A Case Control Study of Risk Assessment of Diabetes and Nephropathy with eNOS (T786C and 27bp VNTR) Gene Polymorphisms

OBJECTIVES

To determine the association of eNOS (T786C and 27bp VNTR) gene polymorphism with the risk of type II diabetes mellitus and diabetic nephropathy in North India.

METHODS

The prospective case control study was conducted over a period of 18 months. A total of 100 patients of Type 2 Diabetes Mellitus (A1: 50 cases without Diabetic nephropathy-DN and 50 cases with DN) aged 18-75 years and 50 healthy adults as control (Group B) were included. The endothelial nitric oxide gene variant (T786C and 27bp VNTR) genotypes and alleles were studied. Odds ratio with 95% CI was calculated for genotype and alleles for the occurrence of diabetes and DN. p value of less than 0.05 was considered as significant.

RESULTS

With Bb as reference(27bp VNTR), the odds ratio for Ab in the three groups (A1,A2,B) was 2.243, 1.545 and 0.746 respectively; and for Aa was 3.043, 3.058 and 1.878 respectively; with TT as reference (T786C), it was 1.573, 1.55 and 1.055 respectively for TC; and for CC it was 2.121, 2.063 and 2.348 respectively. The OR was comparable among the study groups and control for all genotypes and alleles (p>0.05).

CONCLUSION

In conclusion, there was a trend towards higher predilection of DN with aa genotype and a allele in 27 VNTR, CC genotype and C allele of -786T>C polymorphism however it was not found to be statistically significant. Future large sample studies are required to account for the ethnic variation for a clearer association of the genes and their associated risk with Diabetes and its complications.

The 2017 International Joint Working Group White Paper by INDUSEM, the Emergency Medicine Association and the Academic College of Emergency Experts on Establishing Standardized Regulations, Operational Mechanisms, and Accreditation Pathways for Education and Care Provided by the Prehospital Emergency Medical Service Systems in India

The government of India has done remarkable work on commissioning a government funded prehospital emergency ambulance service in India. This has both public health implications and an economic impact on the nation. With the establishment of these services, there is an acute need for standardization of education and quality assurance regarding prehospital care provided. The International Joint Working Group has been actively involved in designing guidelines and establishing a comprehensive framework for ensuring high-quality education and clinical standards of care for prehospital services in India. This paper provides an independent expert opinion and a proposed framework for general operations and administration of a standardized, national prehospital emergency medical systems program. Program implementation, operational details, and regulations will require close collaboration between key stakeholders, including local, regional, and national governmental agencies of India.

The 2017 Academic College of Emergency Experts and Academy of Family Physicians of India position statement on preventing violence against health-care workers and vandalization of health-care facilities in India

There have been multiple incidents where doctors have been assaulted by patient relatives and hospital facilities have been vandalized. This has led to mass agitations by Physicians across India. Violence and vandalism against health-care workers (HCWs) is one of the biggest public health and patient care challenge in India. The sheer intensity of emotional hijack and the stress levels in both practicing HCWs and patient relative's needs immediate and detail attention. The suffering of HCWs who are hurt, the damage to hospital facilities and the reactionary agitation which affects patients who need care are all together doing everything to damage the delivery of health care and relationship between a doctor and a patient. This is detrimental to India where illnesses and Injuries continue to be the biggest challenge to its growth curve. The expert group set by The Academic College of Emergency Experts and The Academy of Family Physicians of India makes an effort to study this Public Health and Patient Care Challenge and provide recommendations to solve it.

Academic College of Emergency Experts in India's INDO-US Joint Working Group and OPUS12 Foundation Consensus Statement on Creating A Coordinated, Multi-Disciplinary, Patient-Centered, Global Point-of-Care Biomarker Discovery Network

Biomarker science brings great promise to clinical medicine. This is especially true in the era of technology miniaturization, rapid dissemination of knowledge, and point-of-care (POC) implementation of novel diagnostics. Despite this tremendous progress, the journey from a candidate biomarker to a scientifically validated biomarker continues to be an arduous one. In addition to substantial financial resources, biomarker research requires considerable expertise and a multidisciplinary approach. Investigational designs must also be taken into account, with the randomized controlled trial remaining the “gold standard”. The authors present a condensed overview of biomarker science and associated investigational methods, followed by specific examples from clinical areas where biomarker development and/or implementation resulted in tangible enhancements in patient care. This manuscript also serves as a call to arms for the establishment of a truly global, well-coordinated infrastructure dedicated to biomarker research and development, with focus on delivery of the latest discoveries directly to the patient via point-of-care technology.

Association between high molecular weight apolipoprotein isoforms and lipoprotein levels in advanced chronic kidney disease and the effect of hemodialysis

To explore the association between high molecular weight apo(a) isoforms and lipoprotein(a) [Lp(a)] in chronic kidney disease (CKD) and the effect of maintenance hemodialysis (MHD), plasma Lp(a) and apo(a) isoforms were determined in age and sex-matched CKD stage 4 and stage 5 patients (repeated after 4 weeks of MHD) and healthy controls (n = 18). Median Lp(a) increased with severity of CKD. Upon HMW apo(a) isoform stratification, Lp(a) in S₂ isoform group was 37.6 mg/dl in CKD stage 4 and 64.0 mg/dl in stage 5 (P < 0.024 and P < 0.001 vs. controls), whereas in S₃ + S₄ group there was no significant increase. Following MHD, Lp(a) also decreased significantly only in the S₂ group. Increase in Lp(a) in CKD patients with HMW apo(a) isoforms is mainly restricted to S₂ isoform group, furthermore, decrease in Lp(a) levels in response to MHD is also seen in this group only.

End-of-Life Care Attitudes, Values, and Practices Among Health Care Workers

Introduction:

This study aims to ascertain attitudes of health care workers on end-of-life care (EOLC) issues and to highlight the disparity that exists in countries with different backgrounds.

Methods:

It is a cross-sectional questionnaire survey across heterogeneous health care providers in India, Chile, the United Kingdom, and the Netherlands using an indigenously prepared questionnaire considering regional variations, covering different areas of EOLC.

Results:

Of the 109 participants, 68 (62.4%) felt that cardiopulmonary resuscitation should be done selectively, 25 (22.9%) had come in contact with at least 1 patient who had asked them to hasten death, and 36 (33%) felt that training was insufficient to prepare them for skills in issues of EOLC.

Conclusion:

To avoid cumbersome through well-meant interventions, it is important that the caregiving team is aware of the patient’s own wishes with respect to EOLC issues.

Foe turned friend: multiple functional roles attributable to hyper-activating stem cell factor receptor mutant in regeneration of the haematopoietic cell compartment

OBJECTIVES

Stem cell factor receptor, c-kit, is considered to be the master signalling molecule of haematopoietic stem cells. It develops the orchestral pattern of haematopoietic cell lineages, seen by its varying degree of omnipresence in progenitors, lineage committed and mature cells. We have investigated the effect of over-expressing c-kit on early recovery of the haematopoietic compartment, in irradiated hosts.

MATERIALS AND METHODS

Normal bone marrow cells (BMCs) were transfected with Kit(wt) (wild-type c-kit) or its variant Kit(mu) (asp814tyr) by electroporation. Lethally irradiated mice were transplanted with normal or transfected congeneic BMCs. The effect of ectopic expression of c-kit on haematopoietic cell recovery was determined by analysing donor-derived cells. Furthermore, effects of both types of c-kit over-expression on progenitor and lineage-committed cells were examined by flow cytometric analysis of Sca-1 and lineage-committed (Lin(+)) cells respectively.

RESULTS

Hyper-activating Kit(mu) significantly improved recovery of the haematopoietic system in irradiated hosts. In vivo results showed that the donor-derived c-kit(+) cell population was increased to more than 3-fold in the case of Kit(mu)-transfected cells compared to normal and Kit(wt) over-expressing BMCs. In general, survival of progenitor and committed cell was improved in the Kit(mu) over-expressing system compared to the other two cohorts.

CONCLUSION

These results suggest that recruitment of the hyper-activating variant of c-kit (Kit(mu)) lead to early recovery of the bone marrow of lethally irradiated mice.

Tuberculosis of sternum: three cases with different presentations

Sternum is resistant to infections and thus infrequent site of osteomyelitis. Involvement of sternum by Mycobacterium tuberculosis is rare. We report case of 37-year-old male with isolated tuberculosis of the sternum, a 14-year-old girl with tuberculosis of the sternum and Potts spine and a 55-year-old male with tubercular sinus of the sternum, three different presentations of the same disease.

Glycated hemoglobin--a public health perspective

The burden of diabetes mellitus across the world especially in India is substantial, and much of the morbidity and mortality is due to development of diabetic complications. Control of blood glucose is important to reduce occurrence of these complications. Measurement of glycated haemoglobin values provides valuable information about long term glycemic control, and is recommended for routine monitoring by several clinical guidelines on diabetes. Monitoring and appropriate management have been shown to improve outcomes in patients with diabetes in other parts of the world. However, the adoption of glycated hemoglobin as part of routine monitoring of diabetes patients in India will need to answer issues of availability, affordability and accessibility.

A PROFILE OF WOMEN WITH ALCOHOL RELATED PROBLEMS AT BPKIHS, DHARAN

ABSTRACT

Effect of various antihypertensive drugs on plasma fibrinogen levels in patients with essential hypertension

In recent years, substantial evidence has accumulated to unambiguously implicate high plasma fibrinogen levels as a major cardiovascular risk factor. An open prospective and randomised pilot study was therefore undertaken in mild to moderate hypertensives to evaluate the effect of various antihypertensive drugs viz enalapril, felodipine and prazosin on the blood pressure and plasma fibrinogen levels. The systolic and diastolic blood pressures were determined at 0, 4 and 8 weeks whereas plasma fibrinogen assays were done at baseline and at the end of the 8th week of treatment in all the drug-treated groups. It was observed that although all the three drugs effectively controlled blood pressure, only enalapril significantly reduced plasma fibrinogen levels. Due to this additional effect, enalapril has potential to control two major cardiovascular risk factors--hypertension and high plasma fibrinogen levels--simultaneously.

Mumps with cerebellar encephalitis

A 30 years male patient, having typical symptoms of mumps, presented with acute cerebellar ataxia two days after the onset of parotid enlargement. The neurological symptoms showed complete recovery over the subsequent six weeks, suggestive of para-infectious cerebellar demyelination due to mumps.

Central nervous system complications in renal transplant recipients in a tropical environment

Renal transplant recipients are at risk of developing various infectious and non-infectious complications affecting the central nervous system (CNS). There is paucity of data regarding the spectrum of CNS complications and the epidemiology of infective agents varies according to geographical location. We retrospectively studied the spectrum of CNS complications seen in 792 renal allograft recipients followed up at this tertiary care centre in north India over a 19-year period. Autopsy findings of 78 allograft recipients who died in the hospital were also reviewed and included. The brain was examined in 22 of these patients. Overall, 79 (10%) patients developed some form of CNS dysfunction with a mortality rate of 60.8%. CNS infections occurred in 31 renal allograft recipients (3.9% of total) and accounted for the largest group (39.2%). Fungi were the commonest etiological agents (21 patients) and were associated with a 70% mortality, with cryptococcal meningitis occurring in 12, mucormycosis in six, aspergillosis in one, and other unusual fungal infections in the remaining two patients. All patients with mucormycosis had a fatal outcome. The second largest group comprised of patients with non-uremic encephalopathies (23 patients, 29.1%) with metabolic encephalopathy occurring in 13, toxic encephalopathy in nine and hypertensive encephalopathy in one patient) and was associated with an overall mortality rate of 60.9%. Cerebrovascular accidents occurred in 12 patients (15.2%) and were associated with a mortality of 91.7%. Other CNS complications included treatment related complications in four (5.1%), primary CNS lymphomas in three (3.8%), and miscellaneous complications in six patients (7.6%). Patients with non-cryptococcal fungal infections of the CNS, hepatic and toxic encephalopathy and those with cerebrovascular accidents had the worst outcome. There was no relationship between the development of infection or stroke and the type of maintenance immunosuppression used. We conclude that complications involving the CNS occur in 10% of all renal transplant recipients and are associated a with high mortality, warranting early diagnosis and aggressive treatment.

Impaired function of neutrophils in uraemic patients

BACKGROUND

Immunodeficiency explains the very high frequency of bacterial infections in patients with chronic renal failure (CRF), which leads to high mortality and morbidity, despite improved therapeutic interventions. Among several factors, the decreased functional capacity of phagocytic leucocytes appears to be responsible for the defective host defence mechanisms against infection in CRF. We evaluated both oxygen-dependent and oxygen-independent microbicidal activity of neutrophils isolated from uraemic patients.

METHODS

Forty patients with CRF (20 with mild-to-moderate CRF and 20 with advanced CRF) along with 20 age- and sex-matched healthy controls were studied. The assessment of phagocytic capability, ability to produce superoxide (O2.-) anion and H2O2, myeloperoxidase and granule-specific hydrolytic enzymes such as acid phosphatase, cathepsin D and lysozyme activity of the patient's neutrophils were performed to study their bactericidal activity.

RESULTS

The phagocytic index (PI) in the control group was found to be 50.38 (4.58). It was significantly reduced in both mild-to-moderate CRF and advanced CRF, as compared to controls. In mild-to-moderate and advanced CRF patients, O2.- production by resting polymorphonuclear neutrophils (PMN) was low. Also, on stimulation with PMA the O2.- production showed a relative reduction as compared to controls. H2O2 production by resting PMN from CRF patients was unaltered but on stimulation with PMA, the quantum of increase was significantly lower. A marked reduction in the level of intracellular myeloperoxidase activity in PMN was noted in CRF patients. Of the three intracellular lysosomal enzymes assayed, cathepsin D level was increased in the PMN of mild-to-moderate CRF patients; acid phosphatase level was elevated significantly in the PMN of both mild-to-moderate and advanced CRF patients. However, no change in lysozyme levels was observed.

CONCLUSION

With increasing severity of uraemia, neutrophils from uraemic patients showed progressive impairment of phagocytic ability. Impairment of oxygen-dependent microbicidal mechanisms was indicated by a decrease in O2.- and H2O2 production. Increased activity of lysosomal enzymes such as cathepsin D and acid phosphatase suggest a state of neutrophil activation in uraemia. It is likely that the immunodeficiency state in uraemics is partly due to reduced bactericidal activity of the neutrophil cell population.

Factitious disorder with oligoanuria: a case report

A 12-year-old girl presented with complaint of passing very 'scanty' amount of urine, approximately 50 ml every alternate day for the last five years. She had been admitted for investigations several times in different hospitals in the past. On evaluation, she was found to have no abnormality related to the urinary tract. Detailed psychiatric assessment revealed the factitious nature of her symptoms, suggesting the diagnosis of factitious disorder with physical symptoms.

Quantitative enzymuria following aorto-renal angiography

Quantitative estimation of urinary enzymes has been advocated as a more sensitive marker than conventional renal function tests to assess radio-contrast media induced nephrotoxicity. We studied 27 subjects with normal renal functions who underwent abdominal aortography for varied indications. Among these, 8 also required selective renal arteriography and 3 underwent arch aortography in addition. Sodium iothalamate was used as a radio-contrast medium and the average amount injected was 73 ml (45 to 120 ml) per subject. Standard renal function assessment including urinalysis, 24 hour urinary protein excretion, creatinine clearance done both before and after aortography did not show any significant alteration. Urinary excretion of tubular enzymes including leucine aminopeptidase (LAP), alkaline phosphatase (ALP), gamma-glutamyl transpeptidase (GGT) and maltase (MAL) was estimated before and 2, 24 and 48 hours after aortography. All enzymes showed a significant rise at 2 hours. Urinary excretion of LAP, ALP and GGT peaked at 24 hours after aortography without a further change in MAL levels. Enzymuria returned to baseline values 48 hours following the procedure. It is concluded that an increase in the urinary excretion of the brush-border enzymes within 24 hours of contrast media administration may suggest an early nephrotoxicity.

Effect of captopril on serum angiotensin converting enzyme and blood pressure in hypertensive patients

The effect of chronic captopril therapy on serum angiotensin converting enzyme (ACE) was studied in 30 patients with essential hypertension. Patients were assessed for serum ACE levels serially every week for 4 weeks. Thirty healthy individuals served as controls. The basal serum ACE level among hypertensives (57.4 +/- 37.2 u/l) was found to be significantly higher (p < 0.001) than the controls (33.3 +/- 8.8 u/l). One week after starting captopril therapy, serum ACE levels fell to almost half the basal values (p < 0.001). However, thereafter, it rose to levels higher than the basal level even though the blood pressure remained well controlled. Our study suggests that besides its action on ACE, captopril may lower the blood pressure by other mechanisms as well.

Gastrointestinal complications after renal transplantation. 10 Year data from a North Indian Transplant Center

Gastrointestinal complications are responsible for substantial morbidity and mortality among renal allograft recipients in developing countries. During a 10 year period, 166 (62.6%) of 265 allograft recipients developed gastrointestinal complications. This figure reflects the high incidence of infectious complications, especially acute diarrheas. Also notable was the incidence of esophageal candidiasis (7.2%), ischemic colitis (2.6%), and gastrointestinal and peritoneal tuberculosis (3.0%). Almost one quarter of the complications developed in the first 6 months after transplantation. Mortality was the highest with acute ischemic colitis (100%), pancreatitis (60%), and upper gastrointestinal hemorrhage (40%). Improvements in standards of living and sanitary conditions, pre transplant evaluation and assessment of risk factors, prophylaxis with anti ulcer drugs, early diagnosis, and appropriate treatment are needed to decrease the frequency and severity of gastrointestinal complications in renal allograft recipients.

Bilateral renal angiomyolipomatosis in tuberous sclerosis presenting with chronic renal failure: case report and review of the literature

A 45-year-old patient with tuberous sclerosis and bilateral renal angiomyolipomas who presented with chronic renal failure is reported. Although bilateral renal angiomyolipomas are commonly associated with tuberous sclerosis, the occurrence of chronic renal failure in the absence of associated cystic disease of the kidneys as seen in this patient is very rare.

Renal mucormycosis: computerized tomographic findings and their diagnostic significance

Isolated renal involvement by mucormycosis has been reported rarely in immunocompromised individuals. We describe four patients with mucormycosis confined to the kidneys, three of whom did not exhibit any predisposing factors. Only one patient had acute viral hepatitis with fulminant hepatic failure as the preceding disease. Two patients presented with oliguric renal failure of undetermined etiology and investigations revealed bilateral extensive involvement of the kidneys. Computerized tomography showed diffuse enlargement of the kidneys and multiple low-density areas. Treatment included systemic amphotericin B therapy in all four patients and nephrectomy in three patients. Two patients recovered completely. Our experience emphasizes the need for a high index of suspicion and recognition of computed tomographic scan appearances for making a prompt diagnosis. Early surgical intervention and systemic antifungal therapy are necessary for survival in this life-threatening condition.

Emphysematous pyelonephritis and cystitis in a renal transplant recipient--computed tomographic appearance

A 35-year-old nondiabetic renal allograft recipient developed emphysematous pyelonephritis and cystitis emphysematosa necessitating graft nephrectomy. The patient received cyclosporin and prednisolone as immunosuppressive therapy. He developed the first episode of urinary tract infection one week after transplantation and another episode 3 months later. Abdominal CT scan revealed presence of gas in the graft kidney, urinary bladder, and surrounding tissues. Despite appropriate antibiotic therapy, his renal function deteriorated rapidly and he died on the first postoperative day.

Effect of vasodilator and surface active drugs on the efficacy of peritoneal dialysis

The effect of sodium nitroprusside (SNP), a vasodilator drug, and chlorpromazine (CPZ), a surface active drug, on the efficacy of peritoneal dialysis was studied in 25 patients with acute or acute on chronic renal failure in a double blind fashion. Each drug was added to the dialysate during different sets of cycles. In each patient, six clearance periods of 3 cycles each were studied and peritoneal clearances of creatinine and urea and ultrafiltration rates were measured during each clearance period. SNP increased the peritoneal clearance of creatinine and urea by 28.8 percent each (p < 0.001) while CPZ increased the peritoneal creatinine and urea clearance by 17.7 and 26.0 percent respectively (p < 0.001 each). Both drugs significantly increased the ultrafiltration rates (p < 0.001). SNP was found to be superior to CPZ and had prolonged effect even after cessation of administration.

Chronic granulocytic leukaemia presenting with mandibular mass

A case of chronic granulocytic leukaemia with extramedullary deposits in the mandible is reported. Systemic chemotherapy coupled with local irradiation resulted in regression of the mandibular mass.

Estimation of 24 hour protein excretion from single random urine specimen

The product of protein/creatinine ratio (in a random urine specimen) and estimated daily urinary creatinine excretion were evaluated as a function of 24 h urinary protein excretion in 40 patients with pathology proteinuria having varying grades of renal function. An excellent correlation was found between the results obtained by this method and those from the standard 24 h urine collection method in healthy controls (r = 0.99) and in patients with normal (r = 0.88) or mild to moderately impaired renal function (r = 0.99). However, this method did not give a good measure of quantitative proteinuria in patients with advanced renal failure (r = 0.56), possibly due to decreased urinary excretion of creatinine in patients with advanced renal failure as compared to the estimated value. The product of protein/creatinine ratio and estimated daily urinary creatinine excretion thus gave a quick and alternate reliable method of estimating 24 h proteinuria in patients having normal or mild to moderately impaired renal function. However, this method is not suitable for patients with advanced renal failure.

Seasonal variations of arterial blood pressure in normotensive and essential hypertensives

Marked seasonal variations in environmental fluid losses and arterial blood pressure (BP) have been observed by us. Factors causing these changes in BP have been investigated. Effect of seasonal variation on BP was studied in 15 controls and 15 essential hypertensives. Mean temperature and relative humidity in well defined 5 local seasons was recorded. Monthly observations included the plasma levels and 24 hours urinary excretion of norepinephrine (NE), epinephrine (E), sodium (Na+) and potassium (K+). Average systolic, diastolic and mean BP were higher in winter season in both the groups (P less than 0.01). In hypertensives this variation was observed despite a significant increase in drug consumption during winter season (P less than 0.001). Both the groups revealed higher plasma levels and daily urinary excretion of NE and E during winter months, (P less than 0.05 - less than 0.001). 24 hrs urinary volume, Na+ and K+ were significantly higher in winter season (P less than 0.05 - less than 0.001). These parameters showed a negative correlation with mean ambient temperature. Increased sympathetic nervous activity as documented by increased NE and E in plasma and urinary, and decreased environmental loss of fluids and sodium may be contributory to this rise in blood pressure during winter season.

Optimal exchange volume and dialysate flow rate in peritoneal dialysis. A clinical study

To find the optimal exchange volume and dialysate flow rate for use in peritoneal dialysis, 24 adult patients with acute or acute on chronic renal failure were studied. Based on the exchange volume and duration of one cycle, patients were randomly divided into 4 equal groups. Peritoneal clearances for urea and creatinine were calculated at 2, 8 and 14 hours during dialysis. Increase of dialysate flow rate improved the peritoneal clearance of various solutes, and for the same flow rate 2 liter exchange volume gave better results than 1 liter exchange volume.

Aluminium phosphide poisoning: a prospective study of 16 cases in one year

Sixteen patients suffering from aluminium phosphide poisoning were treated during the year from January 1985 to December 1985. These accounted for approximately half the total number of cases of acute poisoning. Profuse vomiting, pain in the upper abdomen and shock were the most common presenting features. Six patients succumbed to their illness. Analysis of various prognostic factors revealed that ingestion of 'unexposed' tablets of aluminium phosphide taken from a freshly opened bottle was associated with a greater risk of fatal outcome. Aluminium phosphide poisoning has become an important matter of public health in parts of India.

Prolonged survival in a Patient with Chronic Myeloid Leukemia

Patients with chronic myeloid leukemia treated with intermittent busulphan therapy havean average survival rate of 2 to 4 years. The authors report here a patient who continues tosurvive beyond one decade on busulphan therapy.

A clinical profile of aplastic anemia

abstract