Presence of 25(OH) D deficiency in a rural North Indian village despite abundant sunshine.

BACKGROUND AND OBJECTIVE: Several studies have shown wide prevalence of vitamin D deficiency with serum 25(OH)D <49.9 nmol/L in urban Indians related to their poor sunshine exposure and skin pigmentation. However, there is limited information in rural Indians. We hypothesized presence of higher 25(OH)D in rural subjects as compared to urban because of farming related abundant sunshine exposure. DESIGN AND METHODS: We assessed serum 25(OH)D levels in residents of a North Indian village with 200 families, located 90 km East of Delhi during February (winter). Fifty seven subjects (32 males and 25 females) from 50 families consented for the study. RESULTS: The mean 25(OH)D values of all subjects in the rural area was 36.4 +/- 22.5 nmol/l/L. Males had significantly higher 25(OH)D values than females. When compared to urban subjects, the mean 25(OH)D value of rural males and females was six and three folds higher, respectively. However even with five hours of daily sunshine exposure only 31.5% had serum 25(OH)D levels > or = 50 nmol/L. CONCLUSIONS: Thus, with longer sunshine exposure subjects residing in rural area had better mean 25(OH)D values than that of urbans. However, 70% of them were still vitamin D deficient. These facts indicate the need for the countrywide vitamin D food fortification program irrespective of rural or urban setting.

Prevalence & potential significance of vitamin D deficiency in Asian Indians.

Studies from our center and other parts of India have drawn attention towards wide prevalence of vitamin D deficiency (VDD) in our country. VDD has been reported in all age groups including toddlers, school children, pregnant women and their neonates and adult males and females residing in rural and urban India. We reviewed implications of VDD in our population based on the preliminary data available from Indian studies on skeletal health. Besides, a brief review is made on the importance of VDD in various other disorders prevalent in equivalent proportions among Indians such as type 2 diabetes mellitus (DM), cardiovascular diseases (CVD), immune competence including relation to tuberculosis, malignancy and osteoarthritis. Data from the West have also associated VDD with increased prevalence of type 2DM, CVD, autoimmune disorders, tuberculosis, prostate, breast and colon malignancy and osteoarthritis. Such association has not been studied to date in our country. Overall results of various studies conducted to date in urban and rural Indians indicate that widely prevalent VDD is functionally relevant to skeletal health including osteomalacia and rickets. However, there is a need to explore its association with osteoporosis related fractures and various other non skeletal disorders linked with VDD.

Role of virulence plasmid of Aeromonas hydrophila in the pathogenesis of ulcerative disease syndrome in Clarias batrachus.

Pathogenic Aeromonas hydrophila (strain VB21), a multiple-drug resistance strain contains a plasmid of about 21 kb. After curing of plasmid, the isolates became sensitive to antimicrobials, to which they were earlier resistant. The cured bacteria exhibited significant alterations in their surface structure, growth profile and virulence properties, and failed to cause ulcerative disease syndrome (UDS) when injected into the Indian catfish Clarias batrachus. Routine biochemical studies revealed that the plasmid curing did not alter the biochemical properties of the bacteria. After transformation of the plasmid into cured A. hydrophila the bacterium regained its virulence properties and induced all the characteristic symptoms of UDS when injected into fish. Thus, the plasmid plays a pivotal role in the phenotype, growth and virulence of A. hydrophila and pathogenesis of aeromonad UDS.

K39 strip test--easy, reliable and cost-effective field diagnosis for visceral leishmaniasis in India.

OBJECTIVE: A firm diagnosis of visceral leishmaniasis (VL) requires demonstration of the parasite in splenic or bone marrow aspirate. The aim of this prospective study was to assess the usefulness of K39 strip test as a noninvasive method of diagnosing visceral leishmaniasis under field conditions by testing serum antibody to the leishmanial antigen K39. MATERIAL AND METHODS: One drop of serum/blood was applied to the sample application pad on the test strip, which was diluted with 2 drops of chase buffer solution. The development of two visible red lines indicates the presence of IgG anti-K39. In the first phase of the study (2001), a total of 200 patients (Active VL-70, ex-VL-30, healthy endemic control-20 and patients with other tropical diseases-80) were tested with the K39 strip test at the School of Tropical Medicine, Kolkata. In the second phase of the study (2002), the test was applied in a remote tribal area of West Bengal where an epidemic of VL had occurred. Thirty-two patients were identified in 207 villagers of the affected area; all of them were tested with the K39 strip test. RESULTS: In the first phase, all VL and ex-VL cases gave positive results (100%). Ten percent of the healthy endemic controls were positive. The test results were negative in all other prevalent tropical diseases (100%). The estimated sensitivity of the test was 100% and the specificity was 98.18%. In the second phase of the study, all 32 patients of the epidemic were shown to be positive. All patients were treated with sodium stibogluconate injections and they recovered uneventfully. CONCLUSIONS: K39 strip test is ideal for rapid reliable field diagnosis of visceral leishmaniasis. The test has high sensitivity and specificity but it remains positive long after treatment (up to 3 years).

Cholelithiasis in a child--an unusual presentation of Wilson's disease.

A nine year old mentally retarded girl with moderate splenomegaly and ascites presented with chronic cholelithiasis. The presence of Kayser-Fleischer rings and low serum ceruloplasmin level confirmed the diagnosis of Wilson's disease. Cirrhosis of liver and recurrent episodes of hemolysis--these two common complications of Wilson's disease make an ideal setting for gall stone formation. Only three such cases have been reported worldwide and ours is the first case report from India. We suggest that cholelithiasis and splenomegaly in a child without evidence of congenital hemolytic disease should be taken as a suspect of Wilson's disease.

Observations on hepatic structure and function in fibro-calculous pancreatic diabetes (FCPD) vis-a-vis other diabetic subtypes.

Investigations of liver function and histology were undertaken in thirty four patients with Fibrocalculous Pancreatic Diabetes (FCPD). The data obtained were compared with those of similarly aged members of a diabetic control group comprising twelve patients with Protein Deficient Diabetes Mellitus (PDDM), twelve with Type 1 diabetes or Insulin Dependent Diabetes Mellitus (IDDM) and four young patients with Type 2 Diabetes of Non-Insulin Dependent Diabetes Mellitus (NIDDM). None of them had apparent past or present liver disease. Elevations of serum ALT (SGPT) and alkaline phosphatase levels were fairly common and was often associated with mild fatty changes and occasionally with focal necrosis and inflammatory changes. Cirrhosis and inflammatory changes per se were infrequent and fatty changes per se did not occur. In contrast patients belonging to the other diabetic subsets were very occasionally afflicted with hepatic abnormalities or not afflicted at all. We propose that loss of hepatotrophic actions mediated by insulin and glucagon could initiate and/or enhance hepatic abnormalities in FCPD where deficiencies of insulin and glucagon coexist.

Dyspnoea, lung function & respiratory muscle pressures in patients with Graves' disease.

To understand the pathophysiology of dyspnoea in patients with hyperthyroidism, lung function, maximum inspiratory, expiratory respiratory muscle pressures (MIP and MEP) and intensity of dyspnoea (after six minutes walking test) were recorded in 12 consecutive patients with active Graves' disease. Reassessment was done after achieving euthyroidism with 8-12 wk of carbimazole therapy. Patients covered similar distance during 6 min walking before and after carbimazole therapy. However, there was a significant reduction in dyspnoea following euthyroidism. This was accompanied by significant decrease in respiratory rate, minute ventilation, forced expiratory volume in one second (FEV1%) and improvement in the forced vital capacity (FVC). No significant changes in tidal volume (TV) and maximum-midexpiratory flow rates (MMEFR), MIP and MEP were observed. Lung function parameters, MIP and MEP did not correlate with the severity of dyspnoea. Serum T4 levels correlated inversely with the distance covered during 6 min walking test, MIP and MEP. To conclude, increased breathing effort in presence of reduced FVC may lead to dyspnoea during hyperthyroid phase in patients with active Graves' disease. Lack of correlation between the severity of dyspnoea and abnormalities in lung function suggests that other mechanisms of dyspnoea may also operate in these patients.

Remission with carbimazole therapy & assessment of T4 suppression test as an index of relapse in patients with Graves' disease in India.

This study determined the relapse rate following the use of antithyroid drugs (ATD) in patients with Graves' disease and assessed T4 suppression test as a follow up index for predicting relapse after carbimazole treatment in 21 patients who had taken 9-12 months of ATD treatment continuously with good compliance. T4 suppression test was done before stopping ATD treatment. During one year of follow up after stopping ATD therapy, 12 (57%) patients relapsed and 9 (43%) remained in remission. Six of the 12 relapses occurred in the first 3 months of stopping ATD therapy. The response following the use of carbimazole therapy was comparable to that reported from iodine sufficient western countries and may be because of the salt iodination programme in our country. T4 suppression test was normal in 14 (66%) and abnormal in 7 (34%) patients. All the patients with abnormal T4 suppression test relapsed after stopping ATD. The overall accuracy of the T4 suppression test (76%) also favourably compared with reported values of other useful but less readily available markers such as thyrotropin releasing hormone (TRH) stimulation test and thyroid receptor antibodies. Thus, in our experience antithyroid drugs were able to induce long term remission in 43 per cent patients with Graves' disease and abnormal T4 suppression test can be used as a reliable parameter for predicting relapse.

Prevalence & significance of pancreatic islet cell & adrenal antibodies in patients with Graves' disease.

The prevalence of adrenocortical (ACAb), islet cell (ICAb) and thyroid microsomal (TMAb) autoantibodies was determined by indirect immunofluorescence, in 88 consecutive patients with Graves' disease. ACAb, ICAb and TMAb positivity was seen in 3 (3.3%), 10 (11%) and 66 (75%) patients respectively. Among these one patient had both ACAb and ICAb positivity. Diabetes mellitus was found to be present in two (2.3%; both ICAb positive) of the 88 patients studied. Two of the four ICAb positive patients had loss of first phase insulin response to intravenous glucose. A significant proportion of patients of Graves' disease had associated islet cell and/or adrenal autoimmunity. A high index of suspicion for associated endocrine autoimmunity should be maintained while dealing with subjects of Graves' disease.

Thyrotoxicosis with osteomalacia and proximal myopathy.

A 36 year old lady, presented with symptoms of proximal myopathy was found to have a history of thyrotoxicosis for which she had taken carbimazole irregularly for 1-1/2 years. On admission, clinical signs of thyrotoxicosis were detected and confirmed by estimating serum T3 and T4. Neurological examination revealed generalised wasting, loss of power in the proximal muscles with a myopathy confirmed on EMG. Serum calcium, phosphorous levels, and a 24 hour urine calcium excretion were low. Alkaline phosphatase levels were high. A diagnosis of thyrotoxicosis with osteomalacia was made. The patient improved within 3 weeks of starting carbimazole and vitamin D.

Circadian desynchronization in pulse rate, systolic and diastolic blood pressure, rectal temperature and urine output in traumatic tetraplegics.

An investigation was undertaken to study the circadian rhythmicity in pulse rate, systolic and diastolic blood pressure, rectal temperature and urine output in eight traumatic tetraplegics in view of the fact that diurnal rhythmicity in prolactin response to thyrotropin-releasing hormone was absent in such patients. The data, analysed by single cosinor procedure, showed absence of rhythmicity in all five parameters. Analysis of variance also showed no significant difference in these parameters at various time points. Knowledge of the alterations in circadian biology subsequent to cervical spinal cord trauma would provide useful guidelines towards chronotherapy and vocational rehabilitation of tetraplegics besides possible restoration of euchronism by pharmacological means.