Impact of tuberculosis on glycaemic status: A neglected association.

Background & objectives: Diabetes mellitus (DM) is an important risk factor for tuberculosis and has received increasing emphasis. However, the reverse association of tuberculosis impacting blood sugar levels has not been well studied. The present study was conducted to evaluate the prevalence of hyperglycemia in patients with tuberculosis and assess its resolution following successful treatment of tuberculosis. Methods: In this prospective study, a total of 582 patients with tuberculosis were evaluated for hyperglycaemia [DM or impaired glucose tolerance (IGT)] with random blood sugar (RBS) and all patients with RBS >100 mg/dl were subjected to a 75 g oral glucose tolerance test (OGTT). All patients received thrice weekly intermittent Directly Observed Treatment Short Course (DOTS) for tuberculosis. Patients with hyperglycaemia were re-evaluated at the end of anti-tuberculosis treatment with an OGTT and glycated hemoglobin (HbA1c) levels to assess for glycaemic status. Results: In the present study, 41 of the 582 patients were found to have DM [7%, 95% confidence interval (CI) (5.2, 9.4)] while 26 patients were found to have IGT [4.5%, 95% CI (3, 6.5)]. Three patients were lost to follow up. Of the 26 patients with IGT, 17 [65.4%, 95% CI (46.1, 80.7)] reverted to euglycaemic status following successful treatment of tuberculosis, while the blood sugar levels improved in all patients with DM following treatment of tuberculosis. Interpretation & conclusions: Our study results show that tuberculosis adversely impacts glycaemic status with improvement in blood sugar levels at the end of successful treatment of tuberculosis. Longitudinal studies with large sample size are required to confirm these findings.

Evolving management of insulinoma: Experience at a tertiary care centre.

BACKGROUND & OBJECTIVES: Since our previous study in 2006, several new modalities for localization of cause of endogenous hyperinsulinemic hypoglycaemia such as multiphasic computed tomography (CT), multiphasic magnetic resonance imaging (MRI), endoscopic ultrasound (EUS), intraoperative ultrasound, and intra-arterial calcium infusion with arterial stimulation venous sampling (ASVS) have become available. Therefore, to evaluate the relative usefulness of various imaging modalities to guide future management in terms of diagnosis and patient care, we analyzed presentation and management of patients of endogenous hyperinsulinemic hypoglycaemia. METHODS: In this retrospective study, medical records of patients admitted with endogenous hyperinsulinemic hypoglycaemia were retrieved. Data pertaining to clinical features, diagnosis, imaging, surgery and patient outcome were extracted. The localization of insulinoma by preoperative imaging techniques was compared with the findings at surgery to assess the accuracy of localization. RESULTS: Fasting hypoglycaemia was present in all, and post-prandial hypoglycaemia (plasma glucose ≤50 mg/dl within four hours of meal) in 25.8 per cent. Mean duration of symptoms before reaching a diagnosis of hyperinsulinemic hypoglycaemia was 3.9 years. Mean duration of provocative fast was 21.8 h (range 6-48 h). Among the currently used imaging modalities, the sensitivity of localizing tumour was 79.3 per cent for multiphasic CT, 85 per cent for multiphasic MRI and 95 per cent for EUS. EUS detected tumour missed by both CT and MRI. All, except one of the operated patients, were cured by surgery. INTERPRETATION & CONCLUSIONS: Our results suggest that patients with insulinoma have a varied presentation. Multiphasic contrast-enhanced MRI/CT scan, EUS and ASVS may be complimentary in pre-operative localization.

Prevalence of standing plantar pressure distribution variation in north Asian Indian patients with diabetes mellitus: a study to understand ulcer formation.

Diabetes Mellitus is a disorder of metabolism. Foot problems are common in diabetes and altered plantar pressures distribution may lead to ulceration in people with Diabetes Mellitus. Therefore the aim of this study was to investigate standing plantar pressure distribution variations in north Asian Indian diabetes mellitus subjects and its association with duration of diabetes. Thirty three subjects with age range from 40 to 75 years are recruited from AIIMS Endocrinology & metabolism lab Delhi, India and divided into three groups: 11 control subjects (non-diabetic), 11 diabetic subjects without neuropathy (DNN) and II diabetic subjects with neuropathy (DN). Neuropathy status was assessed by measuring loss of protective sensation to 10 gm Semen's Weinstein monofilament. Plantar pressure distributions parameter-Power ratio (PR) was measured during barefoot standing using portable PedoPowerGraph and results are analyzed using one way analysis of variance to detect significant difference between the groups. We found significant (p < 0.05; p < 0.01) difference in PR value between DN and CG groups in fore foot and hind foot but no significant (p > 0.05) difference in PR value was found between DNN and CG groups in the foot. As compared to DNN, DN group have maximum PR variations in the fore foot. Plantar pressure distribution parameter-PR was higher with longer duration of diabetes among type 2 diabetes subjects. In this study we conclude that plantar pressure distribution parameter-PR was able to distinguish the DN groups from the CG group in hind and fore foot during standing. Increased forefoot PR value is prevalent in the diabetic neuropathic subjects and may be responsible for the occurrence of foot sole ulcers but additional prospective studies are needed. In the future we will investigate the plantar pressure distribution parameter-PR variations in diabetes with obese and osteoarthritis subject.

The effect of growth hormone deficiency on size-corrected bone mineral measures in pre-pubertal children.

UNLABELLED: Growth hormone deficiency (GHD) in children has been frequently perceived to be a cause of low bone mass accrual. The confounding effects of poor growth limit the interpretation of prior studies of bone health in GHD. We studied size-corrected bone mineral measures in 30 pre-pubertal GHD children and 75 healthy controls. Our study shows that size-corrected whole-body bone mineral content of GHD children were comparable with controls. INTRODUCTION: The purpose of this study is to evaluate the effects of GHD on size-corrected bone measures at the lumbar spine (LS) and the whole body (WB). METHODS: LS bone area (BA), LS bone mineral content (BMC), WB BA, WB BMC, and lean body mass (LBM) were measured in 30 pre-pubertal GHD children and 75 controls by dual-energy X-ray absorptiometry. Multiple linear regressions were used to calculate size-corrected (Sc) LS BA(Sc), LS BMC(Sc), WB BA(Sc), and WB BMC(Sc) from control subjects using height and age as independent variables. Furthermore, the relationship between muscle and bone was studied by first assessing LBM for height (LBM(Ht)) and then determining WB BMC for LBM (WB BMC(LBM)). All values were converted to Z-scores and compared with the control. RESULTS: At diagnosis, WB BMC(Sc) Z-score of GHD children was not significantly different from controls. However, mean Z-scores of LS BA(Sc) (-0.89 ± 0.84, p < 0.0001), LS BMC(Sc) (-0.70 ± 1.1, p < 0.001), WB BA(Sc) (-0.65 ± 1.0, p < 0.006), and LBM(Ht) (-0.66 ± 1.7, p < 0.01) were significantly reduced, and WB BMC(Lbm) (0.78 ± 1.5, p < 0.003) was significantly higher in GHD children than controls. CONCLUSION: Size-corrected WB BMC of GHD children were comparable with controls, and bones were normally adapted for muscle mass. Determinants of bone strength which may primarily be affected by GHD are muscle mass, bone size, and geometry rather than bone mass.

Chromosomal abnormalities & oxidative stress in women with premature ovarian failure (POF).

BACKGROUND & OBJECTIVES: Premature ovarian failure (POF) is defined as the cessation of ovarian function under the age of 40 yr and is characterized by amenorrhoea, hypoestrogenism and elevated serum gonadotrophin levels. The cause of POF remains undetermined in majority of the cases. This study was aimed to investigate the type and frequency of cytogenetic abnormalities in patients with idiopathic POF and also to study the role of oxidative stress in such cases. METHODS: Seventy five women with idiopathic POF were included in this study. Chromosome analysis was done in peripheral blood lymphocytes by conventional GTG banding to identify numerical or structural abnormalities. Cytogenetically normal cases were investigated for reactive oxygen species (ROS) levels in their blood by luminol-chemiluminescence assay. RESULTS: Eighteen chromosomal anomalies were identified in POF patients (24%). Majority of the cases were found to have X-chromosome abnormalities (28%). Overall median ROS range was found to be significantly higher (P<0.01) in POF patients [50480 (120,132966) RLU/min] compared to controls [340 (120,5094) RLU/min]. Among these, 50 per cent of the POF patients had higher ROS levels, 20 per cent had medium elevation and 30 per cent were found to have normal values comparable to controls. INTERPRETATION & CONCLUSIONS: X-chromosome anomalies were found to be the major contributor of POF. Oxidative stress may be the underlying aetiology in idiopathic premature ovarian failure. Thus the results of this study highlight the role of cytogenetic abnormalities and supraphysiological levels of ROS in causation of idiopathic POF. But the role of oxidative stress needs to be confirmed by other studies on patients from different geographical areas and from different ethnicities.

Plasma testosterone in adult normoglycaemic men: impact of hyperinsulinaemia.

This study analysed the relationship of plasma testosterone with ß-cell secretion, insulin sensitivity and other pituitary-target gland hormones in normoglycaemic adult men. The sample frame was the 'Offspring of individuals with diabetes study' database. A total of 358 offspring of individuals with type-2 diabetes (T2DM) and 287 individuals without known family history of T2DM were recruited for the study. Normoglycaemic men aged ≥18 years (maximum 55) were selected for this analysis. All participants underwent 75 g oral glucose tolerance test (OGTT); blood samples were collected at 0, 30, 60 and 120 min for plasma insulin and C-peptide. Total testosterone, cortisol, adrenocorticotropic hormone, thyroid stimulating hormone and thyroxine (T4) were measured in the fasting sample. A total of 164 men (age 28 ± 7.7 years) were included in analysis. Testosterone correlated negatively with BMI, waist to hip ratio (WHR), area under curve (AUC) of C-peptide and insulin (during OGTT) and was positively correlated with insulin sensitivity (r ~ 0.4). Cortisol and T4 positively correlated (weak) with testosterone (r ~ 0.2). In multivariate analysis, AUC C-peptide, BMI, WHR (negatively) and cortisol (positively) were related to testosterone. Concluding, testosterone correlated negatively with BMI and ß-cell secretion. There was a positive association of testosterone with insulin sensitivity, cortisol and T4.

Association of limited joint mobility and increased plantar hardness in diabetic foot ulceration in north Asian Indian: a preliminary study.

The aim of this article is to investigate the association of limited joint mobility and foot sole hardness in north Asian Indian type 2 diabetic patients. Limited joint mobility and hardness of the foot sole were measured for 39 subjects attending the AIIMS Endocrinology & Metabolism Clinic. The total subject divided into three groups: 13 control subjects (nondiabetic), 13 diabetic patients without neuropathy and 13 diabetic neuropathy patients. Neuropathy status was assessed using 10 gm Semen's Weinstein monofilament. Joint mobility parameters, such as ankle dorsiflexion/plantar flexion and metatarsophalangeal-1 dorsiflexion/plantar flexion, are measured using a goniometer. Foot sole hardness was measured using a durometer or shore meter. We found that diabetic patients with a neuropathic foot had significantly reduced joint mobility and increased foot sole hardness, placing them at risk for subsequent ulceration. Metatarsophalangeal-1 dorsiflexion/plantar flexion of both feet of diabetic patients had significant correlation (at p < 0.05, p < 0.001, p < 0.001 level) over age and body mass index. Also ankle plantar flexion/dorsiflexion and metatarsophalangeal-1 dorsiflexion/plantar flexion has a significant correlations (at p < 0.01, p < 0.05, p < 0.001, p < 0.001 level) with foot sole hardness in both feet of diabetic neuropathy subjects. Also linear regression analysis showed that duration of diabetes was significantly associated with the joint mobility parameters. In this study we conclude that joint mobility had reduced further if neuropathy and increased foot sole hardness coexisted owing to high plantar pressures. Hence, both limited joint mobility and increased foot sole hardness appears to be important determinants of foot sole ulceration in diabetic neuropathic subject.

Recurrent ectopic pregnancy with heterotopic pregnancy in a patient of hypogonadotropic hypogonadism: a case report.

BACKGROUND: Heterotopic pregnancy is the simultaneous occurrence of intrauterine and ectopic pregnancies. With an incidence reported to be between 1:8,000 and 1:30,000 pregnancies, heterotopic pregnancy is a rare entity. However, the increasing use of assisted reproductive techniques has contributed to the increasing incidence of heterotopic pregnancy during the past years. CASE: This is a rare case of a hypogonadotropic hypogonadism in a patient with a heterotopic pregnancy six months after successful medical management of tubal ectopic pregnancy. The heterotopic pregnancy was managed expectantly with successful pregnancy outcome. CONCLUSION: Heterotopic pregnancy should always be considered, especially in patients with prior history of ectopic pregnancy and those undergoing assisted reproduction. Its treatment is a challenge as serial beta-hCG is not useful in diagnosis or follow-up, and medical management with methotrexate is contraindicated with an intrauterine pregnancy. Heterotopic pregnancies in select cases can be managed expectantly with strict monitoring and serial ultrasounds, and the viable intrauterine pregnancy can be saved.

Association analysis of ADPRT1, AKR1B1, RAGE, GFPT2 and PAI-1 gene polymorphisms with chronic renal insufficiency among Asian Indians with type-2 diabetes.

BACKGROUND: To determine association of nine single nucleotide polymorphisms (SNPs) in ADP ribosyltransferase-1 (ADPRT1), aldo-keto reductase family 1 member B1 (AKR1B1), receptor for advanced glycation end-products (RAGE), glutamine:fructose-6-phosphate amidotransferase-2 (GFPT2), and plasminogen activator inhibitor-1 (PAI-1) genes with chronic renal insufficiency (CRI) among Asian Indians with type 2 diabetes; and to identify epistatic interactionss between genes from the present study and those from renin-angiotensin-aldosterone system (RAAS), and chemokine-cytokine, dopaminergic and oxidative stress pathways (previously investigated using the same sample set). METHODS: Type 2 diabetes subjects with CRI (serum creatinine > or =3.0 mg/dl) constituted the cases (n = 196), and ethnicity and age matched individuals with diabetes for a duration of > or = 10 years, normal renal functions and normoalbuminuria recruited as controls (n = 225). Allelic and genotypic constitution of 10 polymorphisms (SNPs) from five genes namely--ADPRT1, AKR1B1, RAGE, GFPT2 and PAI-1 with diabetic CRI was investigated. The genetic associations were evaluated by computation of odds ratio and 95% confidence interval. Multiple logistic regression analysis was carried out to correlate various clinical parameters with genotypes, and to study epistatic interactions between SNPs in different genes. RESULTS: Single nucleotide polymorphisms -429 T>C in RAGE and rs7725 C>T SNP in 3' UTR in GFPT2 gene showed a trend towards association with diabetic CRI. Investigation using miRBase statistical tool revealed that rs7725 in GFPT2 was a perfect target for predicted miRNA (hsa miR-378) suggesting the presence of the variant 'T' allele may result in an upregulation of GFPT2 contributing to diabetic renal complication. Epistatic interaction between SNPs in transforming growth factor TGF-beta1 (investigated using the same sample set and reported elsewhere) and GFPT2 genotype was observed. CONCLUSIONS: Association of SNPs in RAGE and GFPT2 suggest that the genes involved in modulation of oxidative pathway could be major contributor to diabetic chronic renal insufficiency. In addition, GFPT2 mediated overproduction of TGF-beta1 leading to endothelial expansion and thereby CRI seems likely, suggested by our observation of a significant interaction between GFPT2 with TGF-beta1 genes. Further, identification of predicted miRNA targets spanning the associated SNP in GFPT2 implicates the rs7725 SNP in transcriptional regulation of the gene, and suggests GFPT2 could be a relevant target for pharmacological intervention. Larger replication studies are needed to confirm these observations.

Late-night salivary cortisol in normal subjects and in patients with Cushing's syndrome.

BACKGROUND: Late-night salivary cortisol is used as a screening test for Cushing's syndrome (CS) in many European and American countries. However, its utility has not been studied in an Asian-Indian population. OBJECTIVE: To establish the reference range in Asian-Indians and to evaluate its usefulness in the diagnosis of CS. METHODS: Three groups of subjects were studied: normal subjects, patients with suspected CS, and patients with proven CS. All participants collected saliva at 23:00 h using a Salivette. Salivary cortisol was measured using an automated electrochemiluminescence assay. RESULTS: There were 56 normal subjects, 40 patients with suspected CS, and 30 with proven CS. Of the 40 with suspected CS, three were confirmed to have CS. The remaining 37 served as control patients. The 97.5th centile of the late-night salivary cortisol concentrations in normal subjects was 10.87 nmol/l. The mean+/-SD 23:00 h salivary cortisol concentration in control patients and those with confirmed CS was 3.21+/-2.36 nmol/l and 32.33+/-44.14 nmol/l, respectively. All the control patients and 30.3% (10/33) of patients with CS had a salivary cortisol concentration of <10.87 nmol/l. With the use of a receiver operating characteristic curve, a cut-off of 4.55 nmol/l gave a sensitivity of 93.9% and specificity of 81.1%. However, as this cut-off is less than the functional sensitivity of the assay, it may not be clinically applicable. CONCLUSIONS: The reference range for late-night salivary cortisol in our population was <10.87 nmol/l. With this cut-off, the sensitivity was 69.2% and specificity 100%. Even though this automated electrochemiluminescence assay is easy and quick to use, its clinical utility in measuring the low salivary cortisol concentrations needs further investigation.

Nucleotide variations in mitochondrial DNA and supra-physiological ROS levels in cytogenetically normal cases of premature ovarian insufficiency.

Premature ovarian insufficiency (POI) is defined as the cessation of ovarian function under the age of 40 years and is characterized by amenorrhea, hypoestrogenism, and elevated serum gonadotrophin concentration (FSH). It is a heterogeneous disorder with a multicausal pathogenesis; however, majority of cases are idiopathic. In idiopathic POI, involvement of unknown mechanisms may increase rate of oocyte apoptosis. Studies have shown that elevated reactive oxygen species (ROS) levels affect the quality of gametes. Mitochondrial mutations in different complexes of electron transport chain have been reported to disrupt the electron flow which lead to formation of more superoxide ions or increased levels of ROS. This study was aimed to screen the mitochondrial genome for variations in idiopathic POI (n = 25) and occult ovarian insufficiency (OI) (n = 5) patients. 30 patients diagnosed with POI and occult OI were enrolled in this study. Blood samples were collected from the patients and controls. DNA was extracted using phenol chloroform method. A total of 102 nucleotide variations were observed in patients as compared with 58 nucleotide variations in controls. 24% variations were found to be non-synonymous and 76% were synonymous. It was found that 48% variations were in complex I, 8% in complex III, 24% in complex IV, and 20% in complex V of electron transport chain. We found most of the non-synonymous mitochondrial variations in complex I (48%) of the respiratory chain which is the largest enzyme complex and is associated with oxidative stress. Some non-synonymous pathogenic alterations (p.M31T, p.W239C, p.L128Q) and non pathogenic alterations (ATPase6:p.T53I, ATPase6:p.L190F, ATPase6:p.L199L) were found to be significantly higher in cases as compared with controls. The preliminary data suggest that the mitochondrial mutations and subsequent decline in ATP levels may accelerate follicular atresia and lead to POI. The results of this preliminary study highlight the need to extend this study by analyzing large number of samples in different ethnic populations and analyze for ROS levels and mitochondrial mutations in oocytes as they are of different embryonic origin and develop in a different microenvironment.

Oxidative stress and ATPase6 mutation is associated with primary ovarian insufficiency.

PURPOSE: Primary ovarian insufficiency (POI) is a heterogeneous, multifactorial disorder. Though genetic anomalies, infections, autoimmune disorder and hormonal imbalance are few of the causes of POI, in the majority of patients (50-60%) no etiology has been identified. Mitochondrial bioenergetics and biogenesis play an important role in oocyte and embryo development, whereas mtDNA integrity and content are essential for the normal development of oocytes. ATPase6 helps to maintain the mt genome integrity, and mutations in ATPase6 are associated with overproduction of reactive oxygen species (ROS) in a variety of diseases; however, its role in POI has not been evaluated. Therefore, we planned to evaluate the potential role of ATPase6 gene mutations and associated oxidative stress in idiopathic cases of POI. METHODS: This pilot study included: 20 cases of POI with FSH level of >40 mIU/ml; 4 cases of occult ovarian insufficiency (occult OI) with irregular menses and mean FSH levels of 16.4 mIU/ml; and 20 age-matched healthy female controls (FSH 2-5 mIU/ml). ROS levels in blood plasma were measured by luminol-dependent chemiluminescence assay and the ROS values were expressed as relative light unit per minute (RLU/min). mtDNA ATPase6 gene was amplified and sequenced from the blood lymphocyte DNA. RESULTS: Of all, 50% patients showed nucleotide changes in the ATPase6 gene, as compared to 10% in controls, and the majority of these mutations were non-synonymous. ATPase6 mt.8684 C>T and mt.9094 C>T were found to be significantly (P < 0.005) higher in cases as compared to controls. ROS levels were found to be significantly (P < 0.005) higher in POI and occult OI patients compared to controls and nucleotide changes were found to positively correlate with ROS levels. Moreover, ROS production was found to positively correlate (r = 0.7038, P < 0.001) with FSH levels of the patients (POI and OI) compared to controls. CONCLUSIONS: This pilot study clearly demonstrates for the first time ATPase6 gene nucleotide alterations and elevated ROS levels in idiopathic cases of POI. Therefore, it may be possible that OS associated with ATPase6 gene mutation may be causal in idiopathic cases of premature OI. However, larger studies with inclusion of more cases of both POI and occult OI are required to strongly establish the correlation between oxidative stress and mitochondrial nucleotide alterations in the pathogenesis of POI. Such cases with OS-induced POI may benefit immensely by early diagnosis and prompt antioxidant administration.

Long-term psychosocial adjustments, satisfaction related to gender and the family equations in disorders of sexual differentiation with male sex assignment.

PURPOSE: The varied management and counseling in disorders of sexual differentiation (DSD) depends a lot on the socioeconomic structure. A follow-up study was designed to evaluate the outcome in terms of patient satisfaction with strong socio-cultural issues. METHOD: Of the 1,134 DSD patients being followed up in pediatric intersex clinic, 60 adolescents and adults assigned male sex in childhood were called for follow-up. They were interviewed for psychosocial and family adjustments including level of acceptance of gender, social relationships and future expectations. RESULTS: The ages ranged from 15 to 25 years (mean, 19.3 ± 3.7 years). The disorders were male pseudo hermaphrodite (MPH)-43, mixed gonadal dysgenesis (MGD)-3, true hermaphrodite (TH)-7 and congenital adrenal hyperplasia (CAH)-7. Of all patients, 85% (51/60) felt satisfied with their gender assignment; 76.9% (46/60) did not feel comfortable with the opposite sex. Penile erections; ejaculation and masculine voice were present in 53, 44 and 47 patients. Facial hair was normal; sparse and absent in 16, 26 and 18 patients, respectively. Stretched penile length was 2.5-9 cm (median, 5.5 cm) and 16/60 patients were satisfied with their penile length; 28 patients required redo surgeries for scrotum diverticulum (1), proximal penile diverticulum (1), stricture urethra (2), hair in the urethra (3), vaginal pouch dilatation (1), orchiopexy (2), residual chordee correction (3), distal urethroplasty (4), urethral fistula repair (21), mastectomy (6) and testicular prosthesis (4). Family support was available to all 85% (51/60) of the patients who had good family relationships. However, only 15% (9/60) felt that they fitted into society. Peer relationships were considered 'good' by 43/60 and poor by 17/60. Two patients had got married and 44.8% (26/58) patients would consider marriage in future. Most patients (42/60) were worried about the smaller size of the phallus and lack of adequate semen, leading to apprehension before marriage. As much as 15 patients had jobs, 15 attended school, 3 attended colleges and 17 illiterate patients were dependent on their families. CONCLUSIONS: Despite moral, social and economic support provided by the parents, children with DSD continue to have apprehensions in social adjustments.

Bone mineral density in Indian women with rheumatoid arthritis.

Osteoporosis (OP) is being increasingly recognized in inflammatory rheumatic diseases like rheumatoid arthritis (RA). Ethnicity influences bone mineral density (BMD) and fracture risk. Due to paucity of data on this aspect of RA from Asian countries including India, we prospectively studied 84 premenopausal women with RA of at least 2 years duration and 247 healthy, age (within 5 years) and sex-matched controls. A significant difference in BMD between patients and controls was observed only at the femoral neck. As many as 22% patients with RA exhibited osteoporosis at least one site in contrast to 9% controls. Nearly 40% of patients exhibited osteopenia at all the three sites. Modified Sharp score, disease duration and DMARD naive period were found to correlate with low BMD. However, on multivariate analysis, only modified Sharp score was shown to be significantly associated with low BMD. Our study draws attention to the poor bone health in Asian Indian women with RA.

Phenotype, hormonal profile and genotype of subjects with partial androgen insensitivity syndrome: report of a family with four adult males and one child with disorder of sexual differentiation.

There is little information on the molecular basis of intrafamilial and inter-familial phenotypic heterogeneity with the same androgen receptor (AR) mutation in patients with partial androgen insensitivity syndrome. A genetic analysis was performed in a large kindred with ambiguous genitalia and the genotype-phenotype correlations were analysed. The index case was brought for sex assignment. Family history revealed four other affected members who had hypospadias and varying degrees of virilisation. All the affected males had hemizygous mutations in the third exon of the AR gene (A596T). One was also found to have a heterozygous mutation in the fourth exon of the 5 alpha reductase type 2 gene (G196S). This affected male with double mutations was better virilised compared with the other affected members with a single mutation. The degree of virilisation correlated with serum testosterone levels. Gynaecomastia was not present in any of these subjects. It is concluded that the subject with dual gene defects also had higher levels of testosterone and pubertal virilsation. Testosterone levels possibly govern the degree of pubertal virilisation in subjects with A596T gene defects. It is not clear whether the better pubertal virilsation and higher testosterone are in any way causally related to the SRD5A2 gene defect.

Association of dopaminergic pathway gene polymorphisms with chronic renal insufficiency among Asian Indians with type-2 diabetes.

BACKGROUND: Genetic markers conferring susceptibility to diabetes specific renal disease remains to be identified for early prediction and development of effective drugs and therapies. Inconsistent results obtained from analysis of genes from classical pathways generate need for examination of unconventional genetic markers having role in regulation of renal function. Experimental and clinical evidences suggest that dopamine is an important natriuretic hormone. Therefore, various genes involved in regulation of dopamine bioavailability could play a role in diabetic chronic renal insufficiency (CRI). We investigated the contribution of 12 polymorphisms from five Dopaminergic pathway genes to CRI among type-2 diabetic Asian Indian subjects. METHODS: Genetic association of 12 polymorphisms (SNPs) from five genes namely-dopamine receptor-1 (DRD1), DRD2, DRD3, DRD4, andcatechol-O-methyltransferase (COMT) with diabetic CRI was investigated using a case-control approach. Logistic regression analysis was carried out to correlate various clinical parameters with genotypes, and to study pair wise interactions between SNPs of different genes. RESULTS: SNPs -141 ins/del C and G>A (1 kb upstream from exon 2) in DRD2 gene showed significant allelic and genotypic association. Allele -141 insC and genotype -141 insC/insC of -141 ins/del C polymorphism, and allele A of G>A SNP were found to be predisposing to CRI. Our result of allelic and genotypic association of -141 insC/delC SNP was also reflected in the haplotypic association. Heterozygous genotype of polymorphism 900 ins/del C in COMT gene was predisposing towards CRI. CONCLUSION: Some polymorphisms in DRD2 and COMT genes are significantly associated with susceptibility to CRI in the Asian Indian population which, if confirmed would be consistent with a suggested role of dopamine metabolism in disease occurrence.

Clinical and laboratory profile of primary hyperparathyroidism in India.

AIM: To assess 25-hydroxyvitamin D (25OHD) concentrations in patients with primary hyperparathyroidism and to study the relationship, if any, between vitamin D concentration and bone disease. METHODS: Consecutive patients with diagnosed primary hyperparathyroidism were enrolled in the study. Clinical and biochemical details, including serum calcium, phosphate, alkaline phosphatase, parathyroid hormone (PTH) and 25OHD levels, were recorded. An abbreviated skeletal survey and preoperative localisation with ultrasound/CT scan of the neck and tetrofosmin/technetium-99m hexakis(2-methoxyisobutylisonitrile) parathyroid scan was performed. RESULTS: 39 patients with primary hyperparathyroidism were identified (mean (SD) age 38.4 (15.0) years (range 12-72)). The most common presenting features were bone pain (80%), fatigue (80%) and proximal muscle weakness (78%). Brown tumours were present in 58% of cases, renal calculi in 42% and nephrocalcinosis in 12%. The mean (SD) corrected serum calcium concentration was 12.47 (1.58) mg/dl (3.2 (0.4) mmol/l). Serum 25OHD concentration was <5 ng/ml in 11 patients (28%), 5-10 ng/ml in nine (23%), 10-20 ng/ml in 14 (36%), and >20 ng/ml in five (13%). Serum alkaline phosphatase, PTH and gland weight were higher, whereas serum 25OHD was lower, in patients with skeletal disease. Patients with 25OHD concentrations

Association of TGFbeta1, TNFalpha, CCR2 and CCR5 gene polymorphisms in type-2 diabetes and renal insufficiency among Asian Indians.

BACKGROUND: Cytokines play an important role in the development of diabetic chronic renal insufficiency (CRI). Transforming growth factor beta1 (TGF beta1) induces renal hypertrophy and fibrosis, and cytokines like tumor necrosis factor-alpha (TNFalpha), chemoattractant protein-1 (MCP-1), and regulated upon activation and normal T cell expressed and secreted (RANTES) mediate macrophage infiltration into kidney. Over expression of these chemokines leads to glomerulosclerosis and interstitial fibrosis. The effect of MCP-1 and RANTES on kidney is conferred by their receptors i.e., chemokine receptor (CCR)-2 and CCR-5 respectively. We tested association of nine single nucleotide polymorphisms (SNPs) from TGFbeta1, TNFalpha, CCR2 and CCR5 genes among individuals with type-2 diabetes with and without renal insufficiency. METHODS: Type-2 diabetes subjects with chronic renal insufficiency (serum creatinine > or = 3.0 mg/dl) constituted the cases, and matched individuals with diabetes of duration > or = 10 years and normoalbuminuria were evaluated as controls from four centres in India. Allelic and genotypic contributions of nine SNPs from TGFbeta1, TNFalpha, CCR2 and CCR5 genes to diabetic CRI were tested by computing odds ratio (OR) and 95% confidence intervals (CI). Sub-analysis of CRI cases diabetic retinopathy status as dependent variable and SNP genotypes as independent variable in a univariate logistic regression was also performed. RESULTS: SNPs Tyr81His and Thr263Ile in TGF beta1 gene were monomorphic, and Arg25Pro in TGF beta1 gene and Delta32 polymorphism in CCR5 gene were minor variants (minor allele frequency <0.05) and therefore were not considered for case-control analysis. A significant allelic association of 59029G>A SNP of CCR5 gene has been observed and the allele 59029A seems to confer predisposition to development of diabetic CRI (OR 1.39; CI 1.04-1.84). In CRI subjects a compound group of genotypes "GA and AA" of SNP G>A -800 was found to confer predisposition for proliferative retinopathy (OR 3.03; CI 1.08-8.50, p = 0.035). CONCLUSION: Of the various cytokine gene polymorphisms tested, allele 59029A of CCR5 gene is significantly associated with diabetic renal insufficiency among Asian Indians. Result obtained for 59029G>A SNP of CCR5 gene is in conformity with reports from a Japanese population but due to sub-optimal power of the sample, replication in larger sample set is warranted.

Necessity of nuclear and mitochondrial genome analysis prior to assisted reproductive techniques/intracytoplasmic sperm injection.

Assisted reproductive technique (ART) has revolutionized the management of severe male factor infertility and in some countries 5% babies are conceived through ART/intra cytoplasmic sperm injection (ICSI). However, the carry-home live birth rate after several ART cycles is low (18-25%) and this is financially, physically and emotionally crippling for the couples. Genetic factors could lead to pre or post-implantation failure and thus explain for low ART success rate. Thus, this study was planned to understand, if infertile men harbour genetic abnormalities which may be iatrogenically transmitted by ART and adversely affect growth potential of embryo. Ninety infertile men underwent semen, cytogenetic, Yq microdeletion and mitochondrial mutation analysis. Of these, 14.4% cases harboured cytogenetic abnormality, and 8.89% Yq microdeletions. A high frequency of mitochondrial mutations was found in 23 men with asthenospermia. It is important to understand that through ART genetic abnormalities are transmitted to offspring, resulting in impaired growth and development potential of embryo and poor take-home live birth rate. Thus, genetic analysis is strongly recommend in all men with idiopathic infertility who opt for ART to counsel couples and provide them with most adapted therapeutics.

A clinico-microbiological study of diabetic foot ulcers in an Indian tertiary care hospital.

OBJECTIVE: To determine the microbiological profile and antibiotic susceptibility patterns of organisms isolated from diabetic foot ulcers. Also, to assess potential risk factors for infection of ulcers with multidrug-resistant organisms (MDROs) and the outcome of these infections. RESEARCH DESIGN AND METHODS: Pus samples for bacterial culture were collected from 80 patients admitted with diabetic foot infections. All patients had ulcers with Wagner's grade 3-5. Fifty patients (62.5%) had coexisting osteomyelitis. Gram-negative bacilli were tested for extended spectrum beta-lactamase (ESBL) production by double disc diffusion method. Staphylococcal isolates were tested for susceptibility to oxacillin by screen agar method, disc diffusion, and mec A-based PCR. Potential risk factors for MDRO-positive samples were explored. RESULTS: Gram-negative aerobes were most frequently isolated (51.4%), followed by gram-positive aerobes and anaerobes (33.3 and 15.3%, respectively). Seventy-two percent of patients were positive for MDROs. ESBL production and methicillin resistance was noted in 44.7 and 56.0% of bacterial isolates, respectively. MDRO-positive status was associated with presence of neuropathy (P = 0.03), osteomyelitis (P = 0.01), and ulcer size >4 cm(2) (P < 0.001) but not with patient characteristics, ulcer type and duration, or duration of hospital stay. MDRO-infected patients had poor glycemic control (P = 0.01) and had to be surgically treated more often (P < 0.01). CONCLUSIONS: Infection with MDROs is common in diabetic foot ulcers and is associated with inadequate glycemic control and increased requirement for surgical treatment. There is a need for continuous surveillance of resistant bacteria to provide the basis for empirical therapy and reduce the risk of complications.