Anti oxidant potential of Metformin and Pioglitazone in Type 2 Diabetes Mellitus: Beyond their anti glycemic effect

OBJECTIVE

Insulin sensitizers might influence oxidative stress to improve insulin resistance in diabetes mellitus. The present study was designed with the aim to study the effect of Metformin & Pioglitazone on markers of oxidative stress after 4 weeks of therapy in patients with type 2 diabetes mellitus (Type 2 DM).

RESEARCH DESIGN AND METHODS

This was a prospective study with follow up of 4 weeks in patients with Type 2 DM. They were randomized into metformin treated group (N=20) and Pioglitazone treated group (N=20) and healthy age-matched control group (N=20). Data was presented as mean±S.D. Student "t" test, ANOVA and Pearson correlation co-efficient tests were performed to analyze the parametric data in this study.

RESULTS

Baseline clinical characteristics of the two study groups were similar. There is a significant difference for Fasting plasma glucose (FPG) and 2h-Post Prandial Plasma Glucose (PPPG) after 30 days of metformin and pioglitazone treatment. Metformin significantly reduced MDA (p=0.041) and increased SOD (p<0.001). Pioglitazone significantly reduced MDA (p<0.001) but failed to raise SOD level (p=0.132). Mean MDA was 4.57±0.57μM/L in metformin and 2.91±0.66μM/L in pioglitazone treatment with a p-value of <0.001. Further, a similar significant difference was obtained for SOD value by metformin and pioglitazone treatment (7.87±0.72U/ml vs. 6.94±0.53U/ml; p<0.001).

CONCLUSION

Pioglitazone was superior to Metformin to improve oxidative stress as reflected by reduction in MDA but the antioxidant effect i.e. increase in SOD was seen with metformin only. The differing mechanism of actions of the two drugs on oxidative stress favors co prescription of these drugs for better outcome in improving insulin resistance and diabetic complications.

Consensus Statement on Management of Post-Prandial Hyperglycemia in Clinical Practice in India

Postprandial hyperglycemia (PPHG) is a detrimental factor in the evolution of diabetes related complications. Numerous studies have established the role of PPHG in development of atherosclerosis and associated cardiovascular conditions. It is seen that management of PPHG can be more troublesome than fasting plasma glucose (FPG). Currently, there are various strategies both monitoring as well as therapeutic to control PPHG but there is no uniformity in practicing these strategies. In the absence of any standard guidelines, widespread variations in the management of PPHG are observed among physicians and diabetologists. The objective of this document is to set forth uniform guidelines to manage PPHG. This will not only result in optimal management and prevention of long term complications of diabetes but also better co-ordination and collaboration among the care providers. Moreover, an Indian perspective that can take into consideration the issues relevant to Indian patient pool will be effective. An expert committee comprising of prominent physicians and researchers associated with diabetes care provided their inputs to provide a basic platform for the formulations of guidelines. Their inputs were supplemented by extensive literature search to collect the relevant evidences. An initial draft was prepared which was reviewed by the core committee. Inputs from other experts were also sought and an initial guideline version was formulated that was presented in a conference, discussed and debated among experts. The guidelines on PPHG were then finalized and published.

Recent advances on the association of apoptosis in chronic non healing diabetic wound

Generally, wounds are of two categories, such as chronic and acute. Chronic wounds takes time to heal when compared to the acute wounds. Chronic wounds include vasculitis, non healing ulcer, pyoderma gangrenosum, and diseases that cause ischemia. Chronic wounds are rapidly increasing among the elderly population with dysfunctional valves in their lower extremity deep veins, ulcer, neuropathic foot and pressure ulcers. The process of the healing of wounds has several steps with the involvement of immune cells and several other cell types. There are many evidences supporting the hypothesis that apoptosis of immune cells is involved in the wound healing process by ending inflammatory condition. It is also involved in the resolution of various phases of tissue repair. During final steps of wound healing most of the endothelial cells, macrophages and myofibroblasts undergo apoptosis or exit from the wound, leaving a mass that contains few cells and consists mostly of collagen and other extracellular matrix proteins to provide strength to the healing tissue. This review discusses the various phases of wound healing both in the chronic and acute wounds especially during diabetes mellitus and thus support the hypothesis that the oxidative stress, apoptosis, connexins and other molecules involved in the regulation of chronic wound healing in diabetes mellitus and gives proper understanding of the mechanisms controlling apoptosis and tissue repair during diabetes and may eventually develop therapeutic modalities to fasten the healing process in diabetic patients.

Cutaneous T-cell lymphomas and their management strategies

Cutaneous T-cell lymphomas (CTCLs) comprise a heterogeneous group of lymphoproliferative disorders characterized by the proliferation of skin-homing post-thymic T-cells. It is the second most common extranodal non-Hodgekin's lymphoma. Many variants of mycosis fungoides and CTCLs are known to date, differing in clinical, histological, and immunophenotypic characteristics. Oral involvement has also been reported rarely in CTCLs. Treatment depends on the disease stage or the type of variant. New insights into the disease and the number of emerging novel therapeutic options have made it an interesting area for dermatologists and medical oncologists.

Promising role of ANGPTL4 gene in diabetic wound healing

Diabetes mellitus (DM) is one of the severe metabolic disorders of carbohydrate metabolism worldwide. Developing countries are at higher risk of DM, and there is significant evidence that it is epidemic in many economically developing and newly industrialized countries. Among all other complications associated with DM, delayed wound healing is a major concern in diabetic patients. Wound healing is a natural healing process that starts immediately after injury. This involves interaction of a complex cascade of cellular events that generates resurfacing, reconstitution, and restoration of the tensile strength of injured skin. There are multiple factors responsible for delayed wound healing among which the contribution of DM has been well documented. The wound healing process is also delayed by the metabolic, vascular, neurological, and inflammatory alterations, which are well known in both type 1 and type 2 diabetes. Keratinocytes are crucial for wound re-epithelialization, and defects in directed migration of keratinocytes due to DM are associated with the delayed wound healing process. Many factors responsible for re-epithelialization have been identified, characterized, and well described; however, the genes responsible for the healing process have only partially been illustrated. This article will therefore focus on the efficacy of ANGPTL4 (angiopoietin-like 4) gene, which plays a novel role in keratinocyte migration during wound healing.

Clinical and imaging perspective and unanswered questions in a case of metronidazole induced encephalopathy

We discuss the clinical and imaging perspective in a case of a 78-year-old male who developed slurring of speech and ataxia acute in onset for the last 3 days. During his hospital stay, he developed multiple episodes of focal seizures without secondary generalization involving the angle of mouth on the right side. The patient had ataxia and positive cerebellar signs. In the past, the patient was treated for amoebic liver abscess and had undergone percutaneous aspiration of abscess. The patient was prescribed oral metronidazole and was discharged. This time, the patient underwent magnetic resonance imaging examination, which revealed lesion highly suggestive of metronidazole-induced encephalopathy. The offending drug was discontinued immediately after which the patient improved clinically. A follow-up scan was performed after 12 days and showed complete resolution of lesions.

Screening of Hyperglycemic Patients Admitted in Intensive Care Unit

Background & objectives: It is a prospective, randomized, controlled study involving adults admitted to medical Intensive care unit (ICU) who were receiving mechanical ventilation. Methods: On admission, patients were randomly assigned to receive intensive insulin therapy (maintenance of blood sugar at a level between 80 and 110 mg/dl) and were found to have hyperglycemic. We study the clinical profile of critically ill hyperglycemic patients and associated metabolic profiles of all such patients were analyzed in relation to final outcome. Results: The benefit of intensive insulin care was from 8.0 percent with conventional treatment to 4.6 percent (P<0.04, with adjustment for sequential analyses). Intensive insulin therapy to maintain blood glucose at or below 110mg per deciliter reduced the morbidity and motility among critically ill patients in the surgical intensive care unit. Hyperglycemia was present in 38% of patient admitted to the hospital, of whom 26% had a known history of diabetes, and 12% had no history of diabetes before admission. Interpretation & conclusions: New hyperglycemic patients had a longer length of hospital stay, a higher admission rate to an intensive care unit, and were less likely to be discharged to home, frequently requiring transfer to an intermediate care unit. DOI: http://dx.doi.org/10.3126/ajms.v5i1.8507   Asian Journal of Medical Science Vol.5(1) 2014 pp.63-69

Correlation of insulin resistance, beta cell function and insulin sensitivity with serum sFas and sFasL in newly diagnosed type 2 diabetes

Pancreatic beta cell dysfunction and reduced insulin sensitivity are fundamental factors associated with glucotoxicity, lipotoxicity and oxidative stress in type 2 diabetic patients (T2DM). Diabetic milieu can induce apoptosis in several types of cells. The aim of present study was to compare circulating soluble apoptotic markers (sFas and sFas-L) with HOMA-IR, HOMA-%S, HOMA-%B in the serum of newly diagnosed T2DM and healthy subjects. For this study, 94 T2DM and 60 healthy subjects were enroled and evaluated for various parameters. Biochemical quantifications were performed with Syncron CX5 auto-analyzer. The levels of serum sFas-L, TNF-α and IL-6 were estimated by flowcytometry. The fasting serum insulin and sFas quantified by ELISA. HOMA-IR, HOMA-%S and HOMA-%B were calculated with HOMA calculator v2.2.2. The levels of TC, TG, LDL-C, VLDL-C were augmented and HDL declined significantly (P < 0.001) in diabetics. The levels of serum insulin, TNF-α, IL-6, sFas, HOMA-IR were raised (P < 0.001) and sFas-L, HOMA-%S and HOMA-%B were decreased significantly (P < 0.001) in T2DM subjects than healthy. In diabetics, serum sFas was positively correlated with HOMA-IR (r = 0.720, P < 0.001) and negatively with HOMA-%B (r = -0.642, P < 0.001) significantly while serum sFasL was negatively correlated with HOMA-IR (r = -0.483, P < 0.001) and positively with HOMA-%B (r = 0.466, P < 0.001) significantly. Further, the multivariate stepwise regression analysis shows that HOMA-IR contributes significantly to the variance of sFas and sFasL. Our findings suggest that the pancreatic beta cell dysfunction along with increased insulin resistance appears to be associated with apoptotic markers.

Hodgkin's Lymphoma Presenting as Alopecia

Alopecia is a rare manifestation of Hodgkin's disease. It may be due to follicular destruction due to direct infiltration by the disease, or it may be a secondary or paraneoplastic manifestation. In this patient, hair loss, diffuse yperpigmentation, and generalized itching preceded other manifestations of the disease. The pattern of hair loss was diffuse and generalized in nature involving scalp, eyebrows, axilla, and groin. Subsequently, the patient was diagnosed to be a case of Hodgkin's lymphoma, based on clinical and histopathological features. Earlier reports on alopecia accompanying Hodgkin's disease have also been discussed. This case highlights the importance of keeping a high suspicion of an underlying malignancy in patients presenting with such cutaneous manifestations.

Study of Mutations in β-Thalassemia Trait among Blood Donors in Eastern Uttar Pradesh

BACKGROUND

Knowledge on distribution of different mutations of thalassaemia, which are prevalent in a particular area, is a prerequisite for prenatal diagnosis.

OBJECTIVES

Studying mutations in β - thalassaemia trait among blood donors in eastern Uttar Pradesh, India.

MATERIAL AND METHODS

One thousand non - remunerated voluntary blood donors who were between 18 - 40 years of age, were included in the study. Both replacement and voluntary healthy blood donors were included. 4ml of venous blood was collected and it was stored at 4°C. Complete Blood Count (CBC), Haemoglobinopathy Screening and Molecular Analysis by ARMS - PCR (Amplification Refractory Mutation System - PCR) were done. Screening for β thalassaemia was done in a blood bank by using D - 10, Bio Rad, which was based on High Performance Liquid Chromatography (HPLC).

RESULTS

Twenty Eight subjects with β- thalassaemia trait were found among 1000 voluntary blood donors. IVS 1-5 (G-C) mutation was most common type (50%), followed by FS 8/9 (+G) 25% which was the second most common type. In our study, a rare mutation of CD 16 (-C) was also found. Out of 14 subjects who had IVS 1-5 (G-C) mutation (most common), six were from Varanasi (6/261) and five of them were Sindhis. It was seen that FS 41/42 (TCTT) mutation was distributed among all groups of populations which had higher prevalences of β-thalassaemia trait.

CONCLUSION

A comprehensive knowledge on beta thalassaemia mutations is necessary for determining a prenatal diagnosis. The occurrence of mutations may vary according to geographic region. Therefore, this study dealt with current problem of unknown mutations, in order to avoid complications.

A rare case of Balo concentric sclerosis showing unusual clinical improvement and response with oral prednisolone

The present report is a rare case of Balo Concentric Sclerosis. Most cases have either been diagnosed post mortem or have succumbed to the disease after being diagnosed ante mortem. In our case, the patient showed a dramatic response to treatment, and after a one-year follow-up, he was asymptomatic, with no relapses or residual effect of the illness.

Kinetic and Mechanistic Study of the Influence of Micelles on the Oxidation of Acetone by N-Bromophthalimide in Aqueous Acetic Acid Medium

The effect of cationic micelles of Cetyltrimethylammonium bromide (CTAB) and anionic micelles of Sodium dodecyl Sulphate (SDS) on the kinetics of oxidation of acetone by N-Bromophthalimide (NBP) was studied iodometrically at 308 K. In addition to kinetic experiments, conductivity measurements have also been done to obtain critical micelle concentration and other thermodynamic properties. The kinetic observations indicate fractional order and first order dependence, with respect to [Acetone] and [NBP] respectively. Cationic surfactant (CTAB) strongly catalysed the oxidation of acetone in aqueous acetic acid medium and typical kobs and [CTAB] profile was observed i.e. with the progressive increase in [CTAB], the reaction rate increased, at higher concentration constancy in kobs was observed, whereas anionic surfactant (SDS) was found to show no considerable effect on reaction rate. Mercuric acetate and phthalimide exhibited nil effect on the reaction rate. The presence of inorganic salts (KCl, KBr) exhibits positive effect in the reaction rate. The various activation parameters in presence of CTAB and SDS have been also evaluated. A suitable mechanism consistent with the experimental findings has been proposed. The binding constant with surfactants has been evaluated.

Pharmacognostical study of Tamalaki (Phyllanthus fraternus Webster), a herb used in Tamaka-svasa

Tamalaki is a herbacious medicinal plant, described in Ayurvedic texts in many occurrences with different properties, actions, uses and synonyms, supposed to indicate more than one species commonly used in practice. Modern scholars mostly suggest Phyllanthus fraternus Webster (syn. P. niruri Linn.), P. amarus Schum. and Thonn. and P. urinaria Linn. as the source plants of Tamalaki. In this study, an attempt has been made to designate P. fraternus as the source plant of Tamalaki used in the treatment of Tamaka-svasa (Bronchial asthma) and other respiratory disorders by analyzing therapeutic uses, actions, properties, taste, synonyms as well as pharmacognostical characters. Smooth capsule, six tepals, less and short fibrous root, pentagonal outline with wing-shaped young stem are some of the specific characters observed in this species.

Correlation between IL-7 and MCP-1 in diabetic chronic non healing ulcer patients at higher risk of coronary artery disease

Cytokines play an extremely important role in the pathogenesis of coronary artery disease (CAD) in which interleukin (IL)-7 is a major regulator of T-cell homeostasis which is conced in the stimulation of leukocyte-endothelial cell adhesion during inflammatory events. Circulating IL-7 is associated with activation of monocyte and natural killer cells, leading to enhanced production of inflammatory cytokines and chemokines observed in atherosclerosis and acute coronary syndromes. Plasma levels of IL-7, hs-CRP and monocyte chemoattractant protein (MCP)-1 were measured by an immunoenzymatic ELISA technique. Ninety neuropathic diabetic foot patients were divided into two groups: group B [those without CAD (n=45)] and group C [those with higher risk of CAD (n=45)]. Thirty-five healthy subjects were included as control (group H). Plasma concentration of IL-7, MCP-1 and hs-CRP were significantly higher in group C as compare with group H and B. Plasma IL-7 levels also showed significant positive correlations with plasma levels of hs-CRP and MCP-1. Abnormalities in lipid profile were also observed. In conclusion the positive correlation between plasma concentration of IL-7, MCP-1 and hs-CRP in diabetic foot patients observed herein, suggests a plausible role for IL-7 in the promotion of clinical instability in coronary artery disease.

Visceral leishmaniasis or systemic lupus erythematosus flare?

Systemic lupus erythematosus (SLE) is a multisystem disorder characterised by B-cell hyperactivity with production of multiple autoantibodies. Fever in SLE may be caused by disease exacerbation or by infection. We report a patient of SLE that was later complicated by fever, pancytopenia, and massive splenomegaly. Corticosteroid therapy for SLE might have masked the underlying infection at earlier stage. Despite negative results of rk-39 test and bone marrow biopsy, a very high suspicion for visceral leishmaniasis (VL) led us to go for direct agglutination test (DAT) and polymerase chain reaction (PCR) for leishmanial antigen that revealed positive results. Moreover, significant improvement in clinical and biochemical parameters was noted on starting the patient on antileishmanial therapy.

Relationship between oxidative stress and apoptotic markers in lymphocytes of diabetic patients with chronic non healing wound

AIMS

Hyperglycemia causes generation of free radicals which leads to oxidative stress and apoptosis in various cells. The present study was undertaken to investigate the correlation between oxidative stress and apoptotic markers in lymphocytes of diabetic patients with chronic non healing wounds.

METHODS

Thirty healthy, thirty uncontrolled type 2 diabetes mellitus (T2DM) and thirty uncontrolled T2DM with chronic, non healing, neuropathic diabetic foot patients were included in this study. Indices of oxidative stress inside the lymphocyte lysate were estimated by measuring content of superoxide dismutase (SOD), Catalase, Glutathione and malonaldialdehyde (MDA). Protein expression studies of pro and anti apoptotic markers were carried out to elucidate their possible involvement in diabetic context.

RESULTS

SOD and MDA activity was significantly higher in the lymphocytes of diabetic patients having chronic, non healing diabetic wound as compared with healthy (p<0.001); whereas catalase and GSH activity was significantly reduced (p<0.001) in the same group. Expressions of pro apoptotic markers (Caspase-3, Fas and Bax) were significantly higher whereas reduced expression of anti-apoptotic marker (Bcl-2) were obtained in lymphocytes of diabetic and non diabetic individuals.

CONCLUSIONS

Hyperglycemia confers pro apoptotic manifestations which are mostly through altered indices of oxidative stress within lymphocytic milieu.

Effect of selenium on connexin expression, angiogenesis, and antioxidant status in diabetic wound healing

This study was done to analyze the effect of selenium on antioxidant status and expression of different connexins in diabetic wound healing. The levels of vascular endothelial growth factor, superoxide dismutase, lipid peroxide, and connexins were analyzed in wound tissues taken from diabetic and non-diabetic mice before and after sodium selenite administration. The mRNA transcript levels of Cx 26, 30.3, 31, 31.1, and 43 were significantly elevated in diabetic wounds as compared to the non-diabetic wounds. After selenium administration, the expression of connexins along with serum glucose decreases more significantly in diabetic wounds as compared to non-diabetic wounds. In diabetic wounds, the low levels of vascular endothelial growth factor and extracellular superoxide dismutase were restored to normal level following selenium administration. The lipid peroxidation decreased significantly in diabetic mice post-selenium administration. The histopathological analysis revealed that administration of selenium improves angiogenesis at the wound site. The results of this study demonstrate that selenium, acting as an essential component of the antioxidant system, normalizes the antioxidant status, and as an insulin mimetic compound, downregulates connexin expressions and induces angiogenesis. Together, these effects of selenium accelerate wound healing in diabetic conditions.

Level of serum IL-12 and its correlation with endothelial dysfunction, insulin resistance, proinflammatory cytokines and lipid profile in newly diagnosed type 2 diabetes

AIM

This study was an attempt to evaluate and correlate serum interleukin-12 (IL-12) with different circulating markers in newly diagnosed type-2 diabetes mellitus (T2DM) for possible progression of atherosclerosis.

METHODS

For this study, we recruited 1968 family members of diabetics and 349 had abnormal glucose. Out of 349 subjects, 197 were T2DM as per American Diabetes Association guidelines and further investigated for cardiovascular abnormalities. 63 T2DM have high sensitive C-reactive protein (hsCRP)>3.0mg/l and cardiovascular complications. Overall, 150 subjects, 50 healthy, 50 T2DM (D1) and 50 T2DM with cardiovascular complications (D2) were enrolled and investigated for soluble markers.

RESULTS

The levels of serum glucose, proinflammatory cytokines (IL-6, IL-12, tumor necrosis factor), endothelial dysfunction markers [vascular cell adhesion molecule-1 (VCAM-1), inter-cellular adhesion molecule-1 (ICAM-1), nitric oxide] and lipid abnormality were highest in D2 group. Correlation and regression study showed that IL-12 was dependent on hsCRP, insulin resistance, VCAM-1, ICAM-1 and lipids. The multivariate stepwise regression analysis demonstrates that hsCRP contributes significantly for variance of IL-12.

CONCLUSION

This study reveals that, even first-time diagnosis of T2DM, subjects with higher insulin resistance and abnormal lipids have elevated IL-12, endothelial dysfunction and proinflammatory markers. Further increased hsCRP enhance IL-12 which up-regulate cardiovascular disease progression.

Impact of Lymphocyte Apoptosis in Diabetes mellitus

Diabetes mellitus is a metabolic disorder. It is the most common cause of blindness, kidney failure, and amputations in adults and a leading cause of heart disease and stroke. These patients are more prone to infection which shows that there is suppressed cell mediated immunity during diabetes progression. Lymphocytes play a crucial role in  maintenance of cellular & humoral immunity both and its development requires cellular selection to remove potentially auto reactive cells via apoptosis. Apoptosis of lymphocyte clones play a pivotal role in purging the body of dangerous lymphocytes to maintain the development and regulation of the immune system. Indeed, inefficient elimination of lymphocytes can contribute in the pathogenesis of autoimmune diseases like insulin dependent diabetes mellitus. Several clinical and experimental studies have revealed that uncontrolled diabetes leads to lymphocyte death which enhances susceptibility towards infections and creates a permissive environment for bacterial growth. The aim of this article is to review the findings that the high incidence of infection in poorly  controlled diabetic states may be positively correlated with an increased proportion of apoptotic lymphocytes. Keywords: Lymphocyte; Infection; Programmed cell death; Autoantigens; Immunity   DOI: 10.3126/ajms.v2i1.3516 Asian Journal of Medical Sciences 2 (2011) 1-6

Pneumatocele in an adult

We report a case of 25-year-old male who presented with high grade fever with cough and expectoration. Chest examination revealed amphoric breath sounds on the right interscapular region. Chest X ray revealed multiple air fluid levels with collapse lung at places. Staph pneumonia with pneumatoceles is common in children but uncommon to in adult population.

Effect of pioglitazone and rosiglitazone on mediators of endothelial dysfunction, markers of angiogenesis and inflammatory cytokines in type-2 diabetes

The purpose of this study was to assess the effects of PPAR-gamma agonists (pioglitazone and rosiglitazone) on mediators of endothelial dysfunction and markers of angiogenesis in patients with type-2 diabetes. Pioglitazone group showed favorable reductions in serum total cholesterol, triglycerides, LDL cholesterol, VLDL cholesterol and increase in HDL cholesterol as compared to rosiglitazone group, after 16 weeks of treatment and also with control group. There was significant reduction of CRP level in pioglitazone and rosiglitazone group. The level of serum TNF-alpha decreased significantly in pioglitazone and mildly decreased in rosiglitazone group. The level of VEGF, IL-8 and Angiogenin were increased in pioglitazone than rosiglitazone group. There were no significant changes observed in the serum angiogenin and IL-8 levels in the control group. Pioglitazone and rosiglitazone therapy in type-2 diabetes subjects have additional benefits of reducing mediators of endothelial dysfunction. Increase in angiogenesis markers in patients receiving pioglitazone could have variable effects in diabetic nephropathy and retinopathy as there may be increased vascular neogenesis. Pioglitazone has advantage over rosiglitazone in lowering lipid and proinflammatory cytokines.

Acanthamoebae presenting as primary meningoencephalitis in AIDS

A rare case of Acanthamoebae meningoencephalitis is diagnosed in cerebrospinal fluid (CSF) of a 24 years old male suffering from acquired immunodeficiency syndrome (AIDS) patient on the basis of bright field microscopy and culture growth on non-nutrient agar with Escherichia coli. This case illustrates that Acanthamoebae should be considered in the differential diagnosis of meningoencephalitis in AIDS in addition to tuberculosis and cryptococcus infection in tropical areas.

Decreasing incidence of renal cortical necrosis in patients with acute renal failure in developing countries: a single-centre experience of 22 years from Eastern India

BACKGROUND

Renal cortical necrosis (RCN) accounts for 2% of all cases of acute renal failure (ARF) in adults and 15-20% of ARF during the third trimester of pregnancy in developed nations. However, RCN incidence is higher in developing countries ranging from 6-7% of all cases of acute renal failure. The present study describes changing trends in the clinical spectrum of RCN in patients with ARF in Eastern India.

METHODS

Patients with ARF suspected to have RCN on clinical grounds underwent percutaneous renal biopsy. Patients showing cortical necrosis on histology were included in the present study. Diffuse and patchy cortical necrosis was classified based on standard histological criteria. The patients with cortical necrosis were studied over a period of 22 years; from July 1984 to December 2005. The results of our observation were compared with respect to etiology, incidence, prognosis and outcome of renal cortical necrosis in two study periods; namely, 1984-1994 and 1995-2005.

RESULTS

The incidence of RCN was 3.12% of all cases of ARF of diverse etiology. RCN was observed in 57 patients; obstetric 32 (56.2%); non-obstetric 25 (43.8%). Diffuse cortical necrosis was the dominant lesion in 41 (71.9%) patients and the remaining 16 (28%) patients had patchy cortical necrosis. The overall incidence of RCN in obstetric ARF was 15.2%; the incidence being higher (11.9%) in the post-abortal group in comparison to 3.3% in late pregnancy. RCN had occurred complicating abruptio placentae, puerperal sepsis and postpartum haemorrhage (PPH) in late pregnancy, while septic abortion was the sole cause of RCN in early pregnancy. Haemolytic uraemic syndrome (HUS) was the major (31.5%) cause of RCN in the non-obstetric group and miscellaneous factors were responsible in seven (12.3%) patients. Partial recovery of renal function was observed in 11 (19.2%), and 16 (28%) patients had progressed to ESRD. The incidence of RCN decreased from 6.7% in 1984-1994 to 1.6% in 1995-2005 of total ARF cases. RCN following obstetrical complication decreased significantly; 4.7% in the 1990s to 0.5% of the total ARF cases, in the 2000s. The mortality decreased to 19% in 1995-2005 from the initial high mortality of 72% in 1984-1994. The renal prognosis improved as a result of the decreased mortality of patients.

CONCLUSION

We observed a decreasing trend in the incidence of RCN in patients with ARF in recent years, which is associated with increased patient survival and better renal prognosis. This improvement was mainly due to declining incidence and severity of RCN in obstetrical ARF.

Hemangiopericytoma of the spleen: unusual presentation as multiple abscess

Background

Hemangiopericytoma is a soft tissue vascular neoplasm arising from capillary pericytes and is found throughout the body in soft tissues and bone. It was first described in 1942. Primary vascular neoplasm of the spleen constitutes the majority of nonhaematolymphoid splenic tumors like haemangioma, lymphangioma, hemangioendothelioma, hemangiopericytoma etc. Splenic hemangiopericytoma is a rare tumor and probably first case was described in 1989. Uptill now only eight cases are reported in the English literature.

Case presentation

A-35-year old male presented with fever and dull aching pain in left hypochondriac region. Radiological evaluation showed presence of multiple abscesses in spleen. Investigations were done to rule out common causes of abscess in spleen. After failure of medical management, he was subjected to elective splenectomy. There were dense adhesions between the spleen and the adjacent structures and the diaphragm. The histopathology of the resected specimen showed hemangiopericytoma of spleen.

Conclusion

The present case illustrate that the hemangiopericytoma of spleen can mimic as multiple abscess. Splenectomy is the treatment of choice.

Apoptosis: a basic physiologic process in wound healing

Apoptosis, or programmed cell death, is a complex network of biochemical pathways for controlling such events in a cell. Apoptosis is essential, as its failure can lead to disease. Because apoptosis concerns the regulation of sequential events, including the removal of inflammatory cells and the evolution of granulation tissue into scar tissue, it has an essential role in wound repair. This article examines the literature and proposes that apoptosis features in the development of diabetic foot wounds. Hyperglycemia deregulates the sequential apoptotic events by multiple mechanisms, leading to delayed wound healing. Deregulated apoptosis is emerging as a prominent cause of delayed wound healing, especially in diabetic wounds, along with the well-known triad of peripheral vascular disease, neuropathy, and infection.

Effect of glycaemic control on apoptosis in diabetic wounds

OBJECTIVE

To study the effect of glycaemic control on apoptosis in chronic ulcers in diabetic patients and the differential roles of insulin and oral hypoglycaemic agents (OHAs).

METHOD

Ten non-diabetic (group I) and 20 diabetic patients (groups II and III), with a wound of more than four weeks' duration, who were attending the wound clinic at University Hospital, Varanasi, India were recruited. The 10 patients in group 11 received insulin and the 10 in group III an oral hypoglycaemic agent; all had diabetic foot ulcers. Wound biopsy and other routine investigations were performed. Both DNA fragmentation and morphological changes under light microscopy (apoptotic index) were used as determinants of apoptosis. Different variables, including fasting and post-prandial blood sugar, serum low-density lipoprotein (LDL) and markers of microangiopathy, such as proteinuria and diabetic retinopathy, were compared with apoptosis.

RESULTS

DNA fragmentation in groups I, II and III was 40.00 +/- 2.97, 45.26 +/- 3.21 and 60.8 +/- 3.13 respectively (p < 0.01). Near linear correlation was observed with blood sugar level, particularly post-prandial blood sugar (p < 0.05) and DNA fragmentation. DNA fragmentation was significantly correlated with serum LDL and proteinuria, and it was much greater in the OHA group than in the insulin group (p < 0.05). Similarly, in the diabetic patients with background retinopathy the DNA fragmentation was 46.50 +/- 3.42 (n=3) in the insulin group and 66.70 +/- 6.48 (n=4) in the OHA group (p < 0.05).

CONCLUSION

There is a significant increase in apoptosis in diabetic wounds with poorly controlled blood sugar and microangiopathy. This increase was greater in patients on OHAs than those on insulin, and it contributes to delayed wound healing. Morphological markers do not appear to be a reliable index of apoptosis in the diabetic wound.

Primary amyloidosis presenting with predominant lymphnodal masses

A 50 year young farmer presented with clinical features of bilateral carpal tunnel syndrome and generalized lymphadenopathy including paratracheal and retroperitoneal lymphodes. The histological diagnosis confirmed primary amyloidosis of lymphnodes. Presentation of primary amyloidosis as lymphnodal mass with deposition of amyloid in carpal tunnel is extremely rare and can only be diagnosed by histochemistry. The clinical response to drugs is variable and needs surgical intervention for decompressive therapy which can improve the symptoms of carpal tunnel syndrome.

Mucocutaneous lesions in transplant recipient in a tropical country

Dermatological manifestations are common in renal transplant patients, but differ markedly with ethnic group and geographical location. We studied mucocutaneous lesions in 54 renal allograft recipients (related donors = 30; unrelated donors = 24) living in tropical atmospheres. Their gender was 50 males, and 4 females ranging in age between 15 and 63 years (mean = 37.84 years). The mean duration of follow-up was 124 months (range = 4 to 173 months). All patients received kidneys from living donors and were kept on immunosupression with mean daily doses of prednisolone, azathioprine, and cyclosporine of 10.2 mg, 68.6 mg, and 252 mg, respectively. The mean trough concentration of cyclosporine was 185 ng/mL. The mucocutaneous lesions were divided into four groups: drug-induced (n = 24, 44.4%), fungal (n = 18, 33.3%), viral (n = 9, 16.6%), and bacterial (n = 10, 18.5%). Cushingoid features, gum hypertrophy, and hypertrichosis were seen in 7 (12.9%) patients. Steroid acne was seen in three cases. Pityriasis versicolor was the most common (20.3%) fungal infection of the skin. In addition, Tinea unguium and mucocutaneous candidiasis were noted in four and three cases respectively. Herpes virus infection (Herpes zoster 5; Herpes simplex 2) was noted in 7 (12.9%) cases. Chicken pox at 5 years posttransplant and cutaneous vasculitis associated with cytomegalovirus disease at 6 months posttransplant were seen in one case each. We have not seen warts in our patients. Pyogenic bacterial infection of skin in the form of abscess (n = 6), cellulitis (n = 3), and pyoderma (n = 1) were observed in 10 (18.5%) patients. Thus, drug-induced mucocutaneous side effects and skin fungal infections are the most common dermatological manifestations among renal transplant recipients living in a tropical country.

Spectrum of renal disease in malaria

Between January 2000 and December 2001, renal involvement in 81 cases of malaria was studied. Their age ranged between 05 and 66 (mean 35.5) years. Distribution of malarial parasite was P falciparum (75), mixed infection (4) and P vivax (2). The evidence of clinical renal disease in the form of acute renal failure, electrolyte abnormality, abnormal urinary sediment and increased urinary protein excretion (>500 mg/24 hours) was found in 100%, 91.3%, 46.9% and 18.5% respectively. Probable aetiopathogenesis of acute renal failure (ARF) was multifactorial. Volume depletion (72.8%) was the dominant cause of ARF in these patients. In addition, hyperbilirubinaemia, intravascular haemolysis and sepsis were responsible for ARF in 64.2%, 70.3% and 25.9% cases respectively. All the patients were managed with anti-malarial drugs and dialysis support was needed in 35 patients (43.2%). Prognosis of malarial acute renal failure is favourable with mortality rate of 18.5%. Multi-organ failure was the commonest cause (33.3%) of death.

Role of kidney in hypertension

Renin angiotensin system in the genesis of hypertension was established long after Goldblatt's belief that the minute capillaries of the kidney regulate blood pressure and he also suggested kidney released a pressure substance which lead to rise of blood pressure. Guyton provided experimental and analytical data supporting the role of renal pressure natriuresis in the regulation of normal circulation and its function resulting in the pathogenesis of hypertension. Hady and Overbeck proposed that the blood pressure of volume expanded hypertension was raised by a circulating inhibitor of the Na+/K+ ATPase pump. Brenner et al proposed that hypertension may arise from a congenital reduction in the number of nephrons or in the filtration surface area per glomerulus, thereby limiting ability to excrete sodium, raising blood pressure. Renin angiotensin system can be interrupted at four sites by adrenergic blocker, renin inhibitor, angiotensin converting enzyme inhibitor and angiotensin receptor blocker. Non-modulation in the face of relatively high dietary sodium could explain the pathogenesis of sodium sensitive hypertension and provide a more targeted, rational therapy for its correction.

An experimental study of some indigenous drugs with special reference to hydraulic permeability

The effect of commonly used indigenous drugs for hepatic disorders i.e. Tinospora cordifolia, (Guduchi/Amrita), Andrographis paniculata (Kalmegha), Picrorhiza kurroa (Kutki), Phyllantnus niruri (Bhoomyamalaki) and Berberis aristata (Daruharidra) was tested on the hydraulic permeability of water in the presence of bile salt through a transport cell model. The data on hydraulic permeability were calculated as t (time). JV = Lp x AP, where Lp = hydraulic conductivity and AP is the pressure difference. It was observed that the value of controlled hydraulic permeability (0.49 x 10(-8) M3 S(-1) N(-1)) decreased in the presence of indigenous drugs and bile salt. The results suggest that these drugs might have the cell membrane stabilizing property which may lead to prevention of the toxic effect of bile salts in various hepatic disorders.

A study of prostane in the treatment of benign prostatic hyperplasia

A clinical trial was conducted in a study group of 70 males diagnosed with symptomatic benign prostatic hypertrophy (BPH) (synonym of benign prostatic hyperplasia). They were administered Prostane, a herbal formulation, at a dose of two tablets a day for 1 year and monitored every 4 months during the study period. Analysis of the results showed an improvement in the symptom score of the American Urological Association symptom index rating. There was total relief in pain and haematuria in all the patients (100%); dribbling of urine decreased in 67%, dysuria in 50%, urgency in 60% and hesitancy in 40%. Blood urea levels were within the normal range in 70% of the patients and in the range 31-40 mg/dL in the remaining patients of the study group. Serum prostate specific antigen levels returned to normal in 56% of patients and were in the range 4.1-5.0 ng/mL in 25% of patients. There was a decrease in prostate specific antigen values which were >6 ng/mL in 9 patients at the commencement of the trial. Uroflowmetry studies showed that the peak flow increased from 12.6 to 30.7 s (p<0.001) and the void volume from 60.72 to 660 mL (p<0.001), the latent period reduced from 12.78 s to 2.61 s; the flow time from 57.01 s to 20.17 s and the residual volume from 620 mL to 20 mL (p<0.001). From these results, it is evident that Prostane was effective in alleviating symptoms, reducing prostate specific antigen values and normalizing uroflow dynamics in patients with benign prostatic hypertrophy.

Assessment of carbonic anhydrase activity in blood by alteration in pH

Carbonic anhydrase enzyme activity could be measured by manometeric and colorimetric techniques. A simpler and modified method of carbonic anhydrase enzyme activity assessment in blood is proposed. In the present method differences in pH by hydration of CO2 in absence and presence of carbonic anhydrase inhibitor have been used to measure the carbonic anhydrase activity in the blood.

Renal cortical necrosis in pregnancy-related acute renal failure

Of 63 patients of obstetrical acute renal failure, 15 cases (23.8%) had biopsy proven bilateral renal cortical necrosis. Remaining 48 patients (76.2%) had acute tubular necrosis. Eight of 39 cases in early pregnancy had cortical necrosis (postabortum) and 7 of 24 patients in late pregnancy revealed cortical necrosis. Diffuse and patchy cortical necroses were seen in 12 and 3 patients respectively. The incidence of cortical necrosis was almost equal in both early as well as late pregnancies. The high incidence (20.5%) of cortical necrosis following septic abortion remains the interesting feature of the present study in contrast to very low incidence (1.5%) of cortical necrosis in postabortum group in developed countries. The death occurred in most patients (14 ie, 93.3%) of cortical necrosis because of uraemic complications and sepsis.

Acute renal failure in eastern India

The present study included 426 patients with acute renal failure age range 7 months to 85 years, during 8-year period (1984-1992). Medical, surgical and obstetric causes were responsible for ARF in 68.3, 17.8, and 14% of cases respectively. The main aetiological factors encountered were volume depletion secondary to gastrointestinal fluid loss (35.2%), acute glomerulonephritis (10.3%), nephrotoxin (8.6%), falciparum malaria (4.2%), obstructive uropathy (13%), post-abortal (10.5%), and miscellaneous factors (1.4%) of patients. The overall mortality was 19.2%. Thus our observation revealed that diarrhoeal diseases (35.2%), obstructive uropathy (13.3%), and septic abortion (10.5%) were the main causes for ARF in medical, surgical, and obstetric groups respectively. In contrast to our studies, acute renal failure associated with diarrhoeal diseases, septicaemia, falciparum malaria and septic abortion are rare in European countries.

Spectrum of renal cortical necrosis in acute renal failure in eastern India

Renal cortical necrosis is an uncommon cause of acute renal failure. We report 23 cases of biopsy-proven renal cortical necrosis which constituted 6.3% (23/363) of all cases of acute renal failure studied over a period of seven years (1985-92). The patients were divided into two groups: obstetric and non-obstetric. Obstetric complications were responsible for renal cortical necrosis in 15 (65.2%) patients while non-obstetric conditions accounted for the remaining eight (34.8%) cases. The overall incidence of cortical necrosis in obstetric acute renal failure was 15/63 (23.8%) patients, the incidence being nearly equal in early (20.5%) and late (29%) pregnancy. Post-abortum renal failure was the sole cause of cortical necrosis in early pregnancy in the obstetric group. Haemolytic uraemic syndrome (three patients) and septicaemia (two patients) were the main cause of necrosis in the non-obstetric group. The cortical necrosis was diffuse and patchy in 17 and six patients, respectively. The disease had a fatal prognosis in 20 (87%) patients; mortality was due to uraemic complications and infections in the majority of patients. The high frequency of post-abortum renal cortical necrosis in our patients is similar to the experience of other Indian workers.