Association of diabetic nephropathy with diabetic retinopathy in type 2 diabetes mellitus patients

Background: Microvascular complications of Type 2 Diabetes Mellitus (T2DM), (retinopathy and nephropathy) have a similar etiopathogenetic mechanism besides genetic predisposition. Even though these two complications frequently co-exist, their frequency varies. The association of these two significant complications and their co-existence needs a relook.Methods: Four hundred patients suffering from type 2 DM visiting a tertiary care hospital in Western India were included in this cross-sectional study. Of these, 200 patients were of Diabetic Nephropathy (DN) and 200 were without DN. The presence of albuminuria (urine albumin-creatinine ratio) was used to detect diabetic nephropathy. Fundoscopy was performed in all patients to look for Diabetic Retinopathy (DR).Results: In this study, 77.5% patients with DN had retinopathy, while in patients without DN, only 52% patients had retinopathy. This was a statistically significant finding. (p value <0.001). The distribution of types of retinopathy in patients with DN was 63.0% Non-Proliferative Diabetic Retinopathy (NPDR), 12.5% Proliferative Diabetic Retinopathy (PDR) and 2% Clinically Significant Macular Edema (CSME). While in those without DN, 50.5% had NPDR, 1.5% had PDR and none had macular edema.Conclusions: Microalbuminuria, which has been used so far to diagnose DN, may be considered as a reliable predicter of diabetic retinopathy in type 2 diabetes mellitus patients. This simple marker can help screen all patients with Diabetes for nephropathy and retinopathy both and should take place at the first visit/ contact of the healthcare personnel. This can help prevent microvascular complications early and help in goal directed therapy.

Utility of colour Doppler Sonography in patients with graves' disease / Utilidad de la Sonografía Doppler en color en pacientes con la enfermedad de graves

OBJECTIVE: Assessment of thyroid blood flow gives valuable information about underlying functional status. Colour Flow Doppler Sonography (CFDS) is a powerful tool which displays tissue blood flow and vascularity. Colour Flow Doppler Sonography of the thyroid gland in different subsets of patients with Graves' disease was studied to define its role in initial diagnosis and management. METHODS: Eighty consecutive patients with Graves' disease (both treated and untreated) presented to hospital between August 2007 and February 2008. All patients were evaluated with CFDS of the thyroid for size, vascularity and peak systolic velocity (PSV) of the Inferior Thyroid Artery (ITA). Pertechnate scan and thyroidal autoantibody levels were done in selected cases. The patients were divided into Untreated Graves' disease (n = 31), Graves' disease on treatment but hyperthyroid (n = 26) and euthyroid Graves' disease on therapy (n = 23). Mann-Whitney U-test was used for statistical analysis and a p-value of less than 0.05 was considered significant. RESULTS: Thyroid blood flow, as assessed by PSV of ITA, was significantly higher in untreated Graves' disease than in Graves disease on treatment but hyperthyroid and euthyroid Graves respectively (61.5 ± 19.5 versus 42.9 ± 24.7 versus 32.2 ± 12.9 cm/s, p < 0.05). Parenchymal vascularity of the thyroid gland was higher in hyperthyroid patients than in euthyroid patients irrespective of therapy. In both groups on therapy, the dose of carbimazole correlated with the vascularity of the gland (r = 0.492 versus 0.564, p < 0.05). Colour Flow Doppler Sonography parameters correlated significantly with pertechnate scan results giving comparable sensitivity and specificity. CONCLUSION: Assessment of thyroid blood flow by CFDS is an effective marker in the initial diagnosis of Graves' disease. Vascularity of the gland can predict long term disease course while on medical therapy.

OBJETIVO: La evaluación del flujo sanguíneo tiroideo ofrece una valiosa información acerca del estatus funcional subyacente. La sonografía del flujo con Doppler a color (CFDS) es un poderoso instrumento que muestra el flujo del tejido sanguíneo y la vascularidad. La sonografía con Doppler a color, de la glándula tiroides en diferentes subconjuntos de pacientes con la enfermedad de Graves, fue estudiada para definir su papel en el diagnóstico inicial y el tratamiento. MÉTODOS: Ochenta pacientes consecutivos con la enfermedad de Graves (con y sin tratamiento) acudieron al hospital entre agosto de 2007 y febrero de 2008. Mediante CFDS, a todos los pacientes les fueron evaluados el tamaño del tiroides, la vascularidad y la velocidad del pico sistólico (PSV) de la arteria tiroidea inferior (ATI). En casos seleccionados, se realizaron gammagrafías con pertecnetato y estudios de los niveles de anticuerpos tiroideos. Los pacientes fueron clasificados tomando como criterios: la enfermedad de Graves sin tratamiento (n = 31), la enfermedad de Graves con tratamiento pero hipertiroideos (n = 26), y la enfermedad de Graves eutiroidea bajo terapia (n = 23). La prueba U de Mann-Whitney fue utilizada para el análisis estadístico, y un valor p menor de 0.05 fue considerado significativo. RESULTADOS: El flujo sanguíneo tiroideo tal cual fue evaluado mediante PSV de ATI, fue significativamente más alto en la enfermedad de Graves sin tratamiento que en otros grupos (61.5 ± 19.5 versus 42.9 ± 24.7 versus 32.2 ± 12.9 cm/s, p < 0.05). La vascularidad parenquimal de la glándula tiroides fue mayor en los pacientes hipertiroideos, independientemente de la terapia. En los dos grupos bajo terapia, las dosis de carbimazol estaban en correlación con la vascularidad de la glándula (r = 0.492 versus 0.564, p < 0.05). Los parámetros de la sonografía del flujo con Doppler a color guardaban una correlación significativa con los resultados de la gammagrafía de pertecnetato, arrojando sensibilidad y especificidad comparables. CONCLUSIÓN: La evaluación del flujo sanguíneo del tiroides mediante CFDS es un marcador efectivo en el diagnóstico inicial de la enfermedad de Graves. La vascularidad de la glándula puede predecir el curso de la enfermedad a largo plazo, bajo terapia médica.

Obesity and thyrotropinemia.

Objective. To study the relation between body mass index (BMI) and TSH in euthyroid and subclinical hypothyroid obese children and compared serum TSH level among obese and overweight children. Methods. Fifty consecutive children (aged 2-18 yr) presenting for obesity were studied. All cases with TSH > 10, low T3/T4, organic and syndromic obesity were excluded. Patients were divided into Group 1: Overweight (n=20) (BMI between 85th to 95th centile) and Group 2: Obesity (n=30) (BMI > 95th centile). Fisher’s exact test, Mann-Whitney U test and Pearson’s correlation were used for statistical analysis. P value < 0.05 was considered significant. Results. Elevated TSH level (between 4.5 – 10 mIU/L) with normal T3, T4 was seen in 4/20 overweight and 9/30 of obese children (P=0.5219). The mean TSH was comparable in both the groups (3.22 ± 3.1 mIU/L vs. 3.63 ± 2.2 mIU/L, P=0.3491). Overall TSH showed no correlation with BMI (r= 0.0014, P=0.9924). Conclusion. The preliminary data did not show any relation between severity of obesity and TSH level. Further large scale data from population are required to confirm these findings.

Symptomatic primary hyperparathyroidism: a retrospective analysis of fifty one cases from a single centre.

OBJECTIVE: Widely prevalent vitamin D deficiency and delayed diagnosis contributes to severe symptomatic primary hyperparathyroidism in India. We analysed fifty one consecutive patients of primary hyperparathyroidism managed at our centre. All of them were symptomatic. DESIGN: Retrospective analysis. MATERIAL AND METHODS: Fifty one consecutive cases of symptomatic primary hyperparathyroidism, presenting to our centre from January 1994 to May 2007 were retrospectively analyzed. Clinical presentation, biochemical, radiological and details of underlying parathyroid lesion were noted. RESULTS: A total of 51 cases of primary hyperparathyroidism were studied. Mean age was 39.5 +/- 11.5 yrs (Range 13 to 70 years, Female: Male 2:1). Mean duration of symptoms was 35.8 + 29.1 months. Bone pains and painful proximal myopathy were the commonest presentation (24/51), followed by pathological fractures in 12 cases. Distal Renal tubular acidosis was diagnosed in 4 cases, 3 of whom normalized after surgery. At initial evaluation, twenty one patients had elevated alkaline phosphatase with normal calcium levels indirectly suggesting associated vitamin D deficiency. Low serum levels of 25-hydroxy vitamin D were documented in five of them. Parathyroid carcinoma was diagnosed in 3 patients. Ectopic parathyroid adenoma was seen in 7 cases (3 mediastinal, 3 intrathyroidal, 1 near left carotid sheath). All the cases responded well to surgical excision. CONCLUSION: Lack of universal screening for hypercalcemia, normocalcemia contributed by associated vitamin D deficiency and lack of awareness about unusual presentations of primary hyperparathyroidism led to delayed diagnosis in our patients. Delayed diagnosis and associated vitamin D deficiency in our patients contributed to greater severity of symptomatic primary hyperparathyroidism.

Ectopic parathyroid adenoma--the hidden culprit.

Primary Hyperparathyroidism is known to present with protean manifestations leading to misdiagnosis in the initial stages of the disease. Inability to locate the adenoma in an ectopic parathyroid gland may further delay the diagnosis of these cases. Aberrant migration during development may lead to intrathyroidal or other ectopic locations of parathyroid glands. This may lead to their misdiagnosis as a thyroid nodule or failure to locate parathyroids during surgery. Similarity in cytological picture between thyroids and parathyroids may further complicate diagnosis by fine needle aspiration cytology. Nuclear imaging scintigraphy accurately localizes the tumor in 90% of cases and simplifies the surgical management. We encountered three such cases with the parathyroid gland adenomas in ectopic locations in which pre-operative nuclear imaging played a major role.

Toxicity assessment and microbial degradation of azo dyes.

Toxic effluents containing azo dyes are discharged from various industries and they adversely affect water resources, soil fertility, aquatic organisms and ecosystem integrity. They pose toxicity (lethal effect, genotoxicity, mutagenicity and carcinogenicity) to aquatic organisms (fish, algae, bacteria, etc.) as well as animals. They are not readily degradable under natural conditions and are typically not removed from waste water by conventional waste water treatment systems. Benzidine based dyes have long been recognized as a human urinary bladder carcinogen and tumorigenic in a variety of laboratory animals. Several microorganisms have been found to decolourize, transform and even to completely mineralize azo dyes. A mixed culture of two Pseudomonas strains efficiently degraded mixture of 3-chlorobenzoate (3-CBA) and phenol/cresols. Azoreductases of different microorganisms are useful for the development of biodegradation systems as they catalyze reductive cleavage of azo groups (-N=N-) under mild conditions. In this review, toxic impacts of dyeing factory effluents on plants, fishes, and environment, and plausible bioremediation strategies for removal of azo dyes have been discussed.

Distal spinal muscular atrophy.

Spinal muscular atrophies (SMA) are clinically heterogenous group of motor system disorders characterised by progressive pure lower motor neuron involvement. The distal form of SMA is an extremely rare disorder, which presents in the adults and has a relatively slow progression with almost no effect on the patients' life-span. Differential diagnosis of this syndrome include other forms of neuromuscular disorders with peroneal muscular atrophy like hereditary motor sensory neuropathy (HMSN) and distal myopathies, which need exclusion before confirming this rare entity. We present a young male with this disorder and briefly discuss the theoretical aspects.

Microbes in heavy metal remediation.

Heavy metal contamination due to natural and anthropogenic sources is a global environmental concern. Release of heavy metal without proper treatment poses a significant threat to public health because of its persistence, biomagnification and accumulation in food chain. Non-biodegradability and sludge production are the two major constraints of metal treatment. Microbial metal bioremediation is an efficient strategy due to its low cost, high efficiency and ecofriendly nature. Recent advances have been made in understanding metal--microbe interaction and their application for metal accumulation/detoxification. This article summarizes the potentials of microbes in metal remediation.

Biodegradation of benzidine based azodyes Direct red and Direct blue by the immobilized cells of Pseudomonas fluorescens D41.

Benzidine based azodyes are proven carcinogens, mutagens and have been linked to bladder cancer of human beings and laboratory animals. The textile and dyestuff manufacturing industry are the two major sources that released azodyes in their effluents. The dye, Direct blue contains two carcinogenic compounds namely benzidine (BZ), 4-amino biphenyl (4-ABP), while the dye Direct red has benzidine (BZ). Among 40 isolates of Pseudomonas fluorescens screened, one isolate designated as D41 was found to be capable of extensively degrading the dyes Direct blue and Direct red. Immobilized cells of P. fluorescens D41 efficiently degraded Direct red (82%) and Direct blue (71%) in the presence of glucose.