Depression is not associated with peripheral insulin resistance in patients with chronic hepatitis C infection.

Depression is common in individuals infected with hepatitis C virus (HCV), and both depression and HCV infection are independently associated with insulin resistance (IR). To evaluate the relationship between depression and IR, among other factors, in an HCV-infected cohort. In this cross-sectional analysis, seventy-four non-type 2 diabetic, noncirrhotic, HCV-infected patients underwent comprehensive clinical, histologic and metabolic evaluation. IR was assessed directly with an insulin suppression test by measuring steady-state plasma glucose (SSPG) levels during continuous infusions of octreotide, glucose and insulin. Logistic regression modelling was used to evaluate predictors associated with depression. Thirty-nine (53%) patients were depressed, and 21 (54%) depressed patients were on at least one antidepressant. A higher estimated proportion of depressed patients were Caucasian (51% vs 20%, P = 0.005), unemployed (69% vs 49%, P = 0.07), heavier smokers (18 pack-years vs 13 pack-years, P = 0.07), on substance abuse therapy (16% vs 3%, P = 0.06) and had lower HDL levels (1.2 mmol/L vs 1.4 mmol/L, P = 0.01). The mean SSPG levels in depressed and nondepressed patients were 7.3 and 8.3 mmol/L (P = 0.45), respectively. In multipredictor adjusted analysis, only Caucasian race (OR 4.19, 95% CI 1.42-12.35, P = 0.009) and lower HDL (OR 0.95, 95% CI 0.89-0.99, P = 0.046) were associated with depression. In conclusion, although prevalent, depression was not associated with peripheral IR in this HCV-infected cohort. Attention to other modifiable factors associated with depression in the HCV-infected population is warranted.

The clinician, the lab and the patient: Understanding lab diagnostics to eradicate tuberculosis.

BACKGROUND: Diagnostic modalities for diagnosing Tuberculosis caused by Mycobacterium group of organisms include mainly AFB smear by Ziehl Neelsen carbol fuchsin smear microscopy, GeneXpert (CB NAAT) molecular method, Line probe assay (Molecular method) and AFB culture (Liquid automated systems and solid media) methods. METHODS: This study was initiated to understand and prioritize TB lab diagnosis, with reference to selection of lab diagnostic tests and its order of preference for MTC and NTM/MOTT closely associating it with the TB irradication program initiated by the Government of India. RESULT AND CONCLUSION: The results and discussion bring to light the importance of each test and the purpose of their requisition. When diagnosis is handled half heartedly eradication of TB becomes a challenge. All the efforts including planning, resources in the form of manpower, infrastructure, finances, education, time etc., would be hampered. This challenge is not only for India but the globe. For countries harboring TB, Correct diagnostic request and timely diagnosis and treatment is the key to eradication of tuberculosis.

Systematic review with meta-analysis: mucosal healing is associated with improved long-term outcomes in Crohn's disease.

BACKGROUND: Clinical manifestations of Crohn's disease (CD) do not reliably correlate with endoscopic activity. While treating to achieve clinical remission (CR) has neither proven to improve CD outcomes nor alter the natural disease course, it is unclear whether targeting objective measures like mucosal healing (MH) is associated with improved long-term outcomes. AIM: To perform a systematic review and meta-analysis comparing long-term outcomes in active CD patients who achieve MH compared to those who do not. METHODS: We performed a systematic literature search to identify studies with prospective cohorts of active CD patients that included outcomes of patients who achieved MH at first endoscopic assessment (MH1) compared to those who did not. The primary outcome was long-term (≥50 weeks) CR. Secondary outcomes included CD-related surgery-free rate, hospitalisation-free rate and long-term MH rate. Pooled odds ratio (OR) and 95% confidence intervals (CI) were calculated. RESULTS: Twelve studies with 673 patients met inclusion criteria. Patients achieving MH1 had a pooled OR of 2.80 (95%CI, 1.91-4.10) for achieving long-term CR, 2.22 (95%CI, 0.86-5.69) for CD-related surgery-free rate, and 14.30 (95%CI, 5.57-36.74) for long-term MH. Sensitivity analyses suggested no difference in outcomes if MH1 was achieved on biologics vs. non-biologics. No significant publication bias or heterogeneity was detected. CONCLUSIONS: Achieving MH1 is associated with increased rates of long-term clinical remission, and maintenance of mucosal healing in active Crohn's disease and may therefore be a reasonable therapeutic target.

Hemoglobin South Florida. New variant with normal electrophoretic pattern mistaken for glycosylated hemoglobin.

An 8.75-yr-old Caucasian boy was discovered to have a markedly elevated (14.8%) hemoglobin A1c (HbA1c) as estimated by ion-exchange chromatography (Bio Rex 70). Glycohemoglobin (GHb) measured by a colorimetric method with thiobarbituric acid (TBA) was normal (equivalent to a 6.4% HbA1c). Nondiabetic quantities of GHb were found with affinity chromatography, and the glucose tolerance test was normal. Intensive efforts to identify an abnormal variant hemoglobin by several electrophoretic methods were unsuccessful. A family survey identified a similar abnormality in 11 other individuals, revealing an autosomal-dominant pattern. None of the affected individuals had any other hematologic abnormality. Structural analysis in one family member revealed a new hemoglobin variant (approximately 45% of the total hemoglobin) with the substitution of methionine for valine at the beta-NH2-terminal. In addition, the initiator methionine residue was preserved. Approximately 20% of the variant hemoglobin was modified by acetylation of the NH2-terminal methionine. The modified variant coeluted with HbA1c. We suggest that patients who do not have an explanation for their elevated HbA1c should have GHb measured by the TBA method or affinity chromatography because hemoglobin electrophoresis does not identify this confounding artifact.

Comparison of insulin levels after injection by jet stream and disposable insulin syringe.

Intermediate-acting biosynthetic human (NPH) insulin was administered by disposable insulin syringe into the right upper thigh of nine insulin-dependent diabetic youths. Seven days later, the same amount and type of NPH insulin was given in the same anatomic site with a Medi-Jector II, which delivers insulin as a jet stream. Blood was collected before insulin injection and at hourly intervals subsequently for the measurement of glucose and insulin. The total serum insulin measured before the first morning dose with the needle and syringe and the Medi-Jector II was 41.2 +/- 10.7 microU/ml and 46.2 +/- 10.7 microU/ml, respectively. During the next 9 h, the areas under the respective total insulin curves were not different, but the area under the free-insulin curve after jet injection was greater than the free-insulin area after needle injection (P less than .01). The ratio of free/total serum insulin was 0.31 +/- 0.02 after needle injection and 0.40 +/- 0.03 after jet injection (P less than .0025). The peak of total insulin concentration occurred 4.2 h after jet injection of NPH: 1 h earlier than the peak after needle injection. The plasma glucose at time zero was 197 +/- 15 mg/dl before needle injection and 242 +/- 19 mg/dl before jet injection. Although the diet consumed by each subject on the 2nd study day was identical to that of the 1st day, the mean glucose increase was greater after needle-injected insulin than after jet-spray injection. This indicates that the greater amount of free insulin observed after jet-injected insulin had a direct effect in lowering the plasma glucose. Jet injection may reduce insulin requirements by increasing the availability of free insulin.

Insulin resistance and hyperinsulinemia induce hyperandrogenism in a young type B insulin-resistant female.

An adolescent female with type B insulin resistance and hyperandrogenemia is described. Evidence presented suggests that hyperinsulinemia leads to an increase in serum total and free testosterone. Support for this hypothesis is noted during an in vivo experiment in which large doses of regular insulin (305 U/kg-day) were infused iv, and multiple serum total testosterone measurements obtained. After 35 days of iv insulin therapy, the serum total testosterone values rose from 4.9 nmol/L (142 ng/dL) to 22.8 nmol/L (660 ng/dL), and the ovarian volume increased 2-fold. Basal (9.8 nmol/L; 282 ng/dL) and stimulated (16.8 nmol/L; 481 ng/dL) androstenedione measurements were elevated, and the dehydroepiandrosterone/androstenedione ratio was low, suggesting increased 3 beta-hydroxysteroid dehydrogenase activity. After resolution of the insulin-resistant state and the concomitant hyperinsulinemia, the serum total testosterone values returned to normal. This case illustrates that long term hyperinsulinemia leads to elevation of serum total testosterone.

Hematuria and hypercalciuria in children with diabetes mellitus.

Hematuria of unknown origin occurs in 30% of patients with diabetic nephropathy. In nondiabetic persons, hematuria may be caused by hypercalciuria with or without nephrolithiasis. Eight children with type I diabetes mellitus, hematuria, and hypercalciuria were observed in our clinic during a 1-year period. Two of these also had evidence of renal papillary necrosis. To assess the importance of hypercalciuria in the pathogenesis of hematuria in children with diabetes mellitus, we measured urinary calcium excretion in a large population of such patients. The calcium to creatinine ratio in the urine of diabetic children (0.21 +/- 0.01) was greater than that of nondiabetic children (0.12 +/- 0.01). A calcium to creatinine ratio of 0.28 was established as the upper limit of normal in our nondiabetic population, and 27% of the diabetic children were hypercalciuric on this basis. The diabetic children with hypercalciuria also had hyperphosphaturia and a urinary CaHPO4 X 2H2O molar ion product three times that found in the nondiabetic control population. These data suggest that many children with diabetes are at risk for renal damage due to hypercalciuria. Because hypercalciuria is more common in diabetic than nondiabetic children, it may play a previously unrecognized role in the renal disease associated with diabetes mellitus.

Hypercalciuria, hyperphosphaturia, and growth retardation in children with diabetes mellitus.

The role of hypercalciuria and hyperphosphaturia in the growth retardation of children with diabetes mellitus was investigated in 157 children with diabetes whose mean height was less than that of 37 nondiabetic siblings of similar age (P less than .025). Hyperglycemia, hypercalciuria, and hyperphosphaturia were assessed coincident with the height measurement of each child in a cross-sectional survey. The distribution of height percentiles of the children with diabetes was skewed to the left with 61% at or below the 50th percentile. Eleven percent of the insulin-dependent children with diabetes mellitus were shorter than would be anticipated by a normal distribution of the 157 children. The duration of diabetes (hyperglycemia) had the greatest influence upon the children's height. Children with diabetes were shorter than the nondiabetic subjects by the fourth year of hyperglycemia, and this difference in height became statistically significant after 7 years or more of diabetes. The degree of hypercalciuria and hyperphosphaturia was more closely associated with reduced height in children with diabetes than was the degree of hyperglycemia, although the renal wastage of calcium and phosphorus seemed to be the result of glucosuria. Because hypercalciuria and hyperphosphaturia impair growth in nondiabetic children, they may also play an important role in the poor growth of children with diabetes mellitus.

Evaluation of endoscopic variceal sclerotherapy in various grades of liver disease.

Forty four patients with portal hypertension of varying etiology, including 25 patients with an acute episode of variceal bleeding and 19 with past history of hematemesis, were followed up for eighteen months following endoscopic variceal sclerotherapy (EVS). Of 11 patients in Child's A group, two died of acute bleed, three were subjected to shunt surgery and the remaining six survived the follow-up period. Ten of 11 cases in Child's C did not survive more than six months in spite of sclerotherapy. We conclude that rebleed and death due to rebleed following EVS occur more commonly in patients with poor hepatic reserve (Child's C) as compared to patients in Child's A and B.

Bilateral phrenic nerve injury after neck dissection: an uncommon cause of respiratory failure.

The case of a patient with carcinoma larynx who developed diaphragmatic paralysis and post-operative respiratory failure due to bilateral phrenic nerve injury is reported. The use of portable ultrasonography for an early diagnosis of diaphragmatic paralysis is discussed.

Preliminary experience with use of a selective 5HT3 receptor antagonist (ondansetron) to prevent high dose chemotherapy induced emesis.

Ondansetron was used as an antiemetic along with dexamethasone during 16 cycles of highly or moderately ematogenic chemotherapy. There was major control in two cycles and complete control in the remaining 14. Side effects were minor and did not require discontinuation of the drug. This combination, therefore, appears to be safe and effective in preventing chemotherapy induced emesis.

Clinical characteristics of children with febrile seizure.

BACKGROUND: Febrile seizure is common in children below five years of age. This study was conducted to evaluate the clinical profile of children presenting with febrile seizure in a teaching hospital. METHODS: This was a descriptive retrospective study among children presenting with febrile seizure in a teaching hospital from July 2009 to June 2013. Children between six months to six years were included in the study while patients with prior episodes of afebrile seizures, abnormal neurodevelopment and not meeting the age criteria were excluded. Patient's demographic and clinical data were collected from the in-patients records and analyzed. RESULTS: This study included 103 children with febrile seizure. Out of which 67% were male. Simple febrile seizure and complex febrile seizure were observed in 76.7% and 23.3% of patients respectively. Majority of children (71.8%)had generalized tonic clonic seizure followed by tonic seizures. Most of children (72.8%) who developed first episode of seizure were below 24 months of age with the mean age of 20.7 (±12.1) months. Overall 33% of patients developed recurrence of febrile seizure and first episode of febrile seizure at age one year or below was associated with the seizure recurrence. Upper respiratory tract infections were the commonest cause of fever in these children. CONCLUSIONS: Febrile seizure was observed predominantly in children below age of two years and simple febrile seizure was the ommonest variety. Recurrence of febrile seizure was common and significantly associated with the first episode of febrile seizure at the age of one year or below.

Meta-analysis: antibiotic therapy for small intestinal bacterial overgrowth.

BACKGROUND: Small intestinal bacterial overgrowth (SIBO) is an under-recognised diagnosis with important clinical implications when untreated. However, the optimal treatment regimen remains unclear. AIM: To perform a systematic review and meta-analysis comparing the clinical effectiveness of antibiotic therapies in the treatment of symptomatic patients with documented SIBO. METHODS: Four databases were searched to identify clinical trials comparing effectiveness of: (i) different antibiotics, (ii) different doses of the same antibiotic and (iii) antibiotics compared with placebo. Data were independently extracted according to predetermined inclusion and exclusion criteria. Study quality was independently assessed. The primary outcome was normalisation of post-treatment breath testing. The secondary outcome was post-treatment clinical response. RESULTS: Of 1356 articles identified, 10 met inclusion criteria. Rifaximin was the most commonly studied antibiotic (eight studies) with overall breath test normalisation rate of 49.5% (95% confidence interval, CI 44.0-55.1) (44.0%-55.1%) then (46.7%-55.5%), then (4.6%-17.8%). Antibiotic efficacy varied by antibiotic regimen and dose. Antibiotics were more effective than placebo, with a combined breath test normalisation rate of 51.1% (95% CI 46.7-55.5) for antibiotics compared with 9.8% (95% CI 4.6-17.8) for placebo. Meta-analysis of four studies favoured antibiotics over placebo for breath test normalisation with an odds ratio of 2.55 (95% CI 1.29-5.04). Clinical response was heterogeneously evaluated among six studies, but tended to correlate with breath test normalisation. CONCLUSIONS: Antibiotics appear to be more effective than placebo for breath test normalisation in patients with symptoms attributable to SIBO, and breath test normalisation may correlate with clinical response. Studies were limited by modest quality, small sample size and heterogeneous design. Additional higher quality clinical trials of SIBO therapy are warranted.

A report of near fatal ceftriaxone induced anaphylaxis in a child with review of literature.

Ceftriaxone is a widely used antibiotic in pediatric clinical practice. Usually ceftriaxone is well tolerated and serious adverse effect like anaphylaxis is rare. We report a near fatal anaphylaxis reaction in a child after the first dose of intravenous ceftriaxone who revived successfully.

Spectrum of pediatric dermatoses in tertiary care center in Nepal.

Children with dermatological problems constitute a major group presenting to the Outpatient Department. This study was done to see the pattern of skin disorder among the pediatric age group in a tertiary care center in Nepal. To determine the pattern of skin disorders among children visiting the Department of Dermatology and Pediatrics in a tertiary care center in Nepal. All the patients visiting the Dermatological Out patient Department in the age group 0-14 years were enrolled in the study during the time period of 3 years (2009-2011). The cases were diagnosed based on the detailed clinical history and clinical examination, and the patients were investigated as needed. A total of 1086 (22.64%) patients out of 4795 patients were having skin disorder and among them 584 (53.77%) were males and 502 (46.23%) were females. The age range was 0-14 with the mean age of 7 years. Dermatitis and eczema were the most frequently encountered disease 298 (26.46%), followed by bacterial infections 156 (16.13%), urticarial 190 (15.71%), viral infection (14.12%), fungal infection 76 (7.3%), scabies 54 (5.03%), miliaria 25 (2.75%), vitiligo 27 (2%) and others 87 (6.53%). Nutritional disorders, vascular, pigmentary, nevi, drug eruptions had a comparatively low incidence.