Diabetic ketosis as a presenting feature of acromegaly.

Secondary diabetes mellitus is known to occur in acromegaly due to insulin resistance caused by growth hormone excess. However diabetes in acromegaly usually does not lead to ketosis. We describe here a case of acromegaly who presented in diabetes ketosis, which is unusual.

Clinical dysautonomia in diabetes mellitus--a study with seven autonomic reflex function tests.

Thirty-eight patients of NIDDM, 12 of IDDM and 10 healthy age matched controls were subjected to seven standardised autonomic reflex function tests. A scoring criteria was utilised for diagnosing and grading the severity of dysautonomia. Eight patients of IDDM and 24 of NIDDM had dysautonomia. One-third of the patients in each group had grade IV autonomic dysfunction. Severity of autonomic dysfunction was directly related to the duration of disease in NIDDM whereas in IDDM this relation was not seen. Peripheral neuropathy was almost always associated with dysautonomia in NIDDM. On the contrary, in IDDM dysautonomia was independent of peripheral neuropathy. Charcot's arthopathy, dysphagia, constipation and nocturnal diarrhea were always associated with evidence of dysautonomia. Other symptoms viz. gustatory sweating, postural dizziness and impotence did not necessarily indicate dysautonomia.

Comparison of biochemical parameters in pleural effusion.

A comparison of various biochemical parameters used in differentiation of nature of pleural effusion in transudate and exudate was done in 84 patient of pleural effusion. Pleural fluid (P) cholesterol and bilirubin which have gained an importance in recent years were compared with pleural fluid protein, LDH, P/S protein, P/S LDH and Light's criteria. It was seen that Light's criteria is still the best in differentiation. Sensitivity of individual test was nearly same for Pl. protein (94.11%), P/S Protein (94.11%), Pl. LDH (95.5%), P/S LDH (92.75%). Pl cholesterol (88.3%) and P/S cholesterol (91.42%) had slightly lower sensitivity. Pl. Protein and P/S LDH had 100% specificity. Lights criteria had 100% specificity and sensitivity % of cases misclassified by various criteria were Pl Protein 5.95%, P/S protein 5.95%, PLDH 4.76%, P/S LDH 4.76% P. Cholesterol 13% and P/S Cholesterol 9.52% Measurement of Bilirubin did not provide any correlation in classifying the effusion and thus did not hold any value.

Clinical assessment of autonomic functions in anemics.

Sixty five anemics and 20 healthy control subjects carefully age and sex matched were subjected to seven standardised tests to evaluate autonomic status. Due care was taken to remove factors which could interfare with the results. Tests concerned with the basal parasympalhetec tone viz heart rate response to standing (p < 0.001) and intravenous atropine test (p < 0.05) showed significant difference which persisted with severity and type of anemia. Test requiring stimulation of the parasympathatic system i.e. deep breathing test, valsalva maneuver and carotid sinus massage did show not significant difference. No difference of significance was found with postural fall of blood pressure and sustained hand grip test, chiefly concerned with the sympathatic system. These results suggest that anemics have low basal parasympathatic outflow to increase the heart rate as compensatory mechanism. Stimulation of parasympathatic and sympathetic system arouse normal response.

Modification in sucrose tolerance test with acarbose, guargum and their combination in patients with non-insulin dependent diabetes.

The study was undertaken to assess the efficacy guargum, Acarbose and their combination in modifying the sucrose absorption in patients of non Insulin dependent diabetes mellitus (NIDDM). Fifty patients of NIDDM were randomly distributed in three groups. Group A had 20 patients who received 20 grams of guargum, Group B had 10 patients who received 100 mg of Acrabose, Group C had 20 patients who received 10 grams of guargum and 50 grams of Acrabose. All the patients underwent 50 grams sucrose tolerance test with and without the trial drugs. Blood glucose levels were determined at 0, 30, 60, 90 and 120 minutes after sucrose loading. With the drugs, there was a significant decrease in the blood glucose levels at all time intervals (p < 001) in all the three groups. In all the three groups the blood glucose levels with the trial drugs was significantly lower (p < 001) than without the drug. It was seen that acarbose alone and guargum alone did not differ significantly in reducing the blood sugar level whereas combination of two produced significantly greater reduction in blood glucose levels than either of the drug used alone. Thus both guargum and acarbose are equally effective in modifying the absorption of sucrose. When combined in half the dosage they have synergistic effect and the reduction in blood glucose level is greater than either of the drug used alone.

Effect of beta-blockers on ventilatory function in smokers and non smokers.

Twenty healthy nonsmokers, 20 asymptomatic mild smokers and 20 asymptomatic moderate smokers were assessed for ventilatory functions, before and after equipotent dosages of atenolol, propranolol and oxprenolol in a single blind longitudinal study. The basal spirometric values were significantly lower in smokers than non smokers. After propranolol significant reduction was seen from basal values in FEV1, FEF 75%, MMFR, FEF 200-1200 in all the three groups. After oxprenolol significant difference was seen only with MMFR in the moderate smokers. With atenolol the variation was not significant in any group. Intercomparison of values after the drugs in each group was done. The values after propranolol was significantly lower than values after atenolol or oxprenolol for FEF 75%, MMFR and FEF 200-1200 in both the smoker groups whereas values after oxprenolol and Atenolol did not differ significantly from each other. Thus, in smokers atenolol offers a safe choice. If propranolol is to be used, the possibility of significant bronchospasm should be considered.

Functional hypothalamic amenorrhoea-isolated gonadotropin deficiency.

A 21 year old female patient with primary amenorrhoea was diagnosed to have isolated gonadotropin deficiency with probable functional hypothalamic amenorrhoea. The evaluation included buccal smear for sex chromatin, trial of medroxy-progesterone acetate, trial of oestrogen-progesterone preparation and estimation of serum prolactin, gonadotrophin and oestrogen levels. When diagnosed as isolated gonadotropin deficiency, treatment with gonadotropin is rewarding.

Clinical dysautonomia in patients with bronchial asthma. Study with seven autonomic function tests.

Fifty asthmatic patients and 20 healthy control subjects, carefully age- and sex-matched, were subjected to seven standardized tests to evaluate their autonomic status. Due care was taken to remove factors which could interfere with results. Of the tests concerned with the parasympathetic system, the intravenous atropine test (p greater than 0.10) and heart rate response to standing (p greater than 0.01) which measured the basal parasympathetic tone, did not show a significant difference. Tests requiring stimulation of the parasympathetic system, ie, deep breathing test (p less than 0.001), Valsalva maneuver (p less than 0.001), and carotid sinus massage (p less than 0.001) showed significantly heightened response. Postural fall of blood pressure (p greater than 0.10) and sustained hand grip test (p greater than 0.10), chiefly concerned with the sympathetic system, did not show a significant difference. Of the 50 asthmatic patients, nine were atopic and 41 nonatopic. When the results were compared in the two groups separately, we found that there was no alteration in the measurements except the intravenous atropine test which showed heightened response with atopic subjects (p less than 0.05). These results suggest that hyperresponsiveness of the parasympathetic system is an important factor in producing bronchial spasm in asthmatic patients, and atopic and nonatopic subjects do not differ much in their autonomic status.

Cardiovascular response to dynamic treadmill exercise in patients with essential hypertension before and after therapy with atenolol or captopril.

Thirty eight patients with essential hypertension and 20 healthy volunteers were subjected to treadmill exercise test. The hypertensives were then controlled with atenolol or captopril by randomly forming two groups of 19 patients each, and treadmill evaluation was repeated. The resting rate-pressure product (RPP) and myocardial oxygen consumption (MVO2), as well as peak RPP and MVO2 and recovery time, were increased and exercise duration decreased significantly in uncontrolled hypertensives (p less than 0.001). Control of hypertension resulted in significant improvement of exercise performance in both the groups. Atenolol, when compared to captopril, resulted in better exercise conditioning with considerable lowering of resting and peak RPP and MVO2 (p less than 0.001), though the difference in exercise duration, maximum work load and recovery time were not significant (p greater than 0.05). Thus, where myocardial oxygen consumption is an important consideration while treating hypertension, atenolol offers a better choice.

Acute scleredema with fatal outcome.

Death due to scleredema is rare. We report a patient with scleredema, which had an acute onset and rapid progression, leading to death within a month. Such an acute course terminating in fatality has not been described earlier.

Cardiovascular dysautonomia in patients with lepromatous leprosy.

Autonomic functions were studied by six standard tests in 65 patients with lepromatous leprosy and 25 healthy controls. Dysautonomia was observed in 22 patients, all having the disease for more than five years. Associated peripheral neuropathy, judged clinically, was present in all, except one patient. Of the 22 dysautonomic patients, 9 each had mild or moderate dysantonomia and 4 had severe dysautonomia as per the scoring schedule devised by us. Syncope, gustatory sweating and impotence were the symptoms suggestive of dysautonomia. But not all affected patients reported these symptoms. Involvement of the sympathetic system was more frequent than that of the parasympathetic system. Statistically significant abnormality was seen with Atropine ratio, standing 30:15 beat ratio, postural hypotension and sustained hand grip test. Sustained hand grip test was the one which consistently gave abnormal results in all the 22 dysautonomic patients.

Diagnostic significance of pleural fluid eosinophilia during initial thoracocentesis.

A prospective study of pleural fluid eosinophilia (PFE) during initial thoracocentesis in 162 patients of pleural effusion was undertaken to determine its value in establishing an etiological diagnosis. Eighteen of the 162 cases showed pleural fluid eosinophilia (PFE), twelve could not be labelled with any definitive etiology even after extensive investigations, four belonged to the para-pneumonic group and resolved with treatment. Of the 32 patients with malignancy, PFE was seen in a single case of pleural mesothelioma. None of the patients with tuberculosis, empyema, systemic lupus erythematosus or amoebiasis had PFE. These findings suggest that PFE seen at initial thoracocentesis favours a benign diagnosis, with a rare chance of malignancy. Tuberculosis is unlikely in such patients.

Pulmonary infiltration with blood eosinophilia after scorpion sting.

A 30-year-old man developed bilateral pulmonary infiltrates with blood eosinophilia after receiving a scorpion sting. A short course of corticosteroids resulted in rapid improvement. The PIE syndrome after scorpiasis has not, to our knowledge, been described previously.

A case of subacute effusive constrictive pericarditis with a probable amoebic aetiology.

A 48 year old man with amoebic pericarditis did not improve after pericardiocentesis. Facilities for echocardiography and haemodynamic studies were not available. Cardiac compression was suspected and at emergency pericardiectomy subacute effusive constrictive amoebic pericarditis was found. The patient recovered. This is believed to be the first report of a case of subacute effusive constrictive pericarditis caused by amoebiasis.