Serum Levels of Activin A: Predictor of Insulin Resistance and Atherosclerosis in Prediabetics

Background: Pathological effects of dysglycemia and insulin resistance on atherosclerosis and cardiac remodeling starts as early as in the prediabetic state before the onset of overt diabetes. Activin A is a molecule with multiple functions, including an important part in glucose homeostatic mechanisms as well as inflammatory processes and is therefore being researched as a useful novel biomarker for prompt recognition of the risk of cardiovascular disease (CVD) in prediabetic individuals, thereby helping in disease prognostication and early institution of therapeutic measures. Objective: The study aimed to measure serum levels of activin A in prediabetic patients and evaluate them in comparison to normoglycemic controls. The association of activin A with carotid intima media thickness (CIMT), left ventricular diastolic dysfunction (LVDD), and homeostatic assessment of insulin resistance (HOMA-IR) was also studied. Materials and methods: A total of 60 prediabetic cases and 60 normoglycemic control subjects [matched as per age, gender, and body mass index (BMI)] were recruited. Measurement of serum glucose levels (fasting and postprandial) and fasting insulin levels and glycated hemoglobin (HbA1c) levels were done in all the subjects. The values of HOMA-IR were computed using established formulae. Enzyme-linked immunosorbent assay (ELISA) kits were used for the evaluation of serum levels of activin A in both groups. Parameters for the two groups were compared. In the cases, CIMT (using B-mode ultrasound) and LVDD (using two-dimensional (2D) echocardiography) were measured and correlated with activin A levels. Results: Serum fasting insulin (mIU/L) was considerably higher in cases than in the controls (p < 0.001). HOMA-IR median [interquartile range (IQR)] was 4 (3.25–4.93) in some cases, and that in the control group was 1.2 (0.88–1.5) (p < 0.001). Serum activin A levels in the cases group had a median (IQR) of 263.55 (227.1–279.5) ng/mL, which was substantially greater as compared to the control group 159.9 (150.7–178.7) ng/mL (p < 0.001). A significant positive association of serum activin A levels with HOMA-IR (? = 0.75, p < 0.001) and CIMT (? = 0.50, p < 0.001) was found. In LVDD grade I and II groups, the serum levels of activin A were 257.86 (219.3–271.2) ng/mL and 269 (244.19–291.5) ng/mL, respectively (p = 0.12). Conclusion: A substantial proportion of morbidity and mortality related to dysglycemic states can be attributed to cardiovascular complications. Elevated levels of activin A in prediabetes can act as an indicator of subclinical CVD leading to early diagnosis and intervention.

Small cell neuroendocrine carcinoma with adenocarcinoma and high grade squamous intraepithelial neoplasia of the cervix

ABSTRACT Neuroendocrine neoplasm (NEN) of the cervix is a malignant tumor and is classified into low and intermediate-grade neuroendocrine tumor (NET), and high-grade small cell neuroendocrine carcinoma (SCNEC), and large cells neuroendocrine carcinoma (LCNEC). SCNEC of the cervix is an Infrequent tumor with an incidence of less than 1% of all gynecological malignancies. It is characterized by small to medium-sized tumor cells with scant cytoplasm and neuroendocrine differentiation. Most cases of SCNEC of the cervix manifest in pure forms, and only cases show coexisting, non-neuroendocrine component of HPV-associated adenocarcinoma or squamous cell carcinoma. In this report, reviewing the literature, we present one such unique case of SCNEC of the cervix with adenocarcinoma and high-grade squamous intraepithelial neoplasia.

Primary pituitary tuberculosis

Tuberculosis is an infectious disease that involves any organ. However, the primary pituitary tuberculosis is an extremely rare disease. Intracranial tuberculomas account for 0.15-5% of intracranial space-occupying lesions, of which, pituitary as the primary site is unusual, and easily misdiagnosed as pituitary adenoma. In this setting, the late diagnosis can result in permanent endocrine dysfunction. We report the case of a 50-year-old woman who presented to the neurosurgery outpatient department with complaints of progressively increasing headache and diminished vision over the last year. On the clinical examination, the patient was conscious and oriented. The routine hematological and biochemical workup showed an increased erythrocyte sedimentation rate (ESR) and increased prolactin levels. The radiological working diagnosis was consistent with pituitary macroadenoma. No other radiological and/or clinical clue that could elicit the suspicion of pulmonary or extrapulmonary lesions of tuberculosis was found. The transsphenoidal endonasal tumor excision was done. The histopathology showed numerous epithelioid cell granulomas, Langhans giant cells along with scant necrosis. Ziehl Neelsen staining demonstrated acid-fast bacilli, and the final diagnosis of pituitary tuberculoma was made. We report this rare case of pituitary lesion that may be included in the differential diagnosis of sellar lesions to avoid unnecessary surgical interventions, especially in regions where the disease is endemic.

Ayurvedic approach for management of Wilson's disease: A case report

Wilson's disease betides due to mutation in ATP-7B that leads to snagging in copper transport by the hepatic lysosomes resulted in the deposition of copper in the brain, liver, kidney or skeletal system. The symptoms are jaundice, edema in legs, ascites, Kayser-Fleischer rings, dysarthria, dysphagia, ataxia, dyskinesia, and muscle spasticity. Current therapeutic modalities for the management of Wilson's disease include zinc, trientine, penicillamine and ammonium tetrathiomolybdate. A 12 year old child diagnosed with Wilson's disease came with complaints of inability to speak, difficulty in swallowing and generalized stiffness for 6 months. His investigations showed SGPT 43 U/L, Ceruloplasmin 0.03 g/L, urine copper level 225.03 μg per 24 h, a chronic parenchymal disease in the liver and splenomegaly. According to Ayurveda, this case of generalized stiffness with hepatomegaly and splenomegaly was correlated with Agnimandya at the Dhatu level that led to Vatavyadhi, Yakrutodara, and Plihodara. The treatment mentioned for Vatavyadhi is Snehana (oleation), MruduSwedana (mild sudation), Anuvasana Basti (oil enema) and for Yakrutodara and Plihodara is Niruha Basti (Decoction Enema) and Anuvasana Basti (oil enema). The case was treated with Abhyanga, Swedana, Basti and oral medication. After treatment, the symptoms were reduced and he was able to extend both lower limbs completely. His urinary copper level came to normal (47.01 μg per 24 h), so, it can be concluded that the Ayurvedic approach and diet modifications in such patients may help in providing supportive care and improving the quality of life.

Cardiac magnetic resonance in tropical endomyocardial fibrosis

Background: Endomyocardial fibrosis has varied presentatation and difficult to diagnose. Aim to elucidate the role of Cardiac Magnetic Resonance (CMR) imaging in the evaluation of Endomyocardial Fibrosis (EMF) and to devise diagnostic criteria for the disease.Methods: Retrospective analysis of cases of restrictive cardiomyopathy referred for Magnetic resonance imaging over a period of 5 years. All patients underwent 1.5 T CMR imaging (Magnetom Avanto, Siemens, Germany) with standard cardiomyopathy protocol. Criteria for diagnosis of RCM included normal sized ventricles, normal/reduced systolic function, uni-/bi-atrial enlargement, normal pericardium and absent septal bounce. Cases diagnosed as EMF on CMR were included in this study. Statistical analysis performed using SPSS software.Results: EMF was diagnosed in 20 patients (31%) [12 males; age 39±18 years]. Ten patients had Right Centricular (RV) EMF, 3 had Left Ventricular (LV) EMF, while 7 had bi-ventricular EMF. Oedema indicating ongoing inflammation was seen in 4 (20%) cases. Apical thrombus was seen in 8(40%) cases and was present in 35% cases of RV and 20% cases of LV involvement. Subendocardial delayed enhancement was always present in the involved ventricle. The RV apex was obliterated in 100% of patients with RV EMF, while LV apex was similarly obliterated in 66% cases with LV disease. Mild-moderate pericardial effusion was observed in 8 patients. On the basis of CMR findings, the disease was classified as early necrotic phase in 1, thrombotic necrotic in 4 and late fibrotic phase in 13 and of different stages in ventricles in 2 cases.Conclusions: EMF was the commonest cause of RCM in this series. Major diagnostic criteria of EMF on CMR include subendocardial delayed enhancement and apical obliteration. Oedema and thrombus are variable findings, depending on disease severity.

The rare case of a cystic pancreatic neuroendocrine tumor

The pancreatic neuroendocrine tumors (PanNETs) most commonly present as solid neoplasms; however, very rarely, they may present primarily as cystic neoplasms. Most of the cystic PanNETs are non-secreting tumors, and the radiological features are not well defined. Hence pre-operative diagnosis is usually challenging and the tumors are misdiagnosed as mucinous cystic neoplasms, intraductal papillary mucinous neoplasms, serous cystic neoplasms, solid pseudopapillary neoplasms, and non-neoplastic cysts. However, the management depends on the accurate diagnosis of these cystic lesions, which poses a dilemma. Herein, we report the case of a cystic PanNET in the tail of the pancreas, which was clinically and radiologically misdiagnosed as a mucinous cystic neoplasm. This case is reported to highlight this issue to the medical community regarding the diagnostic difficulty in such rare non-functioning pancreatic neuroendocrine tumors.

Malignant glomus tumor of the index finger

Glomus tumor (GT) is a benign mesenchymal tumor with an estimated incidence of 1.5 to 2% of soft tissue tumors. The majority of glomus tumors are benign and are mostly seen in the superficial skin & soft tissue of upper and lower distal extremity. The malignant variant of the glomus tumor is scarce. We report a case of a recurrent glomus tumor diagnosed in a 28-year-old male patient, who complained of painful swelling in the proximal phalanx of the right index finger. The magnetic resonance imaging of the hand revealed a well-defined multilobulated soft tissue mass at the palmar aspect of the 2nd digit along the shaft of the proximal phalanx. Histopathology revealed a well-circumscribed tumor arranged in solid sheets, nests and cords interconnect by vessels of varying size. The tumor cells were round to oval, showed moderate nuclear pleomorphism, eosinophilic cytoplasm, atypical mitoses (>5/10HPF), and necrosis. Immunohistochemically tumor cells reveal diffuse and strong cytoplasmic positivity with smooth muscle actin (SMA). Based on histomorphology and immunohistochemistry, a final diagnosis of malignant glomus tumor was made. We report this case due to its rarity, and it to be included among the differential if the lesion is painful and recurrent.

Evaluation of home based postnatal care provided by accredited social health activist worker in a rural community of Haryana: a cross-sectional study

Background: The post-natal period is the most critical time for the mother and the newborn. Most of the maternal deaths occur in first month of life. Based on these facts Government of India took an initiative, home based postnatal care (HBPNC), to follow up postnatal mothers and newborns for first six weeks. The present study assessed the quality of HBPNC provided by accredited social health activist (ASHA) workers and various factors associated with it.Methods: This cross-sectional study was conducted under Community Health Center, Dubaldhan in block Beri of Haryana. A total of 60 ASHA workers were visited and all the postnatal mothers under the supervision of each ASHA worker were included in the study. In this way 264 postnatal mothers were contacted. A scoring system was used to assess the quality of HBPNC given by ASHA worker.Results: Majority of ASHA workers were not able to record temperature and weight of the baby correctly. Regarding care of cord and danger signs in newborn only half (50%) of the mothers were counselled, whereas, only 48% mothers were counseled regarding care of eyes. Statistically significant association of quality of newborn care with education and training attended by ASHA workers was seen.Conclusions: Our study confirmed that most of the new born babies were not getting good quality of home based newborn care. Recent training attended by ASHA worker is highly associated with providing good quality newborn care to babies by ASHA workers.

Risk Prediction of Cardiovascular Events Using Thickness of Carotid Intima Media: An Institutional Based Study

Background: The load of coronary artery disease is on therise worldwide, developing countries, Like India, are acceptinglifestyle alterations that predispose to cardiovascular disorders.The present study was conducted with the aim to determinethe role of carotid intima media thickness in predictingcardiovascular events.Materials and Methods: The present prospective study wasperformed in the Department of Cardiology, Dr. Ram ManoharLohia Hospital & PGIMER, New Delhi, India. A detailed historyof all the subjects including medical history, biochemicalevaluation and ECG was performed amongst all the patients.The thickness of internal carotid artery and common carotidartery were measured bilaterally. A total of 3 readings wereobtained and mean was calculated. All the data thus obtainedwas arranged in a tabulated form and analyzed using SPSSsoftware.Results: A total of 200 subjects were enrolled in the study, themean age of the subjects was 44.87+/-3.89 years. There were120 males and 80 females in the study. The mean thickness ofright common carotid amongst cases was 0.12 ± .0085 andamongst control was 0.05 ± 0.0095. There was a significantdifference between the two as the p value was less than 0.05.Conclusion: Association between intimal thickness andcoronary artery disease is significant. Atherosclerosis is evenlydistributed amongst vasculature and primarily responsible forheart diseases.

Evaluation of Change in Dento-Skeletal Vertical Dimensions using Two Retraction Methods: A Comparative Study

Introduction: The goal of Orthodontic treatment is toimprove the patient’s life through enhancement of Dentofacialfunctions and esthetics. Paradigms have started to shift inOrthodontic world since the introduction of mini-implantsin the anchorage armamentarium. So the present study wasundertaken to analyse and compare the amount of Intrusionin maxillary anterior teeth segment using one and twominiscrews, while paying an utmost attention to patientscomfort and esthetics during the treatment.Material and Methods: The sample consisted of 20 subjectswith deep overbite and complete root formation with increasedincisor show. Lateral cephlogram and P.A Cephalogram wererecorded before placement of implant. Sample was furtherdivided in to two groups, Group I (Implant group one implantis placed between maxillary central incisors and two implantsplaced between second premolar and first molar) and GroupII (Implant Group with Power arms, one implant is placedbetween maxillary central incisor and power arms fabricatedon first molar bilaterally). Clinical evaluation of intrusion wasrecorded on every six weeks.Results: The mean intrusion achieved is 0.28mm per 6weeks interval of time in both groups suggesting there is nodifference in amount of intrusion achieved in both groups withp value of 0.697 which is statistically non-significant. Changein Frankfort mandibular plane angle was observed with GroupI and Group II.Conclusion: On the base of study it was concluded thatimplant and power arm is better choice for intrusion inmaxillary anterior segment for correction of deep overbite andcorrection of gummy smile with minimal effect on posteriorsegment

Prevalence of depression, anxiety and stress among jail inmates

Background: There are about 1387 prisons in the country with an authorized accommodation of 356,561; however, the total number of jail inmates is 418536 indicating severe overcrowding in prisons. Prison population is an underserved section of the society. Often their health problems are neglected. They carry a much greater burden of illness than other members of the society; they harbour diseases that are determined both by the environment out of which they come and by the prison in which they live. Therefore, present study was conducted with the aim of studying the mental health status of persons from a section of our society, who were condemned by law and are behind the high walls.Methods: A cross sectional study was carried out on 400 convicted inmates in district jail, Rohtak, Haryana over the period of one and half years. Data was collected by interview method using DASS-21 scale and analysed by SPSS 20.0 and Chi square test was applied for results.Results: The prevalence of depression came out to be 18.5%, anxiety came out to be 8% and stress was found to be prevalent in 8% of the convicted inmates confined in jail which was much higher in comparison to general population.Conclusions: As the prevalence of depression, stress and anxiety was found much higher in convicts than the general population, there should be a timely screening, diagnosis and appropriate intervention to combat the mental health problems.

Calculation of dose volume parameters and indices in plan evaluation of HDR interstitial brachytherapy by MUPIT in carcinoma cervix

BACKGROUND: Evaluation of a HDR- interstitial brachytherapy plan is a challenging job. Owing to the complexities and diversity of the normalization and optimization techniques involved, a simple objective assessment of these plans is required. This can improve the radiation dose coverage of the tumour with decreased organ toxicity. AIM: To study and document the various dose volume indices and parameters required to evaluate a HDR interstitial brachytherapy plan by Volume normalization and graphical optimization using MUPIT (Martinez Universal Perineal Interstitial Template) in patients of carcinoma cervix. SETTINGS AND DESIGN: Single arm, retrospective study. METHODS AND MATERIALS: 35 patients of carcinoma cervix who received EBRT and HDR brachytherapy using MUPIT, were selected. The dose prescribed was 4 Gray/Fraction in four fractions (16Gy/4) treated twice daily, at least 6 hours apart. CTV and OARs were delineated on the axial CT image set. Volume normalization and graphical optimization was done for planning. Coverage Index (CI), Dose homogeneity index (DHI), Overdose index (OI), Dose non-uniformity ratio (DNR), Conformity Index (COIN) and dose volume parameters i.e. D2cc, D1cc, D0.1cc of rectum and bladder were evaluated. STATISTICAL ANALYSIS: SPSS version 16 was used. RESULTS AND CONCLUSION: CI was 0.95 ± 1.84 which means 95% of the target received 100% of the prescribed dose. The mean COIN was 0.841 ± 0.06 and DHI was 0.502 ± 0.11. D2cc rectum and bladder was 3.40 ± 0.56 and 2.95 ± 0.62 respectively which was within the tolerance limit of this organs. There should be an optimum balance between these indices for improving the quality of the implant and to yield maximum clinical benefit out of it, keeping the dose to the OARs in limit. Dose optimization should be carefully monitered and an institutional protocol should be devised for the acceptability criteria of these plans.

Combined presence of multiple gastrointestinal stromal tumors along with duodenal submucosal somatostatinoma in a patient with neurofibromatosis type 1.

Neurofibromatosis type‑1 (NF‑1) is an autosomal dominant disorder, with increased risk of developing benign and malignant tumors of the gastrointestinal tract (GIT). However, the synchronous presence of multiple GIT stromal tumors and duodenal submucosal somatostatinoma, like in this 50‑year‑old female NF‑1 patient, is very rare. She presented with hematemesis, malena, along with multiple neurofibromas all over the body. Thorough radiological and peroperative work‑up revealed multiple ulcerated submucosal and serosal nodules in the proximal small intestine. Histological work‑up revealed diagnosis of a duodenal submucosal somatostatinoma with multifocal serosal gastrointestinal stromal tumors. This case is being reported to highlight the rare coincidence of multiple GIT tumors in an NF‑1 patient.

Assessment of interns and postgraduate dental student’s knowledge regarding equipment ergonomics.

Context: The substantial knowledge concerning ergonomics and its practical application is vital for forestalling musculoskeletal disorders. The role of equipment ergonomics (EE) in preventing these work‑related ailments is significantly noteworthy. Aim: The aim of the study was to assess the prevailing perception of postgraduates (PGs) and interns regarding EE and preparing the Indian dental workforce for the challenges of India’s growing economy and population. Settings and Design: Authors conducted a cross‑sectional survey between December 2013 and February 2014 amidst the interns and PG dental students of Davangere city, Karnataka, India. Subjects and Methods: The data were collected using 21‑item custom designed proforma, comprising of questions evaluating student’s basic knowledge about EE. Statistical Analysis Used: Statistical analysis was done using Chi‑square test in each group (PGs and interns) and Mann–Whitney test was implemented for comparison between both groups. Results: Of 358 subjects surveyed, 48% PGs and 52% interns affirmed that they came across EE only through this survey. In addition, 91.18% of PGs and 90.59% interns believed that the accentuation on EE is less in the current dental curriculum. Conclusions: Comprehensive understanding and practical application of EE among the participants was found to be lacking. The importance of microbreaks and chair side exercises should be emphasized and training should be initiated at an early stage before improper postural habits develop.

Effect of Inclusion of Hepatitis B Vaccine in Childhood Immunization Program in India: A Retrospective Cohort Study.

Objective: To assess the effectiveness of hepatitis B immunization program in a field setting in India. Design: Serological survey of retrospective cohorts of children, vaccinated or not vaccinated with hepatitis B vaccine. Setting: Rural field areas of five districts in Andhra Pradesh state, where childhood hepatitis B immunization began in 2003. Participants: Children aged 5-11 years who had received HB immunization (n=2674; 1357 boys) or not received such immunization (n=2350; 1236 boys). Main Outcome Measures: Serum HBsAg, anti-HBc and anti- HBs (quantitative) using automated enzyme-immunoassays in the year 2010. Results: Anti-HBs positivity was higher among immunized than in unimmunized children (53% vs.18%; P<0.001), and anti-HBc positivity was lower (1.1% vs 10.8%: P<0.01). HBsAg positivity was low in both the groups (0.15% and 0.17%; P=0.855). Anti- HBs positivity rate declined with increasing age. Conclusions: Administration of hepatitis B vaccine as part of Universal immunization program led to anti-HBs in a large proportion of children and a reduction in anti-HBc positivity, a marker of hepatatis B virus infection. These data provide evidence supporting efficacy of hepatitis B immunization program in an Indian field setting, justifying the decision to include it in the universal immunization program.

Paper currencies, a potential carrier of pathogenic microorganisms.

Microbial analysis of 500 Indian currencies collected from people of different categories across the state Assam (India) has shown the presence of various pathogenic microorganisms viz, E. coli, Pseudomonas spp., Klebsiella spp., Streptococcus spp. and Staphylococcus sp. which are known to be responsible for watery diarrhea, mouth skin diseases, pneumonia, respiratory track diseases, gastro intestinal diseases etc. This may be due to the climatic conditions of most of the third world Asian countries which favors the optimum growth conditions for the microorganisms and a huge number of carriers handling them due to larger population in these regions.

Perineal canal: an uncommon entity with good prognosis.

This article reports two patients with perineal canal (anovestibular fistula) who were treated at Dept. of Pediatric Surgery, LTMG Hospital, Mumbai. Both the patients had normal anus and a fistula between the anal canal and the vestibule. They were treated by vestibulo anal pull through procedure. The pathogenesis of this condition and the pertinent literature is reviewed.