Journal of clinical and diagnostic research

Role of Atorvastatin in Anti-diabetes Management

MITRA A

The hyperinsulinaemic/insulin-resistant state is a metabolic condition linked to widespread and heterogeneous clinical syndromes like hypertension, obesity, type 2 diabetes, dyslipidaemia, atherosclerosis and coronary vascular disease. About 25% of the non-diabetic population shows abnormalities of insulin sensitivity and compensatory hyperinsulinaemia. Data from National Health and Nutrition Examination Survey (NHANES) show 50 million Americans or more had hypertension. In world scenario, it approximates 1 billion individuals and 7.1 million deaths per year. India has 4% of adult population at risk of hypertension. India is facing a diabetic explosion also. It has the world’s largest diabetic population – about 25 million, and the number is predicted to rise to 35 million by 2010 and to 57 million by 2025. The exact cause of the increase in prevalence of hyperinsulinaemic/insulin-resistant state is unknown, and both genetic and life style factors are being blamed. Beta-blockers (atenolol) and statins (atorvastatin) are widely used to combat hypertension and dyslipidaemia, particularly in obese patients who are also prone to diabetes and coronary artery disease. A 3-month study is done to compare the effects of atenolol with atenolol and atorvastatin in two groups of hypertensive volunteers. The study shows that statins improve the dyslipidaemic picture and also increases insulin sensitivity.

Learning Sessions on Critical Appraisal of Randomised Clinical Trials: Student Feedback

SHANKAR PR, SUBISH P

Context:Critical appraisal skills are essential for students to become rational prescribers. Evidence-based medicine requires the ability to appraise articles critically. Manipal College of Medical Sciences, Pokhara, Nepal, mainly admits students from Nepal, India and Sri Lanka for the undergraduate medical (MBBS) course. Pharmacology is taught during the first four semesters. The department recently started learning sessions on the critical analysis of published randomised clinical trials for the third- and fourth-semester students. Aims: The study is aimed to obtain information on the student attitudes towards the sessions and note the association, if any, of the attitudes with demographic characteristics of the respondents. Settings and design: The study was conducted among the third- and fourth-semester basic science students of the institution. The design was a prospective questionnaire-based study. Methods: Basic demographic information about the respondents was collected, and the degree of agreement with a set of 16 statements was noted. The agreement was noted using a modified Likert-type scale. The total score was calculated for each respondent. The scores of some statements were reversed while calculating the total score. Statistical analysis: The median total score was compared among different subgroups of respondents. The level of statistical significance for all analyses was set at p < 0.05 using two-tailed comparisons. Results: A total of 116 students participated (overall response rate was 81.8%). Nepalese and Indians were the major nationalities. The median score (interquartile range) was 54 (50.5–56.5). No significant difference in scores was seen among different subgroups. The students were of the opinion that the sessions made them aware of the technique of critical analysis of a journal article. Conclusions: Student opinion about the sessions was positive. Lack of knowledge of statistics among the students was a limitation. A student elective on reading and writing science can be considered.

Fuzzy Expert System for Fluid Management in General Anaesthesia

RAHIM F*, DESHPANDE A**, HOSSEINI A***

Background: Fuzzy set and fuzzy logic founded by Prof. Lotfi Zadeh (1965) make it possible to define inexact medical entities as fuzzy sets and models the subjective information. Fuzzy logic is reasoning with fuzzy sets. In medicine, the contradictory natures are common facts. Anaesthetists use rules of thumb when managing patients. He adjusts the drug and fluids inflow, or possibly ventilation, to monitor physiological state of the patient. Real-world knowledge is characterised by incompleteness, inaccuracy and inconsistency. It is not possible to define precisely the terms such as high temperature, low mean arterial pressure (MAP), very high intravenous fluid rate (IFR), and alike. The field of surgery and anaesthesia is very wide as many factors contribute to it, such as diagnosis, image processing, and path physiological reasoning and anaesthesia control. Fuzzy logic seems suited to use in anaesthesia because of the way it so naturally represents the subjective human notions employed in much of medical decision making. Patient and methods: We have selected 71 patient ASA I–II classes, aged between 15 and 50 years and weight between 40 and 85 kg. In this sequel, we have made an honest attempt to incorporate fuzzy techniques and developed a fuzzy expert system for fluid management in general anaesthesia. MAP and hourly urine output (HUO) are the fuzzy input to the fuzzy expert system as the antecedent parts of the rule and the output is the defuzzified value of IFR at the desired level. Results: We have predicted nine different fuzzy rules by using Min–Max approach, and eventually we find out the action that must be taken by using centroid approach. Then out of nine fuzzy rules four rules will be fired for patients. Based on COA, the computed value of IFR for the above set parameters, which for one sample of patient data was 118 ml/hr. Similarly, we calculated the results of fired rule for all 71 patients and got results that were in the range of predefined limit by the experts. Conclusion: It could be done with minimal capital outlay by having a human operator periodically enter MAP and HUO values into a personal computer. The objective of the study was to estimate IFR based on the linguistic description of MAP and HUO sum of these four actions. The rates of change of MAP and HUO could be fuzzified into sets such as DECREASING, STABLE, and INCREASING and would serve to indicate the trend in a patient’s fluid status. This would allow more precise control of fluid balance. Inputs from the domain experts and the judicious use of fuzzy techniques are important to achieve success. This modal is suitable for application only in otherwise healthy patients undergoing surgery involving minimal blood loss. For other patients undergoing surgeries involving moderate-to-severe blood loss, more complicated modals are needed utilising other parameters as well.

Columnar Cell Lesions of the Breast –Significant or Not?

SEEMA HS, RAJALAKSHMI T

Columnar cell lesions (CCLs) of the breast range from the innocuous CAPSS (columnar alteration with prominent apical snouts and secretions) to DCIS. Their precancerous potential poses diagnostic and therapeutic riddles, especially in those which show mammographic microcalcifications. Aims: 1. To document the prevalence of CCLs in the breast. 2. To study their morphologic spectrum. 3. To study the significance of their association with benign and malignant breast lesions. Material and Methods:One hundred consecutive breast specimens were studied. These specimens included biopsies, lumpectomies and mastectomies. CCLs were classified as per Schnitt criteria. Associated lesions in the adjacent tissue were studied. Results: Of the 100 samples (43 malignant and 57 benign), 37 cases showed CCL: CAPSS – 23, columnar cell hyperplasia – 11 and columnar cell hyperplasia with atypia – three. The commonest associated lesion was fibrocystic change (n = 54). Their incidence in benign and malignant lesions was 42% and 30%, respectively, with no statistical significance in the difference. Lesions with atypia were seen only in malignant cases. Conclusions:CCLs are common and often overlooked. These lesions are seen in association with both benign and malignant breast lesions. It is only the presence of atypia in CCL that warrants a special mention and necessitates follow-up, and resection if indicated.

Prescribing Pattern in Diabetic Outpatients in a Tertiary Care Teaching Hospital in Nepal

UPADHYAY DK* **, PALAIAN S* **, RAVI SHANKAR P**, MISHRA P* **, SAH AK*

Background: Diabetes is a chronic disease associated with significant morbidity and mortality. Diabetics are at a higher risk of polypharmacy and more vulnerable to irrational prescription. Data regarding drug use pattern in diabetes is lacking in South Asian countries. Objectives: The present study was conducted with the objectives of collecting the demographic details of diabetes patients, studying the pattern of drug prescribing among diabetic outpatients, calculating the mean prescription cost for the diabetes patients and analysing the prescriptions according to prescribing indicators. Methods: A cross-sectional study was carried out at the Out-patient Pharmacy (OPP), Manipal Teaching Hospital, Pokhara, Nepal, from 22nd August to 7th December 2006. All the diabetes patients who visited the OPP during the study period were enrolled after getting verbal consent and interviewed by the researchers, based on the study objectives. The details were entered in the structured patient profile form, and the filled forms were analysed. Results: Altogether 182 patients, 103 males (56.59%) and 79 females (43.41%), were enrolled. Among these, 69 (37.91%) were in the age group 51–60 years, 128 (70.33%) had a diabetic history of less than 5 years and 136 (74.72%) had at least one concurrent illness. Two, three and four drugs were prescribed in 39 (21.43%), 35 (19.23%) and 40 (21.98%) patients, respectively. Altogether, 685 drugs were prescribed with an average of 3.76 drugs per prescription. Antidiabetics were accounted for 314 (45.84%) of the total drugs. Among the various antidiabetics, biguanides were accounted for 161 (51.27%) of the total antidiabetic medications. Among the study patients, 28 (15.38%) had an encounter with an injection prescribed and 16 (2.34%) of the total drugs were fixed-dose combinations and 0.88% (n = 6) of the drugs were antibiotics. The duration of prescription of medicines ranges from 29 to 35 days for 41.17% (n = 282) of the total drugs and 57 to 63 days for 44.23% (n = 303) drugs. Majority [650 (94.89%)] of the drugs were prescribed in oral dosage form. The average cost per prescription was NPR 1156.15 (US $16.17). Antidiabetic medications constituted 58.93% of the total cost. Among the antidiabetic medications insulin accounted for 41.07% of the total cost followed by biguanides (32.60%). Conclusions: Insulin and biguanides were the most commonly prescribed antidiabetics. Our study was done for a short period of time, and the number of patients studied was low. Hence, similar studies covering large number of patients are needed to confirm our findings.

Job Stress, Job Satisfaction and Mental Health

MARZABADI E A, TARKHORANI H

Introduction: Stress has been proven to be a big contributor to medical ailments and a lot of people suffer from stress throughout the world. There are different factors that lead to stress, and among them stress from work has been learnt as a major contributor to illnesses. There have been a lot of studies conducted that have shown that a lot of people are suffering from stress at work due to various reasons, and these studies have helped us a lot to understand the situation much better. Methods: Our study revolves around finding the relationship between job stress, job satisfaction and mental health. There were about 164 individuals in our study who were employees of a governmental organisation in Iran. All the individuals were interviewed, and the questionnaires that were used included the General Health Questionnaire (GHQ), Occupational Stress Inventory (OSI), and Job Descriptive Index (JDI). Results: The statistics were collected from 164 individuals who were employees of a governmental organisation in Iran. In the study, it was found that a large number of participants were ranked in the low-stress range, which was about 93.9%. Discussion: There have been a lot of studies conducted to understand the relationship between job stress and job satisfaction. A lot of the researches have shown that the people are suffering from increased amount of stress in their work environment and hence that caused them to suffer from medical illnesses. On the other hand, a good number of participants in our study showed very low stress in their work environment that helped us to learn the different factors that can provide an ideal environment for people at their jobs.

Oxidant–Antioxidant Status in Gestational Diabetes Patients

SURAPANENI K M

The exact pro-oxidant and antioxidant status in gestational diabetes is still not clear. To add a new insight to the question, erythrocyte antioxidant glutathione (GSH) and malondialdehyde (MDA) levels in erythrocytes and plasma glutathione–S–transferase (GST) activity were estimated in patients with gestational diabetes and compared to controls. Statistical analysis between controls and patients was performed by the unpaired t-test using the stat-view package. It was observed that there was a significantly lower erythrocyte GSH levels (9.6 ± 6.1 vs. 16.8 ± 5.9 mg/g of Hb, p = 0.0005) and plasma GST activity (3.1 ± 1.3 vs. 10.3 ± 2.3 micromoles/dl of plasma, p < 0.0001) in patients with gestational diabetes when compared to controls. There was a significantly higher erythrocyte MDA levels in patients with gestational diabetes when compared to controls (21.0 ± 4.7 vs. 10.3 ± 2.7, p < 0.001). The results of our study suggests that there was higher oxygen free radical production, as evidenced by higher MDA and lower GSH, supporting the hypothesis that there is increased oxidative stress in patients with gestational diabetes and the decreased GST activity supports the decreased detoxification capacity in pregnancy-complicated diabetes.

The Role of NK and NKT Cells in Patients with Acute Brucellosis

AKBULUT H*,ILHAN F*,CELIK I**,OZDEN M*,GÖDEKMERDAN A*

Background: The major role of T cells in Brucella immunity is secretion of gamma interferon (IFN-γ) for activation of bactericidal function in macrophages. Natural killer T (NKT) cells are new subtype of T cells and produce IFN-γ very quickly and promptly when they are stimulated. Therefore, NKT cells can play an effective role in immunity of brucellosis. Aim: It was aimed to evaluate whether natural killer (NK) and NKT cells have an effect on brucellosis immunity and whether there is any difference for these cell percentage between pre- and post-treatment period. Methods and Material: The study included a total of 40 acute brucellosis cases and 20 healthy subjects. Two-colour flow cytometric analysis was performed on a FACScan flow cytometer, using monoclonal antibodies CD45/CD14, isotype control and CD3/CD16+56. Results: No statistical significant difference was observed between patient and control groups for NKT cell counts and NK cell percentages. There were no differences between before and after treatment period in terms of NK and NKT cells ratio. Conclusion: According to our result, acute brucellosis has no effect on increasing of NK and NKT cells. To the best of our knowledge, this is the first study about NKT cells ratio in patients with acute brucellosis.

Delayed Respiratory Arrest in a Patient Following Interscalene Block: A Case Report with an Overview of Complications Associated with Interscalene Approach to Brachial Plexus Block

SHUKLA A N, JOSHI S C

First Report of Shewanella alga as Emerging Infection in India: Two cases

MUKHOPADHYAY C, CHAWLA K, SHARMA Y, BAIRY I

Shewanella alga is a rare isolate from clinical specimens. Repeated isolation of the organism from two cases in elderly non-immunocompromised males, as treated successfully thereafter, confirms the need of utmost microbiological vigilance to identify this unusual pathogen.

Non-O1 non-O139 Vibrio cholerae Bacteraemia and Peritonitis Associated with Chronic Liver Disease

KHAN FY*, EL-HIDAY AH*, El SHAFIE S**, ABBAS MT*

A 53-year-old Bangladeshi male was admitted to the hospital with a 2-day history of watery diarrhoea associated with fever, vomiting and abdomen pain. The patient admitted that his symptoms started after he had eaten fish at a local restaurant. Past medical history was remarkable for liver cirrhosis due to hepatitis B virus. Clinical examination showed positive shifting dullness. Both samples of blood and ascitic fluid grew Vibrio cholerae non-O1 non-O139, which was sensitive to ampecillin, amoxil-clavulanic acid, ceftriaxone and co-trimoxazol. The results were confirmed by the reference laboratory (Bioscience – Germany). Tazocin (piperacilline-tazobactam) was given for 10 days. On the following days, the patient recovered; diarrhoea and fever were subsided and consequently the patient was discharged.

Spontaneous scrotal faecal fistula in infant: A case report and literature review

GHRITLAHAREY R K, SHRIVASTAVA D K, KUSHWAHA A S

A one month old infant presented with an irreducible right inguino-scrotal swelling and faecal discharge from the scrotum for a week. Inguinal exploration revealed an incarcerated right inguinal hernia containing loop of small intestine, Meckel’s diverticulum and a perforation of the small intestine measuring 3 cm. Resection of part of ileum containing the diverticulum and perforation was done and end– to–end anastomosis was performed. Spontaneous intestinal - scrotal fistula from incarcerated inguinal hernia in neonates and infants is a rare occurrence and hitherto only seven such cases have been reported in the world literature.

Diagnostic Dilemma of Painful Red Eye With Severe Headache

KUMAR S

Traditionally, the differential diagnosis of non traumatic painful red eye is limited to microbial keratitis, acute congestive glaucoma & acute iritis. However, if painful red eye is associated with headache, then migraine, sinusitis, orbital infection and inflammation are the usual differential diagnoses. Cluster headache as a cause of painful red eye with severe headache may be missed both by internists as well as by ophthalmologists. I report two cases initially diagnosed, investigated and treated variously as glaucoma, partial third nerve paresis due to diabetes and meningitis. The correct diagnosis became apparent when all investigations were normal and the patient did not respond to treatment appropriate for the initial, presumed diagnoses. These cases emphasize the importance of a high index of suspicion for cluster headache, and the dramatic response to corticosteroid therapy in this usually overlooked malady.

Thanatophoric Dysplasia: Case Report and Review of literature

ASHISH VERMA, SUYASH MOHAN, SUNIL KUMAR

Thanatophoric Dysplasia (TD) is the most common, congenital, sporadic, usually lethal skeletal dysplasia characterized by shortening of the limbs, small conical thorax, platyspondyly and macrocephaly. TD is divided into 2 clinically defined subtypes type 1 and 2 with some clinical overlap between the 2 subtypes. Autosomal dominant mutations in the fibroblast growth factor receptor 3 gene (FGFR3), which has been mapped to chromosome band 4p16.3, results in both subtypes. The vast majority of cases are due to de novo mutations. This condition has characteristic sonographic features that suggest the diagnosis prenatally, although distinction from other short-limbed dysplasia syndromes may be difficult. To date, over 100 cases have been described. Thanatophoric fetuses usually die within the first 48 hours of life from pulmonary hypoplasia caused by a narrow thorax. We report a case of type 1 TD with typical imaging findings, along with a short review of the available literature.

Haemorrhagic Pleural Effusion in an HIV infected patient with Salmonella typhimurium

MUKHOPADHYAY C*, RAO P S*, SHETTY A K*, VIDYASAGAR S**, VARMA M**

Non-typhoidal salmonellosis is rarely encountered in immunodeficient individuals, including HIV/AIDS, where pleural effusion is an unlikely manifestation as well. Tuberculosis and Pneumocystis carinii pneumonia are the two leading causes of pleural effusion, which are mainly non-haemorrhagic. We report a rare case of haemorrhagic pleural effusion in an HIV-positive patient with Salmonella typhimurium as the only opportunistic infection. It was diagnosed timely and treated successfully with institution of appropriate antibiotics. S. typhimurium is a rare opportunistic infection to cause haemorrhagic pleural effusion in HIV positive patients with decreased CD4+ count.

Benzene Exposure and Its Relation to Multiple Myeloma

JOSHI SC, PANT I, SHUKLA AN

The positive epidemiological evidence for benzene as a risk factor for multiple myeloma is supported by biological plausibility. According to the investigators, findings are consistent with previous reports 9of haematological malignancies following occupational exposure to benzene and definitely raise the possibility that multiple myeloma could also be linked to benzene exposure. This does not necessarily mean that any increase in the incidence of multiple myeloma in recent years can necessarily be ascribed to benzene exposure, but it raises the issue that needs to be further investigated for relation between benzene exposure and multiple myeloma.

Gene Therapy: A Double-Edged Modality with Few Propitious Targets against Cardiovascular Disorders like Heart Failure, Hypertension and Infarction

KHANNA A*, KHANNA R**

Cardiovascular diseases like that of congestive heart failure, hypertension and infarction have reached epidemic proportions, and even though many novel pharmacological formulations and devices have improved survival, a real cure is yet to be found. After extensive research and trials (both preclinical and clinical), gene therapy is seen as an important upcoming tool against cardiovascular disorders. Advancements in the vector technology and in the molecular understanding of various diseases like that of heart failure, ischaemic heart diseases and even polygenic diseases like hypertension have opened doors to a new era of cure. With the improved understanding of the pharmacodynamics and the pharmacokinetics of gene transfer, there is a substantial growth being seen in the treatment of cardiovascular disorders using gene therapy with an increasing number of potential targets (genes), especially in the post-human genome era. Few potential targets have been identified for gene therapy from various molecular pathways, which along with the newly developing delivery systems will accelerate and strengthen the fight against heart failure and ischaemia (therapeutic angiogenesis), in which at present most of the clinical trials are going on. But at the same time, all the potential adverse effects and safety concerns arising with these new modalities should also be assessed before enforcement

Influence of Helicteres isora Bark Extracts on Plasma and Tissue Glycoprotein Components in Streptozotocin Diabetic Rats

KUMAR G, MURUGESAN AG

Background: The present study investigated the effect of aqueous bark extracts of Helicteres isora on dearrangement in glycoprotein levels in the streptozotocin-induced diabetic rats. Materials and Methods: The bark extracts of H. isora (100, 200 mg/kg) was administered orally for 30 days to normal and diabetic rats. The effect of bark extracts on glucose, insulin, and plasma and tissue glycoproteins were studied. The effect of bark extract was compared with tolbutamide, a reference drug. Result: The levels of glucose, glycosylated haemoglobin and plasma glycoproteins containing hexose, hexosamine and fucose were increased significantly, whereas the level of plasma insulin and haemoglobin were decreased significantly in diabetic rats. There was a significant decrease in the level of sialic acid and elevated levels of hexose, hexosamine and fucose in the liver and kidney of streptozotocin-diabetic rats. Administration of H. isora (100, 200 mg/kg) to diabetic rats was followed by a decreased level of glucose, glyosylated haemoglobin and plasma glycoproteins. The levels of plasma insulin, haemoglobin and tissue sialic acid were increased, whereas the levels of tissue hexose, hexosamine and fucose were near normal. Conclusion: The present study indicates that the bark extract of H. isora possesses a significantly beneficial effect on the glycoprotein moiety in addition to its anti-diabetic effect.

Multi Hit, Dropoff Percentage and NCM-2: Three Improvements in BLAST

GARG D

Various algorithms are in use in medical processes to improve the speed, sensitivity and accuracy of the computations and analyses involved in those experiments. The aim of this paper is to suggest three improvements, namely Multi Hit, Dropoff percentage and NCM-2 in the BLAST algorithm. BLAST (Basic Local Alignment Search Tool) is a popular tool used for determining the patterns in genomic sequences. As the data is increasing exponentially, the need for advanced and complex algorithms for improving the accuracy, speed and sensitivity of pattern discovery tools in bioinformatics is also increasing. First Improvement: The initialization of the word matches in a pairwise sequence alignment works either on single hit or two-hit algorithms. Instead, if we use a 3-hit or n-hit in general then the results improve in general and improve dramatically for some specific species and sequences. Second Improvement: BLAST is using a drop-off score to calculate the highest scoring pairs between two sequences. A change has been proposed to calculate the threshold score that determines the inclusion of the subsequence in the result. Instead of using a drop-off score, if we use a drop-off percentage, it gives better results for some sequences. Third Improvement: We propose an NCM-2 approach for normalizing BLAST values for simple regions. This approach is based upon the natural properties of the Amino acid sequences. The algorithms have been run on Linux ES platform with Compaq Presario 2GB RAM and compared to the original BLAST.