Extrafollicular Variant of Adenomatoid Odontogenic Tumor in Maxilla: A Diagnostic Enigma

Introduction: Adenomatoid odontogenic tumor (AOT) is a rare epithelial odontogenic tumor of jaws. It is a benign, painless, non-invasive, slow-growing lesion, with a frequency of 2.2-7.1%. Upon clinical examination it can be misdiagnosed as an odon- togenic cyst. AOT affects young individuals with a female predominance, occurs mainly in the second decade, more common in anterior maxilla and usually surrounds the crown of unerupted tooth mostly impacted canine. AOT has three clinical subtypes named as follicular, extrafollicular, and peripheral. Clinical presentation: This case report represents a 20 years old female patient with the chief complaint of swelling on the right upper anterior region for 8 months. Management and prognosis: After surgical excision and histopathological evaluation it is diagnosed as a rare case of extrafol- licular variant of intraosseous AOT.

The need for obtaining accurate nationwide estimates of diabetes prevalence in India - Rationale for a national study on diabetes.

According to the World Diabetes Atlas, India is projected to have around 51 million people with diabetes. However, these data are based on small sporadic studies done in some parts of the country. Even a few multi-centre studies that have been done, have several limitations. Also, marked heterogeneity between States limits the generalizability of results. Other studies done at various time periods also lack uniform methodology, do not take into consideration ethnic differences and have inadequate coverage. Thus, till date there has been no national study on the prevalence of diabetes which are truly representative of India as a whole. Moreover, the data on diabetes complications is even more scarce. Therefore, there is an urgent need for a large well-planned national study, which could provide reliable nationwide data, not only on prevalence of diabetes, but also on pre-diabetes, and the complications of diabetes in India. A study of this nature will have enormous public health impact and help policy makers to take action against diabetes in India.

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.

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.

Seroprevalence of human immunodeficiency virus (HIV) infection among tuberculosis patients in Tamil Nadu.

BACKGROUND & OBJECTIVES: The dual epidemic of HIV and tuberculosis is a cause for concern in those countries where these two infections are prevalent in epidemic proportions. We undertook a survey at two sites in North Arcot district of Tamil Nadu in 1992-1993, to know the seroprevalence of HIV infection among tuberculosis patients. The objective of this study was to re-examine the prevalence of HIV infection among tuberculosis patients in a repeat survey. METHODS: The study was undertaken in four centres: District Tuberculosis Centre (DTC), Vellore, Tuberculosis Sanatorium, Pennathur (Vellore), District TB Centre (DTC), Kancheepuram and the Government Thiruvotteswarar Tuberculosis Hospital (GTTH), Chennai in the northern part of Tamil Nadu during 1997-1998. A total of 2361 newly diagnosed TB patients were registered in this study. HIV serology after pre-test counseling was done along with sputum examination for acid-fast bacillus by smear and culture for mycobacteria for all patients. RESULTS: The overall HIV seroprevalence among TB patients was 4.7 per cent. The highest HIV seropositivity rate was found among patients aged 30-39 yr (10.6%). HIV seroprevalence showed a wide variation among the different centres ranging from 0.6. per cent in DTC, Kancheepuram to 9.4 per cent in Pennathur Sanatorium, Vellore. Sputum smear positivity was 88 per cent among the HIV-negative and 83 per cent among HIV-positive tuberculosis patients. INTERPRETATION & CONCLUSION: HIV infection is on the rise among TB patients in Tamil Nadu. Acid-fast smear microscopy is adequate for the diagnosis of pulmonary tuberculosis, and drug resistance among HIV positive patients is not a major problem at this point of time; hence antituberculosis regimens recommended by the Revised National Tuberculosis Control Program (RNTCP) can be used to treat HIV positive patients with tuberculosis.

Sero diagnosis of tuberculosis in children using two ELISA kits.

The diagnosis of childhood tuberculosis is based on circumstantial evidence in the absence of a gold standard in the majority of cases. Sero-diagnosis offers scope for an early diagnosis in a variety of clinical conditions and is simple to perform. A number of mycobacterial antigens have been used for antibody detection assays and several are available as kits in the market. This study was done to evaluate the value of antibody detection kits (ELISA) against the A60 antigen and 38 kDa antigen of Mycobacterium tuberculosis in the diagnosis of childhood tuberculosis at the outpatient department of the Institute of Social Paediatrics, Government Stanley Hospital in collaboration with Tuberculosis Research Centre, Chennai. Thirty five children with pulmonary tuberculosis, 7 with TB lymphadenitis and 22 healthy controls were studied. In addition to routine investigations including gastric lavage for AFB culture, serum antibodies against the A60 and 38 kDa antigens were assayed using commercially available ELISA kits. With A60, IgM serum levels were positive in 74% of pulmonary TB cases, 57% of TB lymphadenitis cases and 50% of controls. A60 IgG was positive in 17% of pulmonary TB, 86% of TB lymphadenitis and 14% of controls. The 38 kDa IgG antibody was positive in 37% of pulmonary and 86% of TB lymphadenitis cases and 27% of controls. Among 10 culture confirmed cases, A60 IgM was positive in 8, A60 IgG in 3 and 38 kDa IgG in 5 patients. The sensitivity of the tests ranged between 29% and 71% and specificity between 50% and 86%. Although the numbers are small, the results suggest that serodiagnosis using the currently available antigens of M. tuberculosis is unlikely to be a confirmatory test for tuberculosis in children.

Isolation of tubercle bacilli from sputum samples of patients in the field studies by the cetylpyridinium chloride-sodium chloride & sodium hydroxide methods.

A total of 125 sputum specimens, collected in the field, were homogenised, aliquoted in sterile universal containers and randomly allocated to the cetylpyridinium chloride - sodium chloride (CPC-NaCl) method and sodium hydroxide (NaOH) method for culture of tubercle bacilli. After storage for 8 days at ambient temperature in the field laboratory at Thiruvallur, the aliquots were transported to the main laboratory at Madras where they were processed for culture by the respective methods. The yield of positive cultures in the CPC-NaCl (31/125) method was only marginally better than that in the NaOH method (27/125) (95% CI being-3.4 to 9.8%), while the contamination of cultures was significantly less in the CPC-NaCl method (3/125) than in the NaOH method (12/125) (95% CI being 2.2 to 12.2%). As the CPC-NaCl method has advantages over the NaOH method in reducing contamination, in augmenting the yield of positive cultures and also in its simplicity, it can be applied in field studies.

Vancomycin for controlling contamination of selective Kirchner's liquid medium in the culture of gastric lavage for tubercle bacilli.

Gastric lavage (GL) was collected for culture of tubercle bacilli from children too young to expectorate sputum. The selective Kirchner's liquid medium (SKLM), routinely used as one of the media for culture of all extrapulmonary specimens, was found to often get contaminated when cultured with GL. We have shown that vancomycin at a concentration of 10 mg/l successfully reduced the contamination from about 60 to 20 per cent, and enhanced the isolation rate of tubercle bacilli from 3 to 6 per cent. Decontamination of the liquid culture before subculture on solid medium also helped to reduce the contamination rate. Vancomycin was found to be an effective selective drug for use in the Kirchner's liquid medium for culture of tubercle bacilli.

Heriditary pattern of cancer.

Three thousand nine hundred and twelve patients with cancer in various sites reporting to the out patient department were questioned for history of cancer among blood relatives. A positive history of cancer was obtained in 154 of whom 89 were male and 65 female. Thirty nine patients gave history of cancer among siblings and five gave history of cancer among spouses related by consanguneous marriage. The other 110 gave history of cancer among second and third generation relatives. Sixty one percent maternal relatives of the female patients had cancer as compared to only 33 percent of paternal relatives. This difference was not seen among male patients where there were about 45 percent of maternal and 47 paternal relatives giving history of cancer. Further it was found that 6 of 20 patients with cancer of the breast, 7 of 22 with stomach cancer and 4 of 12 with cervix cancer had blood relatives with the same type of cancer.

Association between obesity and hypertension in south Indian patients.

Two hundred and forty four newly diagnosed hypertensives (cases) of age 40 years and above, attending the hypertensive clinic of the Government General Hospital during one year and three hundred and twelve normotensives (controls) belonging to the same age group and attending the outpatient department during the same period for other minor ailments formed the subjects for this case control study. There were 18 (7.4%) obese subjects among hypertensives and 6 (1.9%) among controls. In spite of these low proportions, there was a strong association between obesity and hypertension with an overall odds ratio of 4 and there appeared to be a significant increasing trend in the proportion of cases of hypertension (37%, 63%, 75%) observed according to the different grades (underweight or normal, overweight, obese) of nutrition.

Classification of children as slow or rapid acetylators based on concentrations of isoniazid in saliva following oral administration of body-weight and surface-area-related dosages of the drug.

The acetylator phenotype of 180 children aged 3-11 years was determined on the basis of isoniazid concentrations in saliva collected at 5 hours after oral administration of body-weight and surface-area-related dosages of the drug in a syrup form. Isoniazid 2.5 mg/kg was administered on one occasion and 75 mg/m2 surface-area on another, with an interval of 3 days between the occasions. A cross-over design was employed and the sequence was determined by random allocation. The distribution of the concentrations was bimodal with both procedures, indicating the presence of two groups namely, the slow and rapid acetylators. The criterion for a rapid acetylator was a concentration of 0.3 micrograms/ml or less by body-weight-related dosage and 0.4 micrograms/ml or less by that based on surface-area. Based on these criteria, 62% of the children were classified as slow acetylators and 38% as rapid acetylators by body-weight, and 59 and 41%, respectively by surface-area, and the findings were similar in children in the different age-groups. The agreement between the two procedures was 98%.