Congenital adrenal hyperplasia complicated by gonadotropin-dependent precocious puberty.

Precocious puberty, characterised by the early appearance of secondary sexual characteristics, poses challenges in diagnosis and management. Here, we describe a case of precocious puberty diagnosed in a boy in middle childhood, who presented with progressive phallus enlargement, pubic hair development and increased aggressive behaviour. Hormonal evaluation confirmed the diagnosis of congenital adrenal hyperplasia (CAH), complicated by gonadotropin-dependent precocious puberty. The case highlights the importance of assessment of testicular volume in a patient presenting with precocious puberty. Symmetrical testicular enlargement in a patient with CAH suggests premature activation of the hypothalamic-pituitary-gonadal axis. The patient received glucocorticoid therapy to suppress androgen production related to CAH and gonadotropin-releasing hormone analogue therapy to control premature activation of the hypothalamic-pituitary-gonadal axis. Follow-up visits showed regression of secondary sexual characteristics and improved growth velocity.

The Prevalence of Anemia in Hospitalized Patients With Diabetic Foot Ulcer (DFU) and the Relationship Between the Severity of Anemia and the Severity of DFU.

BACKGROUND AND AIMS: We aim to determine the prevalence of anemia in hospitalized patients with diabetic foot ulcers (DFUs) and estimate the relationship between the severity of anemia and diabetic foot ulcer. MATERIALS AND METHODS: We retrospectively collected and evaluated the data of 323 patients hospitalized with diabetic foot ulcer (DFU). We included 299 type 2 diabetic patients with foot ulcers of neuropathic or neuroischemic nature with infection. Anemia was defined based on World Health Organization (WHO) criteria, and the severity of DFU was classified in University of Texas (UT) grades. RESULTS: Anemia was detected in 94.3% of DFU, and the prevalence of mild, moderate, and severe anemia was 16.7%, 55.7%, and 27.6%, respectively. There was a significant difference in the mean hemoglobin (Hb) levels among the patients with varying grades of severity of DFU (1B: Hb=10.17±2.08 gm/dL, 2B: Hb=9.27±2.04 gm/dL, 3B: Hb=8.03±1.829 gm/dL; p value=<0.0001). The iron study was available in 141 (47.15%) patients and was suggestive of anemia of chronic disorder (mean serum iron=40.22±23.81 mcg/dL, mean total iron-binding capacity (TIBC)=239.34±67.24 mcg/dL, mean ferritin=378.05±141.337 ng/mL). TIBC significantly decreased (1B=262.13±61.05, 2B=233.65±71.26, 3B=222.43±74.18; p=0.04), and ferritin significantly increased (1B=309.9±70.76, 2B=351.73±94.22, 3B=488.58±170.4; p<0.0001) with increasing DFU severity. Hemoglobin was significantly decreased at the time of discharge in comparison to that at admission (9.3±2.1 gm/dL versus 8.8±1.5 gm/dL; p value=0.01). Red blood cell (RBC) counts, mean corpuscular volume (MCV), mean corpuscular hemoglobin concentration (MCHC), lymphocyte counts, albumin, calcium, and high-density lipoprotein (HDL) significantly decreased with the increase of DFU severity. The duration of hospitalization, total leucocyte counts, neutrophil counts, and neutrophil-to-lymphocyte ratio (NLR) increased with the severity of DFU. CONCLUSIONS: The prevalence of anemia was very high in DFU and more than three-fourths of the patients had moderate to severe anemia. The severity of anemia was associated with the severity of DFU. The most common cause of anemia was anemia of chronic disorder secondary to diabetic foot infection. During the period of hospitalization, hemoglobin decreased despite improvement in DFU infection.

Prevalence of Organ-Specific Autoimmunity in Patients With Type 1 Diabetes Mellitus.

INTRODUCTION: Type 1 diabetes mellitus (T1DM) is associated with other autoimmune disorders that are characterized by presence of organ-specific autoantibodies. The present study was undertaken to assess the prevalence of organ-specific autoantibodies among newly diagnosed T1DM subjects of India and to study its relationship with glutamic acid decarboxylase antibody (GADA). We also compared the clinical and biochemical parameters in GADA-positive and -negative T1DM subjects. METHODS: In a hospital-based cross-sectional study, we studied 61 patients with newly diagnosed T1DM ≤ 30 years of age. T1DM was diagnosed on the basis of acute onset of osmotic symptoms with or without ketoacidosis, severe hyperglycaemia [blood glucose > 13.9 mmol/l (>250 mg/dl)] and insulin requirement from the onset of diabetes. Subjects were screened for autoimmune thyroid disease (thyroid peroxidase antibody [TPOAb]), celiac disease (tissue transglutaminase antibody [tTGAb]), and gastric autoimmunity (parietal cell antibody [PCA]). RESULTS: Of the 61 subjects, more than one-third (38%) had at least one positive organ-specific autoantibody. In particular, 13 (21.3%) were found to be positive for TPOAb, nine (14.8%) were positive for tTGAb and 11 (18%) were positive for PCA. GADA was positive in 15 (25%) subjects. The frequency of TPOAb tended to be higher in patients who had GADA positivity compared with those with no circulating GADA (40% vs. 15.2%; p=0.07). Subjects positive for GADA were also more likely to be PCA positive compared with those who were GADA negative (40 vs.10.9%, p=0.02). There were no differences in frequency of diabetic ketoacidosis, body mass index, hemoglobin A1C (HbA1c), insulin requirement or fasting C-peptide in GADA-positive and -negative patients. CONCLUSION: We support the recommendation for regular screening of organ-specific autoantibodies, in particular TPOAb, tTGAb and PCA in all patients with T1DM. Detection of these autoantibodies at onset may prevent complications associated with delayed diagnosis of these disorders. We also conclude that there is higher frequency of TPOAb and PCA in GADA-positive T1DM patients as compared to negative ones. However, patients with positive GADA had similar clinical and biochemical parameters compared to GADA-negative subjects. Lastly, low GADA positivity in our study cohort as compared to Western populations suggests the heterogenous nature of T1DM in the Indian population.

Bone Mineral Metabolism During Chemotherapy in Childhood Acute Lymphoblastic Leukemia.

OBJECTIVE: The aim of this study was to evaluate levels of vitamin D, bone mineral density (BMD), and radiograph features at diagnosis and after 6 months of chemotherapy in patients with acute lymphoblastic leukemia (ALL). Vitamin D levels were also correlated with BMD and radiograph features. MATERIALS AND METHODS: 25-Hydroxy vitamin D [25(OH)D] levels, BMD, and radiograph features were assessed in 50 newly diagnosed patients of ALL in the age group of 2 to 14 years. A total of 30 age-matched and sex-matched children were recruited as controls. Vitamin D deficiency was defined as 25(OH)D <10 ng/mL, Vitamin D insufficiency as 10 to 29 ng/mL, and Vitamin D sufficiency as ≥30 ng/mL. Enzyme immunoassay (EIA) was used for the quantitative measurement of 25(OH)D levels in plasma and a LUNAR DPX NT bone densitometer was used for the assessment of BMD. RESULTS: The mean age of the patients was 6.3 years, with a male:female ratio of 1.38:1. The mean 25(OH)D levels were 31.90±16.90 ng/mL in patients at diagnosis against 41.63±20.50 ng/mL in controls (P=0.02). Levels were 18.50±11.10 ng/mL postchemotherapy (P=0.00). Female sex was a risk factor for deficient 25(OH)D levels. There was a significant decrease in BMD postchemotherapy in the age groups of 5 to 10 and above 10 years at the femoral neck. Osteopenic changes were observed in more number of patients after 6 months of chemotherapy. There was a significant correlation between vitamin D levels, BMD, and osteopenic changes. CONCLUSIONS: Vitamin D deficiency was common among ALL patients, which worsened after chemotherapy. This had a significant correlation with BMD and osteopenic changes in radiograph.

Metabolic changes in the patients on second-line highly active antiretroviral therapy (HAART): A prospective cohort study from north India.

INTRODUCTION: In India, there is a genetic predisposition to insulin resistance and cardiovascular risk, the impact of ART (antiretroviral therapy) on lipid profile and blood sugar may be significant. The study of potential implications of highly active antiretroviral therapy (HAART)-associated metabolic syndrome is critical to prevent cardiovascular diseases in the Indian population. AIMS: This study was done to determine the prevalence of metabolic changes (dyslipidaemia, hyperglycemia and insulin resistance) among HIV patients on second-line ART. SETTINGS AND DESIGN: A prospective cohort study. METHODS AND MATERIALS: We enrolled 150 patients, who were started on second-line HAART. Patients were investigated for fasting blood sugar, lipid profile and insulin level at baseline and after 6 months. STATISTICAL ANALYSIS: The data were analysed using SPSS software (version 20; IBM Corp., Armonk, N.Y., USA). Student's t-test was used to compare numerical variables in the two groups. P value < 0.05 was considered as statistically significant. RESULTS: There was a significant increase in serum cholesterol, LDL and triglyceride in patients with protease inhibitors (PIs) containing regimens. LDL levels were increased from 65 to 80 mg/dL (P = <.003) after treatment. Triglycerides were increased from 138 to 152 mg/dL. (P = <0.001). Median fasting blood sugar was increased from 85 to 96 mg/dL (P = <0.002). HOMA-IR was also significantly increased in the PI group (1.54 vs. 2.1, P <.003). However, serum HDL did not change significantly. CONCLUSIONS: Appropriate drug selection with timely switching of ART is crucial to prevent metabolic complications in patients taking long-term PIs.

Novel mutations and spectrum of the disease of NR0B1 (DAX1)-related adrenal insufficiency in Indian children.

Background X-linked adrenal hypoplasia congenita (AHC), due to mutations in the nuclear receptor superfamily 0, group B, member 1 (NR0B1)/dosage-sensitive sex reversal, AHC, critical region on the X chromosome, gene 1 (DAX1) gene, usually presents with a salt-wasting adrenal crisis in infancy and hypogonadotropic hypogonadism (HH) in adolescents. Genetic reports in the literature from patients of diverse ethnicity are limited. We describe the atypical clinical characteristics and molecular genetic results in six Indian patients. Methods Both exons and flanking intronic sequences of the NR0B1 gene were amplified and sequenced in five patients. In the sixth patient, suspected to have a large deletion, multiplex ligation-dependent probe amplification (MLPA) and chromosomal microarray analysis were performed. Results Sequencing revealed three novel mutations: a nonsense mutation (c.776C > A), a deletion (c.298del), both causing loss of domains which are highly conserved among nuclear receptor families, and a missense mutation (c.1112T > C). In-silico analysis by structure-based protein modeling predicted a de-stabilizing effect of the novel missense mutation. Two previously reported mutations were seen in patients with atypical manifestations such as late-onset adrenal insufficiency and precocious puberty. One patient had a 7.15-Mb contiguous deletion involving the NR0B1, Duchenne muscular dystrophy (DMD), glycerol kinase (GK) and melanoma antigen, family B, 16 (MAGEB16) genes. Conclusions Our report emphasizes the wide clinical spectrum of AHC, including rare manifestations, and enumerates unique mutations in the NR0B1 gene.

Comparison of Indian Council for Medical Research and Lunar Databases for Categorization of Male Bone Mineral Density.

The mainstay of diagnosis of osteoporosis is dual-energy X-ray absorptiometry (DXA) scan measuring areal bone mineral density (BMD) (g/cm2). The aim of the present study was to compare the Indian Council of Medical Research database (ICMRD) and the Lunar ethnic reference database of DXA scans in the diagnosis of osteoporosis in male patients. In this retrospective study, all male patients who underwent a DXA scan were included. The areal BMD (g/cm2) was measured at either the lumbar spine (L1-L4) or the total hip using the Lunar DXA machine (software version 8.50) manufactured by GE Medical Systems (Shanghai, China). The Indian Council of Medical Research published a reference data for BMD in the Indian population derived from the population-based study conducted in healthy Indian individuals, which was used to analyze the BMD result by Lunar DXA scan. The 2 results were compared for various values using statistical software SPSS for Windows (version 16; SPSS Inc., Chicago, IL). A total 238 male patients with a mean age of 57.2 yr (standard deviation ±15.9) were included. Overall, 26.4% (66/250) and 2.8% (7/250) of the subjects were classified in the osteoporosis group according to the Lunar database and the ICMRD, respectively. Out of the 250 sites of the DXA scan, 28.8% (19/66) and 60.0% (40/66) of the cases classified as osteoporosis by the Lunar database were reclassified as normal and osteopenia by ICMRD, respectively. In conclusion, the Indian Council of Medical Research data underestimated the degree of osteoporosis in male subjects that might result in deferring of treatment. In view of the discrepancy, the decision on the treatment of osteoporosis should be based on the multiple fracture risk factors and less reliably on the BMD T-score.

Complete Androgen Insensitivity Syndrome due to Mutations in the DNA-Binding Domain of the Human Androgen Receptor Gene.

Androgen insensitivity syndrome (AIS) is an X-linked recessive disorder with a 46,XY karyotype caused by alterations in the androgen receptor (AR) gene. We have identified 2 mutations in the AR gene that resulted in complete androgen insensitivity syndrome (CAIS) in 2 unrelated cases. This study includes cytogenetics, hormonal, molecular, and bioinformatics analysis including sequencing of the SRY (sex-determining region Y) and AR genes. Mutational analysis in the first case of primary amenorrhea revealed a novel nucleotide substitution (IVS2-2A>G) in the second intron of the AR gene. The mutation is located in the acceptor splice site (2 nucleotides before exon 3) and caused skipping of exon 3 and formation of an abnormal protein. The second mutation (g. 98762_98764delTCT) was identified in a case of oligoamenorrhea and caused the deletion of 1 amino acid (p.∆Phe583). Both identified mutations were located in the conserved P-box region of the DNA-binding domain which is responsible for base-specific contacts with the DNA major groove. Furthermore, a hormonal imbalance was also noticed in both cases with high levels of gonadotropins like FSH and LH in both cases. The present study concluded that both identified AR mutations are predicted to either abolish or decrease the binding ability of the AR to androgen response elements of its downstream genes.

Precontrast T1 signal measurements of normal pituitary and microadenoma: A retrospective analysis through DCE MRI signal time curves.

BACKGROUND: The dynamic contrast enhanced magnetic resonance imaging (DCE MRI) has currently become the most utilized technique for the detection of pituitary microadenoma. However, owing to differential enhancement of normal pituitary, high rate of false positivity remains a concern in its interpretation. PURPOSE: Our aim was to assess the utility of precontrast T1 signal intensity ratio (SIR) of the lesions suspected on DCE MRI, in prediction of presence of microadenoma. MATERIALS AND METHODS: We retrospectively reviewed MRI of 23 patients referred for DCE MRI of pituitary (group 1, 15 patients with diagnosis of pituitary microadenoma; and group 2, patients not clinically labeled as microadenoma). STC were plotted and T1-SIR at t = 0 s was obtained at the suspicious zone of differential enhancement (SIR T) and normal pituitary (SIR P). SIR difference (SIR P - SIR T) and relative SIR difference (SIR P - SIR T/SIR P) were calculated for each patient and was compared between the two groups. RESULTS: Mean T1 SIR is lower in patients with microadenoma than those without (P = 0.065). SIR difference and relative SIR difference was higher in patients with microadenoma (P = 0.003 and 0.005, respectively). Receiver-operated characteristic curve analysis demonstrated that a cut-off of 26 and 0.107 for SIR difference and relative SIR difference, respectively, could diagnose microadenoma with 100% specificity and reasonable sensitivities. CONCLUSION: The baseline precontrast T1 SIR evaluation of the lesion suspected to be microadenoma on DCE MRI, derived through STC curve, can increase diagnostic confidence in diagnosis of microadenoma.

Reversal of nocturnal non-dipping of blood pressure after Levothyroxine therapy in patients with subclinical hypothyroidism.

AIMS: To study the loss of diurnal variation in blood pressure in normotensive patients with Subclinical/overt hypothyroidism and effect of Levothyroxine (L-T4) treatment. MATERIALS AND METHODS: In this interventional study Eighty patients between 17- 50 years with newly detected OH and SCH (74 women and 6 men) and nine euthyroid subjects (all men) with blood pressure <140/90 were recruited. All patients underwent 24h ambulatory blood pressure monitoring (ABPM) using ABPM machine before and after treatment with L-T4. Diurnal index (DI), Percent time elevation (PTE), Hyperbaric impact (HBI) were studied pre and post L-T4 treatment. RESULTS: Of the 89 subjects (22 SCH, 58 OH and 9 controls), 7 of the SCH and 30 of OH subjects reported back in follow up after L-T4 supplementation for evaluation. DI, HBI and PTE when compared at baseline between different groups (SCH- OH, SCH- control, OH- control) were insignificant. After L-T4 supplementation DI, HBI and PTE varied significantly with p value 0.007, 0.003 and 0.003 respectively between SCH- OH only. Post L-T4 analysis in SCH group was statistically insignificant (p-value 0.102) but a trend toward improvement in DI was noted (baseline and post treatment DI mean 7.00 and 13.00 respectively). CONCLUSION: Loss of nocturnal dipping was found in patients with OH and SCH which was restored after L-T4 therapy only in patients with SCH and not with OH. TREATMENT: of SCH patients with high cardiovascular risk may be beneficial in this setting and can be a new indication for LT4 therapy in SCH.

Interleukin-6 and Interleukin-8 Levels Correlate With the Severity of Aplastic Anemia in Children.

AIM: The aim of this study was to evaluate the levels of interleukin (IL)-6 and IL-8 in patients with aplastic anemia and its correlation with severity of the disease. MATERIALS AND METHODS: IL-6 and IL-8 levels were measured in 40 patients with aplastic anemia in the age group of 4 to 14 years. A total of 40 healthy children served as controls. Quantitative estimation of IL-6 and IL-8 was performed using a solid-phase sandwich ELISA kit. Results were presented as IL-6 and IL-8 concentrations in pg/mL. Patients received immunosuppressive therapy per the British Committee for Standards in Haematology Guidelines 2009. RESULTS: Mean age of the patients was 9.78±2.74 years. IL-6 level of patients was elevated compared with controls (193.48±352.3 vs. 4.58±3.39; P<0.001). IL-8 levels were also significantly elevated in patients compared with controls (15.58±18.0 vs. 1.85±0.95; P<0.001). IL levels were also assessed in relation to severity of the disease. Levels were the highest in patients with very severe aplastic anemia (724.33±519.42), followed by severe aplastic anemia (80.51±66.28 pg/mL), and non-severe aplastic anemia (6.01±1.89). Differences were statistically significant. A similar trend was also observed for IL-8 levels, where the levels were 41.02±24.23, 11.34±8.0, and 1.67±0.71 for very severe aplastic anemia, severe aplastic anemia, and non-severe aplastic anemia, respectively. The differences were again statistically significant. IL levels were also correlated with the treatment outcome. Responders had lower levels compared with nonresponders, but the difference was not statistically significant (186.36±322.45 vs. 198.74±368.10). Levels of ILs decreased in responders, but were not comparable with that of controls 6 months after therapy. CONCLUSIONS: High levels of IL-6 and IL-8 were observed in children with aplastic anemia. Increased levels showed correlation with disease severity and therefore appear to play an important role in aplastic anemia. However, levels had no significant correlation with the treatment outcome.

Risk factors of diabetes in North Indians with metabolic syndrome.

AIM: Metabolic syndrome progresses to diabetes and determinants of this progression like hyperinsulinemia, hypertriglyceridemia and genetic factors have been speculative. The present study was aimed at quantifying the insulin resistance and influence of family history of diabetes in subjects with metabolic syndrome developing prediabetes and diabetes. METHODS: Consecutive subjects attending the endocrine clinic were evaluated for metabolic syndrome as per definition of International Diabetes Federation, 2005. The family history of diabetes in their first degree relatives was ascertained and Homeostasis model assessment of Insulin resistance (HOMA-IR), Homeostasis model assessment for beta cell function (HOMA-B) and Quantitative insulin sensitivity check index (QUICKI) were calculated in 163 subjects enrolled. RESULTS: HOMA-IR was higher (p<0.05) but HOMA-B and QUICKI were lower (p<0.0001) in subjects with metabolic syndrome+prediabetes or diabetes compared to metabolic syndrome with normal glucose tolerance. HOMA-B was lower and prevalence of prediabetes and diabetes was higher in metabolic syndrome subjects with family history of diabetes than in those without such family history (p<0.05). CONCLUSIONS: subjects with metabolic syndrome having prediabetes and diabetes had more severe insulin resistance than those with metabolic syndrome only. Beta cell dysfunction was remarkable and prevalence of prediabetes was high in metabolic syndrome subjects with family history of diabetes. Both the severity of the insulin resistance and family history of diabetes are therefore proposed to be determinants of diminished Beta cell function leading to diabetes in metabolic syndrome.

Low Vitamin D Levels Are Associated With an Adverse Clinical Outcome in Febrile Neutropenia.

AIM: The aim of the study was to evaluate the levels of vitamin D in patients of aplastic anemia presenting with febrile neutropenia and its association with clinically important parameters. MATERIALS AND METHODS: The 25-hydroxy vitamin D (25(OH)D) levels were measured in 35 patients of aplastic anemia with febrile neutropenia in the age group of 4 to 16 years. About 30 healthy children served as controls. Vitamin D deficiency was defined as 25(OH)D<20 ng/mL, insufficiency 20 to 29 ng/mL, and sufficiency≥30 ng/mL. RESULTS: The median age of patients was 9.3 years. The mean 25(OH)D level was 17.71±8.90 ng/mL in patients against 23.67±10.80 ng/mL in the control group (P<0.01). About 65.7% of the patients were 25(OH)D deficient (<20 ng/mL). Only 8.6% had sufficient levels. Older (above 10 y) patients, male children, and those from a rural background and a low socioeconomic status had significantly lower 25(OH)D levels as compared with controls. Low 25(OH)D levels were associated with a longer duration (≥7 d) of febrile neutropenia (17.26±7.19 vs. 20.01±12.12 ng/mL) although the difference was not statistically significant. Two patients who expired had significantly lower 25(OH)D levels (12.85±4.12 ng/mL) compared with those who improved (22.86±6.47 ng/mL, P<0.05). CONCLUSIONS: A high prevalence of vitamin D deficiency was observed in patients with febrile neutropenia. Low levels were associated with an adverse clinical outcome.

Rapid genotypic detection of rpoB and katG gene mutations in Mycobacterium tuberculosis clinical isolates from Northern India as determined by MAS-PCR.

BACKGROUND: There is a growing need to develop rapid laboratory research methods to counter the menace of drug resistant tuberculosis (MDR-TB) cases worldwide especially in developing countries. The present study was undertaken to investigate the type and frequency of rpoB and katG mutations in rifampicin (RIF) and isoniazid (INH) resistant strains respectively of Mycobacterium tuberculosis (MTB) circulating in Northern India and to explore the utility of multiplex-allele-specific (MAS)-PCR assay for detection of drug-resistant MTB isolates in low resource set up. METHODS: Phenotypic and genotypic drug susceptibility testing (DST) was performed on 354 MTB isolates. RESULTS: Mutation in rpoB gene was found most frequently at codons 531, 526 and 516 (59.83%, 45.29% and 22.22%, respectively). Further, combinations of 2-3 point mutations were also observed in 19.66% of RIF-resistant MTB strains. The frequency of mutations in katG gene was found at codon 315 among 82.95% of the INH-resistant MTB isolates. MAS-PCR detected rpoB and katG mutations in phenotypically resistant isolates with sensitivities of 93% and 83% respectively. CONCLUSION: MAS-PCR assays can be used for rapid detection of drug-resistant TB strains in routine diagnostic practice, enabling early administration of appropriate treatment regimens to the affected patients.

Interaction of dihydrofolate reductase and aminoglycoside adenyltransferase enzyme from Klebsiella pneumoniae multidrug resistant strain DF12SA with clindamycin: a molecular modelling and docking study.

Klebsiella pneumoniae strain DF12SA (HQ114261) was isolated from diabetic foot wounds. The strain showed resistance against ampicillin, kanamycin, gentamicin, streptomycin, spectinomycin, trimethoprim, tetracycline, meropenem, amikacin, piperacillin/tazobactam, augmentin, co-trimoxazole, carbapenems, penicillins and cefoperazone, and was sensitive to clindamycin. Molecular characterization of the multidrug-resistance phenotype revealed the presence of a class 1 integron containing two genes, a dihydrofolate reductase (DHFR) (PF00186), which confers resistance to trimethoprim; and aminoglycoside adenyltransferase (AadA) (PF01909), which confers resistance to streptomycin and spectinomycin. A class 1 integron in K. pneumoniae containing these two genes was present in eight (18.18%) out of 44 different diabetic foot ulcer (DFU) patients. Hence, there is a need to develop therapeutics that inhibit growth of multidrug resistant K. pneumoniae in DFU patients and still achieve amputation control. Am attempt was made to create a 3D model and find a suitable inhibitor using an in silico study. Rational drug design/testing requires crystal structures for DHFR and AadA. However, the structures of DHFR and AadA from K. pneumoniae are not available. Modelling was performed using Swiss Model Server and Discovery Studio 3.1. The PDBSum server was used to check stereo chemical properties using Ramachandran plot analysis of modeled structures. Clindamycin was found to be suitable inhibitor of DHFR and AadA. A DockingServer based on Autodock & Mopac was used for docking calculations. The amino acid residues Ser(32), Ile(46), Glu(53), Gln(54), Phe(57), Thr(72), Met(76), Val(78), Leu(79), Ser(122), Tyr(128), Ile(151) in case of DHFR and Phe(34), Asp(60), Arg(63), Gln(64), Leu(68), Glu(87), Thr(89), Val(90) for AadA were found to be responsible for positioning clindamycin into the active site. The study identifies amino acid residues crucial to 'DHFR and AadA -drug' and 'DHFR and AadA -inhibitor' interactions that might be useful in the ongoing search for a versatile DHFR and AadA -inhibitor.

Microbiological and clinical characteristics of diabetic foot infections in northern India.

INTRODUCTION: India has the largest diabetic population of 50.8 million that could reach an epidemic proportion by 2030. Diabetic foot infection is one of the dreaded complications of diabetes.  Only a few studies that focus on patterns of diabetic foot infection in our region, where diabetic foot care is inadequate, are available. This study evaluated microbial and clinical characteristics of diabetic foot infections that will be helpful in taking appropriate measures for their management. METHODOLOGY: In this prospective study conducted during 2008-2009, sixty-two diabetic foot patients underwent detailed history, clinical examination, and laboratory investigations including parameters of systemic infections. Microbial culture and sensitivity were performed at the time of presentation. RESULTS: Among 62 cases, 43.5% had mono-microbial infection, 35.5% had poly-microbial infections, and 21% had sterile culture. Among 82 bacteria isolated, 68% were Gram negative and 32% were Gram positive. Leukocyte counts were higher (16928±9642 versus 14593±6687 cells/mm(3)) and haemoglobin (7.9±2.4 versus 9.2±2.2 mg/dl) lower in poly-microbial compared to mono-microbial infections. Haemoglobin counts were lower and leukocyte counts higher in Gram-negative compared to Gram-positive infections. Patients with sterile cultures also had clinical evidence of persistent infection. Escherichia coli were the most common isolate and piperacillin/tazobactam showed highest sensitivity. CONCLUSIONS: Gram-negative bacteria were most prevalent in diabetic foot infection. It is not uncommon to have culture reports negative despite clinical evidence of infection. This study suggests that piperacillin/tazobactam should be the treatment of choice on an empirical basis prior to a definitive bacteriological study and in cases with negative culture reports.

A new approach to touch down method using betaine as co-solvent for increased specificity and intensity of GC rich gene amplification.

Tissue specific genes that contain high GC segments are difficult to amplify by standard PCR. We report an improved method for successful amplification of gene segment that has >70% GC base pairs. This new method of touch down PCR differed by having an initial annealing temperature (Ta) 1.5°C below the primers melting temperature that descended 0.2°C per cycle for 20 cycles and continued thereafter at fixed Ta for next 15 cycles. Different co-solvents were tested with this method to improve the result and betaine proved better than the other co-solvents. This new method is economical, fast and specific in amplifying GC rich region of other genes also.

Diabetic foot: a continuing challenge.

Diabetes is rapidly emerging as the new global epidemic. The prevalence of diabetes is expected to double in the next three decades. Diabetic foot (DF) is a major complication of long standing diabetes, accounting for nearly 35% of all hospital admissions in diabetic clinics. It also accounts for nearly 80% of all nontraumatic amputations of the lower limb. Due to its significant morbidity and mortality, DF has a staggering economic impact not only on the individual and his family but also the society. The aetiopathogenesis of DF is multifactorial and is related to peripheral neuropathy leading to the insensate foot with foot deformities, peripheral vascular disease and infection in addition to the reduced immunity seen in these patients. The clinical evaluation of the DF in addition to the detailed examination of foot deformities and the ulcers should focus on identifying loss of protective sensation using simple clinical tests as well as an examination of the vascular integrity by a simple hand held Doppler device. Patients of DF should be managed by a multidisciplinary team which in addition to clinical specialists should also include a podiatrist and trained nursing staff. The basic tenets of treatment include of floading, wound bed preparation using repeated debridement, treating local and systemic infection and to identify and correct vascular impairment if it is present. Once the ulcer has healed, recurrences are common and patient education for foot care is of paramount importance as is an annual examination in a dedicated foot clinic. Once an ulcer develops it should be promptly referred to a specialist unit.

Sepsis in diabetes: A bad duo.

Increasing incidence of morbidity and mortality of diabetic subjects due to infection necessitates the understanding of its patho-biology and further remedial measures for its prevention and treatment. The increased incidence of infection is because of systemic illness that has compromising effects on multiple organs including the nervous, vascular, musculoskeletal, and immunologic systems of the diabetic patients. Many factors contribute to this condition including hyperglycemia, insulin deficiency, ischemia and impaired immunity. Sepsis, as a separate entity, lead to destruction of cytokine network that can be fatal. Compromised defense mechanisms due to sepsis and cytokine dysregulation in diabetic patients make the situation worse. Early identification of local infection by applying advanced molecular tools, appropriate selection of antibiotics, intensive wound management, control of glycemic status and supportive treatment can reduce the rate of morbidity and mortality due to sepsis in patients with diabetes.

Multivitamin and micronutrient treatment improves semen parameters of azoospermic patients with maturation arrest.

The study was undertaken to evaluate the efficacy of multivitamin and micronutrient supplementation in azoospermic patients with maturation arrest. A total of 35 azoospermic patients showing maturation arrest on testicular biopsy were recruited in this study. The patients were divided into two groups. Untreated group (n=11) without any treatment and treated group (n=24) who received multivitamins, micronutrients and co-enzyme Q10. The sperm concentration, motility and morphology were evaluated at monthly interval. The results showed reduction in liquefaction time and relative viscosity of the semen in the treated group. Further, in treated group there was appearance of spermatozoa (4.0 million/ml) exhibiting progressive motility (7%) and normal morphology (6%), even in the first follow up visit. The sperm count, motility and normal morphology increased significantly on subsequent visits. Within 3 months (3 visits) 2 pregnancies were reported. These observations indicate that multivitamin and micronutrient supplementation improve the qualitative and quantitative parameters of seminogram in patients with azoospermia of maturation arrest.