Lymphangioleiomyomatosis - Retroperitoneum.

Lymphangioleiomyomatosis (LAM) is a progressive disease affecting women of childbearing age. It is microscopically characterized by abnormal smooth muscle proliferation in the walls of lymphatics and lymph nodes. A 52-year old female presented with pain in left leg and bilateral pedal oedema. USG and CT abdomen revealed a retroperitoneal cystic mass suspicious of malignancy. Retroperitoneal exploration was done and the mass was excised which revealed milky contents within. On gross examination of the specimen, a spongy mass was noted . Histopathological examination led to a diagnosis of lymphangioleiomyomatosis. LAM is a rare disease unfamiliar to many physicians and may pose a diagnostic dilemma to the physician, possibly resulting in delayed or missed diagnosis . Many treatment modalities including corticosteroids, cytotoxic drugs, chemotherapy, radiation and hormonal therapy are suggested. The prognosis of LAM varies with the individual, but many patients respond well to intramuscular medroxyprogesterone injections.

Stress and undetected hyperglycemia in southern Indian coastal population affected by tsunami.

AIM: Natural calamities are known to result in higher stress conditions and also result in adverse health outcomes including development of non-communicable diseases. The impact of tsunami on mental stress and prevalence of hyperglycemic conditions was assessed in a population affected by the calamity in coastal populations of southern India. METHODS: Two populations similar in demography and physical characteristics, but, one affected by tsunami were selected for a comparative study. Subjects aged 20 years or above were randomly selected (control population n = 1176; tsunami population n = 1184). Details of stress were assessed using Harvard trauma questionnaire and scores were assigned. Glucose tolerance was assessed using 2h capillary blood glucose (75gms glucose load) and diagnosis was made using WHO criteria. RESULTS: Stress score was significantly higher in tsunami population. Although the total prevalence of diabetes was similar (control - 10.0 %; tsunami population - 10.5 %) prevalence of undetected diabetes (5.7 % vs. 3.8 %; Z = 9.54, P < 0.001) and impaired glucose tolerance (9.8 % vs. 8.3 %; Z = 12.83, P < 0.001) higher in the tsunami area. Stress score was higher in women and in the young in the tsunami area. CONCLUSION: Population affected by tsunami was under high stress and also showed a high prevalence of undetected diabetes and impaired glucose tolerance.

Development of a reliable and valid psychosocial measure of self-perception of health in type 2 diabetes.

OBJECTIVES: The aim was to develop a reliable and valid psychosocial measure of self-perception of health in type 2 diabetes. METHODS: Item analysis and factor analyses were done in order to stabilize and establish principal components of the questionnaire. Reliability (internal consistency aspect) was established using Chronbach's alpha method. Concurrent and discriminant validities were established using conventional methods. RESULTS: Factor analysis yielded 12 significant factors (eigen value > or =1), but first six components were retained based on Scree test. These six principal varimax factors explain 49.7% of variance of psychosocial measure of self-perception of health. CONCLUSIONS: The final version after all these psychometric procedures had 27 items with six principal components. They were appropriately named as follow: (I) Positive self-feeling; (II) Sociality; (III) Attention seeking; (IV) Feel healthy; (V) Worry about health; (VI) Dependence. Total variance explained is 49.7%.

Pancreatic pseudocyst presenting as odynophagia.

A 40-year-old man presented with abdominal pain and odynophagia. CT scan revealed a pseudocyst in the posterior mediastinum and pleural effusion complicating pancreatitis. He was managed with transpapillary pancreatic duct stenting along with other supportive measures including octreotide, and he improved symptomatically. The stent was removed after four months; there was no pseudocyst on follow up CT scan.

Quality of life and diabetes integration among subjects with type 2 diabetes.

Diabetes integration indicates that a person with diabetes makes an appropriate emotional adjustment to the requirements of diabetic way of life. Diabetes integration and a sense of well-being are expected to be correlated. The aim of diabetes treatment should be to enable a patient to adjust himself to his being a diabetic person. This should ensure a sense of well-being. Aims of this study was to assess the role of diabetes integration and psychological factors in patients with type 2 diabetes. METHOD: A sample of 227 type 2 diabetes patients participated in the study. They were all in the upper middle class social stratum. Diabetes integration scale yields one composite score of adjustment, has 19 items applicable to both type 1 and type 2 diabetic subjects. The psychological well-being scale has 22 items, measures depression (6 items), anxiety (6 items), energy (4 items), positive well-being (6 items) and a general sense of well-being score by the whole test of 22 items. RESULTS: The psychological well-being subscales and the whole scale scores significantly correlated with diabetes integration scale (all P values were < 0.0001). However, we found that diabetes integration and the psychological well-being subscales were not significantly correlated with metabolic and other medical indices. There were gender differences in depression (p < 0.04), anxiety (p < 0.0001), energy (p = 0.004), positive well-being. (p = 0.02) and general sense of well-being (p < 0.0001), men fared in a better than women subjects. No such gender differences were found in diabetes integration score. CONCLUSION: Diabetic patients who integrate themselves and emotionally adjust to diabetes experience a psychological sense of well-being.

Autonomic dysfunction in extra-hepatic portal vein obstruction: correlation with cardiovascular haemodynamics.

Various autonomic dysfunctions (AD) are known to occur in cirrhosis of the liver. The haemodynamic abnormalities of cirrhosis have been correlated with AD and have prognostic implications. The relevance of AD in extrahepatic portal vein obstruction (EHPVO) is not well established. We evaluated AD and cardiac indices in 30 patients, 19 male and 11 female and compared the results with those of 10 controls. The mean age of the patients and controls was 23.77 +/- 1.33 and 20.5 +/- 2.51 years, respectively. Five standard autonomic function tests were done in all the patients. Cardiac output (CO) was measured by echocardiography. Anthropometric measurements were done to determine the cardiac index (CI = Cardiac output/Body surface area) and indicized peripheral vascular resistance (iPVR) was calculated using the formula: mean arterial pressure (MAP) x 80/CI. Each autonomic function test was given a score and the results were interpreted as normal, early or definite, according to the score. AD was recorded as normal in 5, early in 11 and definite in 14 patients. None of the controls had any abnormality in autonomic function. There was a significant difference in the baseline heart rate of controls and patients (76 +/- 2.55 v. 98.9 +/- 2.96 beats/min). There was no difference in the MAP (92.65 +/- 1.71 v. 81.7 +/- 1.99 mmHg), CI (2.99 +/- 0.15 v. 3.23 +/- 0.08), iPVR (2533.59 +/- 124 v. 2176 + 104). CI, iPVR and MAP were also calculated separately in patients in the normal (N), early (E) and definite (D) AD groups. Their respective values were as follows CI: N 3.44 +/- 0.19, E 3.44 +/- 0.19, D 3.23 +/- 0.6; iPVR: N 2150 +/- 75.4, E 2140 +/- 180, D 2372 +/- 142; MAP: N 86 +/- 3.01, E 85.8 +/- 3.59, D 90.79 +/- 3.09. Results are expressed as mean +/- SE. Unlike in cirrhotics, cardiovascular haemodynamics are not altered in patients with EHPVO, even in the presence of AD.

Foot care economics--cost burden to diabetic patients with foot complications: a study from southern India.

OBJECTIVE: To estimate the direct cost burden of diabetic patients with foot complications. METHODS: An illustrative sample of 270 subjects with type two diabetes were seen at the clinic selected for the study. Among them 164 were without any complication (Group I) and 106 patients were with foot complications (Group II). In the latter group 83 (Group IIA) required in-patient (IP) care and 23 (Group IIB) required out-patient (OP) care. Annual expenses on medical care were estimated by a questionnaire method. Validation of the questionnaire data was verifying the amount spent by checking up the bills. RESULT: Group I spent Rs.4373 (US $ 104 Approx.), Group II spent Rs.15450 (US $ 343 Approx.), Group IIA spent Rs.7200 (US $ 171 Approx.) and Group IIB spent Rs.16910 (US $ 403 Approx.) in the study year. In the total sample of 270 subjects 61% were without foot problems, 22% had foot problems requiring OP treatment only (Group IIA), and 78% had foot problems requiring IP treatment (Group IIB). CONCLUSION: Group IIB spent significantly greater percentage of their income than Group IIA, and both groups spent greater percentage of their income than Group I. All differences were statistically significant.

Cost burden to diabetic patients with foot complications--a study from southern India.

AIM: To study the economic burden of management of diabetes in patients with foot complications, as a large number of them suffer from foot complications of varying severity. This study relates to direct cost to diabetic patients with foot complications. MATERIAL AND METHODS: An illustrative sample of 270 Type 2 diabetic subjects, 164 without foot complications (Control group, Group 1) and 106 with foot complications (Group 2) were studied. They were available for the study during a six month period from January to June 1998. Group 2 had two sub-groups, i.e., those who needed out-patient (OP) treatment only (n = 23) and those who needed treatment in the hospital (HP) (n = 83). The study subjects were interviewed personally by the educator to collect demographic data and treatment expenditure. RESULTS: Total median expenditure incurred by the diabetic subjects without foot complications (Group 1) was Rs. 4373/- and by those with foot complications (Group 2) was Rs. 15,450/-. Patients who required hospitalised treatment incurred higher expenses than the OP patients, towards doctor's fees and hospitalisation (P < 0.0001). The percent of total income spent by the HP patients was higher than by the OP patients (P < 0.02). CONCLUSIONS: Diabetic subjects with foot problems incur very heavy expenditure in the treatment process. Most of the direct costs of diabetes treatment results from its complications. The hospitalisation costs for the complications of diabetes are particularly heavy. This underscores the need to reduce complications and also their economic burden.

Patients' adherence to diabetes treatment.

OBJECTIVES: a) To evaluate the patients' adherence to the treatment prescriptions and b) to analyse the reasons for non adherence. METHODS: A random sample of 386--type 2 diabetic subjects (M:F 223:163) were studied. Each subject was personally interviewed using a computerised proforma. The mean age of the study group was 52 +/- 10 years and 53% were treated with oral hypolycenic agent (OHA) and the rest with a combination of insulin and OHA. The mean duration of diabetes was 11.0 +/- 6.9 yrs. The overall adherence to the treatment regimen, diet and drug prescriptions and also regularity of home glucose monitoring by blood or urine tests were assessed. RESULTS: It was noted that only 25% of the study group were adhering to the treatment regularly. Dietary prescriptions were followed regularly only by thirty seven percent. Home glucose monitoring was being done only by twenty three percent. Non adherence was not related either to the age or duration of diabetes. Non adherence was more in the lower socio-economic group and was inversely related to the educational status. It was noted that approximately 20% of the subjects had an indifferent attitude to the advice given. CONCLUSIONS: The results showed that the rate of non adherence of treatment prescriptions was high. It stresses the need for constant motivation and one to one level education at frequent intervals to ensure better compliance to the treatment.

Need for education on footcare in diabetic patients in India.

OBJECTIVES: The patient himself plays the crucial role in the prevention of diabetic foot disease and therefore education on foot care is important. In this study, we have evaluated the knowledge of the diabetic subjects regarding the foot problems and the care of feet in order to identify areas that require stress in the education programme. PATIENTS AND METHODS: Two hundred and fifty, consecutive cases of Type 2 diabetes (M:F, 176:74, age 57.2 +/- 9.7 yrs, duration 12.9 +/- 7.9 yrs) were selected for this study from the out-patient department of our hospital. A questionnaire was filled up for each patient by personal interview. The total score was 100 and a score of < 50 was considered as a low score for foot care knowledge. RESULTS: A score of < 50 was obtained in 67.2%. Low score was more common in women (78.5%) than in men (62.5%) (chi 2 = 5.26, P = 0.022). Low scores (< 50) were more common among those with lower level of formal education (chi 2 = 70.0, P < 0.0001), there were more women with low educational status. Significant foot problems like gangrene, foot ulcers were present in 27.2% and low scores were more common among those with these complications (82% vs 62%) (chi 2 = 8.3, P = 0.004). In general the scores on awareness of general foot care principles and basic facts about the foot complications were poor. Most of them (72%) had good knowledge about the right usage of foot wear. There was a trend to have lower scores with poor formal education (chi 2 = 51.1, P < 0.0001) and also with increasing age. There was no correlation between the scores and the number of hospital visits. Multiple linear regression analyses showed that 31.2% of the variations in the scores were explained by the level of education. CONCLUSIONS: This study underscores the importance of patient education on foot care principles, especially so, considering the magnitude of the problem of diabetes and the lower levels of literacy and poor socio economic status of many patients in this country.