Differential Impact of Insulin Sensitizers vs. Anti-Androgen on Serum Leptin Levels in Vitamin D Replete PCOS Women: A Six Month Open Labeled Randomized Study.

Women with PCOS are linked to insulin resistance, inflammation, and vitamin D (VD) deficiency. The study endeavors to comprehend the differential impact of insulin sensitizers vs. anti-androgen on serum leptin levels among women with PCOS rendered vitamin D replete with high VD oral supplement. This was open-labeled randomized study that screened 180 eligible women presenting to Endocrine clinic with oligomenorrhea or features of hyperandrogenism. Ninety-nine women who furnished written informed consent and fulfilled the Rotterdam 2003 criteria for diagnosis of PCOS were randomized into 3 drug treatment arms to receive either spironolactone (50 mg/d; n=30), metformin (1000 mg/d; n=30) or pioglitazone (30 mg/d; n=30). These women were also administered oral VD (4000 IU/day) in addition to the allocated drug for a period of 6 months. Detailed history, clinical examination, and laboratory evaluation was carried out at baseline and 6 months after intervention. Number of menstrual cycles/year increased while as Ferriman-Gallwey score, blood glucose, HOMA-IR, and plasma insulin levels significantly decreased in all the three arms with better outcomes in spironolactone and pioglitazone arms (p<0.05). Similarly, serum leptin levels superiorly improved in spironolactone and pioglitazone group. Pioglitazone group showed better efficacy in lowering serum total testosterone (p<0.05). Co-supplementation of high dosage VD with spironolactone or pioglitazone are more effective in reducing plasma leptin levels than metformin, and thus might prove to be better therapeutic strategies for women with PCOS.

Role of cardiac magnetic resonance imaging in identifying infarct related artery and non-ischemic pathogenesis in patients presenting with non ST elevation myocardial infarction.

INTRODUCTION: Identifying an Infarct-related artery (IRA)in Non-STEMI is sometimes tricky. Besides, myocardial infarction with non-obstructive coronary arteries (MINOCA) mimickers are often labeled as myocardial infarction. Late Gadolinium enhancement (LGE) on cardiac MRI can help in identifying IRA besides MINOCA mimickers. AIMS: To study the role of LGE on cardiac MRI(CMR) in NSTEMI. MATERIAL METHODS: It was a prospective observational, double-blinded study. 70 NSTEMI patients were prospectively enrolled over two years. CMR was done before coronary angiography (CAG) during the index hospitalization. Matching was done between IRA selected by CAG and IRA as determined by LGE on MRI. RESULTS: Mean age was 58 ± 15 years. CAG could not identify IRA in 38.6% (n = 27) patients. In this patient group, LGE-CMR identified IRA in 48.1% (n = 13) & a new non-CAD diagnosis was identified in 18.5% (n = 5) patients. IRA was identified in 61.4% (n = 43) by CAG & in this patient group, LGE-CMR identified a different IRA in 6.9% (n = 3) patients. LGE-CMR also identified a new non-CAD diagnosis in 11.6% (n = 5) of patients from this group. Overall, LGE-CMR led to a new IRA diagnosis in 23% (n = 16) patients & a diagnosis of non-ischemic pathogenesis in 14% (n = 10) patients. Non-Ischemic diagnosis on CMR included stress cardiomyopathy in 3, myocarditis in 6, and infiltrative disorder in 1 patient. CONCLUSION: CMR leads to new IRA diagnoses or non-ischemic pathogenesis in one-third of the cohort.

Endoscopic Third Ventriculostomy in Noncommunicating Hydrocephalus: Report on a Short Series of 53 Children.

INTRODUCTION: Endoscopoic third ventriculostomy (ETV) is currently considered the best alternative to cerebrospinal fluid (CSF) shunt systems in the treatment of obstructive hydrocephalus. The aim of ETV is to communicate the third ventricle with the interpendicular cistern and create CSF flow which bypasses an obstruction to the circulation of the CSF. AIMS AND OBJECTIVES: The purpose of this study was to elucidate the indications, efficacy, safety and outcome Of ETV pediatric patients of noncommunicating hydrocephalus. MATERIAL AND METHODS: This study is a 3 year prospective study from June 2012 to May 2015. Records were kept for age, gender, etilogical factors, symptoms, signs, previous use of shunt or external ventricular device, imaging findings, and surgical complications (intraoperative and postoperative). Only those patients with age between 6months and 18 years with symptoms of intracranial hypertension and radiographic evidence of noncommunicating hydrocephalus were included in the study. RESULTS: A total of 53 patients were studied, out of these 29 were boys and 24 were girls. The mean age of the patients was 6.6 years. Overall a total of 50 successful ETVs were done in 53 patients. The success rate is estimated to be 94%. There was no mortality. The average postoperative hospital stay was 4 days. The followup ranged from 6 to 16 months (mean, 12 months). CONCLUSION: ETV in children is a safe, simple and effective treatment and a logical alternative to shunting procedure for patients of noncommunicating hydrocephalus.

Spinal angiolipoma mimicking a schwannoma: A case report.

BACKGROUND: Angiolipomas rarely involve the spinal canal/foramina, and may prove difficult to differentiate from schwannomas. CASE DESCRIPTION: Here we report a patient who presented with a spinal angiolipoma contributing to spinal cord and neural foraminal compression that was difficult to differentiate from a schwannoma. CONCLUSION: Spinal angiolipomas rarely involve the spinal canal/foramina. Utilizing neurodiagnostic studies with pathological confirmation, these lesions may be differentiated from schwannomas.

Utility of Placental Laterality and Uterine Artery Doppler Abnormalities for Prediction of Preeclampsia.

OBJECTIVE: To find out whether placental laterality and abnormal uterine artery waveform and resistance index, as determined by antenatal ultrasonography and Doppler, can be used as a predictor for the development of preeclampsia. METHODS: This prospective observational cohort study was conducted from August 2013 to October 2014. Two hundred and one (201) normotensive, primigravida women with singleton pregnancies attending the antenatal clinics without any high-risk factor for development of hypertension were subjected to ultrasonography at 18-22 weeks of gestation to determine the placenta location. All the subjects with lateral placentas were subjected to Doppler ultrasonography to look for abnormal Doppler waveform and resistance index. They were followed for the development of preeclampsia till 40 weeks of gestation or delivery. RESULT: Out of the total 201 women, 71 (24.5 %) had laterally located placentas and of them 37 (52 %) developed preeclampsia, while the remaining 130 (75.5 %) had centrally located placentas and of them 14 (10.8 %) developed preeclampsia (p < 0.001). In subjects with lateral placentas alone (n = 33), 2 (6 %) developed preeclampsia while as those with lateral placentas with Doppler abnormality (n = 38), 35 (92 %) developed preeclampsia (p < 0.001). The overall risk of developing preeclampsia with laterally located placenta was 9.27 (odds ratio), and 95 % confidence interval was (4.30-19.98). CONCLUSION: Pregnant women with lateral placentas are at significant risk for development of preeclampsia. Lateral placentas when associated with uterine artery Doppler abnormality, risk for development of preeclampsia increases significantly as compared to lateral placentas alone.

(99m)Tc Diethylenetriaminepentacetic Acid Angiotension-coverting Enzyme Inhibitor Renography as Screening Test for Renovascular Hypertension in Unilateral Small Kidney: A Prospective Study.

To know the probability of renal artery stenosis (RAS) in unilateral small kidney and function of the unilateral small kidney, which includes glomerular filtration rate, differential function, uptake, Tmax by (99m)Tc diethylenetriaminepentacetic acid (DTPA) base and (99m)Tc DTPA angiotensin converting enzyme (ACE) inhibition scan. All our patients were subjected to (99m)Tc DTPA ACE inhibition renal scintigraphy. All the patients underwent either computed tomography (CT) angiography and magnetic resonance (MR) angiography was done in those patients in which kidney function test was deranged. Renal angiography was subsequently performed in cases with the suggestion of RAS on CT or MR angiography. The quantitative data was expressed as the arithmetic mean, standard deviation and percentages. The intergroup comparisons for parametric data were done by Student's t-test, whereas non-parametric data was compared with Mann-Whitney U-test. The intergroup comparisons were made by paired t-test and Wilcoxon sign rank test. P <0.05 was considered to be significant, and data was analyzed by Statistical package for social sciences(SPSS-20) software. Out of 47 patients, 25 patients were in the low probability group out of which none was positive for RAS on CT/MR angiography. Out of 47 patients, 12 were in the intermediate group out of which none was positive for RAS. Ten, out of 47 patients were suspected of high probability for RAS by ACE inhibition scan out of which 4 were positive for RAS by CT/MR angiography including one with bilateral RAS. (99m)Tc DTPA angiotension-coverting enzyme inhibitor renography is a safe, non-invasive, sensitive, specific, and cost-effective test for excluding renovascular hypertension in patients who have normal or nearly normal renal function in unilateral small kidney.

Endorectal coil MRI and MR-spectroscopic imaging in patients with elevated serum prostate specific antigen with negative trus transrectal ultrasound guided biopsy.

BACKGROUND: The aim of this study was to see the efficacy of endorectal coil MRI and MR spectroscopic imaging in patients with elevated serum PSA and negative transrectal ultrasonography (TRUS)-guided biopsy. MATERIALS AND METHODS: This study was conducted on 87 patients presented with: • Elevated prostatic specific antigen levels >5 ng/ml • Symptoms and signs of prostatic carcinoma • Patients with negative TRUS-guided biopsy • Suspicious lesion on TRU. All the patients were subjected to TRUS and followed by TRUS-guided biopsy of the lesion identified on endorectal coil MRI and MR-Spectroscopy. TRUS-guided biopsy of prostate was done with a Siemens Sonoline Adana Scanner. The scanning was performed by mechanical probe 5-7.5 MHz. RESULTS: Out of 87 patients, 43 (49.4%) had hypointense lesion, 11 (12.6%) had hyperintense lesion. Out of 87 patients, MR-spectroscopy showed peak choline-creatine in 74 patients. Normal citrate peak was seen in 13 patients. Patients who had choline-creatine peak, among them 28 (37.8%) had peak in left peripheral zone, 23 (31.1%) had peak in the right peripheral zone, 2 (2.7%) had peak in the central zone, 17 had (23%) peak bilaterally. Four patients (5.4%) had peaks in right and central zones. The difference was statistically significant (P < 0.001). CONCLUSION: Prostatic biopsy directed with endorectal coil MRI and MR-spectroscopic imaging findings in patients with elevated serum PSA and prior negative biopsy, improves the early diagnosis of prostatic carcinoma and accurate localization of prostate cancer within the gland.

64-section multiphase CT enterography as a diagnostic tool in the evaluation of obscure gastrointestinal bleeding.

BACKGROUND AND AIM: Small bowel follow through (SBFT) and enteroclysis have low sensitivity in picking up lesions in obscure gastrointestinal bleed (OGIB). Computed tomographic enterography (CT-EG), performed with 64-slice multiphase CT system by using large volumes of ingested neutral enteric contrast material, has high spatial and temporal resolution in visualization of the small bowel wall and lumen. The role of 64-slice multiphase CT-EG in the evaluation of OGIB is still evolving, and data on this role are scarce. We evaluated the efficacy of 64-slice multiphase CT-EG using polyethylene glycol (PEG) electrolyte solution as neutral contrast in patients of OGIB. METHODS: CT-EG was performed with 64-slice multiphase CT system using large volume (2,000 mL) of PEG electrolyte solution as oral contrast in patients of OGIB. RESULTS: Thirty-five patients (21 men, age 41.4 [13.5] y, range 19-70 year) with OGIB underwent CT-EG; 20 patients had overt OGIB whereas 15 patients had occult OGIB. Among 15 patients with occult OGIB, 10 patients had iron deficiency anemia (IDA) with fecal occult blood test (FOBT) positive and 5 had IDA with FOBT negative. Thirty-two patients (92 %) completed the procedure successfully. The total time taken for the ingestion of 2,000 mL of PEG electrolyte solution was median 64 (range 60-78) minutes. Adequate luminal distension of small bowel was seen in 29 (90.6 %) patients for successful interpretation of radiological images. Fifteen of 32 (46.9 %) patients had positive findings on CT-EG; 12 of them underwent exploratory laparotomy. The surgical findings were in conformity with CT-EG findings in all patients, which included gastrointestinal stromal tumors (GIST; n = 6), carcinoid (1), Meckel's diverticulum (1), small bowel adenocarcinoma (2) and jejunal vascular malformation (2). CONCLUSION: 64-slice multiphase CT-EG is a useful investigation in the evaluation of both occult and overt OGIB.