Rational use of glucocorticoid during pituitary surgery--a pilot study.

BACKGROUND & OBJECTIVE: The conventionally used perioperative glucocorticoid replacement protocol in patients with pituitary tumours is far from optimal. In this study we evaluated the validity of a modified protocol for perioperative glucocorticoid replacement in non-functioning pituitary macroadenomas. METHODS: A total of 24 consecutive patients with non functioning pituitary macroadenomas were included in this interventional study. Patients with a pre-operative 0800 h cortisol of > or = 350 nmol/l (> or = 12.6 microg/dl) did not receive glucocorticoid replacement during perioperative (d(0)-d-(2)) period, while those with < or = 100 nmol/l (< or = 3.6 microg/dl) received glucocorticoid replacement. Those patients with 0800 h cortisol value between > 100-349 nmol/l (> 3.6-12.6 microg/dl) required them to undergo an insulin induced hypoglycaemia (IIH). In response to IIH, patients with a peak cortisol of < 550 nmol/l (< 19.8 microg/dl) received glucocorticoid replacement. Post-operatively, patients on day 3 with 0800 h cortisol of < or = 100 nmol/l (< or = 3.6 microg/dl) received hydrocortisone 10 mg/m(2) per day; those between > 100-449 nmol/l (> 3.6-16 microg/dl) received hydrocortisone replacement only if they had symptoms of adrenal insufficiency (AI) or during stress; while patients with > or = 450 nmol/l (> or = 16.0 microg/dl) did not receive any glucocorticoid replacement. Retesting was done at 12 wk in 23 subjects based on the algorithm. RESULTS: Pre-operatively, 8 (35%) patients were hypocortisolic and received glucocorticoid supplementation, thereby sparing 15 (65%) subjects from glucocorticoid replacement. On d(3) of surgery, 13 (57%) patients were hypocortisolic, but only 6 with serum cortisol of < or = 100 nmol/l (< or = 3.6 microg/dl), had symptoms and were substituted with glucocorticoid. Remaining seven patients, with serum cortisol between >100-349 nmol/l (> 3.6-12.6 microg/dl), were asymptomatic and advised glucocorticoid support only during stress but none required. Overall, 17 (74%) patients were spared from unnecessary glucocorticoid support. At 12 wk, 13 (57%) patients were hypocortisolic and only 6 either with serum cortisol level of < or = 100 nmol/l (< or = 3.6 microg/dl) or symptomatic for AI received glucocorticoids. Post-operative complications including diabetes insipidus and CSF leak remarkably decreased. INTERPRETATION & CONCLUSION: The protocol used was safe and spared unnecessary use of glucocorticoids peri- and post-operatively. However, more number of patients are to be studied to substantiate the validity of this protocol.

Hypomagnesaemia masquerading as hypoparathyroidism.

Magnesium deficiency is a common clinical problem. Dietary malabsorption and renal wasting are the commonest causes. Hypomagnesemia induces a state of functional hypoparathyroidism due to decreased secretion of parathormone (PTH) as well as resistance to its action. Contrary to typical autoimmune hypoparathyroidism, it is associated with decreased levels of serum phosphate. We report a patient who presented with hypocalcemic tetany associated with hypomagnesaemia due to renal wasting. Subsequently, he improved with magnesium supplementation of therapy.

Clinical and etiological profile of hyperprolactinemia--data from a tertiary care centre.

OBJECTIVE: To study the clinical presentation and etiology of hyperprolactinemia, a common disorder encountered in endocrine practice. METHODS: We analyzed the clinical data, hormone profile and imaging reports of 187 females with documented hyperprolactinemia, over a period of 6 years (5 years retrospective analysis and one year prospective study). RESULTS: Majority of the 187 subjects studied presented in 3rd or 4th decade. Galactorrhoea was the commonest presenting symptom occurring in 159 subjects (85%), followed by amenorrhea in 68.9%; both amenorrhea and galactorrhea were seen in 45.4%. A microprolactinoma was demonstrated in 67 patients (35.8%), a nonfunctioning pituitary macroadenoma with stalk hyperprolactinemia occurred in 30 patients (16%) and polycystic ovarian disease was documented in 24 (12.8%). In 52 patients (27.8%) no apparent cause could be ascertained. CONCLUSIONS: Syndrome of amenorrhea and/or galactorrhea is the commonest presentation in hyperprolactinemia. Microprolactinoma was the most frequent identifiable etiology followed by idiopathic and stalk hyperprolactinemia in our series.

Diffuse abdominal lipomatosis.

We report a 22-year male who developed progressive distension of abdomen, clinically diagnosed as ascites. A diagnosis of abdominal lipomatosis was made on the basis of CT evidence of excessive fatty tissue in abdominal cavity which was confirmed on laparotomy.

Clinical and aetiological profile of early onset diabetes mellitus: data from a tertiary care centre in the Indian subcontinent.

BACKGROUND: Type 2 diabetes mellitus (DM) in youth is emerging as a serious clinical entity and its incidence has increased over the years. AIM: To analyse the causes of DM in the age group of <40 years of age. SETTINGS AND DESIGN: Tertiary care centre; retrospective analysis of data from January 1990 to December 1999. SUBJECTS AND MATERIAL: Analysis of data of all the subjects of DM in whom disease started before the 40th birthday. RESULTS: 724 subjects were detected to have diabetes mellitus before their 40th birthday. Of these, 205 had Type 1, 174 had Type 2 and 48 had fibrocalculous pancreatic diabetes. Males outnumbered in Type 1 and fibrocalculous pancreatic diabetes while as females in Type 2 diabetes mellitus. Chronic complications were more common in Type 2 diabetes mellitus. CONCLUSION: Type 2 diabetes mellitus is becoming an important cause of diabetes in subjects with onset of disease at younger age.

The foam mattress-back syndrome.

BACKGROUND: Many medical residents used to sleeping on cotton mattresses at home complain of mild to moderate back pain after sleeping on foam mattresses provided in the hospital and hostel rooms. OBJECTIVE: To determine the relationship of sleeping on foam mattress with the appearance of back pain in a 500 bedded multispecialty tertiary care hospital. METHODS: One hundred medical residents were interviewed for the appearance of backache after sleeping on 10 cm thick foam mattress provided to them in the hostels. Pain was scored over a visual analog scale of 10 cm. Effect of sleeping on a regular cotton mattress was assessed. RESULTS: Sixty-three (5 female residents) developed back pain on the morning of a night of sleep over the foam mattress. The pain was mostly of lower back and was not associated with any objective neurodeficit. Four residents on account of the backache reported thirteen episodes of absenteeism. Sixty-one residents had a relief of the pain on going home where they would sleep on regular cotton mattresses, only to recur after sleeping again on the foam mattress in the hospital/hostel. CONCLUSION: Sleeping on foam mattress is associated with the appearance of backache in medical residents which is reproducible and gets relieved after using regular cotton mattresses.

Mepacrine therapy in niclosamide resistant taeniasis.

OBJECTIVE: To evaluate the efficacy of mepacrine (quinacrine) in patients with niclosamide resistant Taenia saginata infection. METHODS: Eighty six cases with niclosamide resistant Taenia saginata (unresponsive to 2-8 courses of niclosamide) were treated with quinacrine (1 g) administered orally or via a nasogastric tube, and followed at 2, 4, 8 and 12 weeks for recurrence of passage of proglottids and presence of Taenia eggs in the stool examinations. Pre and post-therapy egg counts were obtained and egg viability was tested by staining with methylene blue. RESULTS: Eighty-one (94.2%) patients responded promptly with passage of the worm within 4-72 hours. The egg counts showed a drastic fall in 79 cases and a fall in viability from a median of 100% to 0% was observed. Only one patient demonstrated a relapse at 4 weeks. Gastrointestinal side effects occurred in 9 cases but were controlled easily by symptomatic therapy. CONCLUSION: We conclude that quinacrine is a safe, inexpensive, effective and generally well tolerated drug for the treatment of niclosamide resistant Taenia saginata infestations.