Pleuropulmonary nocardiosis due to Nocardia otitidiscaviarum in a debilitated host.

Nocardia otitidiscaviarum is a rare cause of pulmonary nocardiosis. We present a case of pulmonary nocardiosis with pleural involvement in an adolescent with rheumatic heart disease and congestive cardiac failure presenting with right lower lobe consolidation and pleural effusion. Direct gram‑stain of pleural fluid showed pus cells with Gram‑positive filamentous branching bacilli. Empiric treatment with parenteral ceftriaxone and supportive therapy for cardiac failure was initiated. Pleural fluid culture yielded growth of N. otitidiscaviarum at 72 h. Antibiotic susceptibility testing showed resistance to cephalosporins. The patient expired due to congestive cardiac failure on the 5th day.

Significance of Expression of PSP94 Isoforms in Etiology of Benign Prostatic Hyperplasia and Prostate Cancer.

Background: Prostate Secretory Protein of 94 Amino Acids (PSP94) level is known to increase in benign prostatic hyperplasia (BPH) and decrease in prostate cancer (PCa). However, there has not been a consensus on the abundance and significance of the different isoforms of PSP94 during the development of BPH and PCa. Methods: Benign and malignant prostate tissue was ascertained histologically. Biplex polymerase chain reaction (PCR) and real-time PCR were employed to quantitate the two isoforms, PSP94 (MSMB1) and PSP57 (MSMB2). Results: Higher abundance of both MSMB1 and MSMB2 transcripts was observed in BPH as compared to PCa. Further, there was a strong positive correlation between the transcript levels of these isoforms, MSMB1 and MSMB2, in samples from both BPH and PCa patients. Conclusions: PSP57 (MSMB2) transcript may not be involved in the development of BPH or PCa and could have a physiological role in prostate cells.

Successful Pregnancy and Delivery with Good Maternal and Fetal Outcome in a Kidney Transplant Recipient.

Conception and successful completion of pregnancy is rare in women with end-stage kidney disease. Given the rising burden of chronic kidney disease, it is quite common to see more women in their childbearing ages being diagnosed with the condition. As the kidney disease progresses, fertility chances reduce and pregnancy becomes a rarity. In addition to dealing with dialysis and its consequences, the women with end-stage kidney disease also face the trauma of infertility and inability to start their families. At such times, pregnancy and delivery following successful kidney transplantation with return of normal kidney function, offers a ray of hope to women of childbearing ages. We report the case of a young woman with end-stage renal/kidney disease (ESRD) on hemodialysis for 2 years, who underwent cadaveric kidney transplantation with subsequent excellent allograft function. Two years post-transplantation, she went ahead with a successful pregnancy and delivery of a normal birth weight baby, and preserved renal allograft function.

Myroides odoratus and Chryseobacterium indologenes: Two rare isolates in the immunocompromised.

Myroides spp and Chryseobacterium spp are uncommon clinical isolates, though more frequently reported to cause infections than other pigmented non‑fermentors. Two cases of Myroides odoratus and Chryseobacterium indologenes infection in a diabetic with pulmonary tuberculosis and a patient with de‑compensated alcoholic liver disease, respectively, are reported here. Anti‑microbial susceptibility testing of the isolates was performed by determining the minimum inhibitory concentration. The clinical picture, characteristic features of the isolates and the antibiotic susceptibility pattern are discussed briefly.

Intraosseous fibrosarcoma of maxilla in an HIV patient

Fibrosarcoma is a malignant mesenchymal neoplasm of fibroblasts that rarely affects the oral cavity and can cause local recurrences or metastasis. Fibrosarcomas account for 15% of all soft tissue sarcomas, which represent only 1% of all malignant tumors of the head and neck region. The clinical behavior of the fibrosarcoma is characterized by a high local recurrence rate, and low incidence of loco regional lymph node and/or distant hematogenous metastasis. The etiology for fibrosarcoma has no definite cause but is thought to occur from preexisting lesions or in previously irradiated areas of bone lesions. Immunosuppression associated with HIV infection and acquired immune deficiency syndrome [AIDS] has been consistently linked to various cancers, including Kaposi's sarcoma, non-Hodgkin's lymphoma, and invasive cervical cancer. Rare neoplasms like Hodgkin's disease, anal cancer, leukemia, basal cell carcinoma, and squamous cell carcinoma have also been demonstrated. This paper presents one such a rare incidence of an intraosseous fibrosarcoma occurring in an HIV-positive patient

Complement-dependent lymphocytotoxicity crossmatch in deceased donor renal transplant: A single institutional experience.

Complement-dependent lymphocytotoxicity crossmatches (n=217) between 47 deceased donors and 150 potential renal recipients were retrospectively studied. A negative cross match was reported in 48 (22.1%), doubtful positive in 126 (58.1%), weakly positive in 32 (14.7%) and positive in 11 (5.1%). No autoantibodies were detected. Renal transplantation was performed in 35.5% of the potential recipients. There was no incidence of hyperacute rejection. The graft survival rate was 88% at 15 months of follow up. The study concludes that a negative pretransplant lympocytotoxicity crossmatch using the basic National Institute of Health technique eliminates hyperacute rejection, but carries drawbacks, which require modification and supplementation with more sensitive and specific assays.

Association of leukocyte count and hsCRP with metabolic abnormalities in subjects with normal glucose tolerance (CURES – 64).

Objective : The aim of the present study was to assess the association of leukocyte count and high sensitivity C-Reactive protein (hsCRP) with metabolic abnormalities in subjects with normal glucose tolerance. Methods : Subjects with Normal Glucose Tolerance (NGT) (n = 865) were recruited from the Chennai Urban Rural Epidemiology Study [CURES]. Standard methods were used for assessing hsCRP [Nephelometry, in a subset] and leukocytes [Flowcytometry, Sysmex SF-3000]. Insulin resistance was calculated using the Homeostasis Assessment model (HOMA-IR). Results : Body mass index, waist circumference, systolic and diastolic blood pressure, fasting plasma glucose, HbA1c, serum cholesterol, LDL cholesterol, HOMA IR and hsCRP increased significantly with increasing tertiles of leukocyte count [p for trend < 0.001]. Both leukocyte count and hsCRP showed a positive correlation with cardiovascular risk factors. Leukocyte count showed a positive correlation with hsCRP [p=0.008]. Both mean leukocyte count [p<0.001] and hsCRP [p=0.04] were higher in subjects with Metabolic Syndrome (MS), which increased with increase in number of metabolic abnormalities [p for trend <0.001]. Regression models showed leukocyte count [p<0.001] and hsCRP [p=0.03] to be associated with MS, even after adjusting for age and gender. Conclusion : A significant association exists between systemic inflammation [leukocyte count and hsCRP] and MS/ cardiovascular risk factors in Asian Indians even among non-diabetic subjects. ©

Incidence of diabetes and pre-diabetes in a selected urban south Indian population (CUPS-19).

OBJECTIVES: Several cross-sectional studies have reported on the prevalence of diabetes in India. However, there are virtually no longitudinal population-based studies on the incidence of diabetes from India. The aim of the study was to determine the incidence of diabetes and prediabetes in an urban south Indian population. METHODS: The Chennai Urban Population Study [CUPS], an ongoing epidemiological study in two residential colonies in Chennai [the largest city in southern India, formerly called Madras] was launched in 1996; the baseline study was completed in 1997. Follow-up examination was performed after a mean period of 8 years. At follow-up, 501 [47.0%] subjects had moved out of this colonies and were lost to follow-up. Of the remaining 564 individuals, 513 [90.9%] provided blood samples for biochemical analysis. Regression analysis was done using incident diabetes as dependant variable to identify factors associated with development of diabetes or pre-diabetes. RESULTS: Among subjects with normal glucose tolerance (NGT) at baseline [n=476], 64 (13.4%) developed diabetes and 48 (10.1%) developed pre-diabetes (IGT or IFG). The incidence rate of diabetes was 20.2 per 1000 person years and that of pre-diabetes was 13.1 per 1000 person years among subjects with NGT. Of the 37 individuals who were pre-diabetic at baseline, 15 (40.5%) developed diabetes [incidence rate: 64.8 per 1000 person years], 16 (43.2%) remained as pre-diabetic and 6 (16.2%) reverted to normal during the follow-up period. Regression analysis revealed obesity [Odds Ratio (OR): 2.1, p=0.001], abdominal obesity [OR: 2.23, p<0.001] and hypertension [OR: 2.57, p<0.001] to be significantly associated with incident diabetes. The Indian Diabetes Risk Score (IDRS) showed the strongest association with incident diabetes [OR: 5.14, p<0.001]. CONCLUSION: The study shows that the incidence of diabetes is very high among urban south Indians. While obesity, abdominal obesity and hypertension were associated with incident diabetes, IDRS was the strongest predictor of incident of diabetes in this population.

Prevalence, awareness and control of hypertension in Chennai--The Chennai Urban Rural Epidemiology Study (CURES-52).

OBJECTIVE: To study the prevalence, awareness and control of hypertension in Chennai representing Urban South India. METHODS: The Chennai Urban Rural Epidemiology Study (CURES) is one of the largest epidemiological studies on diabetes carried out in India, where 26,001 individuals aged > or = 20 years were screened using systematic random sampling method. Every tenth subject recruited in Phase 1 of CURES was requested to participate in Phase 3 of CURES and the response rate was 2,350/26,001 or 90.4%. An oral glucose tolerance test was performed in all individuals except self-reported diabetic subjects. Anthropometric measurements and lipid estimations were done in all subjects. Hypertension was diagnosed in all subjects who were on drug treatment for hypertension or if the blood pressure > or = 140/90 mmHg. RESULTS: Hypertension was present in 20% [men:23.2% vs. women:17.1%, p<0.001] of the study population. Isolated systolic hypertension (Systolic BP > or = 140 and Diastolic BP<90 mmHg) was present in 6.6% while isolated diastolic hypertension (DBP > or = 90 and SBP<140 mmHg) was present in 4.2% of the population. Among the elderly population (aged > or = 60 years), 25.2% had isolated systolic hypertension. Age, body mass index, smoking, serum cholesterol and triglycerides were found to be strongly associated with hypertension. Among the total hypertensive subjects, only 32.8% were aware of their blood pressure, of these, 70.8% were under treatment and 45.9% had their blood pressure under control. CONCLUSION: Hypertension was present in one-fifth of this urban south Indian population and isolated systolic hypertension was more common among elderly population. Majority of hypertensive subjects still remain undetected and the control of hypertension is also inadequate. This calls for urgent prevention and control measures for hypertension.

Epidemiology of type 2 diabetes: Indian scenario.

India leads the world with largest number of diabetic subjects earning the dubious distinction of being termed the "diabetes capital of the world". According to the Diabetes Atlas 2006 published by the International Diabetes Federation, the number of people with diabetes in India currently around 40.9 million is expected to rise to 69.9 million by 2025 unless urgent preventive steps are taken. The so called "Asian Indian Phenotype" refers to certain unique clinical and biochemical abnormalities in Indians which include increased insulin resistance, greater abdominal adiposity i.e., higher waist circumference despite lower body mass index, lower adiponectin and higher high sensitive C-reactive protein levels. This phenotype makes Asian Indians more prone to diabetes and premature coronary artery disease. At least a part of this is due to genetic factors. However, the primary driver of the epidemic of diabetes is the rapid epidemiological transition associated with changes in dietary patterns and decreased physical activity as evident from the higher prevalence of diabetes in the urban population. Even though the prevalence of microvascular complications of diabetes like retinopathy and nephropathy are comparatively lower in Indians, the prevalence of premature coronary artery disease is much higher in Indians compared to other ethnic groups. The most disturbing trend is the shift in age of onset of diabetes to a younger age in the recent years. This could have long lasting adverse effects on nation's health and economy. Early identification of at-risk individuals using simple screening tools like the Indian Diabetes Risk Score (IDRS) and appropriate lifestyle intervention would greatly help in preventing or postponing the onset of diabetes and thus reducing the burden on the community and the nation as a whole.

Community empowerment--a successful model for prevention of non-communicable diseases in India--the Chennai Urban Population Study (CUPS-17).

BACKGROUND AND OBJECTIVE: Randomized clinical trials have documented that lifestyle changes through physical activity can prevent diabetes. However there is no data whether such strategies are applicable at community level, that is, in a real life setting. This study demonstrates the first attempt in India, to our knowledge, of increasing physical activity through community empowerment in an attempt at primary prevention of non communicable diseases. METHODS: The Chennai Urban Population Study [CUPS] was conducted in the year 1996 in two residential areas: a middle income group the Asiad colony at Tirumangalam, and a low income group at Bharathi Nagar in T. Nagar. The Asiad colony was selected for this study. Of the 524 eligible individuals available at baseline in 1998 [age > or =20 years], 479 individuals consented for the study (response rate: 91.4%). After seven years, in 2004, the number of eligible individuals increased to 712 of whom 705 consented for the study (response rate:99%). Education regarding the benefits of physical activity was provided by mass awareness programmes like public lectures and video clippings. Both at baseline and during follow-up, details about the physical activity were collected using a validated questionnaire, which included job related and leisure time activities, and specific questions on exercise. Study individuals were then graded as having light, moderate and heavy physical activity using a scoring system. RESULTS: In response to the awareness programmes given by our research team, the colony residents constructed a unique public park with their own funds. Though the occupation grades did not change, there was a significant change in the pattern of physical activity. At baseline, only 14.2% of the residents did some form of exercise. more than three times a week, which presently increased to 58.7% [p < 0.001]. The number of subjects who walked more than three times a week increased from 13.8% at baseline to 52.1% during follow-up [p < 0.001]. CONCLUSION: This study is a demonstration of how community empowerment with increased physical activity could possibly lead to prevention of diabetes and other non communicable diseases at the community level. This study also highlights the importance of sharing the results of research studies with the community.

Accelerated platelet activation in Asian Indians with diabetes and coronary artery disease--The Chennai Urban Population Study (CUPS-13).

AIM : To assess platelet activation in south Indian type 2 diabetic subjects with and without CAD. METHODS : Four groups of subjects were studied; Group 1 comprised of non-diabetic subjects without coronary artery disease (CAD) (n = 30). Type 2 diabetic subjects without CAD formed Group 2 (n = 30); Group 3 comprised of type 2 diabetic subjects with CAD (n = 30) and Group 4 consisted of non- diabetic subjects with CAD (n=14). CAD was diagnosed based on coronary angiographic evidence of severe double or triple vessel disease. Platelet activation was tested after an overnight fast in blood obtained from a bleeding wound at 1 minute post-incision (wound-induced activation) as well as venous blood stimulated in vitro with collagen, using whole blood flow cytometry. In subjects with CAD, aspirin was withdrawn for 7 days and nitrates for 24 hours. RESULTS: Collagen induced GP IIb/IIIa binding was significantly higher among diabetic subjects with (28.10 +/-19.89; p<0.05) and without CAD (21.02+/-19.62; p<0.05) and non-diabetic subjects with CAD (23.89+/-15.65; p<0.05) compared to non-diabetic subjects without CAD (11.69+/-13.69). Regression analysis showed collagen induced GP IIb/IIIa binding to be significantly associated with CAD [odds ratio (OR): 1.029, p = 0.025] and diabetes (OR: 1.037, p = 0.007). CONCLUSION: Increased platelet activation is seen in urban south Indians with diabetes and CAD.

Pregnancy outcomes in pre-gestational and gestational diabetic women in comparison to non-diabetic women--A prospective study in Asian Indian mothers (CURES-35).

BACKGROUND AND OBJECTIVE: Diabetes can complicate pregnancy but it is not the major complication of pregnancy. Though prevalence of diabetes is alarmingly high among Indians there have been very few studies assessing the effect of diabetes on pregnancy outcomes, particularly comparing pre-gestational diabetes mellitus [PGDM] and gestational diabetes [GDM] with non-diabetic mothers. METHODS: Pregnant women attending the Dr. Mohan's Diabetes Specialities Centre, a tertiary care centre for diabetes in Chennai in southern India were selected for the study. PGDM and GDM were defined using standard criteria. Out of the 245 pregnant women with diabetes registered at the centre, follow up data was available for 225, which included 79 PGDM and 146 GDM subjects. Non-diabetic controls (n=30) were recruited from the ongoing population based study the Chennai Urban Rural Epidemiology Study (CURES). Details of outcome variables including abortions, mode of delivery, congenital anomalies and neonate's birth weight were documented. RESULTS: Women with PGDM had significantly higher fasting plasma glucose [p<0.001] and fructosamine [p<0.001] levels compared to GDM. Proportion of women who underwent abortions was 0% in non-diabetic controls, 10.1% in PGDM and 2.7% in GDM and the difference between PGDM and GDM was statistically significant [p = 0.04]. Prevalence of 'low birth weight' babies in the study groups were, 14.3% in non-diabetic mothers, 12.3% in PGDM and 8.2% in GDM. The prevalence of 'large babies' was higher in GDM [27.6%] and PGDM [19.2%] groups compared to non-diabetic controls [7.1%] but the differences reached statistical significance only in the GDM group [p = 0.04]. Prevalence of congenital anomalies was 0% among non-diabetic controls, 3.8% in PGDM and 1.4% in GDM but the differences did not reach statistical significance. A significant increase in frequency of abortions [trend chi square = 5.67, p = 0.017] and 'low birth weight' babies [trend chi square = 4.761,p = 0.029] was observed with increasing fructosamine levels in the diabetic mothers. CONCLUSION: Women with diabetes have worse pregnancy outcomes compared to non-diabetic mothers with and those with pre-gestational diabetes fare worse than those with gestational diabetes. The study emphasizes the fact that strict glycemic control is extremely important during pregnancy.

Mortality rates due to diabetes in a selected urban south Indian population--the Chennai Urban Population Study [CUPS--16].

OBJECTIVE: The aim of this study was to determine the mortality rate in diabetic and non-diabetic subjects in urban south India. METHODS: The Chennai Urban Population Study is an ongoing epidemiological study in Chennai [formerly Madras, in south India]. All individuals > or = 20 years of age living in two residential colonies in Chennai were invited to participate in the study. Of the total 1399 eligible subjects, 1262 individuals responded [90.2%] at baseline, and of these, 1140 individuals [90.3%] could be followed annually from 1997 to 2003-04. Mortality rates and causes of death were the main outcome measures. RESULTS: The median follow up period was six years. The overall mortality rate was higher in diabetic compared to non-diabetic subjects [18.9 vs.5.3 per 1000 person-years, p=0.004]. Mortality due to cardiovascular [diabetic subjects, 52.9%; non-diabetic subjects, 24.2%,p=0.042] and renal causes[diabetic subjects, 23.5%; non-diabetic subjects, 6.1%,p=0.072] was higher among diabetic subjects whereas mortality due to gastrointestinal 112.1%], respiratory [9.1%], lifestyle related [6.1%] and unnatural causes [18.2%] were observed only among non-diabetic subjects. Hazards ratio [HR] for all cause mortality for diabetes was 3.6, [95% Confidence Interval [CI]: 2.02-6.53, p<0.001] and this remained significant even after adjusting for age [HR:1.9, 95% CI:1.04-3.45, p=0.038]. Light grade physical activity was associated with higher mortality rate [p=0.008], but the significance disappeared when adjusted for age. Smoking was also associated with increased mortality. CONCLUSIONS: In urban India, mortality rates are two fold higher in people with diabetes compared to nondiabetic subjects. Cardiovascular and renal diseases are the commonest causes of death among diabetic subjects.

A simplified Indian Diabetes Risk Score for screening for undiagnosed diabetic subjects.

AIM: The aim of this study was to develop and validate a simplified Indian Diabetes Risk Score for detecting undiagnosed diabetes in India. METHODS: The risk score was derived from the Chennai Urban Rural Epidemiology Study (CURES), an ongoing epidemiological study on a representative population of Chennai. Phase 1 of CURES recruited 26,001 individuals, of whom every tenth subject was requested to participate in Phase 3 for screening for diabetes using World Health Organization (WHO) 2 hour venous plasma glucose criteria [i.e. > or = 200 mg/dl]. The response rate was 90.4% (2350/2600). The Indian Diabetes Risk Score [IDRS] was developed based on results of multiple logistic regression analysis. Internal validation was performed on the same data. RESULTS: IDRS used four risk factors: age, abdominal obesity, family history of diabetes and physical activity. Beta co-efficients were derived based on a multiple logistic regression analysis using undiagnosed diabetes as the dependent variable. The beta co-efficients were modified so as to obtain a maximum possible score of 100. Receiver Operating Characteristic [ROC] curves were constructed to identify the optimum value of IDRS for detecting diabetes by WHO consulting group criteria. Area under the curve for ROC was 0.698 (95% confidence interval (CI): 0.663-0.733). An IDRS value > or = 60 had the optimum sensitivity (72.5%) and specificity (60.1%) for determining undiagnosed diabetes with a positive predictive value of 17.0%, negative predictive value of 95.1%, and accuracy of 61.3%. CONCLUSION: This simplified Indian Diabetes Risk Score is useful for identifying undiagnosed diabetic subjects in India and could make screening programmes more cost effective.

Association of small dense LDL with coronary artery disease and diabetes in urban Asian Indians - the Chennai Urban Rural Epidemiology Study (CURES-8).

OBJECTIVE: Earlier studies in Europeans have identified small dense LDL to be associated with coronary artery disease and diabetes. In this study we assessed the association of small dense LDL with diabetes and CAD in Asian Indians. METHODS: Study subjects were selected from the Chennai Urban Rural Epidemiology Study (CURES), a population based study on representative sample of Chennai city in southern India. Group 1:non-diabetic subjects (n = 30); Group 2: diabetic subjects without CAD (n = 30); Group 3:diabetic subjects with CAD (n = 30). LDL subfractions were estimated using LipoPrint LDL system. LDL subfractions 3 and above, defined as small dense LDL was summed up to determine the overall small LDL. 75th percentile of the overall small dense LDL in non-diabetic subjects was used as a cut-off for defining elevated levels of small dense LDL. RESULTS: The mean age of the study subjects was not significantly different among groups. Overall small dense LDL was significantly higher in diabetic subjects with CAD (16.7 +/- 11.1 mg/dl, p < 0.05) and without CAD (11.1 +/- 8.0 mg/dl, p < 0.05) compared to non-diabetic subjects without CAD (7.2 +/- 6.8 mg/dl). Small dense LDL showed a positive correlation with fasting plasma glucose (r = 0.252, p = 0.023), HbA1c (r = 0.281, p = 0.012), total cholesterol (r = 0.443, p < 0.001), triglycerides(r = 0.685, p < 0.001), LDL(r = 0.342, p = 0.002), total cholesterol/HDL ratio (r = 0.660, p = < 0.001) and triglycerides/HDL ratio(r = 0.728, p < 0.001) and a negative correlation with HDL cholesterol (r = -0.341, p = 0.002) and QUICKI values (r = -0.260, p = 0.019). ROC curves constructed to predict elevated small dense LDL ((9.0 mg/dl) revealed that triglycerides/HDL ratio and total cholesterol/HDL ratio had higher AUC values compared to other parameters. A triglycerides/HDL ratio of 3.0 had the optimum sensitivity (80.0%) and specificity (78.0%) for detecting elevated small dense LDL. CONCLUSION: This data suggests that in Asian Indians, small dense LDL is associated with both diabetes and CAD and that a triglycerides/HDL ratio (3.0 could serve a surrogate marker of small dense LDL.

Evaluation of One Touch HORIZON--a highly affordable glucose monitor.

BACKGROUND AND OBJECTIVE: Despite the growing evidence on the benefits of self-monitoring in diabetes, the use of these meters has been low in developing countries, particularly India. Cost seems to be the major constraint. The aim of the present study is to evaluate the accuracy of One Touch HORIZON an affordable glucose meter with laboratory assessment of blood glucose. METHODS: 100 subjects with diabetes over the age of 18 years were recruited from the MV Diabetes Specialities Centre, Chennai. All the study subjects had their fasting blood tested for glucose in One Touch HORIZON by finger prick. Fasting blood glucose was also assessed in YSI 2300 STATPLUS (Yellow Springs Instruments, Ohio, USA) glucose analyzer. The Parke's Error Grid model was used to assess the accuracy of the meter against YSI plasma glucose values. RESULTS: Of the total 100 study subjects, 97 were Type 2 diabetic subjects and three were Type 1 diabetic subjects. 62% of the study subjects were males. 89% did not perform SMBG and only 2% of the diabetic subjects performed SMBG daily. The Parke's Error Grid analysis revealed 97% of results to be in Zone A when patient performed the test, 99 - 100% in Zone A when clinical staff performed the test indicating excellent accuracy and precision. CONCLUSION: One Touch HORIZON meter is an affordable meter with good accuracy and precision, specifically designed to cater to the needs of diabetic patients in developing countries.