Revolutionizing diabetes care: unveiling tirzepatide's potential in glycemic control and beyond

INTRODUCTION

Diabetes is a global public health challenge with rising prevalence. This review explores current diabetes understanding, diagnostic and management guidelines, economic impact, and lifestyle modifications as the primary approach.

AREAS COVERED

Focusing on pharmacological interventions, we discuss the roles of GLP-1 agonists and GLP/GIP agonists in diabetes management and cardiovascular risk reduction. Tirzepatide, a novel medication, is highlighted for its unique mechanism of action. Clinical trials demonstrate its effectiveness in glucose control, weight reduction, and its potential impact on diabetes, obesity, NASH, and cardiovascular risks.

EXPERT OPINION

Tirzepatide shows promise in diabetes treatment, offering glucose control and weight loss. It also holds potential for addressing comorbidities. However, cautious use is vital due to potential adverse effects and contraindications, including hypersensitivity reactions, pregnancy, and breastfeeding precautions. This review underscores tirzepatide as a valuable addition to diabetes therapies, with evolving prospects for enhanced patient outcomes as research advances.

Cardiovascular Outcomes of Hypogonadal Men Receiving Testosterone Replacement Therapy: A Meta-analysis of Randomized Controlled Trials

OBJECTIVE

To investigate the impact of testosterone replacement therapy (TRT) on cardiovascular outcomes in hypogonadal men.

METHODS

A meta-analysis of 26 randomized controlled trials involving 10 941 participants was conducted. Various clinical outcomes, including all-cause mortality, cardiovascular-related mortality, myocardial infarction, stroke, congestive heart failure, atrial fibrillation, pulmonary embolism, and venous thrombosis, were assessed.

RESULTS

No statistically significant differences were observed between the TRT group and the control group in terms of these clinical outcomes. Sensitivity analysis and publication bias assessment supported the robustness of the findings. Meta-regression analysis found no significant associations between clinical outcomes and potential covariates, including age, diabetes, hypertension, dyslipidemia, and smoking.

DISCUSSION

Previous research on TRT and cardiovascular events, with comparisons to studies like the Testosterone Trials and the studies conducted by Vigen et al, Finkle et al, Layton et al, and Wallis et al, is provided. The significance of the systematic review and meta-analysis approach is emphasized, particularly its exclusive focus on hypogonadal patients.

CONCLUSION

This study offers reassurance that TRT does not increase mortality risk or worsen cardiovascular outcomes in hypogonadal men. However, further research, especially long-term studies involving diverse populations, is essential to strengthen the evidence base and broaden the applicability of these findings.

A Review of Clinical Studies Assessing the Therapeutic Efficacy of Escitalopram: A Step Towards Development

BACKGROUND

Major depression is a debilitating, sometimes fatal disorder, deteriorating the quality of life and well-being. Escitalopram showed highly selective and dose-dependent inhibitory activity on human serotonin transport. Selective serotonin reuptake inhibitors (SSRIs) are the first-line drugs to manage major depressive disorder (MDD).

OBJECTIVE

The objective of this study is to explore the therapeutic potential of escitalopram, a clinically approved drug to manage MDD and panic disorders.

METHODS

It emphasizes comparative and clinical trial studies with several pharmacological targets reviewed from the data available on PubMed, Science Direct, Clinicaltrails.gov, and from many reputed foundations.

RESULTS

To highlight the clinical efficacy, safety, recent development, and stable formulation of escitalopram with an increased bioavailability profile. Evidence-based on the available clinical and pharmacoeconomic data, escitalopram represents an effective first-line treatment option for MDD patients.

CONCLUSION

The present review highlights the placebo-controlled clinical studies and the recent development that can be helpful for further research perspectives.

Formulation Development and in-vitro Evaluation of Escitalopram Fast Dissolving Tablets

BACKGROUND

Escitalopram, a selective serotonin reuptake inhibitor (SSRI), acts by increasing the serotonin level in the brain and is used widely for the management of depression and anxiety disorders. However, the poor dissolution rate of escitalopram due to less water solubility is a consequential problem confronting the pharmaceutical industry in developing pharmaceutical dosage forms for oral delivery systems.

OBJECTIVE

The present work aims to deliver a novel formulation for improving the dissolution profile and, thus, the bioavailability of escitalopram.

METHODS

Fast Dissolving Tablets (FDT) are expected to enable quick drug release, which will improve the drug's dissolving profile, allowing for the initial increase in plasma concentration mandatory in an acute depression attack. The use of co-processed excipients in tablets has been shown to increase the compressibility and disintegration properties of the tablets, resulting in improved in-vitro drug release and bioavailability. As co-processed excipients, a mixture of banana powder (a natural super disintegrant with nutritional value) and microcrystalline cellulose (a highly compressible substance with good wicking and absorption capacity) was used.

RESULTS

The tablets were made using a response surface, randomised central composite design and a direct compression technique. The manufactured tablets were found to be released more than 95% of the drug within 10 minutes and showed an improved drug release profile than the available marketed formulation.

CONCLUSION

As a result, after confirming in-vivo potential, the created fast release formulation exhibited impressive in-vitro findings and may prove to be a boon in treating acute depression attacks.

Opportunities to prevent and manage undernutrition to amplify efforts to end TB

The bidirectional relationship between TB and nutrition is well recognized - primary undernutrition is a risk factor for developing TB disease, while TB results in wasting. Although nutrition support is acknowledged as an important intervention in TB programmes, it is seldom afforded commensurate priority for action. TB incidence and deaths worldwide are falling too slowly to meet WHO End TB Strategy milestones, and the number of undernourished people is increasing, likely to be further exacerbated by the ongoing COVID-19 pandemic. Undernutrition needs to be more urgently and intensively addressed. This is especially true for the WHO South-East Asia Region, where the high rates of undernutrition are a key driver of the TB epidemic. The evidence base has been sufficiently robust for clear and workable programmatic guidance to be formulated on assessment, counselling and interventions for TB patients. Many high-burden countries have developed policies addressing TB and nutrition. Gaps in research to date have frustrated the development of more refined programmatic approaches related to addressing TB and malnutrition. Future research can be shaped to inform targeted, actionable policies and programmes delivering dual benefits in terms of undernutrition and TB. There are clear opportunities for policy-makers to amplify efforts to end TB by addressing undernutrition.

Urgent need to address the slow scale-up of TB preventive treatment in the WHO South-East Asia Region

In September 2018, all countries made a commitment at the first ever United Nations High-Level Meeting (UNHLM) on TB, to provide TB preventive treatment (TPT) to at least 30 million people at high-risk of TB disease between 2018 and 2022. In the WHO South-East Asia Region (SEA Region), which accounts for 44% of the global TB burden, only 1.2 million high-risk individuals (household contacts and people living with HIV) were provided TPT (11% of the 10.8 million regional UNHLM TPT target) in 2018 and 2019. By 2020, almost all 11 countries of the SEA Region had revised their policies on TPT target groups and criteria to assess TPT eligibility, and had adopted at least one shorter TPT regimen recommended in the latest WHO TPT guidelines. The major challenges for TPT scale-up in the SEA Region are resource shortages, knowledge and service delivery/uptake gaps among providers and service recipients, and the lack of adequate quantities of rifapentine for use in shorter TPT regimens. There are several regional opportunities to address these gaps and countries of the SEA Region must make use of these opportunities to scale up TPT services rapidly to reduce the TB burden in the SEA Region.

How common are vascular injuries in open tibial fractures? A prospective longitudinal cohort study

BACKGROUND

Tibial fractures have an incidence of 15% of all adult fractures. They have been shown to have the highest incidence of non-union in long bone fractures and the highest incidence of vascular injury. Evidence from the literature suggests that a good vascular supply is important to ensure bone union. The aim of our study was to prospectively assess the incidence of vascular injuries in open tibial fractures and determine whether they were associated with an increased risk of non-union.

METHODS

We performed a prospective study to investigate the incidence of arterial injuries with computed tomography angiography (CTA) in patients with Gustilo-Anderson grade I-III open tibial fractures between 2013 and 2015. CTA was performed with the trauma series at acute admission and reported by two independent musculoskeletal radiologists. Patients were followed up with clinical and radiographic assessment for 1 year.

RESULTS

We recruited 77 patients into the study, and 56 patients (47 males, 9 females) were available for the final analysis, between 16 and 90 years of age. At the initial assessment, 29% had signs of arterial injury with active extravasation in 5%. The most common site of injury was in the diaphysis (87.5%), and the commonest mechanism was a road traffic accident. We found no significant relation between occult vascular injury and non-union (p > 0.05).

CONCLUSION

The incidence of vascular injury in open tibial fractures is 29%, and CTA is therefore a useful test in identifying vascular injuries that may require vascular intervention.

Newborn Screening Guidelines for Congenital Hypothyroidism in India: Recommendations of the Indian Society for Pediatric and Adolescent Endocrinology (ISPAE) - Part I: Screening and Confirmation of Diagnosis

The Indian Society for Pediatric and Adolescent Endocrinology has formulated locally relevant Clinical Practice Guidelines for newborn screening, diagnosis and management of primary congenital hypothyroidism (CH).

RECOMMENDATIONS

Screening should be done for every newborn using cord blood, or postnatal blood, ideally at 48 to 72 h of age. On this screen sample, neonates with TSH > 20 mIU/L serum units (or >34 mIU/L for samples taken between 24 to 48 h of age) should be recalled for confirmation. For screen TSH > 40 mIU/L, immediate confirmatory venous T4/FT4 and TSH, and for milder elevation of screen TSH, a second screening TSH at 7 to 10 d of age, should be taken. Preterm and low birth weight infants should undergo screening at 48-72 h postnatal age. Sick babies should be screened at least by 7 d of age. Venous confirmatory TSH >20 mIU/L before age 2 wk and >10 mIU/L after age 2 wk, with low T4 (<10 μg/dL) or FT4 (<1.17 ng/dL) indicate primary CH and treatment initiation. Imaging is recommended by radionuclide scintigraphy and ultrasonography after CH is biochemically confirmed but treatment should not be delayed till scans are performed. Levothyroxine is commenced at 10 to 15 μg/kg in the neonatal period. Serum T4/FT4 is measured at 2 wk and TSH and T4/FT4 at 1 mo, then 2 monthly till 6 mo, 3 monthly from 6 mo-3 y and every 3-6 mo thereafter. Babies with the possibility of transient congenital hypothyroidism should be re-evaluated at age 3 y, to assess the need for lifelong therapy.

Randomized Assessment of the Safety and Efficacy of Intra-Arterial Infusion of Autologous Stem Cells in Subacute Ischemic Stroke

BACKGROUND AND PURPOSE

Stroke is a debilitating illness for which treatment window is limited. Most patients present to the healthcare facility beyond that window. Autologous stem cells have shown some promise for this group of patients. This study was performed to evaluate the safety and the efficacy of intra-arterial infusion of bone marrow-derived mononuclear cells in patients with middle cerebral artery ischemic stroke.

MATERIALS AND METHODS

A prospective, randomized, open-label, blinded-end point study was performed from July 2015 to June 2016. Of 229 patients with acute stroke who presented to the hospital during this period, 20 patients who satisfied the inclusion/exclusion criteria were included and randomized into the control and intervention groups. Intra-arterial stem cell infusion into the ipsilateral MCA was performed in the patients in the intervention group at 8-15 days post-stroke ictus. Final analysis at 6 months was performed for primary (safety) and secondary outcomes (efficacy).

RESULTS

When we compared the primary end point of the study, no procedure-related mortality, complication, new infarct, or symptomatic intracranial hemorrhage was seen in the intervention group. When we compared the secondary end point of good clinical outcome, 8 (80%) patients in the intervention group showed good clinical outcome (modified Rankin Scale score < 2) with 4 (40%) patients in the control group achieving this (95% confidence interval for good outcome in patients with stem cell infusion, 49.03-94.3, and without stem cell infusion, 16.82-68.73; P = .068).

CONCLUSIONS

Intra-arterial infusion of stem cells can be carried out safely in the subacute stage of ischemic stroke. Improved clinical outcomes were observed with intra-arterial stem cell therapy; however, studies with larger cohorts are needed to validate the results.

Clinical Outcomes of a Team Approach to Thyroidectomy

OBJECTIVE

The aim of this study is to assess the rates of thyroidectomy complications performed by two attending surgeons operating together.

STUDY DESIGN

This is a retrospective chart review.

METHODS

This is a retrospective chart review from September 2008 through October 2013 of thyroidectomy cases performed by the head and neck team at Sanford Health. The primary intervention was the presence of two head and neck attendings during each procedure. Outcomes assessed include rates of temporary and permanent recurrent laryngeal nerve paralysis, and of permanent hypocalcemia.

RESULTS

There were 282 patients that underwent a thyroid procedure with a total of 449 at-risk nerves. There were five (1.1 percent) cases of transient vocal cord paresis. There was one case (0.22 percent) of permanent vocal cord paresis after planned nerve resection in a patient with anaplastic thyroid carcinoma. There were no other cases of permanent vocal cord paresis. Of 156 total thyroidectomy cases, there was one case of chronic hypocalcemia (0.64 percent).

CONCLUSIONS

A two-surgeon approach to thyroidectomy produces excellent functional outcomes. Further investigation into cost-effectiveness is warranted.

Renal Cell Carcinoma Metastases to Thyroid and Pancreas: A Rare Occurrence

OBJECTIVE

To report on a case of late metastases of clear cell renal carcinoma to the thyroid and pancreas.

METHODS

A 51-year-old female with a history of nephrectomy 15 years prior for renal cell carcinoma presented with new metastases in the thyroid and pancreas, which were surgically excised.

RESULTS

Pathology noted that both lesions were clear cell carcinomas, and the immunohistochemistry was consistent with metastases from clear cell renal carcinoma.

CONCLUSION

1) Renal cell carcinoma can present late metastases to unusual organs like the thyroid and pancreas. 2) A prior history of renal cell carcinoma should raise suspicions of metastases when evaluating a thyroid or pancreatic mass. 3) An ultrasound-guided fine needle aspiration biopsy of the thyroid may not be diagnostic. 4) The treatment of choice is surgical resection.

Serum 25 hydroxyvitamin D profile after single large oral doses of cholecalciferol (vitamin D3) in medical staff in North India: a pilot study

BACKGROUND

Vitamin D deficiency is widely prevalent in India and subjects who have almost no exposure to sunlight are severely deficient. Daily oral doses of cholecalciferol (vitamin D3) are costly as compared to stoss doses and further, take a long time for the serum levels to reach a plateau. Compliance to supplementation may also be better if a regimen involves single oral doses of vitamin D at specified intervals rather than daily doses. Evidence-based guidelines regarding the dosing and the frequency of dosing for prophylactic intermittent supplementation (stoss doses) in severely-deficient subjects are few.

MATERIALS AND METHODS

In a prospective intervention study, we serially assessed 30 asymptomatic healthy medical staff for serum 25-hydroxyvitamin D [25(OH)D] and parathyroid hormone (PTH); (a) at baseline; (b) monthly for 3 months after single oral 60,000 units (U) cholecalciferol; (c) monthly for 3 months after 120,000 (or 180,000 for those with elevated alkaline phosphatase) U cholecalciferol; and, (d) subsequently, at 3 months after a repeat dose of 60,000 U cholecalciferol by repeated measures analysis of variance.

RESULTS

The baseline serum 25(OH)D was 7.1 ± 5.4 ng/mL (< 10 ng/mL in 85% subjects) which increased to 18.7 ± 8.9 ng/mL at 1 month after 60,000 U of cholecalciferol (P < 0.001) and decreased to 11.1 ± 5.3 ng/mL by the 3 rd month. The higher dose of 120,000 (or 180,000) U increased mean 25(OH)D to 28.9 ± 9.9 ng/mL at the end of 1 st month, declining to 17.9 ± 4.9 ng/mL (P < 0.001) at 3 months. With the subsequent 60,000 U the serum 25(OH)D was 18.4 ± 3.9 ng/mL at 3 months. PTH showed a corresponding negative trend. No hypercalcemia was observed.

CONCLUSIONS

Vitamin D deficiency is highly prevalent amongst medical staff in Northern India. An initial dose of 120,000-180,000 U of cholecalciferol is required to elevate 25(OH)D out of the deficiency range. Maintenance dose is needed at 2 months.

Prospective clinical study of endoscopic ultrasound-guided choledochoduodenostomy with direct metallic stent placement using a forward-viewing echoendoscope

A prospective clinical study was conducted to evaluate the safety, feasibility, and efficacy of endoscopic ultrasound (EUS)-guided choledochoduodenostomy (CDS) with direct metallic stent placement using a prototype forward-viewing echoendoscope. The indication for EUS - CDS in this study was lower biliary obstruction only, and not failed endoscopic biliary drainage, because the aim was to evaluate EUS - CDS for first-line biliary drainage therapy. The technical and functional success rates were 94 % (17 /18) and 94 % (16 /17), respectively. Early complications (focal peritonitis) were encountered in two patients (11 %). No patients developed late complications. EUS - CDS with direct metallic stent placement using a forward-viewing echoendoscope was generally feasible and effective for malignant distal biliary tract obstruction. The forward-viewing echoendoscope was useful, especially for deploying the metallic stent.

Adenosine induced coronary spasm – A rare presentation

Adenosine is commonly used as a pharmacological agent in myocardial perfusion imaging, as an antiarrhythmic agent, and in Cath Lab. during PCI for treating no reflow phenomenon. Coronary spasm has been reported following adenosine injection during stress imaging. We report a rare complication with ST segment elevation, following adenosine injection, given for treatment of supraventricular tachycardia.

Paraduodenal pancreatitis

Paraduodenal pancreatitis is a distinct clinicopathological entity involving the duodenum and the pancreatic tissue in the vicinity of the minor papilla. Most afflicted patients are young alcoholic males who present clinically with upper abdominal pain, weight loss, nausea, and vomiting. Pancreatic tissue elements in the duodenal wall and impedance to exocrine pancreatic secretions at the minor papilla are key factors in the pathogenesis of this condition. On imaging, the condition may manifest as a solid fibrotic mass around the minor papilla or as cysts in the duodenum and the pancreaticoduodenal groove. Duodenal stenosis, biliary strictures, chronic calcifying pancreatitis, and pancreatic ductal dilatation are also often observed.

Ipilimumab immune-related adverse reactions: a case report

Ipilimumab is an immunomodulating agent approved by the Food and Drug Administration (FDA) as of March 2011 for the treatment of metastatic melanoma. The medication works by inhibiting cytotoxic T-lymphocyte antigen 4, which typically works to down-regulate the T-cell response and protects self-antigens from recognition by the immune system. Since the T-cells are no longer down-regulated by this antigen, they are allowed to proliferate, thereby helping to prevent melanoma tumor evasion. As a result of the up-regulation of the immune system, numerous immune-mediated adverse effects have been reported including colitis, dermatitis, hepatitis and rarely hypophysitis. Typically, these effects are treated with high-dose steroids and most eventually resolve. We present a case of autoimmune (lymphocytic) hypophysitis following treatment with four doses of ipilimumab 3mg/kg and discuss the work-up, treatment and prognosis of the event.

Ketosis-resistant diabetes: a rare case in unlikely territory

BACKGROUND

Ketosis-resistant diabetes is a syndrome that has undergone numerous classification schemes in the past. In 1979, the National Diabetes Data Group (NDDG) introduced an association of malnutrition and diabetes. In 1985, the World Health Organization (WHO) created a new diabetes category called malnutrition-related diabetes mellitus (MRDM). MRDM consisted of two subclasses: fibrocalculous pancreatic diabetes (FCPD) and protein-deficient pancreatic diabetes (PDPD). Ketosis-resistant diabetes of the young (KRDY) was included in the subclass of PDPD. We report a rare case of a 37-year-old Sudanese immigrant with ketosis-resistant diabetes.

CASE

A previously healthy 37-year-old male presented with increased lethargy, polydipsia, polyuria and weight loss for the last seven to eight months. The patient had immigrated to the U.S. from his native country of Sudan about seven years earlier. He was hemodynamically stable. Physical exam was unremarkable with no evidence of retinopathy or neuropathy. Initial laboratory findings revealed a random blood sugar of 1,409 mg/dl and hemoglobin A1C of 17.8 percent. Urinalysis showed negative proteinuria, positive glycosuria, but only trace ketones were detected. Interestingly, the patient's serum ketones were negative. Arterial blood gas revealed PH 7.37, PCO2 47, P02 108 and HCO3 27. Further diagnostic workup revealed C-peptide 0.36, insulin antibodies less than 2, glutamic acid decarboxylase (GAD) antibodies less than 0.5, ICA 512 antibodies 2.9 and negative anti-islet cell antibodies. An abdominal ultrasound did not show any evidence of pancreatic calcifications or any pathology. Aggressive fluid resuscitation and intravenous insulin was initiated. The patient's hospital course was uncomplicated. He responded well to intravenous insulin drip and hydration. He was eventually transitioned to subcutaneous insulin. He was discharged three days later on a home regimen that included Lantus 28 units SQ at night, Novolog 8 units SQ with meals and a sliding scale with Novolog as needed. The patient's recent follow-up appointment revealed adequate glycemic control with HbA1C level of 7 percent.

CONCLUSION

Our patient did not meet criteria for either type 1 or type 2 diabetes mellitus. After a literature review of atypical etiologies of diabetes and comparing them to our patient, we concluded that the most likely diagnosis was KRDY. In light of a high influx of refugees and immigrants to the U.S., we should entertain. KRDY and other rare causes of diabetes mellitus in patients not satisfying criteria of either type 1 or type 2 diabetes.

103 OVIDUCTAL SECRETORY PROTEINS AS MEDIA SUPPLEMENT FOR IN VITRO EMBRYO DEVELOPMENT IN CATTLE

The objective of this study was to determine the effect of oviducal secretory proteins (cOSP) as a media supplement on in vitro embryo development in cattle. Oviducal secretory proteins were collected from slaughterhouse oviducts by repeated freeze–thaw process and purified by ammonium sulfate precipitation (30%, 40%, 50% and 60%) followed by dialysis in 50 mM tris-HCl (pH 7.0) buffer. Dialyzed products were further purified by SP Sephadex cation exchange column and diethylaminoethyl cellulose (DEAE) anion exchange column, extensively washed and eluted by 50 mM tris-HCl (pH 7.0) containing 1.5 M NaCl. Both bound and unbound proteins were collected separately, dialyzed in phosphate buffer saline and quantified. Presence of protein was confirmed by running sodium dodecyl sulfate–polyacrylamide gel electrophoresis (SDS–PAGE) and OSP bands between ∼66 kD to ∼97 kD were found. The pooled purified cOSP were used as a media supplement in 3 different concentrations (0, 10, 50 and 100 μg mL–1) for in vitro production (n = 3) of cattle embryos. Cumulus–oocyte complexes (n = 370) were collected from slaughterhouse ovaries, washed thoroughly and cultured in maturation media for 24 h in 5% CO2 at 38.5°C with maximum humidity. In vitro-matured oocytes were fertilized with in vitro capacitated sperm in Fert-BO media at 38.5°C in 5% CO2. After 16 to 18 h, oocytes were washed and cultured in embryo development media for cleavage. After 40 to 42 h, cleavage was observed and embryos were transferred into the replacement media for further development. A total of 68.42%, 69.31%, 61.82% and 41.67% cleavage rate and 15.38%, 21.31%, 14.70% and 15.0% blastocyst rate was observed at concentrations of 0, 10, 50 and 100 μg mL–1, respectively. These results indicate that addition of cOSP at 10 μg mL–1 increased blastocyst formation significantly (P < 0.05) compared with 0, 50 and 100 μg mL–1 and increased cleavage rate significantly (P < 0.05) compared with 50 and 100 μg mL–1. The authors acknowledge sincere thanks to the Director, Joint Director (Research), National Dairy Research Institute, Karnal and Incharge, Eastern Regional Station, National Dairy Research Institute, Kalyani, for providing the necessary facilities to carry out the work.

Type IV Dual Left Anterior Descending Coronary Artery:A Rare Anomaly

Type IV dual left anterior descending (LAD) coronary artery is a rare anomaly and was detected incidentally during a routine coronary angiogram. The article discusses the types of dual LAD and their clinical implications.

Development of pancreatic cancers during long-term follow-up of side-branch intraductal papillary mucinous neoplasms

BACKGROUND AND STUDY AIMS

Side-branch intraductal papillary mucinous neoplasms (SB-IPMNs), and associated synchronous and metachronous pancreatic cancers are increasingly detected as imaging modalities become more sensitive. We investigated the natural history of SB-IPMN, and the incidence and characteristics of pancreatic cancers among patients undergoing long-term follow-up.

PATIENTS AND METHODS

We reviewed the clinical, imaging, and pathological features in 103 patients, diagnosed at the Aichi Cancer Center between September 1988 and September 2006 as having SB-IPMN, and conservatively followed up for ≥ 2 years (median 59 months) based on an endoscopic ultrasonography (EUS) database.

RESULTS

74 (71.8 %) patients had nonprogressive lesions. Overall, six patients (5.8 %) developed pancreatic cancers during follow-up, with intraductal papillary mucinous (IPM) carcinoma in four, and ductal carcinoma of pancreas that was not IPMN in two patients. Of the six pancreatic cancers, five were diagnosed at a resectable stage. The 5-year and 10-year actuarial rates of development of pancreatic cancer were 2.4 % and 20.0 %, respectively. Although, at the last follow-up, cyst size, main pancreatic duct (MPD) diameter, mural nodule size, and frequency of metachronous and/or synchronous cancers of other organs were significantly higher in patients who developed IPM carcinoma, resected SB-IPMNs without mural nodules and dilated MPDs had no IPM carcinomas.

CONCLUSIONS

The frequency of pancreatic cancers is high on long-term follow-up of SB-IPMN. Although conservative management is appropriate for selected patients, regular and long-term imaging, especially by EUS is essential, even if SB-IPMN remains unchanged for 2 years. Presence of mural nodule and dilated MPD seem to be more appropriate indicators for resection than cyst size alone for SB-IPMNs.

Two novel AIRE mutations in autoimmune polyendocrinopathy-candidiasis-ectodermal dystrophy (APECED) among Indians

Autoimmune polyendocrinopathy-candidiasis-ectodermal dystrophy (APECED) is a rare recessive disorder resulting from mutations in the autoimmune regulator (AIRE) gene. There is no information on AIRE mutations in Indians. In a cross-sectional study, nine patients (eight families), from four referral hospitals in India, were studied for AIRE mutations by direct sequencing. We screened for new mutations in 150 controls by allele-specific PCR. The patients had 1-7 known components of APECED. Three patients had unusual manifestations: presentation with type 1 diabetes; chronic sinusitis and otitis media; and facial dysmorphism. All patients carried homozygous, probably recessive, AIRE mutations. Two unrelated patients from a small in-bred community (Vanika Vaisya) in south India carried an unreported missense mutation, p.V80G, in the N-terminal caspase recruitment domain. Another unique mutation, p.C302X, resulting in a truncated protein with deletion of both zinc-finger domains, was detected in a patient from Gujarat. Neither mutation was detected in controls. Other mutations, previously described in Caucasians, were: 13 base pair deletion (p.C322fsX372) in 4 (38%), and Finn-major (p.R257X) and p.R139X (Sardinian) mutation in one subject each. In conclusion, in this first series of APECED in Indians, we detected AIRE mutations previously reported in Caucasians, as well as unique mutations. Of these, p.V80G is possibly an ancestral mutation in an in-bred community.

Adults with Tourette's syndrome with and without attention deficit hyperactivity disorder

OBJECTIVE

Comorbidity between Tourette's syndrome (TS) and attention deficit hyperactivity disorder (ADHD) is high. In children, those with both TS+ADHD fare less well than those with TS-only on measures of both psychopathology and behaviour. The objective of this study was to document such measures in adult patients.

METHOD

Eighty adults with TS-only were compared to 64 with TS+ADHD using a clinical interview and standardised measures of depression, anxiety and obsessionality.

RESULTS

The two groups were no different on measures of TS severity. TS+ADHD patients had significantly more depression, anxiety, obsessive-compulsive behaviour and maladaptive behaviours than patients with TS-only. There were also significant differences in the incidence of copro- and echo-phenomena and family history of ADHD.

CONCLUSION

The finding of increased overall behavioural difficulties and psychopathology in adult patients with TS+ADHD when compared with TS-only is in agreement with previous findings in children with TS. Appropriate treatment of ADHD in TS patients during childhood may prevent many behavioural problems in adulthood.

Hypogonadotrophic hypogonadism in type 2 diabetes, obesity and the metabolic syndrome

Recent work shows a high prevalence of low testosterone and inappropriately low LH and FSH concentrations in type 2 diabetes. This syndrome of hypogonadotrophic hypogonadism (HH) is associated with obesity, and other features of the metabolic syndrome (obesity and overweight, hypertension and hyperlipidemia) in patients with type 2 diabetes. However, the duration of diabetes or HbA1c were not related to HH. Furthermore, recent data show that HH is also observed frequently in patients with the metabolic syndrome without diabetes but is not associated with type 1 diabetes. Thus, HH appears be related to the two major conditions associated with insulin resistance: type 2 diabetes and the metabolic syndrome. CRP concentrations have been shown to be elevated in patients with HH and are inversely related to plasma testosterone concentrations. This inverse relationship between plasma free testosterone and CRP concentrations in patients with type 2 diabetes suggests that inflammation may play an important role in the pathogenesis of this syndrome. This is of interest since inflammatory mechanisms may have a cardinal role in the pathogenesis of insulin resistance. It is relevant that in the mouse, deletion of the insulin receptor in neurons leads to HH in addition to a state of systemic insulin resistance. It has also been shown that insulin facilitates the secretion of gonadotrophin releasing hormone (GnRH) from neuronal cell cultures. Thus, HH may be the result of insulin resistance at the level of the GnRH secreting neuron. Low testosterone concentrations in type 2 diabetic men have also been related to a significantly lower hematocrit and thus to an increased frequency of mild anemia. Low testosterone concentrations are also related to an increase in total and regional adiposity, and to lower bone density. This review discusses these issues and attempts to make the syndrome relevant as a clinical entity. Clinical trials are required to determine whether testosterone replacement alleviates symptoms related to sexual dysfunction, and features of the metabolic syndrome, insulin resistance and inflammation.

Annular pancreas in an adult patient: diagnosis with endoscopic ultrasonography and magnetic resonance cholangiopancreatography

Annular pancreas is an uncommon congenital anomaly that usually presents early in childhood. The role of endoscopic ultrasonography in the diagnosis of this condition has been only sparsely reported. We present annular pancreas in a 50-year-old man; the anomaly was initially suspected during endoscopy and endoscopic ultrasonography, and subsequently confirmed on magnetic resonance cholangiopancreatography.

Choice of DES: is there a difference?

Restenosis after percutaneous coronary interventions has been a major limitation of this otherwise very well-accepted method of coronary revascularisation. Coronary stents work by scaffolding the intimal flaps and preventing elastic recoil, which was a major problem after balloon angioplasty. The neointimal growth response to stenting contributes significantly to the restenotic process. Randomised studies comparing coronary artery bypass surgery with coronary stenting especially in multivessel disease clearly highlighted this problem. The problem has been greater in magnitude in special subgroups: diabetics, patients with small vessels (≤2.5 mm in diameter), long segments of disease (≥20 mm in length), etc. These limitations of Bare metal stents have been addressed by drug-eluting stents (DESs). Third-generation stents with bioabsorbable polymers like the Biolimus releasing Biomatrix stent have already become available in Europe and parts of Asia. A longer follow-up will prove their long-term safety vis-à-vis first-generation DES. The polymer-free stent with capability of using more than one drug, though very attractive, needs larger multicentric studies before gaining wider acceptance. The fully bioabsorbable stent is yet another promising concept. The feasibility has already been demonstrated, and finer refinements are under way. The future of newer DES thus is very promising, and most of the issues related to first-generation DES are at the threshold of being solved.

Prevalence & risk factors of pre-hypertension & hypertension in an affluent north Indian population

BACKGROUND & OBJECTIVES

Urban Indians have a high prevalence of insulin resistance, hypertension and cardiovascular disease. We studied the prevalence of pre-hypertension and hypertension, as well their association with cardiovascular risk factors, in a north Indian upper socio-economic population.

METHODS

A total of 1746 adults (age >or=30 yr) residing in an urban colony of high-income group residents in the city of Lucknow, north India, were invited to be enrolled for the study. The response rate was 64 per cent (n=1112). Blood pressure, anthropometry, plasma glucose in response to oral glucose tolerance test and lipids were measured. The variables contributing significantly to pre-hypertension and hypertension were analyzed by multiple logistic regression analysis.

RESULTS

The age and sex adjusted prevalence of hypertension was 32.2 per cent and pre-hypertension was 32.3 per cent. In contrast to hypertension, which was highest in the age group 60-69 yr (64%), prehypertension was highest (36%) in the group 30-39 yr. There was a high prevalence of cardiovascular risk factors in the general population [central obesity (86.7%), elevated LDL cholesterol (22.8%), abnormal glucose tolerance (41.6%) and smoking (20.3% of males)]. Two or more of the cardiovascular risk factors were present in a higher proportion of hypertensive [66%, odds ratio (OR) 3.0, P<0.0001] and pre-hypertensive, (56%, OR 2.0, P<0.0001) compared to normotensive subjects (39%). Subjects with pre-hypertension had body mass index, waist-hip ratio and frequency of glucose intolerance, which was intermediate between normotensive and hypertensive subjects. In multiple logistic regression analysis, increasing age, body mass index, waist hip ratio and impaired glucose tolerance/diabetes were independent risk factors for both hypertension and pre-hypertension.

INTERPRETATION & CONCLUSION

A high prevalence of pre-hypertension and hypertension were noted in affluent urban north Indians. Increasing age, body mass index, central obesity and impaired glucose tolerance/diabetes were significantly associated with both hypertension and pre-hypertension. Pre-hypertension was associated with an increased prevalence of cardiovascular risk factors.

Hypogonadotrophic hypogonadism in type 2 diabetes

Recent work shows a high prevalence of low testosterone and inappropriately low luteinizing hormone (LH) and follicle stimulating hormone (FSH) concentrations in type 2 diabetes. This syndrome of hypogonadotrophic hypogonadism (HH) is associated with obesity in patients with type 2 diabetes. However, the duration of diabetes or HbA1c are not related to HH. Furthermore, recent data show that HH is not associated with type 1 diabetes. C-reactive protein concentrations have been shown to be elevated in patients with HH and are inversely related to plasma testosterone concentrations. This inverse relationship between plasma free testosterone and C- reactive protein concentrations in patients with type 2 diabetes suggests that inflammation may play an important role in the pathogenesis of this syndrome. This is of interest since inflammatory mechanisms may have a cardinal role in the pathogenesis of insulin resistance. It is also relevant that in the mouse, deletion of the insulin receptor in neurons leads to HH in addition to a state of systemic insulin resistance. It has also been shown that insulin facilitates the secretion of gonadotrophin releasing hormone (GnRH) from neuronal cell cultures. Thus, HH may be the result of insulin resistance at the level of the GnRH secreting neuron. Low testosterone concentrations are also related to an increase in total and regional adiposity. This review discusses these issues and attempts to make the syndrome relevant as a clinical entity. Clinical trials are required to determine whether testosterone replacement alleviates insulin resistance and inflammation. In addition, low testosterone levels are associated with an increase in cardiovascular events. Testosterone therapy may therefore, reduce cardiovascular risk. This important aspect requires further investigation.