Blood pressure levels and hypertension prevalence in a high selenium environment: results from a cross-sectional study.

BACKGROUND AND AIMS: Recent human and laboratory studies have suggested the possibility that selenium overexposure may increase blood pressure. We sought to ascertain whether adults living in a seleniferous area exhibit an association between selenium exposure and both blood pressure levels as well as prevalence of hypertension. METHODS AND RESULTS: We measured selenium levels in blood (serum), hair and nail samples obtained from 680 adult volunteers (267 men and 413 women), living in seven Punjabi villages in a seleniferous area and related them to health outcomes, including systolic and diastolic blood pressure and presence of hypertension. In a multivariable restricted cubic spline regression model, adjusted for age, sex and history of hypertension, we found a positive association between systolic blood pressure and both serum (P = 0.004) and hair (P = 0.058) selenium levels, but not with nail selenium content. Little association emerged between the three selenium biomarkers and diastolic blood pressure. Hypertension prevalence was positively associated with the three exposure indicators (P < 0.001). The associations we found were generally stronger in women than in men. CONCLUSIONS: Overall, these findings suggest that chronic overexposure to environmental selenium may increase blood pressure, though there were inconsistencies for this association according to the choice of exposure indicator, the study endpoint and the sex.

Subacromial Impingement Syndrome of the Shoulder: A Musculoskeletal Disorder or a Medical Myth?

Subacromial impingement syndrome (SAIS) is a commonly diagnosed disorder of the shoulder. Though this disorder has been known for a long time, it remains a poorly understood entity. Over the years several hypotheses have been put forward to describe the pathogenesis of SAIS but no clear explanation has been found. Two mechanisms, the extrinsic and intrinsic mechanism, have been described for the impingement syndrome. The intrinsic mechanism theories which deny the existence of impingement are gaining popularity in recent years. The various shoulder tests used to diagnose SAIS have low specificity with an average of about 50%. Meta-analysis shows that neither the Neer sign nor the Hawkins sign has diagnostic utility for impingement syndrome. Several randomised controlled trials have shown that the outcome of treatment of SAIS by surgery is no better than conservative treatment. Physiotherapy alone can provide good outcome which is comparable to that achieved with surgery without the costs and complications associated with surgery. Since decompression with surgery does not provide any additional benefits as compared to conservative treatment for patients with SAIS, the impingement theory has become antiquated and surgical treatment should have no role in the treatment of such patients. There are calls by some practitioners to abandon the term impingement syndrome and rename it as anterolateral shoulder pain syndrome. It appears that SAIS is a medical myth. There are others who called SAIS as a clinical illusion.

Spinal Fusion for Chronic Low Back Pain: A 'Magic Bullet' or Wishful Thinking?

Chronic low back pain is a common, disabling and costly health problem. The treatment of chronic low back is difficult and is often ineffective. For treatment to be effective the cause of the pain has to be established but unfortunately in 80% to 95% of the patients the cause cannot be determined despite the existence of modern imaging techniques. A pathoanatomical diagnosis which fits into a classical disease model where successful treatment can be carried out, can only be made in 5% to 7% of the patients. The back pain in the rest of the patients where no pathoanatomical diagnosis can be made is often labelled, unscientifically, as chronic low back pain. Despite the existence of sophisticated imaging techniques and a plethora of diagnostic test the source of pain in patients with nonspecific back pain cannot be established. There exist no causal relationship between imaging findings of degenerated disc, lumbar facet arthritis, spondylosis, spondylolysis and spondylolisthesis, to the pain in these patients. Surgical treatment of non-specific back pain where no pathoanatomical diagnosis has been established is bound to fail. Therefore the outcome of spinal fusion in these patients can be no better than nonsurgical treatment. Spinal fusion is a major surgery which can be associated with significant morbidity and occasionally with mortality. Yet there is rapid rise in the rates of spinal fusion. There is a growing tension between ethics and conflicts of interest for surgeons. The spine, unfortunately, has been labelled as a profit centre and there are allegations of conflicts of interest in the relationship of doctors with the multi-billion dollar spinal devices industry. The devices industry has a significant influence on not only research publications in peer review journals but also on decisions made by doctors which can have a detrimental effect on the welfare of the patient.

"Doc' do I need an anterior cruciate ligament reconstruction? What happens if I do not reconstruct the cruciate ligament?"

We are all aware that there has been a dramatic increase in the number of anterior cruciate ligament (ACL) reconstructions that are carried out here in Malaysia as well as around the world. The numbers of ACL injuries have undoubtedly increased over the years with greater participation of young adults in sporting activities. However it is not certain whether the increase in the numbers of reconstructions can be accounted for by the increasing numbers of ACL injuries. Without doubt commercial interests as well the influence of the biomedical companies have a role to play. In the past the rational for surgical treatment of an ACL tear was that the ACL is vital for knee function and that in the long term ACL deficiency will lead to more injuries of the meniscus and more degeneration of the joint. This belief was prevalent because the natural history of an ACL deficient knee was not known although the ultimate outcome of reconstruction of the ACL was not known either. However in past few years a substantial amount research has been published, which has elucidated the natural history of ACL deficient knees as well as the long term outcome of reconstruction of the ACL.

Selenium distribution and speciation in plant parts of wheat (Triticum aestivum) and Indian mustard (Brassica juncea) from a seleniferous area of Punjab, India.

The concentration, distribution, and speciation of selenium in different parts of wheat and Indian mustard, grown in a seleniferous area in Punjab, were investigated using synchrotron based (XAS) and classical acid digestion and extraction methods. The analyses revealed a high Se enrichment in all investigated plant parts, with Se levels in the range of 133-931 mg/kg (dry weight, dw). Such high Se enrichment is mainly due to the considerable amounts of easily available Se detected in the soil, which are renewed on a yearly basis to some extent via irrigation. Speciation analysis in soil and plants indicated selenate and organic Se as major Se species taken up by plants, with a minor presence of selenite. The analyses also revealed that the highest Se enrichment occurs in the upper plant parts, in agreement with the high uptake rate and mobility of selenate within plants. In both wheat and mustard, highest Se enrichments were found in leaves (387 mg/kg·dw in wheat and 931 mg/kg·dw in mustard). Organic species (dimethylselenide and methylselenocysteine) were found in different parts of both plants, indicating that an active detoxification response to the high Se uptake is taking place through methylation and/or volatilization. The high proportion of selenate in wheat and mustard leaves (47% and 70%, respectively) is the result of the inability of the plant metabolism to completely transform selenate to non-toxic organic forms, if oversupplied. Methylselenocysteine, a common Se species in accumulating plants, was detected in wheat, suggesting that, in the presence of high Se concentration, this plant develops similar response mechanisms to accumulator plants.

Ocular disability--WHO grade 2 in persons affected with leprosy.

Leprosy remains to be a leading cause of peripheral neuropathy and disability. In recent years under Leprosy control programme more stress is being laid on disability assessment. This study was aimed to find prevalence of grade of Ocular disability among persons affected with leprosy (PAL) according to WHO disability grading scale and to find Ocular contributors to grade 2 disability in PAL. A cross sectional study was carried out in tertiary care hospital in Lucknow, Uttar Pradesh. About 302 PAL were interviewed and their eyes clinically examined during 2 years. Data was analysed in percentages, x2 test, Anova. Ocular disability was found in 39.40% persons affected with leprosy (PAL). Of 604 eyes, 13.07% had grade 1 disability and 19.86% had grade 2 disabilities. Bilateral disability was more common than unilateral disability. Ocular disability was more common in PAL with more than one year of leprosy and even higher in those staying in leprasoria (p = 0.012). The most common cause of ocular grade 2 disabilities was corneal involvement (14.23% PAL). Cataract was found to be the most common cause of visual disability (although it is not caused by leprosy). Screening for ocular disability should be incorporated as a routine protocol in PAL to reduce the severity of Ocular disability. Early diagnosis and prompt preventive measure is essential to reduce the burden of visual impairment and blindness in PALthus bringing down the load of grade 2 disability due to leprosy in the society which in itself is an indicator of leprosy control.

"'Doc' do I need an anterior cruciate ligament reconstruction? What happens if I do not reconstruct the cruciate ligament?".

We are all aware that there has been a dramatic increase in the number of anterior cruciate ligament (ACL) reconstructions that are carried out here in Malaysia as well as around the world. The numbers of ACL injuries have undoubtedly increased over the years with greater participation of young adults in sporting activities. However it is not certain whether the increase in the numbers of reconstructions can be accounted for by the increasing numbers of ACL injuries. Without doubt commercial interests as well the influence of the biomedical companies have a role to play. In the past the rationale for surgical treatment of an ACL tear was that the ACL is vital for knee function and that in the long term ACL deficiency will lead to more injuries of the meniscus and more degeneration of the joint. This belief was prevalent because the natural history of an ACL deficient knee and the ultimate outcome of reconstruction of the ACL were both not known. However in recent years a substantial amount of research has been published, which has elucidated the natural history of ACL deficient knees as well as the long term outcome of reconstruction of the ACL.

A study of cardio-metabolic risk profile in patients with psoriasis.

INTRODUCTION/BACKGROUND: Psoriasis is a chronic immune mediated inflammatory disorder of the skin and joints. Recent studies have shown increased prevalence of traditional cardiovascular risk factors such as diabetes mellitus, hypertension and metabolic syndrome. Since atherosclerosis and psoriasis share a common link of inflammation, different workers have shown psoriasis to be a risk factor for atherosclerosis. The aim of our study was assessment of cardiovascular risk factors and evidence of subclinical atherosclerosis in patients of psoriasis. METHODS: In a hospital based, cross-sectional study, 96 patients with psoriasis and 100 age, sex and weight matched controls were enrolled. Prevalence of diabetes, hypertension, metabolic syndrome was studied. They were also assessed for endothelial dysfunction by brachial artery flow mediated dilatation(FMD) and carotid intima media thickness (CIMT). RESULTS: There was higher prevalence of hypertension, hypertriglyceridaemia, diabetes mellitus and metabolic syndrome in patients with psoriasis than in controls. FMD was lower in patients with psoriasis than in controls (5.6 +/- 2 vs7.5 +/- 2.8, P = 0.02). The mean CIMT was significantly increased (0.78 +/- 0.12 vs 0.62 +/- 0.08, P = 0.001) in patients with psoriasis compared with controls. In psoriasis patients, CIMT was associated with hypertension, hypertriglyceridaemia, diabetes, insulin resistance, increased severity and duration of psoriasis while in multivariate analysis insulin resistance (OR 2.8, 95% CI 1.92-6.34 P = 0.02) and increased duration of disease (OR 3.12, 95% CI 2.34-7.56) a were the independent risk factors associated with higher CIMT. CONCLUSION: Patients of psoriasis have higher prevalence of metabolic syndrome, cardiovascular risk factors and subclinical atherosclerosis than general population. As a routine, individuals with moderate to severe psoriasis of long duration should be recognised as being at increased cardio vascular risk and thus encouraged for therapeutic interventions to reduce the modifiable risk factors.

Developing a sustainable phytomanagement strategy for excessive selenium in western United States and India.

Phytomanagement technology is recognized as an inexpensive and environmental friendly strategy for managing natural-occurring selenium (Se) in soils and in poor quality waters. Multi-year field and greenhouse studies were conducted with different plant species in California, USA and Punjab, India under high Se growing conditions. Some of the plant species included; canola (Brassica napus), mustard (B. juncea), broccoli (B. oleracea), spearmint (Mentha viridis), sugarcane (Saccharum officcinarum), guar (Cyamopsis tetragonoloba), wheat (Triticum aestivum), and poplar (Populus deltoides). California soils had a sodium-sulfate-dominated salinity between 6-10 dS m(-1), while Indian soils had a calcium carbonate salinity less than 1 dS m(-1). Results demonstrated that high sulfate conditions reduced plant Se accumulation more than 100 x in Californian grown plants compared to Se accumulation in Indian grown plants. Tissue concentrations generally did not exceed 10 and 200 mg kg DM(-1) in leaves of plants grown in California and India, respectively. At these plant concentrations, Se phytomanagement is more effective in Indian soils than in California soils. Successful management of Se by plants requires selecting crops or crop rotations that are tolerant of the soil condition and identifying and creating new viable Se-enriched products.

Selenium accumulation by forage and grain crops and volatilization from seleniferous soils amended with different organic materials.

Greenhouse and field experiments were conducted to study the direct and residual effect of applying different organic materials on Se accumulation by crops and volatilization from seleniferous soils of northwestern India. Among organic manures, press mud and poultry manures proved 4-5 times more effective in reducing Se accumulation by different crops than farmyard manure. Efficiency of organic manures increased with increase in application rates. Application of both press mud and poultry manures reduced Se accumulation by 44-97% in wheat (Triticum aestivum) and rapeseed (Brassica napus) shoots in the greenhouse; 85-92% in wheat straw, 45-74% in wheat grains, 45-74% in rapeseed straw and 76-92% in rapeseed grains under field conditions. Both the manures remained highly effective in reducing Se accumulation by the crops following wheat and rapeseed and the extent of reduction varied from 50% to 87% in maize (Zea mays) and cowpeas (Vigna sinensis) in the greenhouse and 40-89% in maize and rice (Oryza sativa) crops under field situation. Rate of Se volatilization by wheat and rapeseed crops increased by 1.8-4.0 times; the greatest increase was observed with press mud followed by poultry manure, arhar (Cajanus cajan) leaves and farmyard manure. After 134d of incubation of 500g soil amended with 2% of plant tissues, the maximum amount of Se was volatilized with cowpea leaves (385ng) followed by wheat grains, leaves of maize, sugarcane (Saccharum officcinarum), arhar, poplar (Populus deltoides) and the control (91ng). The results of this study convincingly prove the usefulness of applying press mud and poultry manure in enhancing volatilization and retarding the transfer of Se from soil to plant in seleniferous soils.

Bioavailability of selenium to forage crops in a sandy loam soil amended with Se-rich plant materials.

Greenhouse experiments were conducted to study the bioavailability of selenium (Se) to sorghum (Sorghum bicolor L.), maize (Zea mays L.) and berseem (Trifolium alexandrinum L.) fodders in a sandy loam soil amended with different levels of Se-rich wheat (Triticum aestivum L.) and raya (Brassica juncea L. Czern) straw containing 53.3 and 136.7microg Seg(-1), respectively. Each of the fodder crops was grown after incorporation of Se-rich materials either individually or in a sequence - sorghum-maize-berseem by incorporating Se-rich straws only to the first crop. Application of Se-rich straws to each crop, even at the greatest rate of 1%, did not have any detrimental effect on dry matter yield of different crops. With increase in the level of wheat straw from 0% to 1%, Se content in sorghum and maize plants increased to greatest level of 1.3 and 1.5microg g(-1), respectively, at 0.3% of applied straw and thereafter it decreased consistently. In case of raya straw, the greatest Se content in sorghum (2.3microg g(-1)) and maize (3.0microg g(-1)) was recorded at 0.3% and 0.4% of the applied straw, respectively. Unlike sorghum and maize fodders, Se content in all the four cuts of berseem continued to increase with increase in the level of applied straws and for different cuts of berseem it varied from 1.6 to 2.3 and 3.4 to 4.3microg g(-1) in case of wheat and raya straw, respectively. Similar variations in Se content of different fodder crops were recorded when these were grown in the sequence - sorghum-maize-berseem; but Se content was 2-4 times lower than when each crop was grown with fresh application of Se-rich straw. None of the fodders absorbed Se in levels toxic for animal consumption (>5microg g(-1)) even at the greatest level of applied straw. Of the total Se added through Se-rich straws, utilization of Se was not more than 2% in case of sorghum and maize crops and up to 5% in case of berseem. At the time of sowing of sorghum, hot water soluble Se (HWS-Se) in soils treated with different levels of Se-rich wheat and raya straw, respectively, varied from 18 to 36 and 18 to 79microg kg(-1). Whereas in case of berseem, it varied from 33 to 101 and 33 to 154microg kg(-1), respectively. HWS-Se present at the sowing time of berseem was significantly correlated with Se content of all the four cuts in the soil treated with Se-rich straws; the coefficients of correlation 'r' varied between 0.79 (p0.05) and 0.99 (p0.001). Selenium-rich materials supplied significant amounts of S, P and micronutrients to the growing fodder crops. These investigations suggest that Se-rich raya and wheat straw may be disposed off safely in soils used for growing fodders.

Dietary selenium intake by men and women in high and low selenium areas of Punjab.

OBJECTIVE: To determine the selenium intake of adults residing in high and low selenium areas of rural Punjab. DESIGN: All food samples consumed by the subjects were collected and analysed for selenium content. Based on food intake data and selenium content of foods, the selenium intake of the subjects was calculated. Hair, fingernails and urine samples from a sub-sample of subjects were collected and analysed for selenium. SETTING: Three villages from the selenium-endemic area of Nawan Shahr District and two villages from the non-endemic area of Ludhiana District, Punjab, India, were covered. SUBJECTS: Forty families from each of the two areas, with one adult male and one adult female in the age range of 20-40 years, were surveyed. Thus a total of 80 men and 80 women constituted the study sample. RESULTS: In the selenium-endemic area, the average selenium intake of both men and women was more than nine times that in the non-endemic area and exceeded the maximum tolerable limit in more than 60% of men. Mean selenium content of the hair, nails and urine of both men and women was tens of times higher than in the non-endemic area. CONCLUSIONS: High selenium intake in the endemic area resulted in high selenium content in the hair, nails and urine of men and women. In addition, clinical symptoms of selenium toxicity were also observed in some of the subjects. Selenium intake in the non-endemic area was marginally below the suggested value. Based on the study results, steps need to be taken to educate the public in the endemic area to avoid selenium toxicity.

Serum Zinc Levels in Cutaneous Disorders.

Serum zinc levels were studied in 75 patients of different cutaneous disorders and 24 healthy controls. It was found to be significantly lower in acne vulgaris (71.5 ± 21.5µgm/100ml), leprosy(85.9 ± 26.9µgm/100ml) and psoriasis (93.3 ± 25.9µgm/100ml) as compared to healthy controls (105.3 ± 30.1µgm/100ml). No significant correlation was found in other cutaneous disorders studied i.e. vitiligo and aphthous ulcers where serum zinc levels were found to be 97.3 ± 26.6 µgm/100ml and 105.2 ± 23.5 µgm/100ml respectively.

Primary hyperparathyroidism presenting with pathological fracture.

Primary hyperparathyroidism (PHPT) is an intriguing condition. Routine automated biochemical screening has made the diagnosis commonplace in developed countries and the disease is diagnosed early in its course when it is often asymptomatic. In developing countries or in recent immigrants from these countries, PHPT is often seen in an advanced stage with bone involvement. Associated dietary deficiencies may alter the biochemical profile and cause a diagnostic dilemma. It is important to include it in the differential diagnosis of pathological fractures. We report three cases of PHPT presenting with pathological fractures and discuss their diagnosis and management.

Postoperative deep-vein thrombosis in Asian patients is not a rarity: a prospective study of 88 patients with no prophylaxis.

Postoperative deep-vein thrombosis (DVT) is believed to be rare in Asians. We studied 88 consecutive patients in Malaysia who had operations for fracture of the proximal femur or for total hip or knee replacement. No patient had prophylaxis against DVT; bilateral ascending venography was performed between six and ten days after operation. A total of 55 patients (62.5%) showed venographic evidence of DVT. The prevalence was greatest after total knee replacement (76.5%), less after total hip replacement (64.3%) and smallest in the fracture group (50%). One patient developed symptomatic pulmonary embolism. In contrast to other reports from Asia, we found an incidence of postoperative DVT which is similar to that reported in Western populations. This suggests that the present practice of withholding routine prophylaxis against thromboembolism in Asian patients undergoing high-risk orthopaedic procedures should be reconsidered.

The incidence of post-operative wound infection in orthopaedic surgery.

With the increase in the number of orthopaedic surgeons and the aggressive marketing by manufacturing companies, high technology orthopaedic surgery is being more frequently carried out in Malaysia. Post-operative sepsis complicating this type of surgery can have disastrous consequences. No data is available in this country on the incidence of post-operative infection in Orthopaedic Surgery. The aim of this study was to determine the incidence of post-operative infection. A retrospective survey of 703 patients undergoing elective Orthopaedic Surgery in the year 1991 was carried out. We found an overall post-operative infection rate of 6.8% and a deep infection rate of 3.3%. This figure of 3.3% is higher than the internationally accepted figure of less than 2%. A need for ongoing surveillance and concerned effort to reduce the infection rate is stressed.