Pyloric Functional Lumen Imaging Probe Measurements Are Dependent on Balloon Position

Background/Aims@#The functional lumen imaging probe (FLIP) device has been used to assess pyloric dysfunction in patients with gastroparesis. We aim to investigate whether varying FLIP catheter positions affect pyloric FLIP measurements. @*Methods@#Patients undergoing endoscopy for chronic unexplained nausea and vomiting (CUNV) or gastroparesis were prospectively enrolled. FLIP balloon was adjusted for 3 positions within the pylorus: (1) proximal position, 75% of FLIP balloon in the duodenum and 25% in the antrum; (2) middle position, 50% in the duodenum and 50% in the antrum; and (3) distal position, 25% in the duodenum and 75% in the antrum. Pylorus cross-sectional area (CSA), intra-bag pressure (P), and distensibility indices (DI) were measured for 30, 40, and 50-mL balloon volumes. Fluoroscopic images were obtained to confirm FLIP balloon geometry. Data was analyzed separately using FLIP Analytic and customized MATLAB software. @*Results@#Twenty-two patients with CUNV (n = 4) and gastroparesis (n = 18) were enrolled. Pressures were significantly higher in the proximal position compared to the middle and distal positions. CSA measurements were significantly higher at the proximal and middle positions for 30-mL and 40-mL volume compared to the distal position values. DI values were significantly lower at the proximal positions for 40-mL and 50-mL distensions when compared to the middle and distal positions. Fluoroscopic images confirmed increased balloon bending when placed mostly in the duodenum. @*Conclusions@#FLIP balloon position within the pylorus directly affects balloon geometry which significantly affects P, CSA, and DI measurements. Standardized pyloric FLIP protocols and balloon design adjustments are needed for the continued application of this technology to the pylorus.

Erroneous reduction of HbA1c levels in patients with type 2 diabetes mellitus on dapsone treatment for Hansen’s disease - a single-center retrospective cohort study

Background: Dapsone treatment may reduce HbA1c levels in patients with diabetes. Aims: To assess the prevalence and characteristics of dapsone associated reduction of HbA1c in patients with Hansen’s disease. Methods: A retrospective data review of outpatient and inpatient charts of consecutive patients with Hansen’s disease and type 2 diabetes mellitus was conducted over two years from January 2014 to January 2016 at the Department of Dermatology, CMC Vellore, India. Results: Of the 245 patients with a confirmed diagnosis of Hansen’s disease who were on oral dapsone 100 mg/day as part of their treatment regimen, 49 patients had diabetes and were eligible for the study as per predetermined inclusion criteria. Of these, 35 subjects (71%) had an HbA1c discordantly lower than the corresponding mean plasma glucose levels. Patients with discordant HbA1c levels were more likely to be male and to have a higher RBC mean corpuscular volume (MCV). A greater reduction in HbA1c levels was seen during the initial 3 months of therapy of dapsone treatment. Limitations: The small sample size and retrospective design were limitations of this study. Also, we did not analyze the role of methemoglobinemia or the utility of alternative measures of glycemic control in these patients. Conclusion: We describe a high prevalence of dapsone associated inappropriate HbA1c lowering in type 2 diabetes mellitus patients. This may have serious implications for the management of diabetes in patients on therapy with dapsone.

Avances en el diagnóstico y tratamiento de deficiencia de hierro y anemia ferropenica / Advances in the diagnosis and treatment of iron deficiency and iron deficiency anemia

RESUMEN Deficiencia de hierro (DH) y anemia ferropénica (AF) continúan siendo problemas de salud de magnitud en el mundo y afectan especialmente a niños preescolares y mujeres embarazadas. Este artículo tiene como objetivos: a) Describir las pruebas de laboratorio diagnóstico de AF y los factores que influyen en los niveles de ferritina y otros biomarcadores del estado del hierro; b) Presentar avances en el metabolismo del hierro, i.e. el rol regulador esencial de la hepcidina en la absorción y utilización del hierro; c) Describir el impacto que estos avances han tenido en el diseño de investigaciones clínicas comparando la absorción del hierro asociada con esquemas de ingesta diaria versus días alternados; d) Describir las situaciones clínicas en las cuales hierro endovenoso está indicado como tratamiento secundario o de primera línea. Los conceptos y sugerencias expresados en este artículo están basados en literatura actualizada y la experiencia clínica de los autores.

ABSTRACT Iron deficiency (ID) and iron deficiency anemia (IDA) are still major health problems worldwide, affecting especially preschool children and pregnant women. The objectives of this article are: a) To describe the laboratory tests for diagnosing IDA and the factors that may influence results of the serum ferritin and the other iron biomarkers ; b) To present advances in iron metabolism, i.e. the critical regulatory role of hepcidin in the absorption and utilization of iron ; c) To describe the impact this new knowledge has had in the design of clinical investigations comparing the absorption of iron following oral supplementation given in consecutive days vs. alternate days schedules; and, d) To describe the clinical situations in which intravenous iron is indicated as secondary or first-line treatment. The concepts expressed and the suggestions made in this article are based on updated literature and the clinical experience of the authors.

The potential impact of austerity on attainment of the Sustainable Development Goals in Brazil

In the recent decades, Brazil has outperformed comparable countries in its progress toward meeting the Millennium Development Goals. Many of these improvements have been driven by investments in health and social policies. In this article, we aim to identify potential impacts of austerity policies in Brazil on the chances of achieving the sustainable development goals (SDGs) and its consequences for population health. Austerity's anticipated impacts are assessed by analysing the change in federal spending on different budget programmes from 2014 to 2017. We collected budget data made publicly available by the Senate. Among the selected 19 programmes, only 4 had their committed budgets increased, in real terms, between 2014 and 2017. The total amount of extra money committed to these four programmes in 2017, above that committed in 2014, was small (BR$9.7 billion). Of the 15 programmes that had budget cuts in the period from 2014 to 2017, the total decrease amounted to BR$60.2 billion (US$15.3 billion). In addition to the overall large budget reduction, it is noteworthy that the largest proportional reductions were in programmes targeted at more vulnerable populations. In conclusion, it seems clear that the current austerity policies in Brazil will probably damage the population's health and increase inequities, and that the possibility of meeting SDG targets is lower in 2018 than it was in 2015.

Single-centre experience of allogeneic haemopoietic stem cell transplant in paediatric patients in Cape Town, South Africa

Background. Allogeneic haemopoietic stem cell transplant (Allo-HSCT) is a specialised and costly intervention, associated with significant morbidity and mortality. It is used to treat a broad range of paediatric conditions. South Africa (SA) is an upper middle-income country with limitations on healthcare spending. The role of paediatric Allo-HSCT in this setting is reviewed.Objectives. To review paediatric patients who underwent Allo-HSCT at the Groote Schuur Hospital/University of Cape Town Private Academic Hospital transplant unit in Cape Town, South Africa, and received post-transplant care at Red Cross War Memorial Children's Hospital, over the period January 2006 - December 2014 in respect of indications for the transplant, donor sources, conditioning regimens, treatment-related morbidity and overall survival (OS).Methods. A retrospective analysis of patient records was performed and a database was created in Microsoft Access. Descriptive analyses of relevant demographic, clinical and laboratory data were performed. Summary statistics of demographic and clinical parameters were derived with Excel. OS was calculated from the date of transplant to the date of an event (death) or last follow-up using the Kaplan-Meier method in Statistica. Results. A total of 48 children received Allo-HSCT: 24 for haematological malignancies, 20 for non-oncological haematological conditions, 3 for immune disorders and 1 for adrenoleukodystrophy. There were 28 boys (median age 7.5 years) and 20 girls (8.5 years). There were 31 sibling matched peripheral-blood stem cell (PBSC) transplants and 1 maternal haploidentical PBSC transplant. Stem cells were mobilised from bone marrow into peripheral blood by administering granulocyte-colony stimulating factor to donors. PBSCs were harvested by apheresis. Eight patients received 10/10 HLA-matched grafts from unrelated donors. Six were PBSC grafts and 2 were bone marrow grafts. Three of the unrelated PBSC grafts were from SA donors. Eight transplants used umbilical cord blood from international registries. OS for patients with non-oncological disorders was 91.3% (median follow-up 3.9 years), while that for oncology patients was 56.8% (1.9 years). Two of the survivors developed chronic graft-versus-host disease. Conclusions. OS for non-oncological conditions was excellent, while outcomes for oncological disorders were on par with those in high-income settings. Transplantation offers many patients the opportunity for long-term survival and has been shown to be both feasible and rewarding in a less well-resourced environment servicing an economically diverse population

Early clinical exposure through innovative interactive clinical anatomy lectures.

Background. Traditional lecture-based teaching of anatomy tends to focus on the discipline per se rather than relating it to clinical conditions. As a result, students often lose interest in the basic sciences. We hypothesized that a lecture format that encourages students to relate anatomy to case presentations might help them in appreciating clinical relevance. We therefore proposed to develop, implement and evaluate innovative interactive clinical anatomy lectures (ICALs) for first year medical students of our institution as a method to implement the ‘early clinical exposure’ teaching strategy being promoted by the Medical Council of India. Methods. The first year medical students (n=150) were divided into two groups by lottery: the study group (n=75) and the control group (n=75). The study group received nine ICALs along with traditional gross anatomy lectures (TGL) and dissection. The control group received only TGL along with dissection. A post-test in clinical anatomy was conducted for both groups. The responses of the study group on TGL and ICALs on their learning and understanding of the clinical conditions were collected using the nominal group technique. Results and conclusion. It is feasible to introduce early clinical exposure within lectures even with 150 students. There was a statistically significant (p<0.001) difference in the mean post-test scores of the two groups, which shows that ICALs are effective in correlating anatomical and clinical information to students. The nominal group technique responses of the study group showed that they appreciated it as a better method of teaching and learning. Natl Med J India 2015;28:291–4

Association between Smoking and Body Mass Index among Males Aged 20 Years and Above - A Study in Rural Tamil Nadu, South India.

Objective: To investigate the relationship between smoking status and Body Mass Index (BMI) in men aged 20 years and above. Methods: A cross sectional study was conducted in the rural field practice area of Department of Community Medicine, PSG Institute of Medical Science and Research, Coimbatore during June and July 2010. A total of 459 men aged 20 years and above were included in the study. Statistical analyses were done using General Linear Model procedure of SPSS. Results: Cigarette smokers weighed (Kg) less, p<0.01 (age adjusted mean ± standard error = 58.64 ± 0.44) and were leaner, p<0.001 [age adjusted mean BMI (kg/m2) ± standard error = 21.13 ± 0.13] than ex/non-smokers (61.11 ± 0.69 and 22.19 ± 0.2 respectively). Regarding the intensity of smoking and BMI, light smokers (1 to 20 cigarettes per day) were leaner than ex/non smokers (mean ± standard error were 21.13 ± 0.13, 22.19 ± 0.208 respectively, p< 0.001). Regarding the duration of smoking and BMI, a linear diminution in BMI is observed with increasing duration of cigarettes smoking compared to ex/non smokers (mean ± standard error of BMI) for ex/non smokers 22.19 ± 0.208, 1 to 10 years of smoking 21.56 ± 0.221(p<0.05); 11 to 20 years of smoking 21.23 ± 0.256 (p<0.01); 21 to 30 years of smoking 20.30 ± 0.333 (p<0.001); 30 and above years of smoking 20.07 ± 0.501(p<0.001). Conclusion: We found significant results confirming an association between cigarette smoking and lower BMI in men.

Developing a Learning Need Assessment Tool (LNAT) to Teach Epidemiology for Medical Students.

Background: The Department of Community Medicine of PSG Institute of Medical Sciences and Research has been training the medical students to become competent community physicians for improving Community Health. Epidemiology is the subject within community medicine which teaches them the principles of medical research. Objective: This study intends to develop a tool to identify the student learning needs in learning Epidemiology and thereby improves their learning by bridging the knowledge and competency gaps through reinforcing sessions and also to measure the learning outcome using the same tool after the reinforcing sessions. What was done?: LNAT was developed using a matrix which lists cognitive domains and practical skills in Epidemiology and the level of understanding and competency were measured using this matrix containing John P Reiling and G.E Millers Framework on assessment of learning. This Learning Need Assessment Tool was administered to 71 students in Final MBBS Part 1 phase over a period of 3 months. Pre and post self-assessment data were analyzed and proportions were calculated. Results: There was student per-ceived improvement in cognitive domains and computing skills in various measurements used in Epidemiology. Conclusion: This LNAT on Epidemiology identified the gaps and also the learning needs of UG medical students through pre test. The Post test enabled the teacher to measure the change in learning need after the completion of reinforcing epidemiology classes using the LNAT.

Clinical Significance of Serum Autoantibodies in Idiopathic Interstitial Pneumonia

Although autoantibodies are routinely screened in patients with idiopathic interstitial pneumonia, there are no reliable data on their clinical usefulness. The aim of this study was to investigate the prognostic value of autoantibodies for predicting the development of new connective tissue disease in these patients and also mortality. We conducted retrospective analysis of the baseline, and follow-up data for 688 patients with idiopathic interstitial pneumonia (526 with idiopathic pulmonary fibrosis, 85 with nonspecific interstitial pneumonia, and 77 with cryptogenic organizing pneumonia) at one single tertiary referral center. The median follow-up period was 33.6 months. Antinuclear antibody was positive in 34.5% of all subjects, rheumatoid factor in 13.2%, and other specific autoantibodies were positive between 0.7%-6.8% of the cases. No significant difference in patient survival was found between the autoantibody-positive and -negative groups. However, the presence of autoantibodies, especially antinuclear antibody with a titer higher than 1:320, was a significant predictor for the future development of new connective tissue diseases (relative risk, 6.4), although the incidence was low (3.8% of all subjects during follow-up). In conclusion, autoantibodies are significant predictors for new connective tissue disease development, although they have no prognostic value.

Time travel: a discovery tool for identifying individual professional development needs.

After formal qualification, most practicing doctors try to update themselves to keep abreast with new knowledge and practice through periodic Continuing Medical Education (CME) programs. However, as opposed to CME which is teacher driven and only updates clinical knowledge, there is need for promoting Continuous Professional Development (CPD) which is individual learner driven based on individual learning needs and embraces developing and improving a broad range of skills and competencies necessary for improved medical practice. There is evidence from literature which shows that doctors become more motivated to learn and achieve required CPD goals when they discover their own CPD learning needs, plan their own CPD activities, do deliberate practice and receive feedback for improvement in practice at their own pace. This increased motivation is explained by the Need reduction theory. The Need reduction theory can be put to practice by doing a needs assessment (discrepancy analysis) which identifies the gap between “what is” and “what ought to be” (Fox & Miner,1999).

Study of water supply & sanitation practices in India using geographic information systems: Some design & other considerations in a village setting.

Background & objectives: Availability of clean water and adequate sanitation facilities are of prime importance for limiting diarrhoeal diseases. We examined the water and sanitation facilities of a village in southern India using geographic information system (GIS) tools. Methods: Places of residence, water storage and distribution, sewage and places where people in the village defaecated were mapped and drinking water sources were tested for microbial contamination in Nelvoy village, Vellore district, Tamil Nadu. Results: Water in the village was found to be microbiologically unfit for consumption. Analysis using direct observations supplemented by GIS maps revealed poor planning, poor engineering design and lack of policing of the water distribution system causing possible contamination of drinking water from sewage at multiple sites. Interpretation & conclusions: Until appropriate engineering designs for water supply and sewage disposal to suit individual village needs are made available, point-of-use water disinfection methods could serve as an interim solution.

Perforated appendicitis presenting with ileo-caecal ulceration and mechanical intestinal obstruction.

A 30-year-old lady presented with a 6-month history of recurrent partial intestinal obstruction associated with intermittent fever, anorexia and weight loss. Barium meal follow-through and colonoscopic evaluation suggested ulceration of the ileum and caecum with small bowel obstruction. Histology of the lesions showed marked acute and chronic inflammation consistent with ulceration and granulation tissue. Abdominal CT revealed circumferential thickening of the ascending colon, caecum and terminal ileum with extraluminal air pockets. Surgical exploration revealed a large conglomerate mass involving the terminal ileum, caecum and ascending colon. Histopathology of the resected specimen revealed perforated appendix with nonspecific ulceration of the surrounding bowel. She recovered completely after surgery and did not suffer from gastrointestinal symptoms in the 14 months of follow-up.

Glutathione and associated enzymes in toxic cataractogenesis-selenite model.

Glutathione, gamma-glutamyl cysteine synthetase (gamma -GCS) and glutathione reductase (GSH-R) activity were determined biochemically in the lens during various stages after subcutaneous administration of sodium selenite in multiple low dosages and single high dosages. The GSH concentration and gamma-GCS and GSH-R activity declined progressively after the selenite administration. The changes observed were discussed in relation to the possible role of selenite interaction with GSH and the enzymes.

Pregnancy in a patient with hypopituitarism following surgery and radiation for a pituitary adenoma.

This is a case of partial hypopituitarism resulting from surgery and radiation for a non- functioning pituitary macroadenoma. The patient had amenorrhea which was secondary to hypogonadotrophic hypogonadism and had been on L-thyroxine for central hypothyroidism. For pregnancy, ovulation was induced by gonadotrophins and this was followed by an intrauterine insemination. The antenatal period was uneventful and a Caesarean section was done at 33 weeks when the patient presented with preterm labour. Both infant and mother are well, eight months after delivery.

Usual Interstitial Pneumonia and Non-Specific Interstitial Pneumonia: Serial Thin-Section CT Findings Correlated with Pulmonary Function

OBJECTIVE: We wanted to demonstrate and compare the serial high-resolution CTs (HRCT) and the pulmonary function test (PFT) findings of the usual interstitial pneumonia (UIP) and the non-specific interstitial pneumonia (NSIP). MATERIALS AND METHODS: The serial HRCT scans and the PFT results were retrospectively analysed and compared for 35 patients having UIP without significant honeycombing (UIP-w/o hc, or = 5% of honeycombing), and 25 patients with NSIP. The mortality rates were also compared. Follow-up CT scans were available in 75 patients (29 UIP-w/o hc patients, 22 UIP-w/i hc patients and 24 NSIP patients) and the follow-up periods ranged from 150 to 2, 370 days. The initial and follow-up PFT data were available for 71 patients. RESULTS: On the initial CT, significant differences were present between the UIP-w/i hc patients and both the UIP-w/o hc patients and the NSIP patients in the overall extent, ground-glass opacity (GGO) away from the reticulation, reticulation and honeycombing (all p < 0.05). Improvement was noticed in five (17%) of 29 UIP-w/o hc patients, none of 22 UIP-w/i hc patients, and 9 (37%) of 24 NSIP patients; deterioration was noted in six (21%) UIP-w/o hc patients, two (9%) UIP-w/i hc patients and three (13%) NSIP patients (p = 0.044 between UIP-w/o and UIP-w/i hc; p = 0.637 between UIP-w/o hc and NSIP; p = 0.007 between UIP-w/i hc and NSIP). The serial changes of the pulmonary function in the NSIP patients were different from those noted for the UIP-w/i hc and UIP-w/o hc patients (p = 0.440 between UIP-w/o and UIP-w/i hc; p = 0.022 between UIP-w/o hc and NSIP; p = 0.003 between UIP-w/i hc and NSIP). Five (14%) of the 35 patients with UIP-w/o hc, 16 (46%) of the 35 patients with UIP-w/i hc and three (12%) of the 25 patients with NSIP died (p = 0.002, comparison for the three groups). CONCLUSION: On CT, NSIP and UIP-w/o hc patients have similar patterns of parenchymal abnormalities and a similar likelihood of change in the extent of disease on follow-up. Patients with UIP-w/i hc have distinctive features and a worst prognosis.