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Background: Vitamin D deficiency with a resurgence of rickets and tetany is increasingly being reported in young infants from temperate regions, African Americans, and also from India. The data on Vitamin D status of healthy term breastfed Indian infants and mothers are scant. In fact, the correlation between Vitamin D deficiency and alkaline phosphatase (ALP) is inaccurate in many studies. Aim and Objective: The aim and objective of this study are to determine whether serum Vitamin D levels are correlated with serum levels of ALP or not and to study the point, at which ALP surge occurs in Vitamin D deficiency. Materials and Methods: Ninety-six participants at birth were enrolled and followed up till 9 months of age. Serum 25 (OH) D along with ALP was estimated in cord blood at birth and 14 ± 1 weeks of life. Seventy-seven participants were followed up at 9 months for estimation of serum 25 (OH) D, parathyroid hormone, ALP, calcium, and phosphorus. Vitamin D deficiency was defined as serum 25 (OH) D <15 ng/mL as per the United States Institute of Medicine guidelines. Results: At 9 months out of 96 samples, 16 had mild insufficient (≥15--20 ng/mL) (20.8%), 42 had moderate deficient (<15 ng/mL) (54.5%), and 0 had severe deficient (<5 ng/mL) Vitamin D deficiencies. Serum alkaline phosphate were found to be normal in all the three groups of patients and the receiver operating characteristic curve demonstrated that low Vitamin D level is predicted by a high ALP cutoff of ALP is 190.90 IU/L with reasonable sensitivity and specificity. The correlation coefficient of ALP and serum Vitamin D3 levels was r = 0.501 (P = 0.001). Conclusion: Serum Vitamin D3 levels correlated well with increased serum ALP levels but the level, at which the ALP surge occurs was on the lower side. [ABSTRACT FROM AUTHOR]

Background: Insulin resistance can be broadly defined as subnormal biological response to normal insulin concentration. Insulin resistance (IR) is one of the major factors in the pathogenesis of sepsis. Aim: To study the Insulin Resistance as Prognostic Indicator in Severe Sepsis, Septic Shock and Multiorgan Dysfunction syndrome (MODS). Materials and Methods: A prospective observational study done at Intensive care unit of Department of Medicine, at the tertiary care health centre of Northern India, it was done between June 2016-to May 2017. Patients with age between 14 to 75 years and satisfying the criteria for severe sepsis, septic shock, MODS according to third international consensus 2016 guidelines was included in the study. Patients on statins and insulin, those who had chronic disease and who had CPR were excluded. Results: A total of 81 patients were enrolled. Mean of fasting blood glucose (FBG), fasting insulin level and insulin resistance of both groups were calculated and compared on Day 1 and Day of outcome. Out of 81 patients 42 were euglycemic (RBS<140 mg/dl) and 39 were hyperglycemic (RBS>140 mg/dl). Mean fasting insulin (13.36+4.95v/s 9.83+4.54) and insulin resistance (6.65+3.84v/s2.41+1.11) of hyperglycemic was found to be significantly (p<.01) higher than euglycemic group of patients. Of 39 hyperglycemic patients 30% (n=13) expired while out of 42 euglycemic patients 28.5% expired (n=12) showing mortality was higher in hyperglycaemic patients and the value was found to be non-significant. Conclusion: In patients of severe sepsis, septic shock and MODS stress induced hyperglycemia and insulin resistance are associated with increased mortality. IR is a good and easily estimated method for assessing, but it is not the appropriate indicator of mortality in patients with severe sepsis and organ failure as there are many other factors which come into interplay leading to poor prognosis. [ABSTRACT FROM AUTHOR]

Background: Patients suffering from critical illness admitted to the Intensive Care Unit (ICU) exhibit alterations in their thyroid hormone levels, collectively termed as euthyroid sick syndrome or nonthyroidal illness syndrome. Our study was conducted to determine the correlation between these changes in thyroid hormone levels and the prognosis of ICU-admitted patients. Methods: A total of 270 ICU-admitted patients without previous history of thyroid disorder were included in the study. We recorded their baseline characteristics, acute physiology and chronic health evaluation (APACHE-II) score, thyroid hormone levels, lactate, and other parameters on admission. ICU mortality was the primary outcome. We analyzed the ability of each parameter to predict mortality in the participants. Further, we also evaluated whether the combination of thyroid hormone levels with APACHE-II score could improve the mortality prediction. Results: The mean age of the study population was 38.99 ± 18.32 years. A total of 81 patients (30%) expired during their ICU treatment. Both fT3 and fT4 levels were lower in nonsurvivors compared to survivors. Among the thyroid hormones, fT3 had the highest predictive value for ICU mortality, as seen by the largest area under the curve (AUC) value (0.990 ± 0.007) which was even greater than AUC of APACHE-II score (0.824 ± 0.051) and fT4 (0.917 ± 0.049). Univariate logistic regression analysis showed that fT3 (β = 140.560) had the highest predictive potential for ICU mortality compared with APACHE-II score (β = 0.776), fT4 (β = 17.62) and other parameters. Multivariate logistic regression analysis revealed that the combination of fT3 and APACHE-II (R2 = 0.652) was superior in predicting mortality than APACHE-II alone (R2 = 0.286). Conclusion: We observed that fT3 was the strongest predictor of ICU mortality compared to all other parameters included in our study. Further, the combination of fT3 levels and APACHE-II scores provided for a higher probability for predicting mortality in ICU patients. [ABSTRACT FROM AUTHOR]

The dipeptidyl peptidase-4 (DPP-4) inhibitors have facilitated the management of type 2 diabetes mellitus (T2DM) owing to their superior efficacy and safety with low incidence of adverse effects. Gemigliptin is a new member of this family of drugs, and studies have revealed certain advantages of gemigliptin use compared to its previous congeners. Besides, this drug has also been studied for the treatment of T2DM as monotherapy, in combination with metformin or other oral antidiabetic drugs and in T2DM with moderate-to-severe renal failure. In this review, we explore the published data highlighting the pharmacology, efficacy, and safety of gemigliptin along with its recommendations for use in patients with T2DM. [ABSTRACT FROM AUTHOR]

Abdominal obesity is one of the pivotal factors in defining the metabolic syndrome. Abdominal obesity is assessed by the various clinical surrogates among which waist circumference is considered to be simple, inexpensive & sensitive tool. But various controversies surround the exact cut offs and the ideal sites of waist circumference measurement, so in this review we discussed these issues. [ABSTRACT FROM AUTHOR]

SGLT2 inhibitors are a new class of anti-diabetic drugs recently approved by the FDA which act by a novel beta cell independent mechanism. Acute pancreatitis is a very rare adverse effect of this group of drugs, with only three cases described so far in medical literature. Our case describes the occurrence of diabetic ketoacidosis precipitated by acute pancreatitis in a middle aged diabetic individual who was recently started on therapy with Dapagliflozin. Timely diagnosis and management lead to complete recovery of the condition with no residual disabilities. This highlights the importance of awareness of this rare adverse effect associated with SGLT2 inhibitors to facilitate prompt detection, management and preventing morbidity [ABSTRACT FROM AUTHOR]

Hashimoto's encephalitis is a rare, heterogeneous and completely treatable form of neuroendocrine disorder manifesting with seizures, stroke-like episodes, encephalopathy, dementia and variable neuropsychiatric manifestations. It is generally associated with a background of Hashimoto's Thyroiditis, and the patient has high titers of antithyroid antibodies, especially antithyroid peroxidase antibodies. This entity responds dramatically to corticosteroids, hence should be always considered and excluded while treating a patient with encephalopathy in the background of a thyroid disease. [ABSTRACT FROM AUTHOR]

Idiopathic intracranial hypertension (IIH) is a central nervous system disorder characterized by raised intracranial pressure with normal cerebrospinal fluid composition and absence of any structural anomaly on neuroimaging. Among all endocrine disorders associated with the development of IIH, the association of hyperthyroidism and IIH is very rare with few cases reported till date. Thyroid disturbances have a unique association with IIH. Hypo- and hyper-thyroidism have been reported in association with this disorder. We present a rare case of a 25-year-old man with Graves' disease with intractable headache that was later investigated and attributed to development of IIH. [ABSTRACT FROM AUTHOR]

Insulin resistance is one pretty troublesome entity which very commonly aggravates metabolic syndrome. Many methods and indices are available for the estimation of insulin resistance. It is essential to test and validate their reliability before they can be used as an investigation in patients. At present, hyperinsulinemic euglycemic clamp and intravenous glucose tolerance test are the most reliable methods available for estimating insulin resistance and are being used as a reference standard. Some simple methods, from which indices can be derived, have been validated e.g. homeostasis model assessment (HOMA), quantitative insulin sensitivity check index (QUICKI). For the clinical uses HOMA-insulin resistance, QUIKI, and Matsuda are suitable, while HES, McAuley, Belfiore, Cederholm, Avignon and Stumvoll index are suitable for epidemiological/research purposes. With increasing number of these available indices of IR, it may be difficult for clinicians to select the most appropriate index for their studies. This review provides guidelines that must be considered before performing such studies. [ABSTRACT FROM AUTHOR]

Diabetes mellitus is becoming a global health issue with more than 80% diabetics living in developing countries. India accounts for 62.4 million diabetics (2011). Indian Council of Medical Research India Diabetes Study (ICMR-INDIAB) study showed highest weighted prevalence rate in the north India among all studied regions. Diabetes in north India has many peculiarities in all aspects from risk factors to control programmers. North Indians are becoming more prone for diabetes and dyslipidemia because rapid westernization of living style and diet due rapid migration to metropolitan cities for employment. North Indian diabetes is plagued with gender bias against females, poor quality of health services, myths, and lack of disease awareness compounded with small number of prevention and awareness programmers that too are immature to counteract the growing pandemic. [ABSTRACT FROM AUTHOR]

Background: Various autoimmune disorders are associated with pediatric-type-1 diabetes mellitus (DM), but are usually ill-defined and not usually suspected until the disease becomes advanced, and the prevalence of these autoimmune conditions is usually not very well defined in developing part of the world. Aim: To find out the prevalence of various autoimmune disorders associated with pediatric-type-1 DM. Materials and Methods: Total of 164 patients were screened (90 males and 74 females) during the study period of 1-year, patients were evaluated for the clinical signs, biochemical investigations and family history of autoimmune disorders in a tertiary health care center in western Uttar Pradesh. Results: Autoimmune thyroiditis was found to be most commonly associated with type-1 diabetes, followed by the celiac disease, and Graves' disease, others less commonly seen were pernicious anemia, juvenile rheumatoid arthritis and vitiligo. Conclusion: Autoimmune hypothyroidism was found to be significantly associated with type-1 diabetes, timely identification of these disorder are of paramount important for better glycemic control and to reduced the morbidity and mortality associated with the conditions. [ABSTRACT FROM AUTHOR]

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

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

Rupture of the sinus of Valsalva (RSOV) is an uncommonly encountered condition. It can present with wider manifestations ranging from an asymptomatic murmur to cardiogenic shock. The case discussed in this report also had subaortic membrane which usually presents with subvalvular aortic stenosis, left ventricular hypertrophy, myocardial ischemia and sudden death. Corrective cardiac surgery was advised, but due to financial constraints, the patient could not be operated and he died. Here, the authors report for the first time an unusual presence of both RSOV and subaortic membrane and the patient presented with thromboembolic complication resulting from infective endocarditis. [ABSTRACT FROM AUTHOR]

Latent Autoimmune Diabetes of Adult (LADA) is an autoimmune form of diabetes mellitus characterised by onset in adulthood and slow progression of beta cell failure. It is commonly misdiagnosed as type 2 diabetes mellitus and treated with oral hypoglycaemic agents, ultimately resulting in delay of insulin initiation. Acute hyperglycaemic crisis in the form of diabetic ketoacidosis is a rare initial presentation of LADA with very few cases reported so far. We present the case of a 40 year old housewife with no past or family history of diabetes that presented with diabetic ketoacidosis and was subsequently discovered to be affected with LADA. [ABSTRACT FROM AUTHOR]

An introduction to the journal is presented in which the editor discusses various reports in the issue on the topics including one on cerebral malaria (CM), the other on medical emergencies and the third on Japanese encephalitis (JE).

A letter to the editor is presented in response to an article about thyroid acropachy as a manifestation of autoimmune thyroid disorder.

A letter to the editor is presented which reports a case of dengue shock syndrome (DSS) with acute subdural hematoma (SDH) in a male patient and suggests that a high index of suspicion needs be maintained in patients with febrile illness and atypical neurological manifestations.

Background: Hypothyroidism (both subclinical and overt) is associated with increased cardiovascular morbidity. About 3% hypertensive patients found to have hypothyroidism during the routine investigations. Objectives: To assess the effect of thyroid hormone replacement on the level of blood pressure in the cases of newly diagnosed subclinical hypothyroidism. Methods: Patients above the age of 15 years admitted to various wards (Indoor) or attending Endocrinology OPD at teriatary care health centre of north India were enrolled during the period of one year. The cases were divided into two groups, normotensive and hypertensive. Cases with subclinical hypothyroidism after evaluation were prescribed thyroxine replacement therapy to achieve euthyroid function. Each group followed periodically at 1 ½, 03 and 06 month with measurement of blood pressure and serum TSH, T3 and T4 level. Results: The prevalence of hypertension in cases of subclinical hypothyroidism in this study was 33.4 per 100 populations. There was no correlation between serum TSH level and blood pressure level in hypertensive group (p>0.05). In hypertensive group mean fall in blood pressure after thyroxine replacement therapy was systolic blood pressure 20.10±11.2 diastolic blood pressure 13.16±3.8 and in mean arterial pressure 15.2±4.7. With replacement of thyroxine hormone, the blood pressure was normalized in 47.4% (45 out of 95 cases) cases with elevated blood pressure. Conclusion: The effect of thyroxine replacement therapy in cases of hypertension with subclinical hypothyroidism on blood pressure was significant reduction in blood pressure after achieving normal thyroid function. [ABSTRACT FROM AUTHOR]

Background: Diabetic ketoacidosis (DKA) is characterized by a biochemical triad of hyperglycemia, acidosis, and ketonemia. This condition is life-threatening despite improvements in diabetic care. The purpose of this study was to evaluate the clinical and biochemical prognostic markers of DKA. We assessed correlations in prognostic markers with DKA-associated morbidity and mortality. Methods: Two hundred and seventy patients that were hospitalized with DKA over a period of 2 years were evaluated clinically and by laboratory tests. Serial assays of serum electrolytes, glucose, and blood pH were performed, and clinical outcome was noted as either discharged to home or death. Results: The analysis indicated that significant predictors included sex, history of type 1 diabetes mellitus or type 2 diabetes mellitus, systolic blood pressure, diastolic blood pressure, total leukocyte count, Acute Physiology and Chronic Health Evaluation II (APACHE II) score, blood urea nitrogen, serum creatinine, serum magnesium, serum phosphate, serum osmolality, serum glutamic oxaloacetic transaminases, serum glutamic pyruvic transaminases, serum albumin, which were further regressed and subjected to multivariate logistic regression (MLR) analysis. The MLR analysis indicated that males were 7.93 times more likely to have favorable outcome compared with female patients (odds ratio, 7.93; 95% confidence interval, 3.99 to 13.51), while decreases in mean APACHE II score (14.83) and serum phosphate (4.38) at presentation may lead to 2.86- and 2.71-fold better outcomes, respectively, compared with higher levels (APACHE II score, 25.00; serum phosphate, 6.04). Conclusion: Sex, baseline biochemical parameters such as APACHE II score, and phosphate level were important predictors of the DKA-associated mortality. [ABSTRACT FROM AUTHOR]

Dear Editor, Patients with diabetes mellitus who are affected by COVID-19 infection have been shown to have poor outcomes. Similar findings were noted by Mishra et al.[[6]] in their case series in which the blood glucose levels (fasting and post-prandial) got elevated at day 1 post-vaccination in two individuals whereas another patient exhibited a delayed rise after 6 days of vaccination. Such sporadic case reports should not deter the primary care physician from advocating routine COVID vaccination in all diabetics and other patients, who are at risk of developing diabetes. [Extracted from the article]

Background: Neoplastic and infective brain lesions may present as imaging mimickers. This study aims to help differentiate between etiology of lesions based on diffusion tensor imaging (quantitatively and qualitatively). Method: DTI was performed in 50 patients (12 - metastases,13 - high grade glioma,13 - tuberculoma, 12 - Neurocysticercosis). Lesional and perilesional Fractional anisotropy (FA) and mean diffusivity (MD) values were calculated. Lesional and perilesional mean FA and MD values were compared by using Student's 't'-test. Result: Mean FA values in the perilesional area of neoplastic lesions were found to be significantly higher (0.17±0.12 vs. 0.08±0.02), P < 0.001) in comparison to infective lesions. Mean MD values in the perilesional area of infective lesions were found to be significantly higher (1.51±0.22 vs. 1.20±0.33x10-3mm2/sec, P < 0.001) in comparison to neoplastic lesions. Perilesional FA was found to be significantly higher and perilesional ADC to be significantly lower in High Grade Gliomas (HGG) when compared with Metastasis, Tuberculomas or Neurocysticercosis. Infective group showed significantly higher prevalence of displacement of white matter tracts (60%) and the neoplastic group showed significantly higher prevalence of the disruption (40%). Conclusion: FA and MD values from the lesion and from perilesional region are helpful in differentiating among brain lesions. Fiber tracking along with quantitative parameters is helpful in determining type of involvement of tracts, thus helping in prognostication. [ABSTRACT FROM AUTHOR]

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

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

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

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

The authors present insights on thyroid function and metabolic syndrome in light of the rising prevalence of obesity in India. Topics discussed include the effect of obesity on thyroid hormones, the effect of thyroid hormones on low density lipoprotein cholesterol (LDL-C), and thyroid disorders as risk factors for cardiovascular diseases.

Background: Cerebrotendinous xanthomatosis is a very rare autosomal recessive lipid storage disorder affecting bile acid biosynthesis. It is manifested by subtle neurological and non-neurological symptoms due to abnormal tissue lipid deposition. Diagnosis is usually delayed but early diagnosis and replacement therapy can prevent devastating neurological sequelae.Case Presentation: We present a case of a 25-year-old Asian Indian woman who presented with gait difficulty, fusiform swellings of bilateral tendo-Achilles and infrapatellar tendons, along with history of bilateral cataract surgery 1 year earlier. The diagnosis was made on the basis of clinical, biochemical, imaging, and histopathological analysis and replacement therapy was started.Conclusions: The peculiarity of the present case is the absence of any neurological manifestations which are usually the early clues to the diagnosis of cerebrotendinous xanthomatosis. The present case report emphasizes the fact that early age bilateral cataracts along with bilateral tendo-Achilles xanthomas can be early pointers toward the diagnosis of cerebrotendinous xanthomatosis. [ABSTRACT FROM AUTHOR]

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

Introduction: The primary objective of this study was to determine the serum level of antioxidant enzymes and to correlate them with outcome in patients of aluminum phosphide (ALP) poisoning and, secondly, to evaluate the effect of N-acetylcysteine (NAC) given along with supportive treatment of ALP poisoning. Design: We conducted a cohort study in patients of ALP poisoning hospitalized at a tertiary care center of North India. The treatment group and control group were enrolled during the study period of 1 year from May 2011 to April 2012. Interventions: Oxidative stress was evaluated in each subject by estimating the serum levels of the enzymes, viz. catalase, superoxide dismutase (SOD) and glutathione reductase (GR). The treatment group comprised of patients who were given NAC in addition to supportive treatment (magnesium sulfate and vasopressors, if required), while in the control group, only supportive treatment was instituted. The primary endpoint of the study was the survival of the patients. Measurements and Results: The baseline catalase (P = 0.008) and SOD (P < 0.01) levels were higher among survivors than non-survivors. Of the total patients in the study, 31 (67.4%) expired and 15 (32.6%) survived. Among those who expired, the mean duration of survival was 2.92 ± 0.40 days in the test group and 1.82 ± 0.33 days in the control group (P = 0.043). Conclusions: This study suggests that the baseline level of catalase and SOD have reduced in ALP poisoning, but baseline GR level has not suppressed but is rather increasing with due time, and more so in the treatment group. NAC along with supportive treatment may have improved survival in ALP poisoning. [ABSTRACT FROM AUTHOR]

Here, authors present a review on clinical presentation and management of exposure of phosgene gas after reviewing the literature by searching with keywords phosgene exposure on Google, Cochrane, Embase and PubMed with a background of experience gained from 10 patients who were admitted to our institute after an accidental phosgene exposure in February 2011 nearby a city in India. Phosgene is a highly toxic gas, occupational workers may have accidental exposure. The gas can also be generated inadvertently during fire involving plastics and other chemicals and solvents containing chlorine, which is of concern to emergency responders. Phosgene inhalation may cause initially symptoms of respiratory tract irritation, patients feel fine thereafter, and then die of choking a day later because of build up of fluid in the lungs (delayed onset non-cardiogenic pulmonary edema). Phosgene exposure is associated with significant morbidity and mortality. Patients with a history of exposure should be admitted to the hospital for a minimum of 24 h for observation because of the potential for delayed onset respiratory failure and acute respiratory distress syndrome. [ABSTRACT FROM AUTHOR]

Background and Objective: Cancer of the cervix is a leading cause of morbidity and mortality among women worldwide. Therefore, to curb the disease, there is a need to develop a screening test that has good sensitivity and specificity. The present study is aimed to compare the effectiveness of the Pap smear, visual inspection with acetic acid (VIA) and visual inspection with Lugol's iodine (VILI) for mass screening of premalignant and malignant lesions of the cervix; to evaluate the usefulness of VIA and VILI as an adjunct to improve sensitivity of cervical cytology; and to evaluate the role of VILI as a parallel screening method with VIA to enhance its test performance. Design and Setting: This was a prospective, analytical study in which 210 patients of the reproductive age group attending the gynecology OPD were enrolled. Patients and Methods: Patients were first subjected to Pap smear followed by VIA, VILI, colposcopy and biopsy for confirmation of lesion, if needed. Data was obtained and statistically analyzed. Results: Of the 210 patients, 34 (16.27%) had positive Pap test, 29 (13.87%) had positive VIA and 24 (11.43%) had positive VILI and 31 (14.75%) showed features of cervical intraepithelial neoplasia (CIN) on colposcopy. Of the total of 48 patients in whom either of the screening tests was positive and had undergone cervical biopsy, one had CIN-3, three had CIN-2, 12 had CIN-1, three had carcinoma in situ CIS and 29 reported normal. In our study, 40 patients were picked up as positive by combination of these tests, of which 19 (47.50%) had CIN on biopsy. Conclusion: Our study showed that VIA and VILI had sensitivity comparable to Pap smear and can thus be a suitable potential alternative/adjunctive screening test not only in a resource-poor setting but in well-equipped centers also. And, use of a combination of tests (Pap+VIA+VILI) had 100% sensitivity but at cost of low specificity and more false-positive results. [ABSTRACT FROM AUTHOR]

The aim of this observational study was ultrasound evaluation of peripheral nerves cross-sectional area (CSA) in subjects with probable diabetic peripheral sensorimotor neuropathy (DPN). CSA was analyzed with reference to clinical and nerve conduction study's (NCS) parameters for early diagnosis and pattern of involvement. A total of 50 patients with probable DPN due to Type 2 diabetes and 50 age-matched healthy controls underwent sonographic examinations of ulnar nerve at the lower arm, median nerve proximal to carpal tunnel, the common peroneal nerve proximal to fibular head, tibial nerve proximal to the tarsal tunnel, and sural nerve at lower third leg. CSA was increased in cases of DPN as compared to healthy controls. Area changes were more marked with demyelinating pattern. Probable DPN cases with normal NCS had significantly higher number of peripheral nerves showing increased CSA as compared to healthy control. A cut-off of >4 nerve thickening showed a sensitivity of 86 %, and specificity of 56%. The neuropathy pattern in the lower limb was axonal, whereas in the upper limb, it was demyelinating with the majority showing sonographic feature of associated compressive neuropathy. There is an increase in CSA of peripheral nerve in diabetic patients. It can be used as a morphological marker for classifying DPN with changes being picked up earlier to NCS abnormality. Clinical neurological presentation in probable DPN can also be due to compressive neuropathy in early phases, and ultrasound can be a useful tool. Early pick up of DPN cases shall be useful for early therapy and motivating the patients to actively participate in the treatment. Morphological changes on ultrasonography precedes the electrodiagnostic change in DPN. Symptoms of DPN is not only due to metabolic changes but also compressive neuropathy. [ABSTRACT FROM AUTHOR]

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

Madelung deformity is a rare inherited disorder associated with endocrine disorders like Turner's syndrome, pseudohypoparathyroidism, but can be seen with short stature homeobox deficiency conditions such as Leri-Weill dyschondrosteosis (LWD) and Langers mesomelic dysplasia. It has also been reported following trauma to the distal radius epiphysis neoplasia mucopolysaccharidosis (MPS) and achondroplasia. Madelung deformity is an abnormality of distal radial epiphysis where in progressive ulnarand volartilt of the articular surface occurring in association with distal subluxation of ulna. A13-year-old girl was referred to us for evaluation of bilateral deformity of wrist and short stature. There was ulnar deviation and dorsal tilt of bilateral hands without history of pain to the joint trauma and family history of similar illness. On X-ray, wrist showed malformed distal radial epiphysis with dorsal and ulnar shift and with increased length of phalanges suggestive of Madelung deformity. X-ray spine was normal. Ultrasound abdomen showed normal uterus and ovary and her follicle stimulating hormone. Luteinizing hormone was normal and so was urine MPS screening. Based on the above points the diagnosis of LWD was made. [ABSTRACT FROM AUTHOR]

Aims and Objectives: (1). To assess the efficacy of intra-articular injection of high molecular weight sodium hyaluronate (SH) on functional outcome in frozen shoulder in diabetes mellitus (DM) type 2 patients, and (2). To compare it with the efficacy of corticosteroid (methylprednisolone). Materials and Methods: This prospective, double blind, RCT included 67 patients. They were randomized in two groups: Group-A (methyl-prednisolone) and Group-B (SH). Three-weekly intra-articular injections of respective drugs (preceded by intra-articular injection of xylocaine as local anesthetic) were given by posterior technique under ultrasound guidance. Sixty-one patients completed treatment and follow-up. Quick DASH score, total shoulder flexion, and total shoulder abduction (passive) were used for assessment of outcome. Follow-up period was 6 months. Result and Conclusion: Both SH and corticosteroid caused significant improvement in shoulder function beginning within 1 week and lasting for at least 6 months. No significant adverse effects were observed in SH group. Corticosteroid group had 10% incidence of moderate to severe pain in GH joint lasting 12-24 hours. Intra-articular corticosteroid has known adverse effects like worsened glycemic control, osteoporosis, tendon rupture, and decreased immunity at local site. Hence, we suggest that SH may be used as an alternative drug to popular steroid use for the patients of frozen shoulder in DM type 2. [ABSTRACT FROM AUTHOR]