.

Clinical Characteristics and Etiologies of Miliary Nodules in the US: A Single-Center Study

BACKGROUND

Miliary nodules have been typically described as a radiological manifestation of disseminated tuberculosis. However, miliary nodules are known to occur in a wide variety of conditions. The primary objective of the study was to identify clinical characteristics and etiologies of miliary nodules within our institution.

METHODS

Using International Classification of Diseases, Ninth and Tenth Revision codes, electronic medical records were used to retrospectively identify 53 patients who fulfilled criteria of miliary nodules over the last 10 years. Demographic and clinical data were extracted for all the patients in this cross-sectional study.

RESULTS

The diagnosis of tuberculosis was made in 15 (28.3%) patients, sarcoidosis in 12 (22.6%), silicosis in 7 (13.2%), extrathoracic malignancy in 5 (9.4%), and histoplasmosis in 4 (7.6%) patients. Four of 9 HIV patients had histoplasmosis. There was 1 case each of hypersensitivity pneumonitis, Pneumocystis jiroveci pneumonia, Mycobacterium-avium complex, Epstein-Barr virus pneumonia, cryptococcosis, aspergillosis, and primary lung cancer. Sputum was positive for acid fast bacilli in 4 cases (28%), and bronchoscopy had a 57% successful yield in miliary tuberculosis.

CONCLUSION

Our study is the largest single-center data review evaluating the etiology of miliary nodules within the United States; most of the data exist in case reports.

The associations of large-for-gestational-age and infant feeding practices with children's body mass index z-score trajectories: the Early Childhood Longitudinal Study, Birth Cohort

Very few studies have examined if high birth weight and infant feeding practices have implications for the trajectory of body mass index (BMI) growth across the early childhood period. The goal of this study was to assess if large-for-gestational-age (LGA) and infant feeding practices (exclusive breastfeeding for 6 months, and early introduction of complementary food prior to 4 months) are associated with BMI z-score trajectories over the early childhood period. Group-based trajectory modelling (GBTM) methods were employed to describe and classify developmental BMI z-score trajectories (the outcome of interest) in children from 9 months to 4 years of age (n = 4497) born to prenatal non-smoking mothers in the Early Childhood Longitudinal Study, Birth Cohort (2001-2005). Further analyses examined if the identified BMI z-score trajectories varied systematically with the exposures, LGA and specific infant feeding practices, after accounting for sociodemographic and other early-life factors. Two BMI z-score trajectory groups were identified: normal BMI z-score (56.2%) and high BMI z-score (43.8%). Children who were LGA infants had 2.3 times (risk ratio 95% confidence interval: 1.2, 4.5) greater risk of being in high BMI z-score group relative to normal BMI z-score group. BMI z-score trajectory groups did not differ by infant feeding practices, after controlling for LGA at birth. Membership in the high BMI z-score group was associated with LGA, but not with infant feeding practices. Healthcare professionals should provide early obesity counselling to parents of LGA infants so that parents can take appropriate obesity prevention measures for their children.

Ventricular Assist Device-Related Haemolysis Presenting with Acute Pancreatitis

Acute pancreatitis is one of the rare complications in patients fitted with a left ventricular assist device (LVAD). We herein report a case of acute pancreatitis in a patient with LVAD triggered by intravascular haemolysis. A 44-year-old man with non-ischaemic cardiomyopathy (NICM) after VAD implantation presented with epigastric pain. Laboratory work-up showed acute pancreatitis and haemolysis. As there was concern that device thrombosis was causing haemolysis, the patient was started on unfractionated heparin infusion. The patient was discharged when haemolysis and pancreatitis had resolved. To our knowledge, VAD-associated haemolysis presenting with acute pancreatitis is infrequently described in the literature.

Impact of livestock rearing practices on public health and environmental issues in selected municipality areas of Bangladesh

Livestock keeping at urbanized areas is increasing folds in rate now-a-days in Bangladesh. To characterize the urban livestock keeping practices and its implications on public health and environmental issues in Mymensingh, Gazipur and Shariatpur municipality, Bangladesh, a questionnaire survey was carried out. Ninety livestock keepers were freely characterized and data were obtained through interview. Data were analyzed using percentage and mean. Age does not have any role in keeping livestock at municipal areas. Majority (73%) of the respondents have at least primary education. Male dominates in keeping livestock than female. Local political leader kept the highest number of animals then self-employer or trader takes the second position. Dairy cattle share a lion number (67%) over other species. Ninety five per cent (95%) available breeds in municipal areas are crossbred and the rest is indigenous. More than 75% livestock holders keep their animals over 3 years and only 6% keepers sell their animals within 6 months. Most of the livestock keepers (56%) use their calf as replacement stock. The majority (66%) of the livestock depends on grazing and scavenging for feed from government and municipal lands, unfenced open land, roadsides, rubbish dumps. Most of the livestock owner (66%) does not supplement to their animals with feeds other than free scavenging throughout the rearing time. Most of the farmers (85%) have temporal shed for sheltering their animals during night time. Almost 78% flying herds available in municipal areas drink water from drainage line. Disease outbreaks are 21%, 18%, 17%, 16%, 13%, and 10% of ecto-parasite, mastitis, helminthosis, lumpy skin disease, wounds, and diarrhoea. 14% livestock owner follow vaccination program to keep better their animals from viral or bacterial infections. All the respondents (100%) are aware that livestock keeping could have a negative effect on urban health and environment. More than 50% of the respondents choose dung and urine disposal, malodor and blocked roads are the major damages caused by livestock. Strategies for controlling the damages were as follows: awareness through broadcasting documentary via mass media (4.33), regular health check via veterinary services (3.96), keeping database and regular updated of livestock keepers (3.82), proper disposal of waste (3.69), strengthening rules and policy development for local authority (3.61), reducing numbers of animal (3.48), provision of extension services (3.47), cleaning vicinity daily (3.32). There were some measures taken from public interviewing which need to amend for keeping health and environment free from diseases and pollution.Bang. J. Anim. Sci. 2016. 45 (1): 44-51

Effects of probiotics on haematology and biochemical parameters in mice

Probiotic organisms are live microorganisms thought to be beneficial to the host. To know the effect of probiotic supplemented food on haemato-biochemical parameters in mice, a total of 20 two-month-old Swiss Albino mice were randomly divided into four equal groups. Group A was control, fed commercial mouse pellets, and others were treated with 5 g (group B), 10 g (group C) and 20 g (group D) probiotics (curd), respectively, in mouse pellets for 45 days. Total erythrocyte count and haemoglobin concentration were significantly (P<0.01) higher in treated group than in controls. Total serum cholesterol, triglyceride, high density lipoprotein and low density lipoprotein values decreased significantly (P<0.01) in treated groups. Serum uric acid value was significantly higher (P<0.01) in treated groups. It is suggested that probiotics help improve haematology and lipid profile but not kidney function. DOI: http://dx.doi.org/10.3329/bvet.v30i1.16281 Bangl. vet. 2013. Vol. 30, No. 1, 20-24

Coronary angiographic profile in bangladeshi patients with metabolic syndrome and ischemic heart disease

The metabolic syndrome, which is characterized by a constellation of fasting hyperglycemia, hypertriglyceridemia, low HDL cholesterol, hypertension, and/or abdominal obesity, is a risk factor for the development of coronary artery disease (CAD) and cardiovascular events. We evaluated interrelationships between angiographic CAD and the metabolic syndrome, in 478 patients who were referred for coronary angiography to evaluate suspected myocardial ischemia in the department of cardiology of BSMMU between June 2007 and May 2008. We applied the criteria for the metabolic syndrome proposed by ATP III guideline. Study populations were divided into two groups on the basis of presence or absence of metabolic syndrome. Age was similar in both groups. Body mass index (BMI) was higher (26.22 ± 1.94 vs. 22.07 ± 1.55) in metabolic syndrome group (p ≤ 0.0001). All parameters, waist circumference (103.16 ± 10.21 vs. 91.45 ± 7.61) cm, blood pressure both systolic (141.34 ± 21.49 vs. 127.94 ± 13.01) and diastolic (86.8 5 ± 8.42 vs. 79.28 ± 7.77) mm of Hg, serum triglyceride (248.32 ± 77.88 vs. 128.35 ± 19.00)mg/dl, fasting blood glucose (125.40 ± 22.86 vs. 95.65 ± 10.63)mg/dl were significantly higher in metabolic syndrome group (p value=0.0001), whereas HDL (33.10 ± 6.55 vs. 39.30 ± 6.17)mg/dl was lower (p value = 0.0001). More subjects in metabolic syndrome were having type B (55.60% vs. 31.00%) and type C (9.50% vs. 2.70%) lesion as compared to non-metabolic syndrome group. Involvement of left main artery was more (4.80% vs. 0.90%) in metabolic syndrome group. Metabolic syndrome has primary predictive ability for CAD. A metabolic profile should form part of the risk assessment in all patients with coronary disease, not just those who are obese.

Barriers in initiating insulin therapy in a South Asian Muslim community

AIMS

Insulin therapy is often required for optimal glycaemic control. Pakistani patients display reluctance to use insulin. We aimed to determine the reasons for this and to assess impressions after initiation of insulin in our patients.

METHODS

Patients with Type 2 diabetes attending Aga Khan Hospital were surveyed using a questionnaire detailing opinions on insulin use. This was a cross-sectional study of two groups, one with no experience with insulin use and the other who were insulin users.

RESULTS

Three hundred and seventeen patients were interviewed, 55.8% male, mean age 53.6 years. Of 210 patients who had never used insulin, 72.9% felt insulin was a measure of last resort and 45.2% thought that tolerance developed to insulin. Only 45.7% felt insulin would reduce complications, while 24% thought that insulin use would interfere with religious obligations. Thirty-four percent thought that it was difficult or very difficult to learn insulin administration, 41% felt that they could not self-inject even if absolutely necessary and 25% stated they would not use insulin in any circumstances. There was an association of lack of education with negative image of insulin usage. Among 107 patients using insulin, 52.3% were hesitant before initiation. However, 78.5% noted an improvement in glucose control and 86% said they would recommend insulin to others.

CONCLUSIONS

Reluctance to use insulin prior to initiation is high, but views improve considerably after insulin initiation. Further awareness of the benefits of insulin use needs to be highlighted and the concerns of our population addressed.

Clinical and etiological profile of hyperprolactinemia--data from a tertiary care centre

OBJECTIVE

To study the clinical presentation and etiology of hyperprolactinemia, a common disorder encountered in endocrine practice.

METHODS

We analyzed the clinical data, hormone profile and imaging reports of 187 females with documented hyperprolactinemia, over a period of 6 years (5 years retrospective analysis and one year prospective study).

RESULTS

Majority of the 187 subjects studied presented in 3rd or 4th decade. Galactorrhoea was the commonest presenting symptom occurring in 159 subjects (85%), followed by amenorrhea in 68.9%; both amenorrhea and galactorrhea were seen in 45.4%. A microprolactinoma was demonstrated in 67 patients (35.8%), a nonfunctioning pituitary macroadenoma with stalk hyperprolactinemia occurred in 30 patients (16%) and polycystic ovarian disease was documented in 24 (12.8%). In 52 patients (27.8%) no apparent cause could be ascertained.

CONCLUSIONS

Syndrome of amenorrhea and/or galactorrhea is the commonest presentation in hyperprolactinemia. Microprolactinoma was the most frequent identifiable etiology followed by idiopathic and stalk hyperprolactinemia in our series.

Prevalence and pattern of sick euthyroid syndrome in acute and chronic non-thyroidal illness--its relationship with severity and outcome of the disorder

BACKGROUND

Non-thyroidal illness is a common cause of alterations in thyroid hormone economy in absence of underlying intrinsic thyroid disorder.

OBJECTIVE

To study the prevalence and pattern of alterations in thyroid hormone economy in various non-thyroidal illnesses in our region and also to correlate these alterations with the severity and outcome of the non-thyroidal illness.

MATERIAL AND METHODS

We analyzed circulating T3, T4, TSH in 382 patients with non-thyroidal illness (285 acute and 97 acute on chronic) and correlated the alterations with severity and outcome of the non-thyroidal disorder. The patients had one or more organ failure at the time of enrollment to the study. The hormones were estimated at the onset of sickness, and at 3rd and 24th week. T3, T4 and TSH in 75 age and sex matched euthyroid subjects were taken as controls.

RESULTS

T3 (mean +/- SEM) was significantly reduced at the onset of illness, in both acute and chronic patient groups (1.61 +/- 0.05 nmol/l) compared to that in the controls (3.17 +/- 0.06 nmol/l). In spite of clinical improvement in most instances, T3 continued to remain low in the 3rd week (1.49 +/- 0.11 nmol/ l) but increased (2.14 +/- 0.09 nmol/l) in 24th week. Low T3 was found in 93 (32.6%) cases with acute illness in 20 (20.6%) cases with chronic illness. A combination of low T3 and T4 was found in 35 (12.3%) of cases with acute and 15 (15.5%) with chronic illness. Although serum TSH showed noticeable fall and rise in some individuals, no significant difference in mean TSH was observed during any period of illness compared to that in the controls. Severity of illness correlated with decrease in T3 (r=0.58) and T4 (r=0.38). A low T3 and T4 with low or undetectable TSH were associated with increased mortality. At the onset of acute illness low T3 was seen in 113 (29.6%, low T3 -low T4 in 50 (13.1%), high T4 in 28 (7.3%) lowT3-lowT4- low TSH in 10 (2.6%) and low T4 alone in 4 (1%) patients. Fifty one 1 (13.4%) of our patients demonstrated alterations in TSH in presence of normal T3 and T4-26 patients had decreased TSH while as 25 had increased TSH. Of 118 patients who followed at 24 weeks, 11 (9.3%) had low T3, 7(5.9%) had low T3- low T4 and 13 (11%) had elevated TSH.

CONCLUSION

Pattern and prevalence of sick euthyroid syndrome in this part of the world, a recognized iodine deficient region, appears to be similar to that reported elsewhere. Important finding in our study was higher percentage of TSH elevation, which we believe to reflect the underlying iodine deficiency state of our community. Besides a significant number of subjects persisted with alterations in thyroid functions even after 6 months of therapy. Though the severity of thyroid hormone derangement correlated with severity of sickness, the derangement was similar in acute vs. acute on chronic nonthyroidal illnesses.

Ion-acoustic envelope solitons in electron-positron-ion plasmas

Ion-acoustic envelope solitons in a collisionless unmagnetized electron-positron-ion plasma are studied. The Krylov-Bogoliubov-Mitropolsky perturbative technique is used to obtain the nonlinear Schrödinger equation. The critical wave number for the modulational instability depends upon the concentration of different species and the temperature ratios of electrons and positrons. In the limiting case of zero positron concentration we recover the previous results of electron-ion plasma. It is found that a small concentration of ions in the electron-positron plasmas can change the dynamics of the system significantly. The ions can introduce slow time and long spatial scales in the plasmas. Thus the electron-positron plasmas become richer in linear and nonlinear wave dynamics.

Postpartum thyroiditis in India: prevalence of postpartum thyroiditis in Kashmir Valley of Indian sub-continent

Various studies have reported a spectrum of thyroid dysfunction in the postpartum period. Postpartum thyroiditis is a syndrome of thyroid dysfunction that occurs in the first year after parturition. Prevalence of postpartum thyroiditis has been reported to vary from 3 to 6 percent in different regions of the world. Kashmir Valley is inhabited by a relatively homogeneous racial group and the Valley has been documented to have significant iodine deficiency. We studied the prevalence and pattern of postpartum thyroiditis in an urban region of this Valley. 120 women were registered within first month of postpartum period for the study along with one hundred controls. Of these 120 women, 104 reported for follow-up at 3 months postpartum and 106 reported for follow-up at 6 months postpartum. Initial and subsequent clinical details at follow-up were recorded on a pre-determined questionnaire. Overall, postpartum thyroiditis (PPT) was seen in 8 (7%) study subjects. Of these 8 patients with PPT, 4 had biochemical evidence of thyrotoxicosis at first month, 3 developed biochemical thyrotoxicosis at 3-month follow-up while as one study subject developed thyrotoxicosis at 6 months. Most of these subjects were antithyroid antibodies (anti-microsomal and anti-thyroglobulin) positive. We conclude that iodine deficient status of the community doesn't seem to influence the incidence of PPT.

Adrenocortical reserve in patients with active tuberculosis

CONTEXT

In recent years several studies have documented decreased adrenal cortical reserve in patients with active tuberculosis. This reduced adrenal reserve could be an important factor in causing mortality and morbidity in these patients.

OBJECTIVE

To study the adrenal cortical reserve and its relationship with disease duration and severity in patients with active tuberculosis.

DESIGN SETTING AND PARTICIPANTS

Forty patients with confirmed active tuberculosis (28 pulmonary and 12 extra-pulmonary) without clinical evidence of Addison's disease and 10 healthy, age and sex-matched subjects (controls) participated in this study. The study was conducted at Sher-i-Kashmir Institute of Medical Sciences, Srinagar, Kashmir.

INTERVENTIONS

Adrenocorticotropic hormone stimulation test performed in both groups.

MAIN OUTCOME MEASURES

Basal serum cortisol level and parameters of stimulated cortisol response (maximum increase of cortisol over basal, peak rise of cortisol and area under response curve).

RESULTS

The mean basal cortisol levels were comparable between the two groups (P = 0.792). The parameters of stimulated cortisol response including maximum increase of cortisol over basal, the peak rise of cortisol and area under response curves were significantly lower in patients as compared to healthy controls (P < 0.001, 0.002 and 0.049 respectively). However, these parameters were comparable between patients with active pulmonary and extra-pulmonary tuberculosis. Overall 14 (35%) patients exhibited sub-optimal cortisol response (3 negligible and 11 inadequate) to ACTH stimulation. ACTH stimulation revealed significant cortisol rise in patients with active tuberculosis at 4 and 8 hours only, whereas in healthy controls, the cortisol rise was more prolonged and continued up to 24 hours. The adrenocortical reserve was inversely related to the radiological severity of pulmonary tuberculosis (r, -0.41) and chronicity of active tuberculosis (r, -0.59).

CONCLUSION

Patients with active tuberculosis have decreased adrenocortical reserve. The adrenocortical reserve seems to be inversely related to the radiological severity of pulmonary tuberculosis and chronicity of active tuberculosis.

A critical evaluation of signs and symptoms in the diagnosis of Addison's diseases

OBJECTIVES

To determine the usefulness of clinical symptoms and signs in the diagnosis of Addison's disease.

METHODOLOGY

A retrospective, hospital based study from analysis of case records of over 12 years period (1988-1999). Individual or groups of signs and symptoms in 66 patients of confirmed Addison's diseases were compared with 76 subjects with normal ACTH stimulation test, when clinical presentations were similar.

RESULTS

Age spectrum of the two groups was similar. Signs and symptoms like weakness, weight loss, gastro-intestinal disturbances, skin/mucosal pigmentation and blood pressure were not statistically different between the two groups. Similarly blood glucose, sodium and potassium were not different between the two groups. Combination of three or more symptoms/signs had a high predictive value of diagnosing the disease than any individual or a combination of < 3 signs/symptoms (P=0.033).

CONCLUSIONS

Combination of skin and mucosal pigmentation with gut disturbances and weight loss carried high predictive value in diagnosis of Addison's disease, while individual sign and symptom has poor differentiating value.

Puerperal alactogenesis with normal prolactin dynamics: is prolactin resistance the cause?

OBJECTIVE

To determine the cause of puerperal alactogenesis in a young woman.

DESIGN

After proper clinical assessment, a definitive investigative protocol was followed to determine the cause of alactogenesis.

SETTING

Tertiary care medical center in Kashmir, India.

PATIENT(S)

A young married woman with three full-term deliveries, all characterized by puerperal alactogenesis.

INTERVENTION(S)

An investigative protocol to document prolactin reserve and mammography to demonstrate presence of normal breast tissue.

MAIN OUTCOME MEASURE(S)

Prolactin secretory reserve.

RESULT(S)

The patient had normal breast development and an adequate pituitary prolactin reserve.

CONCLUSION(S)

Prolactin resistance may have caused alactogenesis.

Pregnancy in premature ovarian failure: a possible role of estrogen plus progesterone treatment

Premature ovarian failure (POF) is a common occurrence in women during their reproductive years. There is paucity of data on spontaneous ovulation and subsequent pregnancies in such women. In this report, we describe three women with POF, two of whom had spontaneous conceptions and the third resumed spontaneous regular menstrual cycles. All these women had received oestrogen-progesterone tablets for many cycles (ethyl oestradiol 0.05 mg and levonorgestrel 0.25 mg a day, 21 days a month). We speculate about the possibility of elevated gonadotrophins causing down regulation of gonadotrophin receptors and restoration of the sensitivity of the few remaining ovarian follicles by lowering of serum gonadotrophins with oestrogen therapy.

Clinical spectrum of adult onset spontaneous primary hypothyroidism

Full text is available as a scanned copy of the original print version.

Etiological aspects of Cushing's syndrome

Full text is available as a scanned copy of the original print version.

An aetiological profile of short stature in the Indian subcontinent

OBJECTIVE

To determine the aetiological causes of short stature in a developing region of the world.

METHODOLOGY

A retrospective analysis was made of data from 193 subjects who were primarily evaluated for short stature in the Endocrinology Department, Institute of Medical Sciences, Kashmir, India. These subjects had a height of more than 3 standard deviations (SD) below the mean for their age and sex, and were seen over a decade (January 1987 to December 1996). A logical and comprehensive clinical and investigative protocol was followed to identify the aetiology of short stature.

RESULTS

Growth hormone deficiency was the commonest identifiable cause of short stature and accounted for 22.8% of cases. Thirty-six subjects (18.7%) had a normal variant short stature. Renal tubular acidosis was diagnosed in 10.4%, primary hypothyroidism, malnutrition and hypothalamic syndrome in 7.8% each, and growth hormone insensitivity syndrome in 4.1% cases.

CONCLUSIONS

We conclude that, in addition to growth hormone deficiency and normal variant short stature, distal renal tubular acidosis and growth hormone insensitivity syndrome are significant causes of short stature in India.

Spontaneous remission in idiopathic hyperprolactinemia

In this report we describe a 37 year old lady who was demonstrated to have hyperprolactinemia causing amenorrhea-galactorrhea syndrome. Computerized tomography scan done twice did not reveal any sellar or suprasellar abnormality and there was no clinical or biochemical evidence of primary hypothyroidism. She had regression of galactorrhea, resumed regular menstrual cycles, and conceived twice on bromocriptine therapy. Following her second delivery she noticed spontaneous remission of galactorrhea and, prolactin levels estimated multiple times were normal.

Regular ovulatory menstrual cycles in a case of Sheehan's syndrome

In this report we describe an unusual case of postpartum pituitary necrosis who had clinical and biochemical suggestion of decreased thyrotroph, somatotroph, lactotroph, and corticotroph reserve but continued to have regular ovulatory menstrual cycles.

Epidemiologic and etiologic aspects of primary infertility in the Kashmir region of India

OBJECTIVE

To assess the magnitude of primary infertility and to study its etiologic aspects in India.

DESIGN

After proper randomization, 10,063 married couples were interviewed to ascertain the prevalence of primary infertility. A definitive protocol was followed to determine the etiology of primary infertility in 250 consecutive couples.

SETTING

Tertiary care medical center in the Kashmir valley of India.

PATIENT(S)

Couples married for > or = 1 year; 250 consecutive couples attending an endocrine clinic for primary infertility.

INTERVENTION(S)

A logical investigative protocol was followed to identify the etiology of infertility.

MAIN OUTCOME MEASURE(S)

Magnitude of primary infertility in the community as well as the male, female, or combined etiology of infertility.

RESULT(S)

Fifteen percent of the couples interviewed had primary infertility, among whom 4.66% had unresolved infertility at the time of the survey. The etiology of infertility in 250 consecutive couples revealed a female factor in 57.6%, a male factor in 22.4%, combined factors in 5.2%, and an undetermined cause in 14.8%.

CONCLUSION(S)

Primary infertility is as common and distressing a problem in India as in other parts of the world. Semen abnormalities (22.4%), anovulation (17.2%), ovarian failure (8.8%), hyperprolactinemia (8.4%) and tubal disease (7.2%) are common causes of infertility. The pattern of infertility in India is the same as in other parts of the world, except that infertile couples report late for evaluation.

A new vision of imaging

With employers squeezing health plans and health plans squeezing providers, the use of expensive procedures in diagnostic imaging is tumbling. Not surprisingly, so is the pay of radiologists. Despite dwindling salaries, some say that radiology may yet emerge as a stronger, more effective discipline. Maybe, but in the meantime, it's become a mean time.