Evaluation of Early Renal Involvement in Essential Hypertension by Measuring Urinary Biomarkers.

Hypertensive kidney damage results in glomerular as well as tubular dysfunction. Albuminuria is a well-known marker of glomerular damage. On the other hand, urinary uromodulin is increasingly considered as a potential biomarker of early tubular dysfunction. The aim of the study was to assess glomerular and tubular function of the kidney by measuring urinary albumin and uromodulin excretion in hypertensive subjects. This cross-sectional study was conducted from July 2018 to June 2019 in Hypertension Clinic of Dhaka Medical College Hospital, Dhaka and Kidney Care and Research Centre, Sonargaon, Narayanganj, Bangladesh. In this study 122 hypertensive subjects with age >30 years, duration of hypertension <5 years, without accelerated or malignant BP, absence of dipstick proteinuria and eGFR >60ml/min were included. There were also 33 normotensive individuals included as healthy controls. Albumin-creatinine ratio (uACR mg/g), urine uromodulin-creatinine ratio (uUMODµg/g), urinary sodium-creatinine ratio (mEq/g) and potassium-creatinine ratio (mEq/g) were measured from single morning spot urine sample. Urinary uromodulin levels were measured by ELISA method. The hypertensive and normotensive subjects were age matched 49.0±12.0 vs. 48.0±11.0, years (p=NS). The mean uACR was 29.0±65.0 versus 5.6±2.7mg/g, (p<0.001) respectively. The median uUMOD in hypertensive subjects was 3.38 (1.73-9.06) and in normotensives 3.85(2.28-5.69) µg/g (p=non significant). Multivariate analysis showed significant inverse association between diastolic blood pressure and urinary uromodulin excretion. A uUMOD cut-off of 2.9 (25th percentile) showed eGFR, urinary sodium and potassium excretions were significantly lower at low uromodulin group. The glomerular involvement was found in 21.0% of hypertensive subjects as evidenced by albuminuria. No difference was observed in urinary uromodulin level between hypertensive and normotensive subjects. Low urinary uromodulin level was associated with lower eGFR, Na+ and K+ excretion which indicate simultaneous tubular and glomerular involvement.

WITHDRAWN: Diagnostic accuracy of folate receptor-positive circulating tumor cells detected by ligand-targeted polymerase chain reaction in patients with non-small-cell lung cancer: A meta-analysis.

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Vitamin D Status in Polycystic Ovarian Syndrome Patients Attending a Tertiary Hospital of Bangladesh.

Vitamin D deficiency is common in patients with polycystic ovarian syndrome (PCOS) and found to have multiple impacts on the disease process. Vitamin D status of women with or without PCOS in Bangladesh is largely unknown. This cross-sectional study was conducted in a tertiary level hospital of Bangladesh from January 2018 to April 2018 to address this lacuna. Sixty (60) newly diagnosed PCOS patients and 50 healthy controls aging ≥18 years were investigated for serum 25-hydroxy vitamin D [25(OH)D] level, fasting plasma glucose and fasting lipid profile in addition to their clinical and anthropometric profiles. None of the PCOS and the controls had sufficient 25(OH)D. Twenty five percent (25%) of PCOS patients were insufficient, 68.33% were deficient and 6.67% of were severely deficient of vitamin D; whereas in the control group the frequency was 12%, 50% and 38% respectively. PCOS patients had higher 25(OH)D than controls (17.53±4.6 vs. 13.79±6.1ng/mL, p<0.001). Although PCOS group had higher frequency of metabolic syndrome than control group (40% vs. 20%), 25(OH)D levels were similar in subjects with or without metabolic syndrome in both PCOS (16.82±4.74 vs. 17.99±4.49ng/mL, mean±SD, p=0.098) and control groups (14.06±5.94 vs. 13.73±6.20ng/mL, mean±SD, p=0.339). 25(OH)D level correlated with none of the clinical, anthropometric, metabolic and hormonal parameters in PCOS patients. Vitamin D deficiency is highly prevalent in Bangladeshi PCOS patients and healthy women of reproductive age.

Van Wyk and Grumbach Syndrome: An Unusual Presentation of Hypothyroism.

An 18 years-old-girl presented one and half years back with the complaints of short stature, retarded growth, and menorrhagia with sudden severe lower abdominal pain; was diagnosed as bilateral ovarian cysts and underwent bilateral ovarian cystectomy. Later on she was incidentally diagnosed as a case of hypothyroidism when she had been experiencing slowly enlarging left lower abdominal mass with dull ache for the 5 month and then was transferred to the department of Endocrinology for further evaluation. Detailed work up revealed her short stature with obesity, delayed bone age and other features of hypothyroidism which was confirmed by thyroid function testing. She had enlarged left ovary with multiple follicles as shown in ultrasonography. Magnetic resonance imaging (MRI) showed sellar mass which was suspicious of macroadenoma. Levothyroxine replacement was started and she had a dramatic improvement of her problems with disappearance of the ovarian cysts and sellar mass.

Ramadan Perspective Epidemiology and Education in Diabetes (RAPEED) Study.

Ramadan fasting is one of the five pillars of Islam and is obligatory for all healthy adult and adolescent Muslims. A significant number of patients with diabetes observe fasting during Ramadan. The objectives of this Ramadan Perspective Epidemiology and Education in Diabetes (RAPEED) study were to find out the current knowledge, attitude, and practices about Ramadan fasting among people with diabetes in Bangladesh. This retrospective cross-sectional study recruited 648 subjects with diabetes mellitus attending the Endocrinology outpatient department of a tertiary level hospital of Bangladesh within two months of the end of Ramadan in 2016. Socio-demographic data, data related to diabetes treatment, complications and co-morbidities; changes in lifestyle and diabetes treatment during Ramadan and frequency of hypoglycemia were collected from all. The mean age of the study population was 50.32±12.1 years and the majority (98.6%) had type 2 diabetes and 63.9% were overweight or obese. The majority (89.35%) of the patients fasted in Ramadan and among them, more than half of the fasters received physicians' advice for Ramadan fasting (60.6%) and changed diabetes medication (69.90%) during Ramadan. Although the amount of total food consumption was unchanged in more than one half (60.6%) of the fasters, majority of them reduced sugar-sweet intake (75.5%), increased fluid drinking (75.8%) and decreased physical activity (75.8%) during the month. A large portion (37.48%) of them did not check blood glucose and more than half (54.06%) of fasters failed to visit their physicians during Ramadan. Among them 14.85% experienced mild to moderate episodes of hypoglycemia and none had severe hypoglycemia and the most (61.6%) episodes of hypoglycemia occurred in the late evening. Hypoglycemic episodes were more frequent among insulin users, patients who had received fasting advice from physicians and in those who had adjusted diabetes drugs before Ramadan fasting. Safe Ramadan fasting is a great challenge not only for the patients but also the consulting physicians. Current study reflects the necessity of both physicians' expertise and patients' awareness for safe fasting.

Acute glutathione depletion leads to enhancement of airway reactivity and inflammation via p38MAPK-iNOS pathway in allergic mice.

Glutathione (GSH) plays a major role in allergic airway responses through a variety of mechanism which include direct scavenging of oxidative species, being a reducing equivalent and regulation of cellular signaling through redox sensitive mechanisms. Therefore, the aim of the present study was to evaluate the role of acute GSH depletion on airway reactivity, inflammation and NO signaling in a mouse model of allergic asthma. Buthionine sulfoximine (BSO), an inhibitor of gamma-glutamylcysteine synthetase was used for depletion of GSH levels. Acute depletion of GSH with BSO worsened allergen induced airway reactivity and inflammation through increase in nitrosative stress as reflected by increased inducible NO synthase (iNOS) expression, total nitrates and nitrites (NOx), nitrotyrosine, protein carbonyls, and decreased total antioxidant capacity. Treatment with p38 mitogen-activated protein kinase (MAPK) and iNOS inhibitors attenuated the effects of GSH depletion on airway reactivity and inflammation through attenuation of nitrosative stress as evidenced by a decrease in NOx, nitrotyrosine, protein carbonyls and increase in total antioxidant capacity (TAC). In conclusion, these data suggest that acute depletion of glutathione is associated with alteration of airway responses through an increase in nitrosative stress in allergic airways of mice.

Primary hyperparathyroidism: a case report.

Primary hyperparathyroidism results from the excessive secretion of PTH and typically produces frank hypercalcaemia. With the advent of multiphasic screening of serum chemistries, it has been recognized that primary hyperparathyroidism is not an uncommon disorder. Here, a 32 years old lady with burning to colicky recurrent upper abdominal pain, polyuria, polydipsia associated with anorexia, dyspepsia, generalized body ache, joint pain, constipation and weight loss has been described. An initial abdominal ultrasound was performed at hospital and revealed features of cholelithiasis and bilateral nephrocalcinosis. Serum biochemistries revealed that her serum calcium was 12.60mg/dl, serum PTH was 222.80ng/dl, serum creatinine was 0.90mg/dl, 99 Tc-sestamibi scanning for parathyroid evaluation revealed features suggestive of parathyroid adenoma adjoining the lower pole of right lobe of thyroid gland. Bone densitometry of femur and spine by DEXA showed osteoporosis with T score value <-3.5 SD. Right hemithyroidectomy with parathyroid adenoma excision was performed. Patient was closely monitored. Serum calcium and parathyroid hormone levels were markedly reduced near to the normal range within two weeks of surgery. Following five months after surgery, serum PTH was 29.59ng/dl, six months after surgery serum calcium was 9.2mg/dl. Patient is now in good physical condition and under regular follow up.

A case of sebaceous carcinoma arising in a benign cystic teratoma of the ovary and review of the literature.

OBJECTIVE: To present an extremely rare case of sebaceous carcinoma arising in a mature cystic teratoma of the ovary. CLINICAL PRESENTATION AND INTERVENTION: A 66-year-old woman presented with abdominal discomfort and a pelvic mass. Abdominal and pelvic ultrasound, as well as CT scan, revealed a 27 cm complex right pelvic mass, which was diagnosed histologically as a sebaceous carcinoma arising in a mature cystic teratoma. The patient underwent a total abdominal hysterectomy with bilateral salpingo-oophorectomy, peritoneal washings, appendicectomy and infracolic omentectomy. CONCLUSION: This case adds to the rare reports in the literature of sebaceous carcinoma occurring in a mature cystic teratoma. The clinical behaviour and optimal management of this entity are not well established. The patient has been well for 32 months following surgery with no evidence of recurrent disease clinically.

Pacemaker placement and shoulder surgery: is there a risk?

INTRODUCTION: Surgery to the anterior aspect of the shoulder is performed by many surgical specialties but the techniques used by our cardiology colleagues for insertion of cardiac pacemaker wires are often not appreciated by the surgical community. The deltopectoral approach has been used for open pacemaker wire insertion for many years by cardiologists. METHODS: We surveyed a group of subspecialty shoulder surgeons as well as orthopaedic trainees to see if this approach for pacemakers is well recognised. We tried to assess what level of knowledge exists regarding pacemaker placement in general as well as specific risks. RESULTS: There appears to be a paucity of knowledge regarding pacemaker placement and related patient safety issues in both surveyed groups. There was no difference between the two groups, suggesting that the level of knowledge does not increase with experience and specialisation. CONCLUSIONS: There is the potential to cause harm to patients if the insertion site and type of device is not identified before commencing surgery in this region and steps must be taken to minimise any intra-operative risk. There is a risk from direct injury to the pacemaker and/or leads as well as the hazards of using diathermy in close proximity to a pacemaker. There must be more widespread dissemination of this information in order to minimise risks to patients with pacemakers in situ.

Clinical utility of ¹8F FDG-PET/CT in the detection of bone marrow disease in Hodgkin's lymphoma.

OBJECTIVE: The aim of the study was to evaluate the potential role of fludeoxyglucose (FDG)-positron emission tomography (PET)/CT in the detection of bone/bone marrow disease in patients with Hodgkin's lymphoma (HL). METHODS: We retrospectively reviewed ((18)F)-FDG-PET/CT scans of 122 newly diagnosed, biopsy-proven cases of HL performed between November 2009 and June 2010. All the patients were staged before treatment by both PET/CT and bone marrow biopsy (BMB). Patients were subdivided into three groups based on the findings of FDG-PET/CT. Group A consisted of patients showing diffuse FDG uptake, Group B consisted of patients showing unifocal FDG uptake and Group C patients showed multifocal FDG-avid foci on PET/CT scans. Bone marrow results were also reviewed and considered positive if lymphomatous involvement was detected on bone marrow trephine biopsy. BMB results were correlated with FDG-PET/CT findings. RESULTS: There were 122 patients in total-81 (66.4%) were male and 41 (33.6%) were female. The age range was from 6 years to 78 years (mean 35.70 years). PET/CT was reported as negative for bone/bone marrow involvement in 85 (69.7%) patients, while the remaining 37 showed abnormal FDG uptake. The sensitivity of FDG-PET/CT was calculated to be 100%, the specificity was 76.57%, the negative predictive value was 76.57%, the positive predictive value was 29.72% and the diagnostic accuracy was 78.62%. CONCLUSION: (18)F-FDG-PET/CT and BMB are complementary in the evaluation of bone marrow disease.

Imaging characteristics of primary laryngeal lymphoma.

BACKGROUND AND PURPOSE: The larynx is a rare site for primary NHL. Fewer than 100 cases have been reported in the literature, with the largest imaging review involving only 4 patients. We describe the findings of laryngeal lymphoma on CT, PET, and MR imaging and identify features that may distinguish laryngeal lymphoma from the far more common laryngeal squamous cell carcinoma. MATERIALS AND METHODS: Multi-institutional retrospective chart review revealed 20 patients with histopathologically proved laryngeal lymphoma. Pretreatment CT, PET, and MR images were reviewed by a head and neck radiologist, focusing on extent of tumor, cervical lymph node involvement, and enhancement patterns. RESULTS: Patients ranged from 30 to 90 years of age with a mean of 63 years at the time of initial diagnosis and a 2:1 female predominance. The average tumor size was 37 +/- 19 mm. In all patients, laryngeal lymphoma involved the supraglottis but also extended into the glottis (65%) and hypopharynx (60%). The subglottis was less frequently involved (35%). Laryngeal cartilage invasion and cervical lymphadenopathy were each seen in 20% of patients. Lymphoma was consistently FDG-avid (100%) and usually enhanced uniformly with iodinated contrast (73%). Necrosis and calcification were not seen in any cases. CONCLUSIONS: Although laryngeal lymphoma is rare, particular imaging features suggest this diagnosis. A large uniformly enhancing supraglottic tumor without central necrosis and without cervical lymphadenopathy is a characteristic finding of lymphoma. Similar to squamous cell carcinoma, lymphoma may extend into the subglottis, pharynx, and laryngeal cartilages.

Stem cells for tendon and ligament tissue engineering and regeneration.

Tendons and ligaments are frequently injured. Due to their relatively avascular nature, repair is slow and often incomplete. Stem cells offer a new approach to augment healing of native tissues, as well as providing materials to surgically replace injured structures that are beyond repair. Here we discuss the various roles of stem cells in natural repair processes compared to engineered tissues to assist healing or replace tissues.

How we do it: 'tonsillectomy mat', scored rubber sheet to fix the Draffin's rods.

Slipping of the Driffin's rod from the operating table is problematic during tonsillectomy. We describe a technique to overcome this problem by using a 'tonsillectomy mat'.

Unintentional subdural catheter placement during labor analgesia shows typical radiological pattern but atypical response to the Tsui test.

Subdural injection may be associated with abnormally extensive or limited spread of local anesthetics during neuraxial anesthesia. This complication is difficult to diagnose clinically. Radiological imaging is the gold standard for confirming the location of subdural catheter, but electrical stimulation of the catheter has also been described as a useful diagnostic tool. We present the case of an obstetric patient with unintentional subdural catheter placement that presented as a failed epidural block associated with severe upper back and scapular pain on catheter injection. Electrical stimulation of the catheter did not elicit muscle contractions until a current of 4 mAmp was attained, which is the response pattern of epidural placement. Subdural location of the catheter was subsequently confirmed by contrast radiography. This case adds to the evidence that subdural catheters are difficult to identify clinically, and that electrical stimulation may not differentiate them from epidural catheters.

Angiogenesis-a novel therapeutic approach for ischemic heart disease.

Angiogenesis is the biologic process of forming new blood vessels. Undoubtedly, blood vessels growth regulation is a vital aspect in health and disease. Under physiological conditions, angiogenesis is regulated by local balance between endogenous stimulators and inhibitors of this process. In many diseases state body loses control over angiogenesis. Angiogenesis-dependent diseases result when new blood vessels either grow excessively or insufficiently. Insufficient angiogenesis occurs in diseases such as coronary artery disease, stroke and chronic wounds. Myocardial ischemia both acute and chronic has been clearly shown to stimulate angiogenesis in many experimental models. Therapeutic angiogenesis is the biological agents or bioactive material to stimulate the growth of new blood vessels. Traditional coronary revascularization therapies such as coronary angioplasty or bypass graft surgery, act by restoring blood flow through the preexisting coronary vessels. One limitation of these approaches, however, may be the failure to normalize myocardial perfusion, due to the concomitant presence or small of resistance vessel disease. In contrast, therapeutic angiogenesis is based on the concept that coronary collateral development may be stimulated by pharmacological or molecular means and can limit myocardial ischemia. Studies, both in human and animal models support the notion that, various angiogenic growth factors and progenitor cells can enhance new blood vessels. Vascular endothelial growth factor (VEGF), fibroblast growth factor (FGF), recombinant proteins and bone marrow stem cells are currently used therapeutic stimulators for angiogenesis. As coronary artery disease is the major cause of death in the developed societies and also an emerging health problem in developing countries like Bangladesh therapeutic angiogenesis may provide hope as a new treatment modality for ischemic heart disease with or in place of current therapies.

Incretin mimetics and DPP-4 inhibitors: new approach to treatment of type 2 diabetes mellitus.

Type 2 diabetes constitutes the main bulk (85-90%) of diabetic population. It is a chronic metabolic disorder with progressive ?beta-cell dysfunction, impaired insulin actions and various other abnormalities. Insulin response of beta-cell is more after oral glucose or following meal than intravenous infusion of glucose. Gut related peptides, the incretin hormones released after meal following activation of the enteroinsular axis plays an important role in glucose homeostasis by pancreatic and extrapancreatic glucoregulatory effects and helps in preservation of beta-cell function. In type 2 diabetes, there is progressive decline of these incretins level, glucagons like peptide-1 (GLP-1) and glucose dependent insulinotropic polypeptide (GIP) with loss of beta-cell mass, beta-cell function and glycemic deterioration. These peptides are rapidly degraded by endogenous proteases, dipeptidyl peptides-4 (DPP-4) giving a very short half life of 2-3 minutes. Currently available anti-diabetic drugs do not address these arms of glucoregulatory dysfunction of type 2 diabetes. Modern therapeutic strategy should be targeted at preservation of beta-cell mass and function by exploiting the incretin hormones and enteroinsular axis. DPP-4 resistant incretin analogues/mimetics (e.g. exenatide, liraglutide) that have been developed by modifications/ substitutions in the polypeptide chain may be an effective alternative of the existing therapy of type-2 DM. DPP-4 inhibitors (e.g. sitagliptin, vindagliptin) prevent the degradation of endogenous GLP-1 and GIP, thereby potentiate their actions and help in glycemic control. Distinctive features of incretin mimetics are: their action is glucose dependent, do not produce hypoglycemia, help in preservation of beta-cell mass and function, help in weight reduction. DPP-4 inhibitors are weight neutral. Ongoing studies will reveal newer avenues and long term outcome of these molecules.

Classification of radical hysterectomy adopted by the Gynecological Cancer Group of the European Organization for Research and Treatment of Cancer.

The Piver classification of radical hysterectomy for the treatment of cervical cancer is outdated and misused. The Surgery Committee of the Gynecological Cancer Group of the European Organization for Research and Treatment of Cancer (EORTC) produced, approved, and adopted a revised classification. It is hoped that at least within the EORTC participating centers, a standardization of procedures is achieved. The clinical indications of the new classification are discussed.

Risk of cardiovascular diseases with oral contraceptives.

Oral contraceptive pills (OCs) are widely used method of contraception for its effectiveness and easier compliance. However, adverse effects associated with OCs use notably the increased risk of cardiovascular diseases (CVD), manifesting as ischaemic and haemorrhagic stroke, myocardial infarction (MI) and venous thromboembolic diseases were reported soon after their introduction to the market in the early 1960s. Various modifications were made in an attempt to lower these risks including a reduction in the estrogen dose and changes in the progestogen compound. Currently used OCs containing the new progestin (Levonorgestrel, Desogestrel, gestodene or norgestimate) classified as low dose because all contain less than 35 microg of ethinyl estradiol. Despite their low steroid content, all have proved to be highly effective. The rationale of this reviewed study based upon cardiovascular risks in relation to these monophasic low-dose oral contraceptives. To review all relevant articles it is concluded that the risk for cardiovascular disease is lower with current preparations of oral contraceptives. Cardiovascular diseases occur mainly among oral contraceptive users who smoke or have predisposing factors--such as age more than 35 years, overweight, diabetes & hypertension.