A new enigma: doping in E-sports

Electronic sports (e-sports) is a growing entity that is estimated to be valued at USD $200 billion by the end of 2023. With the rapid rate of growth, it will come to a point that e-sports will need to be regulated including regulatory mechanisms of fair play, which includes sports doping. With the emergence of substances that provides unfair advantages in terms of concentration, staying awake and preventing anxiety including tremors, there is a need to regulate doping in e-sports. However, due to the nature of the sport, it might not be as straightforward to regulate as other sports.

Effectiveness of nirmatrelvir/ritonavir (Paxlovid®) in preventing hospitalisation and death among COVID-19 patients: a prospective cohort study

INTRODUCTION

Previous trials and real-world studies have shown that nirmatrelvir/ritonavir (Paxlovid®) reduces hospitalisation and deaths in symptomatic, high-risk, nonsevere COVID-19 patients. However, there was a scarcity of data on its effectiveness in the local setting. This study aimed to determine the effectiveness of Paxlovid® in reducing hospitalisation and mortality among COVID-19 patients and to identify the types of adverse events that occur after taking Paxlovid®.

MATERIALS AND METHODS

A two-arm prospective cohort study was conducted among adult patients with COVID-19 categories 2 and 3 treated with Paxlovid® and a matched control group. A standard risk-stratified scoring system was used to establish Paxlovid® eligibility. All patients who were prescribed Paxlovid® and took at least one dose of Paxlovid® were included in the study. The control patients were selected from a centralised COVID-19 patient registry and matched based on age, gender and COVID-19 stage severity.

RESULTS

A total of 552 subjects were included in the study and evenly allocated to the treatment and control groups. There was no statistically significant difference in 28-day hospitalisation after diagnosis [Paxlovid®: 26 (9.4%), Control: 34 (12.3%), OR: 0.74; 95%CI, 0.43-1.27; p=0.274] or all-cause death [Paxlovid®: 2 (0.7%), Control: 3 (1.1%), OR 1.51; 95%CI, 0.25-9.09; p=0.999]. There was no significant reduction in hospitalisation duration, intensive care unit admission events or supplementary oxygen requirement in the treatment arm. Ethnicity, COVID-19 severity at diagnosis, comorbidities and vaccination status were predictors of hospitalisation events.

CONCLUSION

In this two-arm study, Paxlovid® did not significantly lower the incidence of hospitalisation, all-cause death and the need for supplemental oxygen. Adverse effects were frequent but not severe. Paxlovid® efficacy varied across settings and populations, warranting further real-world investigations.

Magnetocardiography as a noninvasive diagnostic strategy for suspected coronary microvascular dysfunction

Background

Coronary microvascular dysfunction (CMD) is increasingly recognized as an independent predictor of mortality with a 4-fold higher risk. However current diagnostic modalities are limited by the need for an invasive procedure, access, cost, and exposure of ionizing radiation.

Purpose

To investigate the ability of magnetocardiography (MCG) to identify CMD in patients with suspected ischemia and no obstructive coronary artery disease (INOCA).

Methods

This is an observational, prospective pilot study of patients scheduled for coronary functional angiography (CFA), gold standard for evaluation for CMD (defined as coronary flow reserve (CFR) ≤2). 13 patients underwent both CFA and a noninvasive 36-channel MCG scan. A machine learning model was developed to characterize the presence of CMD in these patients against age matched controls (AMCs). The model consists of a logistic regression classifier which takes features representing the relative strengths of the “characteristic dipoles” of the MCG scan as input. The characteristic dipoles are parameterizations of the three strongest magnetic field map components resulting from a singular value decomposition of the MCG signal. A total of 37 patients were included in this analysis including 13 patients who completed CFA (7 had CMD and 6 had CFR >2 and included in the AMCs group). An additional 24 asymptomatic, healthy patients that did not undergo CFR were also included in the AMC group.

Results

The mean age for AMCs was 57 years (70% women) and mean age for CMD patients was 54 years (100% women). The performance of the model was evaluated using repeated stratified cross-validation with 5 folds and 3 repeats, resulting in 15 different 80%/20% train/test splits. Figure 1 shows the distribution of samples belonging to the CMD and AMC groups in a 2-dimensional representation of the feature space. The clear separation of the two groups and the clustering of the AMCs demonstrates the ability of the model to identify patients with CMD. We found that MCG had a mean accuracy of 94.8% (±6.4%), sensitivity of 100% (±0.0%) and specificity of 93.3% (±8.2%) for the detection of CMD using gold standard CFR ≤2 as reference.

Conclusion(s)

First study to show that MCG can be used with 94.8% accuracy to identify CMD among patients suspicious for INOCA with no exposure to ionization, 90 seconds of scan time and minimal cost. The use of this noninvasive modality to identify CMD warrants further investigation.

Funding Acknowledgement

Type of funding sources: Private company. Main funding source(s): Genetesis

Analysis of paediatric cochlear implant candidacy: Single centre, retrospective observational study

INTRODUCTION

The criteria for cochlear implantation can differ among countries or even among regions in the same country. Patient selection is important for the identification of those children who can benefit the most from cochlear implants. A number of patients who are possible cochlear implant candidates do not meet the assessment criteria; and some of these requirements are modifiable components.

MATERIALS AND METHODS

This single-centre, cross-sectional study used secondary data from 2014 until 2018. A consecutive sampling method was applied and a final sample size of 73 samples was achieved. Potential prelingual hearing loss candidates for cochlear implant aged less than 48 months old in Raja Permaisuri Bainun Hospital (HRPB), Ipoh Perak were included in this study. The candidacy selection outcome was analysed and reported as proportions. The associations between the evaluation criteria and outcome were examined using regression analysis.

RESULTS

Of the 73 potential candidates, only 17 (23%) were selected to receive cochlear implants. Bivariate analysis identified hearing compliance, behaviour, medical contraindications and family commitment as significantly associated with cochlear implant evaluation outcome. However, multivariate logistic regression revealed only family commitment as a significant predictor of the outcome of the implant candidacy evaluation (OR 44.7; 95%CI 3.11-643.4; p<0.005).

CONCLUSION

Family commitment, a modifiable element, was the key factor affecting the selection of candidates. Addressing the reasons for this effect could increase the number of potential candidates who ultimately receive implants.

Strategies in confronting the COVID-19 pandemic at a tertiary public hospital for Otorhinolaryngology services in Perak, Malaysia

The COVID-19 pandemic has led to a significant shift in the practice of almost all medical fields. Surgical specialities were particularly hard hit as these services had to give way to the more urgent management of COVID-19 patients both in-ward and in intensive care units. In otorhinolaryngology (ORL) practice, an additional issue to be dealt with was a relatively higher risk of being exposed to viral droplets from aerosol-generating procedures and examination of oral and nasal cavities of patients. This article describes our experience in managing ORL services at a government tertiary referral hospital, Hospital Raja Permaisuri Bainun, Ipoh, during the current COVID-19 outbreak since the year 2020. Two novel strategies were introduced namely the outsourcing of radiotherapy services for cancer patients and an innovative design in endoscopic examination of patients.

Renal and overall outcomes of double-positive (ANCA and anti-GBM antibodies) patients compared to ANCA-associated vasculitis patients with severe renal involvement: A multicenter retrospective study with systematic renal pathology analysis

Objective: Double-positive patients (DPPs), combining serum and/or histological findings for glomerular basement membrane (GBM) disease and anti-neutrophil cytoplasmic antibodies (ANCAs), are rare and poorly described. This study aimed to compare characteristics between DPPs and ANCA-associated vasculitis (AAV) patients with severe renal involvement.Method: This retrospective multicentre study compared 33 DPPs and 45 AAV patients with severe renal involvement (serum creatinine > 300 μmol/L), all with biopsy-proven nephropathy.Results: All DPPs (including 18% exhibiting negative serum anti-GBM antibodies) presented severe acute kidney failure with histological GBM involvement. Compared to AAV patients, they had higher serum creatinine (719 vs 501 μmol/L; p = 0.006) and a higher proportion of patients requiring initial renal replacement therapy (82% vs 36%; p < 0.001). Berden classification differed significantly (p = 0.003), with more crescentic glomerulonephritis and fewer sclerotic lesions in DPPs. One-year renal survival was significantly lower in DPPs than in AAV patients (27% vs 64%; p < 0.0002). With comparable proportions of ANCA subtypes (two-thirds with anti-myeloperoxidase autoantibodies), numbers of extrarenal manifestations (mostly pulmonary in two-thirds), remission-inducing immunosuppressants, and median follow-ups (3 years) between groups, relapse rates were similar: 9.1% of DPPs and 10% of AAV patients.Conclusion: Although DPPs have features of both kinds of vasculitis, the anti-GBM component is the dominant phenotype, with more severe renal presentation and prognosis compared to AAV patients with severe renal failure. Simultaneous testing of both antibodies and systematically performed renal biopsy should be recommended in all rapidly progressing glomerulonephritis patients to recognize this difficult-to-treat, rare disease.

POS0117 RENAL AND OVERALL OUTCOMES OF DOUBLE-POSITIVE (ANCA AND ANTI-GBM ANTIBODIES) PATIENTS COMPARED TO ANCA-ASSOCIATED VASCULITIS PATIENTS WITH SEVERE RENAL INVOLVEMENT: A MULTICENTER RETROSPECTIVE STUDY WITH SYSTEMATIC RENAL PATHOLOGY ANALYSIS

Background:

Among small vessel vasculitis, double-positive patients (DPP), combining serum and/or histologic findings for glomerular basement membrane (GBM) disease, and anti-neutrophil cytoplasmic antibodies (ANCA), is a rare, newly and poorly described condition.

Objectives:

We aimed to compare characteristics between DPP and ANCA-associated vasculitis patients (AAVP) with severe-renal-involvement.

Methods:

Retrospective multicenter study comparing 33 DPP and 45 severe-renal-involvement (serum creatinine >300 μmol/L) AAVP, all with biopsy-proven nephropathy.

Results:

Except for 2 patients (6%) who had pure renal presentation during their entire follow-up period, others exhibited at least one extrarenal manifestation: pulmonary involvement (64%), weight loss (39%), gastrointestinal involvement (33%), ENT manifestations (21%), musculoskeletal symptoms (21%), fever (18%), neurological (12%), cutaneous (6%) and/or cardiac (6%) signs. All DPP (including up to 18% exhibiting negative serum anti-GBM antibodies) presented severe acute kidney failure with histologic GBM involvement. Compared to our AAVP, they had higher serum creatinine (719 versus 501 μmol/L; p=0.006) and a higher of patients requiring initial renal replacement therapy (82% vs 36%; p<0.001). Berden classification significantly differed (p=0.003), with more crescentic glomerulonephritis and fewer sclerotic lesions in DPP. One-year renal survival was significantly lower in DPP than in AAVP (27% versus 64%; p<0.0002). With comparable proportions of ANCA subtypes (2/3 with anti-MPO autoantibodies), numbers of extrarenal manifestations, remission-inducing immunosuppressants and median follow-ups (three years) between groups, relapse rates were similar: 9.1% of DPP and 10% of AAVP. Please, see the table 1 for more detailed data.

Conclusion:

Although DPP have features of both kinds of eponymous vasculitis, the anti-GBM component is the dominant phenotype, with more severe renal presentation and prognosis compared to AAVP with severe renal failure. Simultaneous testing of both antibodies and a systematically performed renal biopsy should be recommended in all rapidly progressive glomerulonephritis patients to recognize this difficult-to-treat, rare disease.

Table 1.

Comparison of clinical characteristics and outcomes between the cohorts of DPP and AAVP

DPP n = 33AAVP n = 45pAge (year)71,5 [14 - 89]63 [45 - 93]0.14Male16 (48)19 (42)0.65Birmingham Vasculitis Activity Score18,1 ± 4,820,4 ± 5,40.07Organ involvement (except kidney)1,7 ± 0,81,9 ± 1,10.31Serum creatinine (µmol/L)719 [238 - 2412]501 [310 - 1683]0.006ANCA (MPO/PR3)22/1134/110.45Berden classificationn = 31n = 440.003s (sclerotic) / c (crescentic)6 (19) / 22 (71)12 (27) / 16 (37)f (focal) / m (mixed)0 / 3 (10)11 (25) / 5 (11)Brix renal risk scoren = 27n = 440.000014Low / Medium / High0 (0) / 4 (15) / 23 (85)1 (2) / 29 (66) / 14 (32)Initial immunosuppressive therapyIV Cyclophosphamide25 (76)40 (82)0.14Rituximab1 (3)3 (7)0.64Plasma exchanges25 (76)19 (42)0.005Maintenance treatment17 (48)40 (89)0.046Initial RRT requirement27 (82)16 (36)0.00007Renal recovery (% initial RRT requirement)4 (12)6 (38)0.91 year renal survival9 (27)29 (64)0.0002

Values are displayed as absolute number (%) or as median [range]. DPP: double positive patients; AAVP: ANCA associated vasculitis patients; MPO: myeloperoxidase; PR3: proteinase 3; RRT: renal replacement therapy; IV: intravenous.

Disclosure of Interests:

None declared

A randomized trial of intravenous acetaminophen versus indomethacin for treatment of hemodynamically significant PDAs in VLBW infants

Objective was to compare the rate of successful treatment of hsPDA based on echocardiogram criteria after use of IV acetaminophen or IV indomethacin in very low-birthweight infants. The study was a multi-center, randomized controlled trial. Infants born prior to 32 weeks with birthweight ≤ 1500 g were included if PDA treatment was indicated within the 21 days after birth. hsPDA was defined by strict echocardiogram criteria. Eligible infants were randomized to treatment with either IV acetaminophen or IV indomethacin. Of 86 eligible infants, 17 infants were randomized to acetaminophen and 20 to indomethacin. One (5.9%) hsPDA in the acetaminophen group had successful treatment compared to 11 (55%) in the indomethacin group (p = 0.002). Eight (47%) in the acetaminophen group and 3 (15%) in the indomethacin group received transcatheter PDA closure (p = 0.07). IV indomethacin was more effective than IV acetaminophen for treatment of hsPDAs. More infants in the acetaminophen group received transcatheter closure.

From the MJM Editors' Desk: Common errors authors make in submission to the Medical Journal of Malaysia

Proper understanding the 'Instructions to authors' for a particular journal is the key towards successful submission of a manuscript which will lead to it being published. Common errors that are frequently made by authors in their submission to the Malaysia Journal of Malaysia (MJM) that lead to rejection of their submission or requiring major revisions or minor revisions are listed and discussed in this article. Outright rejection prior to even a peer review process may be made for an article due to: it is poorly written or when there is suspicion on the authenticity of the submission, which contains elements that are suspected to be plagiarised, it is a duplicate submission or not in the format required by the MJM. The editor in charge of the issue makes a recommendation to the Editor in Chief for the final decision.

[ANCA and anti-MBG double-positive vasculitis: An update on the clinical and therapeutic specificities and comparison with the two eponymous vasculitis]

Double-positive vasculitis with anti-polynuclear cytoplasm (ANCA) and anti-glomerular basement membrane (GBM) antibodies is a rare entity of systemic vasculitis defined by the presence of ANCA and anti-GBM antibodies. The gradual accumulation of clinical and therapeutic data shows the usefulness of identifying and differentiating this entity from the two vasculitis respectively associated with the isolated presence of each of these two antibodies. Indeed, the double-positive ANCA and anti-GBM vasculitis appears to associate the characteristics of the demography and the extra-renal and pulmonary involvement of the ANCA-associated vasculitis on the one hand, and of the histological type and severe renal prognosis of the anti-MBG vasculitis on the other hand, with the renal involvement which is the only involvement consistently observed in double-positive vasculitis. The aim of this focus is to describe the epidemiological, clinico-biological, histological and prognostic characteristics of this entity, in light of recent literature and ongoing therapeutic changes in the two eponymous vasculitis.

Intussusception: Single Center Experience of 10 Years

OBJECTIVE

To analyze the association between the clinical presentation, clinical course, management and outcome in intussusception with emphasis on safety of saline hydrostatic reduction.

METHODS

This retrospective study included 375 patients of intussusception diagnosed between March 2007 to February 2017. Symptoms at presentation, mode of reduction of intussusception and associated complications were recorded.

RESULTS

336 (89.6%) patients were aged below 3 years. Classical triad of abdominal pain, vomiting and red stools was present in 111 (29.6%) patients. While 64 (17.1 %) patients had spontaneous resolution, hydrostatic reduction and surgery cured 283 (75.5 %) and 28 (7.4 %) patients, respectively; overall recurrence rate was 13.1%. Among the patients who underwent operative reduction, blood in stools was present in 15 (53.6%) patients.

CONCLUSIONS

Hydrostatic reduction of intussusception is effective irrespective of duration of symptoms and number of recurrences.

Collaborating to Compete: Blood Profiling Atlas in Cancer (BloodPAC) Consortium

The cancer community understands the value of blood profiling measurements in assessing and monitoring cancer. We describe an effort among academic, government, biotechnology, diagnostic, and pharmaceutical companies called the Blood Profiling Atlas in Cancer (BloodPAC) Project. BloodPAC will aggregate, make freely available, and harmonize for further analyses, raw datasets, relevant associated clinical data (e.g., clinical diagnosis, treatment history, and outcomes), and sample preparation and handling protocols to accelerate the development of blood profiling assays.

Evaluation of bone mineral density among type 2 diabetes mellitus patients in South Karnataka

Background:

Diabetes is one of the world's biggest health problems and the disease affects almost all organ systems. The relationship between type 2 diabetes mellitus (T2DM) and bone mineral density (BMD) has been controversial. Early identification of reduction in bone mass in a diabetic patient may be helpful in preventing the bone loss and future fracture risks.

Objective:

The aim is to study the effect of T2DM on BMD among patients in South Karnataka.

Materials and Methods:

A cross-sectional study was conducted on 150 patients between 40 and 70 years of age which included 75 diabetic and 75 nondiabetic subjects. BMD was measured using qualitative ultrasound and the data were compared among age-matched subjects of both the groups. Statistical analysis was performed using unpaired Student's t-test and test of equality of proportions.

Results:

No significant difference was observed in bone density of both the groups. On further analyzing the data, incidence of osteoporosis was higher among diabetic subjects, whereas incidence of osteopenia was higher among nondiabetic subjects.

Conclusion:

Although significant difference in bone mineral density was not observed in both the groups, the incidence of osteoporosis was higher among type 2 diabetics. Hence, all type 2 diabetics should be evaluated for the risk of osteoporosis and should be offered appropriate preventive measures.

Not all elevated hormones are toxic: A case of thyroid hormone resistance

Resistance to thyroid hormone syndrome (RTH) is a rare disorder and is usually inherited as dominantly negative autosomal trait. RTH is caused by mutations in the thyroid hormone receptor beta. Patients with RTH usually do not have signs and symptoms of thyrotoxicosis, but the thyroid function test shows an elevated T3 and T4, which get misinterpreted as hyperthyroidism, resulting in unnecessary treatment.

Effect of hypothyroidism on female reproductive hormones

OBJECTIVE

Objective was to evaluate reproductive hormones levels in hypothyroid women and impact of treatment on their levels.

MATERIALS AND METHODS

A total of 59 women with untreated primary hypothyroidism were included in this prospective study. Venous blood was taken at baseline and after euthyroidism was achieved for measuring serum free thyroxine, free triiodothyronine (FT3), thyroid stimulating hormone (TSH), prolactin (PRL), follicular stimulating hormone (FSH), luteinizing hormone (LH), estradiol (E2), testosterone (T), and thyroid peroxidase antibody. Thirty-nine healthy women with regular menstrual cycles without any hormonal disturbances served as controls. The statistical analysis was performed using the Statistical Package for the Social Sciences Version 20 ([SPSS] IBM Corporation, Armonk, NY, USA). P < 0.05 was considered statistically significant.

RESULTS

On an average at diagnosis cases have more serum TSH (mean [M] = 77.85; standard error [SE] = 11.72), PRL (M = 39.65; SE = 4.13) and less serum E2 (M = 50.00; SE = 2.25) and T (M = 35.40; SE = 2.31) than after achieving euthyroidism (M = 1.74; SE = 0.73), (M = 16.04; SE = 0.84), (M = 76.25; SE = 2.60), and (M = 40.29; SE = 2.27), respectively. This difference was statistically significant t (58) = 6.48, P <0.05; t (58) = 6.49, P < 0.05; t (58) = 12.47; P < 0.05; and t (58) = 2.04, P < 0.05; respectively. Although average serum FSH (M = 12.14; SE = 0.40) and LH (M = 5.89; SE = 0.27) were lower in cases at diagnosis than after achieving euthyroidism (M = 12.70; SE = 0.40), (M = 6.22; SE = 0.25), respectively, but these differences were statistically insignificant t (58) = 1.61, P = 0.11; t (58) = 1.11, P = 0.27, respectively.

CONCLUSION

The study has demonstrated low E2 and T levels in hypothyroid women which were increased after achieving euthyroidism. Although average serum FSH and LH were increased in hypothyroid women after achieving euthyroidism but this difference was statistically insignificant.

Congenital hypothyroidism

Congenital hypothyroidism (CH) is the one of the most common preventable cause of mental retardation. In the majority of patients, CH is caused by an abnormal development of the thyroid gland (thyroid dysgenesis) that is a sporadic disorder and accounts for 85% of cases and the remaining 15% of cases are caused by dyshormonogenesis. The clinical features of congenital hypothyroidism are so subtle that many newborn infants remain undiagnosed at birth and delayed diagnosis leads to the most severe outcome of CH, mental retardation, emphasizing the importance of neonatal screening. Dried capillary blood is used for screening and it is taken from heel prick optimally between 2 and 5 days of age. Blood spot TSH or thyroxine (T4) or both are being used for CH screening in different programs around the world. Neonates with abnormal thyroid screening tests should be recalled immediately for examination and a venipuncture blood sample should be drawn for confirmatory serum testing. Confirmatory serum should be tested for TSH and free T4, or total T4. Serum TSH and T4 undergo dynamic changes in the first weeks of life; it is important to compare serum results with age-normal reference ranges. Treatment should be started promptly and infant should be rendered euthyroid as early as possible, as there is an inverse relationship between intelligence quotient (IQ) and the age at diagnosis. Levothyroxine (l-thyroxine) is the treatment of choice and American academy of pediatrics and European society of pediatric endocrinology recommend 10-15μgm/kg/day as initial dose. The immediate goal of therapy is to normalize T4 within 2 weeks and TSH within one month. The overall goal of treatment is to ensure growth and neurodevelopmental outcomes as close as possible to their genetic potential.

Composition-structure–physical property relationship and nonlinear optical properties of multiferroic hexagonal ErMn1−xCrxO3 nanoparticles

Nanocrystalline multiferroic ErMn_1−xCr_xO₃ exhibits canted antiferromagnetism with a spin-glass transition and strong nonlinear optical absorption.

Transnasal oesophagoscopy: the feasibility and potential impact on service provision of an office based procedure for upper gastrointestinal disorders in malaysia

A Health Technology Assessment (HTA) was conducted in 2011 to evaluate whether transnasal oesophagoscopy (TNE) should be made available at otorhinolaryngology (ORL) clinics in the Ministry of Health facilities. The safety, efficacy or effectiveness and economic implication of using transnasal oesophagoscopy (TNE) were reviewed. This review provides a summary of the HTA and an updated literature review as well as how this technology might potentially affect services in the Ministry of Health.

An unusual presentation of Hashimoto's encephalopathy

Hashimoto's encephalopathy (HE) is a rare steroid-responsive encephalopathy syndrome, which can have highly variable neuropsychiatric manifestations and can go unrecognized for a long time. HE is a diagnosis of exclusion and should be kept in mind when evaluating a patient with a cognitive dysfunction and high titers of anti-thyroid antibodies as it responds dramatically to steroids. Steroid responsive myoclonus can be a presentation of HE.

Anatomical variations of the sphenoid sinus and its adjacent structures: a review of existing literature

The sphenoid sinus, one of the posterior groups of sinuses, has long been regarded as a 'neglected sinus' due to the anatomical location, poor understanding and poor accessibility, till the advent of endoscopes and modern imaging techniques. Increasing knowledge and greater understanding of this sinus has permitted an evolution in surgical practices and boundaries. Various literatures of the past report a great variety of rates of pneumatization, rates of optic nerve protrusion and dehiscence, as well as internal carotid artery (ICA) protrusion and dehiscence. One similarity noted among these studies is that the rates vary according to the ethnicity of the patients. Recommendations have also been made along the way with regard to modified surgical techniques. This review aims to describe the pneumatization of sphenoid sinus and the topographical relation of the optic nerve and ICA in different populations.

Skeletal manifestations of juvenile hypothyroidism and the impact of treatment on skeletal system

Thyroid hormone mediates growth and development of the skeleton through its direct effects and through its permissive effects on growth hormone. The effect of hypothyroidism on bone is well described in congenital hypothyroidism, but the impact of thyroid hormone deficiency on a growing skeleton, as it happens with juvenile hypothyroidism, is less defined. In addition, the extent to which the skeletal defects of juvenile hypothyroidism revert on the replacement of thyroid hormone is not known. A study was undertaken in 29 juvenile autoimmune hypothyroid patients to study the skeletal manifestations of juvenile hypothyroidism and the impact of treatment of hypothyroidism on the skeletal system of juvenile patients. Hypothyroidism has a profound impact on the skeletal system and delayed bone age, dwarfism, and thickened bands at the metaphyseal ends being the most common findings. Post treatment, skeletal findings like delayed bone age and dwarfism improved significantly, but there were no significant changes in enlargement of sella, presence of wormian bones, epihyseal dysgenesis, vertebral changes and thickened band at the metaphyseal ends. With the treatment of hypothyroidism, there is an exuberant advancement of bone age, the catch up of bone age being approximately double of the chronological age advancement.

Correlation between liver fat content with dyslipidemia and Insulin resistance

Total 33 obese patients were studied to determine correlation in between liver fat content with dyslipidemia and insulin resistance. Liver and spleen attenuation measurements were taken with three regions of interests (ROIs) from the liver and two ROIs from the spleen. Hepatic attenuation indices were measured as follows: (1) Hepatic parenchymal attenuation (CTLP); (2) liver to spleen attenuation ratio (LSratio); and (3) difference between hepatic and splenic attenuation (LSdif). Bivariate correlation analysis showed moderate but statistically significant negative correlation between CTLP, LSratio, and LSdif with body mass index, triglyceride, fasting plasma sugar, fasting plasma insulin, homeostasis model assessment-insulin resistance (HOMA IR), 2 h oral glucose tolerance test (OGTT), and statistically significant positive correlation with high density lipoprotein. Nonalcoholic fatty liver disease (NAFLD) is closely associated with features of the metabolic syndrome. The amount of intrahepatic fat closely correlates with the number of metabolic syndrome features. The values of CTLP, LSratio, and LSdif demonstrate strong inverse correlations with degree of steatosis.

Association of serum lipids with diabetic retinopathy in type 2 diabetes

A total number of 140 type 2 diabetic patients with diabetic retinopathy (DR) were enrolled in the study from diabetic clinic during May 2011 till June 2012 to determine correlation between severity of DR with serum lipid and other modifiable risk factors in type 2 diabetic patients. Information including age, sex, height, body weight, body mass index (BMI), waist-hip ratio (WHR), and systolic and diastolic blood pressure was collected from each patient. Fasting plasma sugar, low density lipoprotein (LDL), triglyceride level (TG), high density lipoprotein (HDL), glycated hemoglobin (HbA1C), creatinine, and 24 h urinary albumin excretion was done for each patient. Estimated glomerular filtration rate (eGFR) was measured by modification of diet in renal disease (MDRD) equation. Patients were divided in five groups according to retinopathy status based on early treatment DR study (ETDRS) disease severity level. Statistical analysis was performed with Statistical Packages for Social Sciences (SPSS) statistical software (version 17.0 for Windows). The alpha level was set at P = 0.05 for all tests. Statistically significant positive correlation between severity of DR with systolic blood pressure P = 0.005 (r = 0.974), diastolic blood pressure P = 0.001(r = 0.994), LDL P = 0.005 (r = 0.976), TG P = 0.001 (r = 0.990), and 24 h urinary albumin P = 0.004 (r = 0.977) was documented. DR was also strongly positively correlated with smoking P = 0.017 (r = 0.941) and duration of diabetes P = 0.003 (r = 0.981). There was strong inverse correlation of DR with HDL P = 0.001 (r = -0.994) and eGFR P = 0.002 (r = -0.987). Serum lipids were significantly correlated with severity of DR.

Re-emergence of a rare syndrome: A case of mauriac syndrome

Mauriac syndrome is a rare syndrome associated with type 1 diabetes (T1DM) in children presenting with growth retardation, hepatomegaly, and cushingoid features. Recently, there has been re-emergence of this syndrome, especially with the use of premix insulin. A 15-year old type 1 diabetic boy, who was on premix insulin with erratic blood glucose, was referred to us for evaluation of short stature. He had significant short stature, hepatomegaly, and cushingoid features. His growth hormone (GH) stimulation was normal, and so was the overnight dexamethasone suppression test, based on which the diagnosis of Mauriac syndrome was reported. He was made to switch over to basal bolus regime, and was advised to follow-up for 6 months. He had reduction in hepatomegaly and a height gain of 3 cms.

Pulse dexamethasone therapy versus pulse methylprednisolone therapy for treatment of Graves's ophthalmopathy

Pulse methylprednisolone therapy is the recommended therapy for moderate to severe and active ophthalmopathy, but high dose pulse methylprednisolone therapy is marred by the chances of fulminant hepatic failure and the high cost of therapy. Dexamethasone pulse therapy can be considered as an alternative to pulse methylprednisolone therapy. A prospective randomized control trial was carried out in 21 patients comparing pulse dexamethasone therapy versus pulse methyprednisolone therapy in Graves's ophthalmopathy. This study proved that pulse dexamethasone therapy is a cheaper and equally effective therapy for Graves's ophthalmopathy and the cost of therapy is reduced to at least 1/8(th) s. Furthermore, dexa had a better effect on reduction of exophthalmos. The dreaded complication of fulminant hepatic failure, associated with high dose of methylprednisolone, is not seen with dexa therapy.

A young diabetic with suicidal risk: Rare disease with a rarer presentation

Rare genetic or inherited forms of diabetes can mimic immune mediated type 1 diabetes. Early age of onset and associated features help to differentiate these diseases from type 1 diabetes. Wolfram syndrome, an inherited neuro degenerative disorder, presents as insulin dependent diabetes mellitus, diabetes insipidus, optic atrophy and deafness. But less well described features like psychiatric manifestations can be the presentation of this disease. We present such a case. Wolfram syndrome should be considered as a differential diagnosis in insulin dependent diabetic children who present with neuropsychiatric problems.

The other side of Turner's: Noonan's syndrome

Noonan Syndrome (NS) is an autosomal dominant disorder characterized by short stature, typical face dysmorphology, and congenital heart defects. NS is a clinical diagnosis. Establishing the diagnosis can be very difficult, especially in adulthood. There is a great variability in expression, and the phenotype becomes less pronounced with increasing age.

A case series of Nasopharyngeal Carcinoma among Indians, a low risk population, in Perak State, Malaysia

Nasopharyngeal carcinoma (NPC) is rare among people of Indian ethnicity. A short retrospective case review of clinical records of Indian patients diagnosed with nasopharyngeal carcinoma in a period of 5 years was conducted. Their slides were further subjected to EBV encoded RNA (EBER) - In- situ Hybridization (ISH). The histologic subtype was nonkeratinizing carcinoma in all 4 patients. All were Epstein Barr Virus (EBV) positive. We believe that the crucial factor responsible for nasopharyngeal carcinoma is genetics; either a genetic susceptibility among high risk groups or genetic resistance/immunity in low risk groups. Further genetic studies are required to look for somatic or inherited chromosomal mutations among the various risk populations.

Endocrine manifestations of celiac disease

BACKGROUND

Celiac disease can have extra gastrointestinal tract (GIT) presentations, most of which are endocrine. The aim of this study was to present patients diagnosed to have celiac disease from an endocrine department and to study the prevalence of endocrinopathies in celiac disease.

MATERIALS AND METHODS

A total of 36 patients from the endocrinology department (LLRM Medical College, Meerut) between January 2011 and July 2012 and who were diagnosed to have celiac disease were included in the study.

RESULTS

Short stature was the commonest presentation (25%), other presentations included short stature and delayed puberty (20%), delayed puberty (11%), screening for celiac disease in type-1 DM patients (17%), rickets (6%), anemia not responding to oral therapy (6%), type-1 DM with recurrent hypoglycaemia (6%), and osteomalacia (3%). The endocrine manifestations include (after complete evaluation) short stature (58%), delayed puberty (31%), elevated alkaline phospahatase (67%), low calcium (22%), X-rays suggestive of osteomalacia or rickets (8%), capopedal spasm (6%), and night blindness (6%). Anti-TPO antibody positivity was found in 53%, hypothyroidism in 28%, subclinical hypothyroidism in 17%, and type-1 DM in 25% of the patients. A total of 14% patients had no GI symptoms.

CONCLUSION

Celiac disease is an endocrine disrupter as well as the great masquerader having varied presentations including short stature, delayed puberty, and rickets. Some patients who have celiac disease may not have any GI symptoms, making the diagnosis all the more difficult. Also, there is significant incidence of celiac disease with hypothyroidism and type-1 DM, making screening for it important in these diseases.

Correlation of acanthosis nigricans with insulin resistance, anthropometric, and other metabolic parameters in diabetic Indians

INTRODUCTION

Acanthosis nigricans is a non-specific reaction pattern that may accompany obesity, diabetes, excess corticosteroids, pineal tumors, malignancies, and other endocrine disorders. It is considered a cutaneous marker of tissue insulin resistance.

AIMS AND OBJECTIVES

To determine the prevalence of acanthosis nigricans in type 2 diabetes mellitus (DM) and its correlation with various anthropometric measurements and insulin resistance by HOMA-IR and other metabolic parameters.

MATERIALS AND METHODS

One hundred and fifty consecutive subjects with newly diagnosed type 2 DM, attending the endocrinology OPD of LLRM Medical College, Meerut were studied. Acanthosis was graded based on standard scale of 0-4 as described by Burke et al. Anthropometric data were obtained and insulin resistance calculated as HOMA-IR from fasting insulin and fasting blood sugar values.

RESULTS

The average age of the study population was 45.2 years, with male to female ratio of 1:5. The prevalence of acanthosis in males was 56.67% and in females was 86.92%. The acanthosis neck severity grading had a statistically significant correlation with fasting glucose levels, fasting insulin levels, and insulin resistance values: HOMA-IR, HOMA-S, and HOMA-B (P < 0.05). Other acanthosis parameters such as axillary grading, acanthosis at knuckles, and skin tags, did not have a statistically significant correlation with insulin resistance.

CONCLUSION

Acanthosis nigricans neck severity grading correlates well with insulin resistance and can be used as a clinical surrogate for assessment of severity of insulin resistance.

Atypical presentations of Wolframs syndrome

BACKGROUND

Wolfram syndrome is a rare hereditary or sporadic neurodegenerative disorder also known as DIDMOAD. The classically described presentation is of insulin-dependent diabetes, followed by optic atrophy, central diabetes insipidus, and sensory neural deafness. Also included are less well-described presentations of Wolframs syndrome. We here present three cases of atypical presentation of this syndrome. CASE 1: A 15-year-old boy with insulin-dependent diabetes was presented for evaluation of depressive symptoms associated with suicidal tendency. Neuropsychiatric manifestations are described with Wolframs syndrome, and wolframin gene, in recessive inheritance, is associated with psychiatric illnesses without other manifestations of Wolframs syndrome. CASE 2: A 17-year-old diabetic boy on insulin with good control of blood sugar presented for evaluation of delayed puberty. Central hypogonadism and other anterior pituitary hormone dysfunctions are the less publicized hormone dysfunctions in Wolframs syndrome. CASE 3: A 23-year-old female who was on insulin for diabetes for the past 14 years, got admitted for evaluation of sudden loss of vision. This patient had developed a vitreous hemorrhage and, on evaluation, was found to have optic atrophy, sensory neural hearing loss, and diabetes insipidus, and presented differently from the gradual loss of vision described in Wolframs syndrome.

CONCLUSION

Wolframs syndrome being a multisystem degenerative disorder can have myriad other manifestations than the classically described features. Neuropsychiatric manifestations, depression with suicidal risk, central hypogonadism, and secondary adrenal insufficiency are among the less well-described manifestations of this syndrome.

Lymphoid organ cell culture system from Penaeus monodon (Fabricius) as a platform for white spot syndrome virus and shrimp immune-related gene expression

Shrimp cell lines are yet to be reported and this restricts the prospects of investigating the associated viral pathogens, especially white spot syndrome virus (WSSV). In this context, development of primary cell cultures from lymphoid organs was standardized. Poly-l-lysine-coated culture vessels enhanced growth of lymphoid cells, while the application of vertebrate growth factors did not, except insulin-like growth factor-1 (IGF-1). Susceptibility of the lymphoid cells to WSSV was confirmed by immunofluoresence assay using monoclonal antibody against the 28 kDa envelope protein of WSSV. Expression of viral and immune-related genes in WSSV-infected lymphoid cultures could be demonstrated by RT-PCR. This emphasizes the utility of lymphoid primary cell culture as a platform for research in virus-cell interaction, virus morphogenesis, up and downregulation of shrimp immune-related genes, and also for the discovery of novel drugs to combat WSSV in shrimp culture.

Parapharyngeal space synovial sarcoma

Synovial sarcoma is a rare soft tissue sarcoma that commonly involves the lower extremities and occurs predominantly in young adults. It very rarely occurs in the head and neck region and carries a poor prognosis. The tumor demonstrates both a loco-regional and a systemic pattern of spread that makes management challenging. Combined modality therapy of this aggressive tumor yields better results. Herein, we described a 58 years old lady presented with left parapharyngeal synovial sarcoma. This is to demonstrate the aggressiveness of the disease despite complete surgical excision followed by post operative radiotherapy. Local regional control was difficult and recurrence of disease was seen in this particular patient.