Prevalence and factors associated with latent autoimmune diabetes in adults (LADA): a cross-sectional study.

BACKGROUND: The Latent Autoimmune Diabetes in Adults (LADA) is a slowly progressive Type 1 diabetes subgroup with onset during middle age. Studies report that about 10% of adults initially diagnosed with clinical Type 2 diabetes (T2D) have LADA. Inappropriate diagnosis and mismanagement of the LADA can increase the risk of diabetic complications, which affect the quality of life and is the cause of increased mortality. In low-income countries setting, data regarding the magnitude of LADA is limited. We carried out this study to estimate the burden of misdiagnosed LADA among T2D patients in selected health facilities in Dar es Salaam and to bring awareness to the use of Glutamic Acid Decarboxylase (GAD) autoantibody in screening for LADA. METHODOLOGY: We enrolled 186 phenotypically T2D patients in this cross-sectional study, through a standardized data collection tool we obtained participants' demographic and clinical information. For testing GAD levels, we used a double-antibody Enzyme-Linked Immunosorbent Assay (ELISA). The Fisher's Exact and student t-tests were used to test the significance of the statistical associations of the glycaemic control and diabetes complications between T2D and LADA. RESULTS: Out of 186 patients, 156 gave conclusive GAD Ab ELISA reading with LADA accounting for 5.1% (95% CI: 2.5 - 10.0). The mean age of subjects was 54.3 years (Range: 33-85 years). The parameters such as mean age, family history of diabetes mellitus status, Fasting Blood Glucose, clinical characteristics, and complications did not show significant statistical differences between patients with LADA and Type 2 diabetes. However, all LADA- Human Immunodeficiency Virus (HIV) comorbid patients had retinopathy, which was statistically insignificant in 20 (87%) T2D-HIV comorbid patients (p = 0.669). Neither neuropathy, nephropathy, nor Diabetic Mellitus (D.M.) foot syndrome was observed among LADA-HIV comorbid patients. Nevertheless, 22 (95.7%), 3 (13%), and 2 (8.7%) of T2D-HIV comorbidity had neuropathy, nephropathy, or D.M. foot syndrome, respectively. CONCLUSIONS: The study established a LADA prevalence of 5.1% among T2D patients and has shown the role of GAD autoantibody in the screening for LADA. The study calls for a well- designed larger longitudinal study to generate strong evidence on the association of risk factors and complications associated with the LADA. This will develop robust evidence on the association of risk factors and complications associated with the LADA and T2D.

CARDIOGENIC SHOCK AND GLOBUS PALLIDUS INJURY AS A PRESENTATION OF CARBON MONOXIDE POISONING.

Carbon monoxide poisoning is one of the leading causes of mortality and morbidity by poisoning in the world. Signs and symptoms are nonspecific and related to impaired oxygen delivery to tissues, with the brain being the most affected organ due to its high oxygen demand. CO-Hb is a poor indicator of severity and long-term outcome, with clinicians relying more on clinical features such as level of consciousness and need for intubation, organ dysfunction and shock and also pH level. A 45-year-old female was found unconscious in her home with the fireplace lit and smoke all over the house. She was last seen well 18 hours before. She was brought to the emergency department and was admitted to the ICU in coma and cardiogenic shock, with a metabolic acidosis with hyperlactacidemia and a CO-Hb level of 15.5%. Laboratorial investigation revealed hepatic cytolysis, acute renal failure, rhabdomyolysis and a troponin I level of 338 ng/L. ECG showed no acute myocardial ischemia. Echocardiogram revealed diffuse hypokinesia with an ejection fraction of 25%. Head CT scan showed bilateral and symmetrical hypodensities of the globus pallidus. The patient underwent hyperbaric oxygen treatment with full neurological and cardiac recovery, allowing extubation 48 hours after admission. This rare severe case of coma due to carbon monoxide intoxication with globus pallidus injury and cardiogenic shock was successfully treated with hyperbaric oxygen, showing that it can be the right treatment choice in these cases, with an excellent impact on neurological and cardiac outcome.

L'intoxication au CO est une des causes principales de décès par empoisonnement dans le monde. Les signes, non spécifiques, sont dus à l'hypoxie cellulaire et le cerveau est le plus souvent atteint en raison de sa consommation d'oxygène élevée. Le taux d'HbCO est un indice peu fiable de la gravité initiale et du risque de séquelles si bien que l'on préfère se baser sur la clinique (conscience, nécessité d'intubation, dysfonctions d'organe, choc) et le pH sanguin. Une femme de 45 ans a été trouvée inconsciente à son domicile entièrement enfumé, cheminée allumée. Le dernier contact remontait à 18 heures. Elle a été hospitalisée en réanimation en coma et choc cardiogénique, avec une acidose lactique et une HbCO à 15,5%. La biologie retrouvait une cytolyse hépatique, une insuffisance rénale aiguë, une rhabdomyolyse et une troponine I à 338 ng/L. L'ECG ne trouvait pas d'ischémie, l'échocardiographie objectivait une hypokinésie globale et évaluait la fraction d'éjection à 25%. La TDM cérébrale montrait une hypodensité pallidale bilatérale. L'oxygénothérapie hyperbare (OHB) a permis une récupération neurologique et cardiaque complètes, permettant l'extubation à h48. Cette récupération complète après OHB confirme qu'il peut s'agir du traitement idoine des intoxications graves au CO, avec un excellent impact sur les devenirs cardiaque et neurologique.

Fibrosis assessment in patients with nonalcoholic fatty liver disease: Adherence to proposed algorithms and barriers to complying with them.

INTRODUCTION AND AIMS: Fibrosis staging in patients with nonalcoholic fatty liver disease (NAFLD) is carried out through the application of stepwise algorithms but there is little real-world data on their use. Our aim was to calculate the number of patients with NAFLD and indeterminate or high risk for fibrosis, assessed through noninvasive scores, that consequently underwent further staging evaluation. MATERIALS AND METHODS: A cross-sectional multicenter cohort study was conducted on patients with NAFLD evaluated by hepatologists within the time frame of June 1 and July 31, 2018. The FIB-4 and NAFLD fibrosis scores were calculated in all the patients, and if at least one of the scores suggested indeterminate or high risk for fibrosis, we believed the patient should have undergone additional fibrosis staging assessment. RESULTS: The study included 238 patients. The median time interval from NAFLD diagnosis and inclusion in the analysis was 12.2 months (IQR 3.0-36.5). A total of 128 (54%) patients had at least one noninvasive score that suggested indeterminate or high risk for fibrosis but studies to confirm the fibrosis grade (elastography, biopsy, etc.) were performed on only 72 (56%). The main barriers encountered by the physicians for applying the staging algorithms were related to health insurance coverage and imaging study costs. CONCLUSIONS: A high percentage of patients with NAFLD were at indeterminate or high risk for fibrosis, according to noninvasive scores, but additional studies were carried out on only half of them, showing low adherence to current recommendations.

Fibrosis assessment in patients with nonalcoholic fatty liver disease: Adherence to proposed algorithms and barriers to complying with them. / Evaluación de fibrosis en pacientes con enfermedad por hígado graso no alcohólico: adherencia a los algoritmos propuestos y barreras para cumplir con ellos.

INTRODUCTION AND AIMS: Fibrosis staging in patients with nonalcoholic fatty liver disease (NAFLD) is carried out through the application of stepwise algorithms but there is little real-world data on their use. Our aim was to calculate the number of patients with NAFLD and indeterminate or high risk for fibrosis, assessed through noninvasive scores, that consequently underwent further staging evaluation. MATERIALS AND METHODS: A cross-sectional multicenter cohort study was conducted on patients with NAFLD evaluated by hepatologists within the time frame of June 1 and July 31, 2018. The FIB-4 and NAFLD fibrosis scores were calculated in all the patients, and if at least one of the scores suggested indeterminate or high risk for fibrosis, we believed the patient should have undergone additional fibrosis staging assessment. RESULTS: The study included 238 patients. The median time interval from NAFLD diagnosis and inclusion in the analysis was 12.2months (IQR 3.0-36.5). A total of 128 (54%) patients had at least one noninvasive score that suggested indeterminate or high risk for fibrosis but studies to confirm the fibrosis grade (elastography, biopsy, etc.) were performed on only 72 (56%). The main barriers encountered by the physicians for applying the staging algorithms were related to health insurance coverage and imaging study costs. CONCLUSIONS: A high percentage of patients with NAFLD were at indeterminate or high risk for fibrosis, according to noninvasive scores, but additional studies were carried out on only half of them, showing low adherence to current recommendations.

Late occurrence of pleural and peritoneal effusion due to Mycobacterium tuberculosis infection (TB) in a patient with posttransplantation recurrent HCV chronic hepatitis: safety of peginterferon and ribavirin treatment after recovery of TB:- a case report.

The late occurrence of a large and often long-lasting effusion in the pleural and peritoneal cavities after liver transplantation is an uncommon and poorly understood complication. Even rarer (<1%) is the incidence of Mycobacterium tuberculosis (MT) in Western world series. Herein we have described a case of massive pleural effusion and ascites due to MT occurring 22 months after liver transplantation for hepatitis C virus (HCV) cirrhosis. The infection was successfully treated with no hepatotoxicity or rejection, so that it was possible to start antiviral treatment with peginterferon and ribavirin for recurrent HCV without reactivation of MT infection.

Access to direct-acting antivirals for the treatment of hepatitis C in a country with limited resources. / Evaluación del acceso a antivirales para el tratamiento de la hepatitis C en un país con recursos limitados.

AIMS: To estimate the number of patients that have access to treatment of hepatitis C with direct-acting antivirals in Argentina and evaluate the factors associated with the lack of access. MATERIALS AND METHODS: A cross-sectional cohort study was conducted that included all the consecutive prescriptions of direct-acting antivirals issued at health centers that participated in the ECHOTM telemedicine project directed by the Hospital Italiano de Buenos Aires, within the time frame of January 2016 and February 2017. RESULTS: A total of 143 treatment prescriptions were included and overall access was 70% (95% CI 62-77%). The only independent factor associated with a lack of treatment access was coverage by a public healthcare system (OR 4.98 [95% CI 2.05- 12.09]). CONCLUSION: Patients with hepatitis C that were covered by a public healthcare system had a 4 times higher chance of not having access to treatment with direct-acting antivirals than patients covered by other healthcare systems (private insurance or the social welfare system).

A randomized trial of pegylated-interferon-alpha2a plus ribavirin with or without amantadine in the re-treatment of patients with chronic hepatitis C not responding to standard interferon and ribavirin.

BACKGROUND: There is yet no established treatment for chronic hepatitis C patients non-responder to standard interferon and ribavirin. AIM: To evaluate efficacy and safety of pegylated-interferon-alpha2a plus ribavirin with or without amantadine in such patients. METHODS: 161 non-responders to standard interferon and ribavirin were randomized into two groups: 81 patients (Group 1) were given weekly Peg-IFN-alpha2a 180 microg plus ribavirin 1,000-1,200 mg/daily for 12 months, 80 patients (Group 2) received weekly Peg-IFN-alpha2a 180 microg plus ribavirin 1,000-1,200 mg/daily and amantadine 200 mg/daily for 12 months. RESULTS: At the end of follow-up, HCV-RNA was negative in 29.6% of Group 1 and in 21.2% of Group 2 patients (P = 0.22). Patients with genotypes 1 and 4 responded better to bi-therapy (21.7%) than to triple therapy (17.3%, P = 0.5) while among patients with genotypes 2 and 3 there was a trend towards a higher sustained virological response rate when retreated with triple treatment (80% vs. 75%, P = 0.82). On multivariate analysis, genotype 1 or 4, high body mass index and >20% reduction of Peg-interferon were associated with the treatment failure. CONCLUSIONS: The addition of amantadine does not improve the overall SVR rate in non-responder patients retreated with Peg-IFN and ribavirin; however, about 30% of non-responders may achieve a sustained response, in particular patients with genotypes 2 and 3 show a high SVR (75%).

Bioecology and vectorial capacity of Aedes albopictus (Diptera: Culicidae) in Macao, China, in relation to dengue virus transmission.

Until 2001, the Chinese Territory of Macao had not registered any autochthonous dengue cases, despite the abundance of Aedes albopictus (Skuse), a known vector. This work describes a bioecological characterization of the local Ae. albopictus adult population, with the purpose of estimating the receptivity of Macao to dengue introduction. In the wet seasons of 1997 and 1998 and the dry season of 1998, Ae. albopictus was the most abundant human-biting mosquito. Daily biting rates of 314 mosquitoes per person were recorded in the wet season with a reduction to 94 in the dry season. Ae. albopictus was mainly exophagic and exophilic and had a human blood index of 44%. The parity rate of field-collected mosquitoes was 57%. Daily survival rate ranged from 91 to 97%. Estimates of vectorial capacity ranged from 144 to 880, depending on what parameter values were used. These estimates indicated a great receptivity for the introduction of dengue viruses, as the 2001 outbreak came to prove.

Transient detection of plasma HIV-1 RNA during postexposure prophylaxis.

Transient plasma human immunodeficiency virus (HIV) copies were detected by nucleic-acid sequence-based amplification during combination antiretroviral prophylaxis in a healthcare worker who reported a percutaneous injury from a stylet and who remained HIV-antibody-negative. An HIV-specific T-helper response, assessed by interleukin-2 production, was observed when tested at 13 months following the exposure.

The value of exploratory laparotomy in patients with endometrial carcinoma according to the new International Federation of Gynecology and Obstetrics staging.

OBJECTIVE: We conducted a retrospective review of 169 consecutive patients diagnosed with endometrial carcinoma to evaluate the advantage of exploratory laparotomy according to the new International Federation of Gynecology and Obstetrics (FIGO) classification as compared with clinical staging. METHODS: All 169 patients were admitted to the Department of Gynecologic Oncology from August 1980 through June 1988 and underwent exploratory laparotomy, which included total abdominal hysterectomy, bilateral salpingo-oophorectomy, and peritoneal washings. We performed complete lymph node dissection of the pelvic and the para-aortic areas on 87 patients with clinical stages I and II. Eighteen more patients were upgraded to stage III or IV during exploratory laparotomy with lymph node biopsy. Forty-nine patients did not have lymph node dissection because of age and medical contraindications. In 15 patients with clinical stage III or IV, lymph node dissection was performed as part of debulking surgery. Clinical staging showed 135 patients (80%) with stage I, 19 (11%) with stage II, three (2%) with stage III, and 12 (7%) with stage IV carcinoma. RESULTS: Surgical restaging according to the new FIGO classification resulted in 117 patients (69%) with stage I, seven (4%) with stage II, 23 (14%) with stage III, and 22 (13%) with stage IV carcinoma. Thirty patients (19%) of 154 with clinical stage I or II had extrauterine spread. Thirty-three of 169 patients (19.5%) had their clinical staging upgraded and six (3.5%) were downgraded. The 5-year actuarial survival rates for clinical stages I, II, and IV were 83, 64, and 8%, respectively. The actuarial survival rates for surgical stages I, II, III, and IV were 89, 100, 58, and 24%, respectively. Cases surgically staged as I with high-risk variables (eg, poor differentiation, unfavorable histologic types, and deep myometrial invasion) or stage II received 5000 cGy to the whole pelvis using a box technique. Patients with surgical stage III or IV received adjuvant intravenous chemotherapy (eg, doxorubicin, hydrochloride, Cytoxan, and cisplatin) consecutively for ten to 12 courses. Megestrol acetate was added for 2 years. CONCLUSIONS: Surgical staging after exploratory laparotomy defined the true extent of disease and identified 20% of the cases that may escape effective treatment.

Squamous cell carcinoma of the endometrium. A case report.

Invasive squamous cell carcinoma of the endometrium occurred secondary to squamous cell carcinoma in situ of the cervix. There have been 27 previous reports of secondary endometrial squamous cell carcinoma and 31 of primary.

Magnetic field strength dependence of chemical shift artifacts.

The dependence of proton MRI chemical shift artifacts on main magnetic field strength was investigated using three MR whole body systems from 0.3 to 1.5 T with both permanent and superconducting magnet designs. The magnetic field gradients varied from 0.09 to 1.0 gauss/cm. The image bandwidth varied from 8.54 to 32 kHz. Both phantoms and normal volunteers were studied. The chemical shift misregistration error in hertz was determined by the main magnetic field strength of the system which was proportional to the Larmor frequency. The actual image error in millimeters was determined by a combination of the shift in hertz as well as by the amplitude of the magnetic field gradients applied to form the image. Steeper gradients mapped a given shift in hertz onto a smaller millimeter displacement. The higher field strength systems tended to use steeper magnetic field gradients, but this increase was not enough to offset the higher absolute shift in hertz due to the higher Larmor frequencies. In general, the chemical shift in millimeters tended to increase with the increasing field strength despite the steeper imaging gradients. Based on these findings, strategies for minimizing the chemical shift artifact may be developed.

Aliasing artifacts in MR imaging.

Aliasing artifacts occur in the phase encoding direction when the dimensions of the imaged object exceeds the field of view. Signal generated from outside the field of view appears as a superimposed object at the opposite edge of the image. Increasing the field of view, changing the gradient axes relative to the patient, or use of surface coils can reduce aliasing and are parameters which are controlled by the radiologist/technologist. The manufacturer may provide software packages which exploit two additional strategies, either limiting the volume of the patient from which the MR signal is acquired as in Inner Volume Imaging or display of resolution unless the number of phase encoding steps is increased at a cost of increased acquisition time. The radiologist may in some clinical situations choose to tolerate aliasing in favor of improved resolution in the area of interest and decreased acquisition time.

Two brothers with severe developmental delay, growth retardation and unusual appearance.

We report on two brothers with short stature, severe developmental delay and unusual appearance. Several conditions including the Russell-Silver, Dubowitz, Floating-Harbour and Cockayne syndromes were considered in the differential diagnosis, but subsequently rejected. These two cases are likely to represent a new autosomal recessive or X-linked recessive syndrome.

[Role of surgery in the prognosis of AIDS and related syndromes. Case reports ]. / Ruolo della chirurgia nella prognosi dell'AIDS e sindromi correlate. Contributo casistico.

The authors review the epidemiologic and etiopathogenetic aspects of AIDS, in agreement with data published in december by the Center for Disease Control and by the WHO for the States, Europe and Italy. In their experience twenty-one patients, with clinical clues of AIDS, undergoing lymph node biopsy, have been analysed (18 LAS-ARC and 3 AIDS) and the role of prophylaxis for the surgical approach to the patient with aids or related syndrome has been underlined.

Utility of kindergarten teacher judgments in identifying early learning problems.

Most existing research on early identification of learning difficulties has examined the validity of methods for predicting future academic problems. The present study focused instead on the sensitivity of kindergarten teachers to learning problems in their students and on the continuity of teacher-identified problems over time. To identify early learning problems, kindergarten teachers in a suburban school district rated student progress toward six academic objectives as satisfactory or unsatisfactory. Twenty percent of the district's 303 kindergarten children received unsatisfactory ratings in at least one area. Thirty-eight of these children (identified group) were matched to 34 children with satisfactory ratings in all areas (nonidentified group). Results of testing conducted during kindergarten revealed poorer academic achievement in identified children than in nonidentified children. Children from the identified group also performed more poorly than children from the nonidentified group on tests of phonological processing and working memory/executive function and were rated by teachers as having more behavior and attention problems and lower social competence. Follow-up of the sample to first grade documented continued learning problems in the identified group. These findings support the use of teacher judgements in early detection of learning problems and argue against reliance on discrepancy criteria.

On Coquilleitidia crassipes, a new record for Macau, with a key to adults of the subgenera and species groups of the genus.

Coquillettidia (Coquillettidia) crassipes is recorded for the 1st time in the Territory of Macau, southern China. The systematics of the genus is examined, new species groups are proposed, and a key to subgenera and species groups of Coquillettidia is provided.

[Evaluation of nutritional status of adult middle class healthy subjects. Energy and protein intake, anthropometry, blood biochemical tests, and immunocompetence tests]. / Avaliação do estado nutricional de indivíduos adultos sadios de classe média. Ingestão energética e protéica, antropometria, exames bioquímicos do sangue e testes de imunocompetência.

Nutritional status was assessed in 151 middle-class healthy adult individuals (69 medical students, 18-29 y, 34 males, 35 females); 48 university personnel, 30-49 y, 24 males, 24 females; and their older relatives, 34 subjects, 50-79 y, 19 males, 15 females) living in Botucatu, S. Paulo. Methods included anthropometric measurements, energy and protein intakes, blood biochemical analyses and cutaneous delayed hypersensitivity tests. Anthropometric measurements showed higher values in men, with the exception of the triceps skinfold thickness (higher in women) and of the arm fat area (higher in the older age female groups); aging seemed to be associated with increases of weight, arm muscle variables and with arm fat accumulation in women and with increases of arm muscle variables in men. The values for anthropometric measurements were in general higher than those found in other Brazilian studies; on the other hand, they approximate to but do not entirely agree with the data representative of the international referential adult population: differences were mainly concerned with body weight and upper arm muscle parameters, which were lower in our sample. As regards energy intake, values found in subjects under 50 years of age were lower than the recommended dietary allowances; averages found for protein intake were above the level recommended by WHO/FAO/UNU (1985). The mean values for serum proteins and lipids were similar to those of referential data. As regards the hypersensitivity tests, it was found that none of the individuals challenged with four antigens (PPD, Candidin, Vaccinia and phytohemagglutinin) presented less than two positive skin reactions.(ABSTRACT TRUNCATED AT 250 WORDS)

[Port malaria caused by Plasmodium falciparum a case report]. / Malaria portuale da Plasmodium falciparum: descrizione di un caso clinico.

A case of unusual transmission by Plasmodium falciparum malaria is reported. The patient, had not been travelling outside North-West of Italy for the previous 6 months, he was not drug abuser. He had spent the last two months prior his admission, partly in his home town, an urban area in the region of Piemonte, and partly in a resort area on the Ligurian sea. Neither place has ever been associated with unusual malaria transmission. The possible transmission way is through a live vector imported from endemic area in a port terminal near a resort area.

[Staff meetings as a fundamental element in work organization]. / As reuniões de equipe como elemento fundamental na organização do trabalho.

The present study was developed as part of the Integrated Research Project "New Forms of Health Work Organization: emphasis on nursing work", carried out at the University Hospital of the Rio Grande Federal University. A series of studies were carried out with the objective of identifying the occurrence, content, periodicity and vision of nursing personnel about staff meetings in order to understand the importance of holding periodic meetings. Interviews were carried out with 21 nursing professionals. Data analysis revealed two main categories: differences in vision about staff meetings among nursing personnel and dichotomy between what theory dictates and what truly happens in staff meetings.