First measurement of neutrino oscillation parameters using neutrinos and antineutrinos by NOvA.

The NOvA experiment has seen a 4.4σ signal of ν[over ¯]_{e} appearance in a 2 GeV ν[over ¯]_{µ} beam at a distance of 810 km. Using 12.33×10^{20} protons on target delivered to the Fermilab NuMI neutrino beamline, the experiment recorded 27 ν[over ¯]_{µ}→ν[over ¯]_{e} candidates with a background of 10.3 and 102 ν[over ¯]_{µ}→ν[over ¯]_{µ} candidates. This new antineutrino data are combined with neutrino data to measure the parameters |Δm_{32}^{2}|=2.48_{-0.06}^{+0.11}×10^{-3} eV^{2}/c^{4} and sin^{2}θ_{23} in the ranges from (0.53-0.60) and (0.45-0.48) in the normal neutrino mass hierarchy. The data exclude most values near δ_{CP}=π/2 for the inverted mass hierarchy by more than 3σ and favor the normal neutrino mass hierarchy by 1.9σ and θ_{23} values in the upper octant by 1.6σ.

Constraints on Oscillation Parameters from ν_{e} Appearance and ν_{µ} Disappearance in NOvA.

Results are reported from an improved measurement of ν_{µ}→ν_{e} transitions by the NOvA experiment. Using an exposure equivalent to 6.05×10^{20} protons on target, 33 ν_{e} candidates are observed with a background of 8.2±0.8 (syst.). Combined with the latest NOvA ν_{µ} disappearance data and external constraints from reactor experiments on sin^{2}2θ_{13}, the hypothesis of inverted mass hierarchy with θ_{23} in the lower octant is disfavored at greater than 93% C.L. for all values of δ_{CP}.

Measurement of the Neutrino Mixing Angle θ_{23} in NOvA.

This Letter reports new results on muon neutrino disappearance from NOvA, using a 14 kton detector equivalent exposure of 6.05×10^{20} protons on target from the NuMI beam at the Fermi National Accelerator Laboratory. The measurement probes the muon-tau symmetry hypothesis that requires maximal θ_{23} mixing (θ_{23}=π/4). Assuming the normal mass hierarchy, we find Δm_{32}^{2}=(2.67±0.11)×10^{-3} eV^{2} and sin^{2}θ_{23} at the two statistically degenerate values 0.404_{-0.022}^{+0.030} and 0.624_{-0.030}^{+0.022}, both at the 68% confidence level. Our data disfavor the maximal mixing scenario with 2.6σ significance.

Operative versus Non operative treatment of displaced intraarticular fracture of calcaneum: a meta-analysis of randomized controlled trials.

Various studies comparing operative and non-operative intervention for displaced intrarticular calcaneal fractures have reported conflicting findings in the past. The objective of this meta-analysis was to compare the efficacy and safety of open reduction and internal fixation (ORIF) vis-a-vis conservative management. Relevant randomized controlled trials (RCTs) comparing operative and non-operative intervention for displaced intraarticular calcaneal fractures were assessed and included in this meta-analysis. Data was extracted independently and methodological quality was further assessed. The inclusion criteria of this meta-analysis were: randomized controlled trials comparing operative with non-operative intervention for displaced intra-articular fractures of calcaneum and reporting atleast one of the main outcomes as failure to resume pre-injury work, residual pain and other complications. Eight randomized controlled trials fulfilled the criteria for this meta-analysis. Pooled results showed that patients managed conservatively failed to resume pre-injury work (RR 0.60, 95% CI = 0.37-0.98, P = 0.04). However operative intervention was associated with more complications (RR 1.74, 95% CI = 1.28 to 2.37, P = 0.0005). There was no statistically significant difference in residual pain (RR 0.73 95% CI = 0.40-1.36, P = 0.33) and reoperation (RR = 0.75, 95% CI = 0.48-1.16, P = 0.20) between the two groups. Surgery can benefit patients with calcaneal fracture and increases their likelihood to resume pre-injury work. However, the complication rates are significantly higher in the operative group. Since the included trials have used different scores to measure patient outcomes, hence little effective data could.

First Measurement of Electron Neutrino Appearance in NOvA.

We report results from the first search for ν_{µ}→ν_{e} transitions by the NOvA experiment. In an exposure equivalent to 2.74×10^{20} protons on target in the upgraded NuMI beam at Fermilab, we observe 6 events in the Far Detector, compared to a background expectation of 0.99±0.11(syst) events based on the Near Detector measurement. A secondary analysis observes 11 events with a background of 1.07±0.14(syst). The 3.3σ excess of events observed in the primary analysis disfavors 0.1π<δ_{CP}<0.5π in the inverted mass hierarchy at the 90% C.L.

Status of Low Birth Weight Babies in Mymensingh Medical College Hospital.

Low birth weight (LBW) is the major neonatal health problem in Bangladesh like other developing countries with limited resource. But only a few studies had done about status of LBW at hospital setting in this country. The objective of the study that to evaluate the status and immediate outcome of the LBW This cross sectional retrospective study was done in neonatal ward of Mymensingh medical college hospital. In this 1000 bedded tertiary care level teaching hospital only 40 cots and 10 open incubators are sanctioned but daily average admission in neonatal ward more than 30. On an average about 100 patients are remaining in the ward. Three or four patients are nursed in each cot. It covers the vast catchment's area of Bangladesh having more than two cores of population. With limited resources and manpower, this neonatal ward has to bear the burden of 100 neonates and daily admission of 30 neonates. Study period was one year (October 2013 to September 2014). Total admitted neonates were 8359. All admitted neonates were considered as study population and all LBW babies were considered as sample. Among total population 41% (3423) were LBW. Among total LBW babies maximum (80.7%) had birth weight 1500-2499gm followed by Very Low birth weight (VLBW) 1000 - 1499gm 14.7%, Extreme Low birth weight (ELBW) 1000-750gm 1.6% and Incredible low birth weight <750gm 1.7%. Term LBW (IUGR) babies were 52% and preterm LBW were 48%. Death rate among LBW babies group were higher (18.5%) than death rate (15.8%) among all admitted neonate. By comparison of mortality rate among different subgroup of LBW shows highest mortality (65.5%) was in incredible low birth weight babies group followed by ELBW group (58.8%) and among VLBW group 26.4% and lowest mortality (15.3%) was among birth weight 1500-2499gm group babies. Death rate was inversely related to birth weight. Death rate among preterm LBW babies (21.5%) was higher than Term LBW (IUGR) babies (15.7%). So, death rate was also inversely related to the maturity. Death rate among LBW babies is still higher in our institute than other developed institute of home and abroad. Death rate specially higher among incredible birth weight group and ELBW group in our institute. Further improvement in neonatal care is needed to decrease the mortality among LBW babies.

Serum Zinc, Copper, Magnesium & Phosphorus Level in Children with Severe Acute Malnutrition (SAM).

Malnutrition is widely prevalent among hospitalized children in most developing countries including Bangladesh. Though malnutrition accounts for the high rate of under 5 mortality sometimes it is overlooked. Keeping in this in mind A comparative cross sectional study was done in Mymensingh Medical College Hospital from 1st October 2009 to 31st May 2011. Children aged 1-5 years with presence of one or more criteria WHM <70%, WHZ-score <-3SD, Bipedal edema & Mid upper arm circumference <110mm were taken as study group and children aged 1-5 years with normal growth allowable normal range of variation is between 3rd and 97th centile curve or median (50th centile) ±2SD of weight for age growth chart (CDC growth chart, USA, 2000) were taken as reference group. Persistent diarrhea, Patients taking medications containing zinc, copper, magnesium, phosphorus & calcium, PEM with shock were excluded from study group. Nutritional assessment was done according to WHO criteria of SAM. Serum Zinc, Copper Magnesium and Phosphorus level were determined by Atomic Absorption Spectrometry using UNICAM - AA Spectrometer, model no. 969, Spain. Total 120 study populations were taken. Ninety Out of 120 were taken as a study group (SAM) & 30 were reference group. In reference group serum Zn, Cu, Mg, P value was 103.80±8.86µg/dl, 135.92±13.57µg/dl, 2.31±0.18mg/dl, 3.96±0.22mg/dl respectively. In study group serum Zn, Cu, Mg, P value was 60.33±11.08µg/dl, 80.60±15.46µg/dl, 1.47±0.22mg/dl, 2.00±0.52mg/dl respectively. All these results show that there is significant difference between study group & reference group. Considering the decreased level of these parameters, close biochemical monitoring and follow up should be emphasized for the children with SAM.

Correlation between grades of intraventricular hemorrhage and severity of hypoxic ischemic encephalopathy in perinatal asphyxia.

This study was done to find out the correlation between various grades of Intraventricular Hemorrhage (IVH) and stages of HIE in perinatal asphyxia and to determine the short-term outcome of the affected baby. This observational study was conducted in Neonatal ward of Dhaka Shishu Hospital (DHS) and Dhaka Medical College Hospital for period of 37 months from January 2004 to January 2007. Total 189 perinatally asphyxiated babies were enrolled for HIE staging and cranial Ultrasonogram (USG) to find out grades of IVH. Finally 178 newborns were fulfilling all the necessary criteria for statistical analysis of the collected data on prescribed questionnaire. Among 178 perinatally asphyxiated newborns HIE stages - I, II, III were 50(28%), 10(56%) and 28(16%) respectively. Out of this 178 neonates total 50(28%) developed various grades IVH. Grades of IVH, I, II, III, IV were 15(30%), 18(36%), 10(20%) and 7(14%) respectively. There was significant correlation between the severity of HIE staging and grades of IVH. Short term outcome was poor in HIE-III, IVH grade III and IV. There is a direct relationship between different grades of IVH and stages of HIE. That is more the severe stages of HIE there is more chances to develop severe grades of IVH, Immediate morbidity and mortality is dependent on the grades of IVH and severity of stages of HIE.

Effects of nebulized budesonide as an adjunct to standard treatment of asthma exacerbations: a randomized, double-blind, placebo-controlled trial.

This study was done to determine the effects and outcome of inhaled budesonide in addition to standard management of asthma exacerbations in pediatric age groups. A randomized, double-blind, placebo controlled trial was done in a tertiary care urban hospital. Sixty six children aged 5 to 15 years with moderate to severe asthma exacerbations were eligible. All patients received a single dose of prednisolone 1mg/kg orally as first dose of systemic corticosteroids and then salbutamol (0.15mg/kg) and ipratropium bromide (500mcg) was nebulized every 20 minutes for 3 doses and then hourly for 2 hours as a part of standard treatment of asthma exacerbations. The intervention was 2mg (4mL) of budesonide or 4mL of normal saline which was nebulized immediately after the 1st dose of nebulized salbutamol and ipratropium bromide. The baseline characteristics of the budesonide group (n=33) and placebo group (n=33) were similar, but at 1 hour, 2 hour and 3 hour PEFR, respiratory rate, pulse rate, SaO2 and asthma score were significantly improved in the budesonide group compared to placebo group (p<0.01). The positive immediate effect of nebulized budesonide added to standard treatment of asthma exacerbations is an encouraging finding for further investigations of its routine use in the treatment of asthma exacerbations in children.

Current Trends of Using Antimicrobials in Acute Watery Diarrhoea in Children Below 5 Years of Age at Paediatrics Outpatient Department of a Tertiary Care Hospital in Bangladesh.

Childhood diarrhoea is a major public health problem in developing countries like Bangladesh which is commonly caused by intestinal infection, mainly viral. Diarrhoea is causing second leading mortality in children below 5 years, where about 2 billion cases occur globally in each year. This study was proposed to evaluate the antimicrobials utilization pattern prescribed for AWD in children below 5 years of age, in a tertiary care hospital in Bangladesh. This record based, cross-sectional, descriptive type of observational study carried out at pharmacology department of Mymensingh Medical College. A total of 205 diarrhoeal patient's up to 5 years of age, attending the paediatric OPD from January 2021 to December 2021, were enrolled in the study. Out of 205 patients 182(88.8%) were prescribed antimicrobials. Azithromycin was the most frequently prescribed antimicrobial (60.0%) and among the antiprotozoals metronidazole was the prescribed most (24.9%). ORS and Zinc were prescribed in all patients (100%). Empirical excessive use of antibiotics was observed in this study. Emphasis on educational and training programs may help in a better and judicious use of drugs in children.

Nutritional status among primary school children of Mymensingh.

The school age is a dynamic period of growth and development. During this period physical, mental, social development of child takes place. The purpose of the study is to observe the nutritional status among the school aged children and to compare the urban and rural children. It is a descriptive cross sectional study. Data were collected from 600 children of primary school in Mymensingh district for a period of one year from October 2009 to September 2010. Among the primary school children in Mymensingh, Bangladesh 15.1% were wasted, 22.1% were stunted, 2.3% were both stunted and wasted and 60.4% children were within normal limit. Malnutrition was more in rural area in comparison with urban area. In rural area severely underweight, moderately underweight children were 62.1%, 65.6%, and corresponding result in urban area were 37.9%, 34.4% respectively. In rural area severely stunted, moderately stunted children were 100%, 58.6%, and in urban area they were 0%, 41.4% respectively. Again severely wasted and moderately wasted, children were 62.5%, 59.5% in rural area and 37.5%, 40.5% in urban area respectively. Malnutrition among girls were more then the boys.

Serum Electrolyte, Serum Calcium and Blood Sugar Status in Severe Acute Malnutrition and Their Relationship with Edema, Vomiting and Diarrhea.

Severe acute malnutrition (SAM) is the most severe form of protein energy malnutrition (PEM). Few studies found serum electrolyte, serum calcium level changes as important factors of poor outcome. Hypoglycemia is already established as a risk factor for death in severe acute malnutrition. Edema, diarrhea and vomiting are commonly present in severe acute malnutrition which has impact on electrolyte balance and blood sugar level in healthy children. Their impact in severe acute malnutrition is not clearly established. This cross sectional descriptive study was conducted in Department of Pediatrics, MMCH from March 2018 to October 2019 to estimate serum electrolyte, serum calcium and random blood sugar level in severe acute malnutrition and their relationship with edema, vomiting and diarrhea. Forty-one (41) cases of SAM were enrolled in this study. Test samples were collected before starting the treatment. Case record form was used to collect information. Cases were divided into Group A and Group B based on the presence or absence of vomiting or diarrhea, respectively. Again, all cases were divided into Group C and Group D based on presence or absence of edema, respectively. Data were analyzed using IBM SPSS statistics version 23. Mean age was 9.71±10.4 months with 85.36% having age less than 1 year. Twenty-four (58.5%) were male and 17(41.5%) were female. Parents had low level of education with 48.8% mother and 51.2% father having primary education or no education. Higher number of serum electrolyte, serum calcium and blood sugar were found with hyperglycemia present in 29.3%, hypocalcemia in 22%, hypokalemia in 22% and hyponatremia in 19.5% cases. Hypokalemia was present more in SAM with vomiting or diarrhea (p=0.008). Other disturbances do not vary on presence or absence of edema and vomiting or diarrhea. Result of the present study shows hypokalemia is associated with SAM with vomiting/diarrhea. Hypocalcemia, hyperglycemia, hyponatremia and hypernatremia were also present in high number. These changes should be detected early and treated accordingly.

Electrosurgical smoke: a real concern.

Electrosurgical techniques including laser surgery have expanded greatly in recent years. Pyrolysis of tissue produces smoke. Recently the smoke is being analyzed using Gas Chromatography-Mass Spectrometry. The nature of smoke depends on the rise of temperature of tissue during electro-surgery. The smoke produced at high temperatures contains low concentration of Group-I carcinogens (IARC) such as Benzene, Hydrogen cyanide, Formaldehyde 1,3-Butadiene and Acrylonitrile. Bioaerosol produced at low temperature as in harmonic scissors may contain live multidrug resistant Mycobacterium tuberculosis, viral DNA of HBV, HCV, HIV and HPV. It also contains live malignant cells and dead cellular materials. These produce an unquantified infection risk. The obnoxious smoke causes ocular and upper respiratory tract irritation, creates visual problems for surgeons. Surgical masks are not capable of filtering the produced bioaerosol. Removal of smoke from the site of operation by local exhaust ventilation is not complete. When produced in a closed cavity as in laparoscopic surgery the patient also suffers from carboxyhaemoglobinaemia and methaemoglobinaemia. Methemoglobinaemia is not detected by standard pulse-oximetry. Laser smoke produces congestive interstitial pneumonia, bronchiolitis and emphysema in rats. Chromosomal aberration and sister chromatid exchange have been found in lymphocyte culture of operating room personnel. Occupational safety and health authorities like Occupational Safety and Health Administration (OSHA), National Institute for Occupational safety and Health (NIOSH), American National Standard Institute (ANSI) and Association of Operating room nurses (AORN) are trying to find effective ways for removal of smoke from site of operation and also the real risk to operating room personnel. Answer lies in minimizing the use of electrocautery whenever possible and completes removal of harmful smoke.

Clinical Profile and Immediate Outcome of Children Admitted With Acute Glomerulonephritis in Pediatrics Department of A Tertiary Level Hospital.

Acute post-streptococcal glomerulonephritis (APSGN) is the commonest cause of acute glomerulonephritis (AGN), which usually present with gross hematuria, mild edema, oliguria, hypertension and varying degree of renal insufficiency. It is more common among the population of school going age where poverty, overcrowding and poor hygienic conditions are prevailing. This cross sectional observational study was aimed to know the socio-demographic variables, clinical profile and immediate outcome of AGN in hospitalized children and was conducted in the Pediatric department of Mymensingh Medical College Hospital (MMCH), Mymensingh, Bangladesh from November 2014 to April 2015. A detailed history was taken from the parents in each case with a written questionnaire. A written consent was also taken from the guardian of the including patients and also permission was taken from the ethical committee of MMCH. Thorough clinical examination and available relevant investigations were done in all patients. Progresses of the patient were monitored by daily clinical examinations and also by investigations. Data were analyzed by statistical package for social science (SPSS) windows version 18. Results were verified by doing standard test for significance. Among total 60 cases male was 58.3% & female was 41.7%. The common age group of presentation was between 7-12 years (73%), peak age of incidence was 7-9 years. Most of them came from low socioeconomic status (83.3%), 63.3% from rural area with average 5-6 member's family size. Most of the parents were illiterate. History of (H/O) skin infection was present in 35(58.3%) patients, 15(25%) had H/O sore throat, 15% did not give any H/O infection before presentation. Average duration of gap between infection and appearance of clinical feature was 7-14 days in 73.40%and 15-21 days was in 45.7% in case of sore throat & skin infection respectively. Almost all (95%) patients presented with puffiness of face, others presented with scanty micturition, gross hematuria, respiratory distress, fever, convulsion and altered sensorium. Edema (75%), hypertension (88.3%), pallor (38%), tachypnea (25%), tachycardia (26.7%) were the important clinical findings. Microscopic hematuria was present among 96.66% patients; low complement level was found in 85% cases. There is significant association between low socioeconomic statuses with more hospital stay. Only one patient died due to heart failure and 98.3% patient had complete recovery. Results of this study conclude that most of the patients came from rural illiterate family with low socioeconomic background. Skin infection is the commonest cause of acute glomerulonephritis. Edema, scanty micturation, hematuria and hypertension are the common mode of presentation. Heart failure and hypertensive encephalopathy are the common complication of AGN. Immediate prognosis of AGN was excellent.

An alternative instrument for making entry point for elastic intramedullary nail.

Femoral shaft fractures are common in children and are increasingly being treated with elastic intramedullary nail. We outline an instrument we have used successfully to make an entry point for placement of elastic nail.

Sequence analysis of the 5'-untranslated region of the human H1 histamine receptor-encoding gene.

A clone containing the H1 histamine receptor (H1HR)-encoding gene was isolated from a human genomic DNA library. The 5'-UTR of the H1HR gene reported here differs upstream from bp -142 from that reported previously [Fukui et al., Biochem. Biophys. Res. Comm. 201 (1994) 894-901]. PCR amplification utilizing primer pairs derived from the 5'-UTR reported herein amplified a DNA fragment of the expected size from human genomic DNA whereas 5'-UTR primers derived from the Fukui et al. sequence did not yield a PCR product. The 5'-UTR of H1HR contains potential TATA and CCAAT boxes, a CACCC sequence, potential GREs and other DNA-binding motifs.

Total and visceral adipose-tissue volumes derived from measurements with computed tomography in adult men and women: predictive equations.

Total and visceral adipose-tissue (AT) volumes were determined by computed tomography (CT) by a multiscan technique in 17 men and 10 women with a wide range of body weights. In these primary materials, weight, height, and various diameters, circumferences, and subcutaneous AT thicknesses of the trunk were examined for their relationships to CT-determined total and visceral AT volumes. Predictive AT equations from the primary materials were then tested on two cross-validation groups consisting of another 7 men and 9 women. For the prediction of the total AT volume, weight/height was the superior single predictor, with errors less than 11% in primary and cross-validation materials. For the prediction of visceral AT volume, simple equations based entirely on the sagittal diameter of the trunk at the L3-L5 level resulted in errors less than 21% in both sexes.

Effect of zinc administration on cadmium-induced suppression of natural killer cell activity in mice.

Natural killer (NK) cells play an important role in immune surveillance against viral infections and neoplasms. The effect of cadmium with or without zinc on mouse spleen NK cell activity was studied. Six-week-old male C57BL/6 mice were given drinking water containing either 50 ppm cadmium, 50 ppm cadmium together with 500 ppm zinc, or 500 ppm zinc. A fourth group receiving no additional cadmium or zinc served as control. After 3 weeks of treatment, the mice were killed, splenic lymphocytes isolated and cultured with 51Cr-labelled YAC-1 target cells for 4 and 12 h in a ratio of 50:1. The percentage of target cell lysis was measured to assess NK cell activity. In the 12-h assay, cadmium-treated animals had significantly lower NK cell activity than controls. Concurrent zinc administration prevented the suppression. In the 4-h assay, a similar trend was observed. Between 4 and 12 h, NK cell activity increased significantly in control and zinc-treated groups, but not in those receiving cadmium. The results suggest that a relatively low dose of cadmium suppresses NK cell activity, which can be prevented by a moderately large dose of zinc.

Computed tomography-determined body composition in relation to cardiovascular risk factors in Indian and matched Swedish males.

Relationships between cardiovascular risk factors, body composition, and tissue distributions were examined in 10 Indian and 10 Swedish males matched by age, height, and weight. The body was divided into 29 compartments by means of a multiscan computed tomography (CT) technique. Fasting glucose, insulin, and triglycerides (TG) were higher in Indians than in Swedes. During the oral glucose tolerance test (OGTT), the glucose area was similar in both groups, whereas the insulin area was 80% larger in Indians. Adipose tissue (AT) and skin volumes were larger and remaining lean tissues were smaller in Indians. Indians had proportionally less muscle and more skeleton in the legs, but no ethnic difference could be demonstrated with respect to AT distribution. The visceral AT to total AT volume ratio was positively related to insulin and TG, and with higher risk factors for Indians at any given ratio. TG and glucose were negatively related to the leg muscle to total muscle volume ratio, and this ratio was smaller in Indians. It is concluded that the metabolic disturbances of Indians are not necessarily dependent on a preponderance of visceral AT, and also that an upper-body muscle distribution-recognized as a new phenotypic companion to the metabolic syndrome-is statistically related to cardiovascular risk factors.

The morphology and metabolism of intraabdominal adipose tissue in men.

Mass, morphology, and metabolism of total adipose tissue and its subcutaneous, visceral, and retroperitoneal subcompartments were examined in 16 men with a wide variation of total body fat. Computerized tomography (CT) scans showed that the intraabdominal fat mass comprised approximately 20% of total fat mass. Visceral and retroperitoneal fat masses were approximately 80% and 20% of total intraabdominal fat mass, respectively. Enlargement of intraabdominal fat depots was due to a parallel adipocyte enlargement only. Direct significant correlations were found between these adipose tissue masses and blood glucose and plasma insulin levels, blood pressure, and liver function tests, while glucose disposal rate during euglycemic glucose clamp measurements at submaximal insulin concentrations (GDR), plasma testosterone, and sex hormone-binding globulin concentrations correlated negatively. The correlations for glucose, insulin, and GDR were strongest with visceral fat mass. Adipose tissue lipid uptake, measured after oral administration of labeled oleic acid in triglyceride, was approximately 50% higher in omental than in subcutaneous adipose tissues. Adipocytes from omental fat also showed a higher lipolytic sensitivity and responsiveness to catecholamines. Furthermore, these adipocytes were less sensitive to the antilipolytic effects of insulin. Both lipid uptake and lipolytic sensitivity and responsiveness showed strong correlations (r = 0.8 to 0.9) to blood glucose and plasma insulin concentrations and also to the GDR (negative), while no such correlations were found with lipid uptake in subcutaneous or retroperitoneal abdominal adipose tissues. Taken together, these results suggest a higher turnover of lipids in visceral than in the other fat depots, which is closely correlated to systemic insulin resistance and glucose metabolism in men.