Clinical assessment of obesity and insulin resistance in type 1 diabetes subjects seen at a center in Kolkata.

OBJECTIVES: Type 1 diabetes mellitus (T1DM) is characterized by a selective destruction of pancreatic beta cells. Recent data suggest a role of insulin resistance (IR) along with the deficient insulin reserve. METHODS: Fifty-eight consecutive patients of T1DM, with low C-peptide levels were included. Patients with an obvious secondary cause like steroid therapy, fibrocalculous pancreatic disease, chronic infections or comorbid illness were excluded. A clinical assessment for the presence of obesity was made based on anthropometric data. Clinical markers of IR and the insulin dose required to achieve a stable glycemic control calculated in terms of body weight were also studied. RESULTS: There were 30 males and 28 females with a mean age of 16.5 +/- 2.3 (5-39) years. The mean body mass index (BMI) was 19.21 +/- 3.7 and the waist circumference was 67 +/- 5.2 cms. Nineteen ( 32.75%) and six (10.34%) patients were overweight (BMI > 23) and obese (BMI > 27) respectively while 16 (27.58%) had abdominal obesity. The body fat percentage was high (> 25%) in 34 (58.62%), mean 28.33 +/- 11.4%. Acanthosis nigricans was found in 14 (24.13%) cases, hypertension in two (3.4%) but none of the girls had clinical polycystic ovarian syndrome (PCOS). The insulin dose required was 1.11 +/- 0.41 u/kg (0.3-2.9) at an glycated haemoglobin A1C (A1C) of 7.56 +/- 1.04% (4.9-9.3), it was more than 0.6 u/kg/day in 38 (65.51%) patients. CONCLUSIONS: The study concludes that IR is present in a large number of Indian T1DM patients along with a high body fat percentage.

Atypical coarctation with severe hypertension: a case report.

A young man of 16 years presented with sudden onset of right sided headache and vomiting for one day. No neurological or visual disturbances were noticed. On examination his BP was 240/120 mmHg. All upper extremity pulses were felt but from the femoral artery down to arteria dorsalis pedis these were absent. He was diagnosed as a case of coarctation of aorta following various biological and radiological investigations. After confirming the findings on aortography an aortoplasty was attempted with a long cordis balloon used to dilate the middle aortic lesion of 15 mm.

The thyroid nodule--evaluation and management.

Thyroid nodules are common; with the growing availability of sensitive TSH assays, fine needle aspiration biopsy (FNAB) and high resolution ultrasonography (HRUSG), thyroid nodules are being increasingly recognised, diagnosed and treated. The diagnosis of a thyroid nodule is associated with considerable anxiety for the patient; a systematic approach, by excluding the possibility of malignancy, helps allay such anxiety. Nodules are sometimes picked up on neck imaging for non-thyroid conditions; these so-called 'incidentalomas' also need evaluation to rule out malignancy. A sensitive TSH assay is usually the first investigation; a suppressed TSH level leading to a radionuclide scan and an FT4 level to detect toxic nodules that are best managed by radio-iodine or surgical ablation. Thyroid peroxidase antibody is estimated if the TSH level is high. Palpable nodules in euthyroid subjects are best evaluated by HRUSG followed by USG-guided FNA. For nodules <10 mm size, USG-guided FNA is recommended only if clinical or USG features are suspicious. While the benign nodules are kept under regular follow-up, all malignant nodules should be removed surgically. Cystic thyroid lesions are well managed by percutaneous ethanol ablation. Routine measurement of serum calcitonin and other sub cellular markers is not recommended.

Jaundice in falciparum malaria--some prospective observations.

The present prospective study of slide positive Plasmodium falciparum patients revealed a higher (17%) incidence of jaundice. This is much higher than reported earlier. Serum transaminases were raised by two to three times the normal value. Histologically the most conspicuous finding was reticulo-endothelial cell proliferation in the liver along with mononuclear cell infiltration. Malarial parasites were not found in the biopsy specimens. Mortality was high especially amongst the late presenters. In areas endemic for malaria, awareness of this entity is important. In a patient with fever and jaundice with or without altered sensorium, disproportionate hyperbilirubinaemia but with only mild elevation of liver enzymes could help differentiate these cases from viral hepatitis. The diagnosis can be confirmed by peripheral blood examination, done if required. As the mortality in late presenters is high, early diagnosis in such cases with institution of specific therapy may be life saving.