Intractable hiccups: How can chest X-ray help?

We describe the case of a young male presenting with hiccups refractory to antacids. Due to high index of suspicion was evaluated with a chest X-ray which revealed pericardial effusion. The effusion was drained, and the hiccups resolved. It is a teaching moment, to consider simple imaging, i.e., chest X-ray in patients with refractory hiccups to rule out more serious underlying causes.

A Study of Correlation of Glucagon-Insulin Ratio with Hba1c in Diabetic Patients in a Tertiary Care Hospital.

Apart from defects in insulin secretion and insulin resistance, hyperglucagonemia is a major factor affecting diabetes development and progression. Diabetic patients show relatively higher fasting and postprandial glucagon levels due to alpha cell resistance or dysfunction. As glucagon secretion is highly affected by insulin, it is better to consider glucagon relative to insulin as a glucagon insulin ratio instead of assessing each absolute value seperately. Data on increase in glucagon relative to insulin and their association with clinical parameters are scarce. In this study, we evaluated whether increase in glucagon relative to insulin correlates with HbA1c in diabetic patients. This will help to develop newer therapies aimed at suppressing glucagon levels for achieving glycemic control in diabetic patients. MATERIAL: A prospective type of observational study was conducted in outdoor and indoor patients of a tertiary care hospital. Patients of either sex, with type 2 DM, who were naive to insulin therapy were participating in the study. Patients with type 1 DM, gestational diabetes and patients on long term insulin therapy were excluded from the study.The sample size was 80. Fasting and post prandial quantitative glucagon estimation was done by Sandwich ELISA kit method. OBSERVATION: We observed that mean fasting and postprandial glucagon/ insulin ratio were 104.85 +/- 59.1 and 101.63 +/- 88.0 respectively. Mean Hba1c value was 9.9 +/- 2.41%, mean duration of diabetes was 6.6 +/- 2.5 years and mean age of subjects was 54.4 +/- 9.9 years. Linear regression analysis was conducted, in which both fasting and post prandial glucagon to insulin ratio showed statistically significant correlation with HbA1c (p values 0.018 and 0.029 respectively). CONCLUSION: In this study, we found that patients with a higher glucagon to insulin ratio in both fasting and postprandial state exhibit worse blood glucose levels i.e, higher HbA1c levels. Thus, instead of concentrating on improvement in insulin resistance, a strategy to suppress glucagon together with increasing insulin secretion maybe another key therapeutic option for achieving glycemic control in type 2 diabetic patients in future.

Impact of Thyroid Dysfunction on Insulin Resistance: A Study from a Tertiary Care Center in India.

INTRODUCTION: The thyroid hormones perpetuate a fine equilibrium of glucose metabolism. Abnormalities of thyroid function can disrupt this balance leading to glucose metabolism abnormalities and insulin resistance. OBJECTIVES: We studied the correlation between insulin resistance and thyroid status in hyperthyroid, euthyroid, and hypothyroid individuals. METHODS: In this observational comparative analysis conducted at a tertiary care center, the 3 study groups comprised of 35 patients each with newly detected hyperthyroidism, hypothyroidism and euthyroid individuals. Assays were conducted for serum insulin, thyroid profile, blood sugar and routine biochemistry in the fasting state. The homeostasis model assessment for insulin resistance (HOMA-IR) was used to evaluate insulin resistance. RESULTS: The mean HOMA-IR was highest in patients with hypothyroidism (3.22 ± 2.69) followed by the hyperthyroid group (2.25 ± 1.59). It was lowest in the euthyroid group (0.79 ± 0.58) with the intergroup difference being statistically significant (P<0.001). Hypothyroid patients showed a significant a positive correlation between TSH and HOMA-IR (r=0.945, P=<0.001) whereas hyperthyroid patients showed positive correlation between FT3 and insulin resistance (r=0.706, P<0.001). CONCLUSION: Thyroid dysfunction is associated with an increase in insulin resistance and glucose abnormalities validating the resultant higher risk of related cardiovascular and metabolic abnormalities observed in these patients.

Assessment of Pituitary Gonadal Axis and Sperm Parameters in Anemic Eugonadal Males Before and After Correction of Iron Deficiency Anemia.

ABSTRACT: :Iron deficiency anemia (IDA) is one of the most common nutritional anemia worldwide. Anemia imposes a significant hypoxic environment in different organs and tissues including the testes. This study evaluated the effect of treatment of IDA on the pituitary gonadal axis (Serum FSH, LH, Testosterone) and sperm parameters in adult eugonadal males. METHODOLOGY: A hospital based interventional, analytic study was conducted at a tertiary care center among 25 eugonadal males (fully sexually developed, fertile) with newly diagnosed and untreated IDA, admitted in medicine wards and not suffering from any inflammatory disorders (excluded by C-reactive protein) after exclusion of patients having other forms of anemia/ hemoglobinopathies/ any malignancy/having MCV >80 fL, aplastic anemia and primary hypogonadism. Sexual maturation was assessed according to maturity stages 5. Investigations were performed before and 6 weeks after treatment of IDA with intravenous iron sucrose included CBC, peripheral blood smear, serum ferritin, serum iron, TIBC, serum FSH, serum LH, serum Testosterone and semen analysis (Semen volume, Sperm count, Sperm motility and Sperm morphology). RESULTS: The change in mean Hb level before (5.66 ± 1.97gm/dl) and after treatment (11.96 ± 0.87 gm/dl) was statistically significant. (P<0.001) Patients who had subnormal and normal serum level of FSH, LH, Testosterone and sperm parameters before treatment were divided into group A and group B respectively. Serum levels of FSH, LH and testosterone along with sperm parameters significantly improved after correction of anemia (p<0.01). The mean change in these parameters was significantly higher in patients having subnormal value of these parameters before treatment (Group A) than in patients having normal pre-treatment level (Group B) (p<0.01). The level of anemia (hemoglobin) had significant positive correlation with serum FSH, serum LH, serum testosterone levels and sperm parameters (semen volume, sperm count, sperm morphology, RPM and sperm motility) (p<0.001). CONCLUSION: IDA had significant negative association with the pituitary gonadal axis (Serum FSH, LH, Testosterone) and sperm parameters in adult eugonadal males. The serum levels of FSH, LH and testosterone along with sperm parameters significantly improved after correction of anemia, especially in patients having subnormal value of these parameters.

Modeling the performance of "up-flow anaerobic sludge blanket" reactor based wastewater treatment plant using linear and nonlinear approaches--a case study.

The paper describes linear and nonlinear modeling of the wastewater data for the performance evaluation of an up-flow anaerobic sludge blanket (UASB) reactor based wastewater treatment plant (WWTP). Partial least squares regression (PLSR), multivariate polynomial regression (MPR) and artificial neural networks (ANNs) modeling methods were applied to predict the levels of biochemical oxygen demand (BOD) and chemical oxygen demand (COD) in the UASB reactor effluents using four input variables measured weekly in the influent wastewater during the peak (morning and evening) and non-peak (noon) hours over a period of 48 weeks. The performance of the models was assessed through the root mean squared error (RMSE), relative error of prediction in percentage (REP), the bias, the standard error of prediction (SEP), the coefficient of determination (R(2)), the Nash-Sutcliffe coefficient of efficiency (E(f)), and the accuracy factor (A(f)), computed from the measured and model predicted values of the dependent variables (BOD, COD) in the WWTP effluents. Goodness of the model fit to the data was also evaluated through the relationship between the residuals and the model predicted values of BOD and COD. Although, the model predicted values of BOD and COD by all the three modeling approaches (PLSR, MPR, ANN) were in good agreement with their respective measured values in the WWTP effluents, the nonlinear models (MPR, ANNs) performed relatively better than the linear ones. These models can be used as a tool for the performance evaluation of the WWTPs.