PARATHYROID ADENOMA PRESENTING AS MULTIPLE BROWN TUMORS AND SEVERE ASYMPTOMATIC HYPERCALCEMIA.

Introduction: Primary hyperparathyroidism may have several presentations, varying from an incidental asymptomatic biochemical finding to gastrointestinal, psychiatric, renal and bone manifestations. Brown tumors are rare non-neoplastic lesions because of abnormal bone metabolism. Herein, we describe a patient who presented with lytic bony lesions and severe asymptomatic hypercalcemia due to parathyroid adenoma. Case presentation: A 38-year-old male presented with multiple painful bony lesions over upper and lower limbs. Radiographs of long bones showed multiple lytic lesions with cortical thinning. Investigations revealed hypercalcemia and hyperparathyroidism. A radionuclide scan showed parathyroid adenoma. The patient was treated for hypercalcemia and a parathyroidectomy was performed. Conclusions: In a patient presenting with multiple bony swellings and asymptomatic hypercalcemia, hyperparathyroidism should be suspected. Parathyroid adenoma is a treatable cause of primary hyperparathyroidism.

Prevalence of and risk factors for hypertension in urban and rural India: the ICMR-INDIAB study.

The aim of the study is to determine the prevalence of hypertension (HTN) and its risk factors in urban and rural India. In Phase I of the Indian Council of Medical Research-India Diabetes (ICMR-INDIAB) study, individuals aged ⩾20 years were surveyed using a stratified multistage sampling design, in three states (Tamil Nadu, Maharashtra and Jharkhand) and one union territory (Chandigarh) of India. Blood pressure was measured in all study subjects (n=14 059). HTN was defined as systolic blood pressure ⩾140 mm Hg, and/or DBP ⩾90 mm Hg and/or use of antihypertensive drugs. Overall age-standardized prevalence of HTN was 26.3% (self-reported: 5.5%; newly detected: 20.8%). Urban residents of Tamil Nadu, Jharkhand, Chandigarh and Maharashtra (31.5, 28.9, 30.7 and 28.1%) had significantly higher prevalence of HTN compared with rural residents (26.2, 21.7, 19.8 and 24.0%, respectively). Multivariate regression analysis showed that age, male gender, urban residence, generalized obesity, diabetes, physical inactivity and alcohol consumption were significantly associated with HTN. Salt intake ⩾6.5 g per day, showed significantly higher risk for HTN (odds ratio: 1.4, 95% confidence interval: 1.0-1.9, P=0.042) even after adjusting for confounding variables. In conclusion, prevalence of undiagnosed HTN is high in India and this calls for regular screening.

Knowledge and awareness of diabetes in urban and rural India: The Indian Council of Medical Research India Diabetes Study (Phase I): Indian Council of Medical Research India Diabetes 4.

BACKGROUND: Representative data on knowledge and awareness about diabetes is scarce in India and is extremely important to plan public health policies aimed at preventing and controlling diabetes. AIM: The aim of the following study is to assess awareness and knowledge about diabetes in the general population, as well as in individuals with diabetes in four selected regions of India. MATERIALS AND METHODS: The study subjects were drawn from a representative sample of four geographical regions of India, Chandigarh, Tamil Nadu, Jharkhand and Maharashtra representing North, South, East and West and covering a population of 213 million. A total of 16,607 individuals (5112 urban and 11,495 rural) aged ≥20 years were selected from 188 urban and 175 rural areas. Awareness of diabetes and knowledge of causative factors and complications of diabetes were assessed using an interviewer administered structured questionnaire in 14,274 individuals (response rate, 86.0%), which included 480 self-reported diabetic subjects. RESULTS: Only 43.2% (6160/14,274) of the overall study population had heard about a condition called diabetes. Overall urban residents had higher awareness rates (58.4%) compared to rural residents (36.8%) (P < 0.001). About 46.7% of males and 39.6% of females reported that they knew about a condition called diabetes (P < 0.001). Of the general population, 41.5% (5726/13,794) knew about a condition called diabetes. Among them, 80.7% (4620/5726) knew that the prevalence of diabetes was increasing, whereas among diabetic subjects, it was 93.0% (448/480). Among the general and diabetic population, 56.3% and 63.4% respectively, were aware that diabetes could be prevented. Regarding complications, 51.5% of the general population and 72.7% diabetic population knew that diabetes could affect other organs. Based on a composite knowledge score to assess knowledge among the general population, Tamil Nadu had the highest (31.7) and Jharkhand the lowest score (16.3). However among self-reported diabetic subjects, Maharashtra had the highest (70.1) and Tamil Nadu, the lowest score (56.5). CONCLUSION: Knowledge and awareness about diabetes in India, particularly in rural areas, is poor. This underscores the need for conducting large scale diabetes awareness and education programs.

Glyphosate poisoning with acute pulmonary edema.

GlySH-surfactant herbicide (GlySH), one of the most commonly used herbicides worldwide, has been considered as minimally toxic to humans. However, clinical toxicologists occasionally encounter cases of severe systemic toxicity. The US Environmental Protection Agency (EPA) states that 'GlySH' is of relatively low oral and acute dermal toxicity. It does not have anticholinesterase effect and no organophosphate-like central nervous system (CNS) effects. The clinical features range from skin and throat irritation to hypotension and death. Severe GlySH-surfactant poisoning is manifested by gastroenteritis, respiratory disturbances, altered mental status, hypotension refractory to the treatment, renal failure, and shock.[1] GlySH intoxication has a case fatality rate 3.2-29.3%. Pulmonary toxicity and renal toxicity seem to be responsible for mortality. Metabolic acidosis, abnormal chest X-ray, arrhythmias, and elevated serum creatinine levels are useful prognostic factors for predicting GlySH mortality.[2] There is no antidote and the mainstay of treatment for systemic toxicity is decontamination and aggressive supportive therapy. We report a case of acute pulmonary edema, which is a rare but severe manifestation of oral GlySH poisoning, where patient survived with aggressive supportive therapy.

Prevalence of diabetes and prediabetes (impaired fasting glucose and/or impaired glucose tolerance) in urban and rural India: phase I results of the Indian Council of Medical Research-INdia DIABetes (ICMR-INDIAB) study.

AIMS/HYPOTHESIS: This study reports the results of the first phase of a national study to determine the prevalence of diabetes and prediabetes (impaired fasting glucose and/or impaired glucose tolerance) in India. METHODS: A total of 363 primary sampling units (188 urban, 175 rural), in three states (Tamilnadu, Maharashtra and Jharkhand) and one union territory (Chandigarh) of India were sampled using a stratified multistage sampling design to survey individuals aged ≥ 20 years. The prevalence rates of diabetes and prediabetes were assessed by measurement of fasting and 2 h post glucose load capillary blood glucose. RESULTS: Of the 16,607 individuals selected for the study, 14,277 (86%) participated, of whom 13,055 gave blood samples. The weighted prevalence of diabetes (both known and newly diagnosed) was 10.4% in Tamilnadu, 8.4% in Maharashtra, 5.3% in Jharkhand, and 13.6% in Chandigarh. The prevalences of prediabetes (impaired fasting glucose and/or impaired glucose tolerance) were 8.3%, 12.8%, 8.1% and 14.6% respectively. Multiple logistic regression analysis showed that age, male sex, family history of diabetes, urban residence, abdominal obesity, generalised obesity, hypertension and income status were significantly associated with diabetes. Significant risk factors for prediabetes were age, family history of diabetes, abdominal obesity, hypertension and income status. CONCLUSIONS/INTERPRETATIONS: We estimate that, in 2011, Maharashtra will have 6 million individuals with diabetes and 9.2 million with prediabetes, Tamilnadu will have 4.8 million with diabetes and 3.9 million with prediabetes, Jharkhand will have 0.96 million with diabetes and 1.5 million with prediabetes, and Chandigarh will have 0.12 million with diabetes and 0.13 million with prediabetes. Projections for the whole of India would be 62.4 million people with diabetes and 77.2 million people with prediabetes.

Association of impaired cognitive functions with cardiovascular risk factors in elderly Indian population.

BACKGROUND: The prevalence of dementia is projected to rise dramatically in future with increasing life expectancy. Though dementia itself is not treatable in majority of cases, modification of co-morbid medical conditions may influence onset and rate of decline of cognitive functions. OBJECTIVE: To determine the prevalence of dementia in elderly by assessing cognitive function and to assess the association of cardiovascular risk factors with cognitive functions. STUDY DESIGN: Cross sectional analytical study. PARTICIPANTS: 400 consecutive elderly subjects > 65 years attending Geriatric OPD, Dept. of Medicine, Indira Gandhi Government Medical College, Nagpur, were recruited and assessed for cognitive functions by applying Mini Mental Status examination Score (MMSE). Relationships between cardiovascular risk factors and impaired cognitive score were determined. RESULTS: Prevalence of impaired cognitive function (MMSE Score < 25) was 33.25% (133 cases), while that of dementia (MMSE < 23) was 3.25 % (13 cases) in this elderly population. Impaired cognitive function was higher in those with low education and low socioeconomic status, (p = < 0.001). Increasing age, Female gender, alcohol intake and high cholesterol were found to be independently associated with impaired cognitive score in multiple logistic regression (p = < 0.001). Hypertension, diabetes mellitus, smoking and obesity were not associated with impaired cognitive score. CONCLUSION: Prevalence of cognitive impairment rises significantly as the age advances and is associated with alcohol intake and high cholesterol.

Effect of Tridax procumbens (Linn.) on bile duct ligation-induced liver fibrosis in rats.

The present study was undertaken to clarify whether methanolic extract of Tridax procumbens prevents liver fibrosis in rat. The hepatic fibrosis was induced by 28 days of bile duct ligation in rats. The 4-week treatment with Tridex procumbens reduced the serum aspartate aminotransferase (U L⁻¹), glutamate pyruvate transaminase (U L⁻¹), alkaline phosphatase (IU L⁻¹), lactate dehydrogenase (IU L⁻¹), total bilirubin (mg dL⁻¹), direct bilirubin (mg dL⁻¹) and hydroxyproline (mg gm⁻¹) content in liver and improved the histological appearance of liver section. The results of this study led us to conclude that T. procumbens can reduce the degree of hepatocellular damage and may become antifibrotic agent for liver fibrosis.

Double burden of underweight and overweight among children (10-19 years of age) of employees working in Indian industrial units.

BACKGROUND: Along with the existing problem of underweight, overweight in children is increasing in the developing world. However, there is little information on its magnitude and pattern in the Indian context. We aimed to study the pattern and correlates of overweight in Indian children and adolescents. METHODS: A total of 3750 children in the age group of 10-19 years, who were family members of randomly selected employees from 10 different industrial sites in India, were surveyed using an interviewer-administered questionnaire. RESULTS: The prevalence of underweight was highest in peri-urban areas (30.2% and 53.2% according to Indian and international criteria, respectively). In urban and highly urban areas, the prevalence of underweight was 14.1% and 9.8%, respectively, according to the Indian criteria, and 27.1% and 19.2%, respectively, according to international criteria. The proportion of overweight children was highest in the highly urban category (19.1% and 13.4% according to Indian and international criteria, respectively). The level of urbanization (OR 3.1 and 4.7 for overweight in urban and highly urban areas, respectively, compared with peri-urban areas, p < 0.001), physical activity (OR 0.4, p < 0.001, in children with physical activity score > or = 75th percentile compared with a score < or = 75th percentile) and frequency of meals outside the home (OR 12, p < 0.001, if > 25% weekly meals taken outside the home compared with < 25% of weekly meals outside home) were significant predictors of overweight. CONCLUSION: There is a double burden of underweight and overweight among Indian children and adolescents.

Simultaneous downregulation of CDK inhibitors p18(Ink4c) and p27(Kip1) is required for MEN2A-RET-mediated mitogenesis.

Multiple endocrine neoplasia type 2A (MEN2A) is predisposed by mutations in the RET proto-oncogene. Low expression of the cyclin-dependent kinase inhibitor (CDKI) p27(Kip1) is present in thyroid tumors, and recent evidence demonstrates p27 downregulation by the active RET mutant, RET/PTC1, found in papillary thyroid carcinoma. This implicates decreased p27 activity as an important event during thyroid tumorigenesis. However, p27(-/-) mice develop MEN-like tumors only in combination with loss of another CDKI, p18(Ink4c). This suggests that p18 and p27 functionally collaborate in suppression of tumorigenesis, that loss of both is critical in the development of MEN tumors and that both p18 and p27 are regulated by RET. We report that induction of the constitutively active MEN2A-specific RET mutant, RET2A(C634R), correlates with reduced p18/p27, and elevated cyclin D protein levels, leading to increased CDK activity, increased pRb phosphorylation and proliferation under growth arrest conditions. Mechanistically, RET2A represses p18/p27 mRNA levels while elevating cyclin D1 mRNA levels. RET2A expression also correlates with decreased p27 protein stability. RET2A-mediated regulation of p18 and p27, but not of cyclins D1 and D2, requires functional mitogen-activated protein kinase signaling. Additionally, RET2A-dependent p18 repression is required and sufficient to increase cell proliferation. Perhaps most significantly, MEN2A adrenal tumors also display these changes in cell cycle expression profile, demonstrating the biological relevance of our cell culture studies. Our results demonstrate for the first time that RET2A regulates p18, and suggest that loss of not only p27 but also of p18 expression is a key step in MEN tumorigenesis.

Methods for establishing a surveillance system for cardiovascular diseases in Indian industrial populations.

OBJECTIVE: To establish a surveillance network for cardiovascular diseases (CVD) risk factors in industrial settings and estimate the risk factor burden using standardized tools. METHODS: We conducted a baseline cross-sectional survey (as part of a CVD surveillance programme) of industrial populations from 10 companies across India, situated in close proximity to medical colleges that served as study centres. The study subjects were employees (selected by age and sex stratified random sampling) and their family members. Information on behavioural, clinical and biochemical determinants was obtained through standardized methods (questionnaires, clinical measurements and biochemical analysis). Data collation and analyses were done at the national coordinating centre. FINDINGS: We report the prevalence of CVD risk factors among individuals aged 20-69 years (n = 19 973 for the questionnaire survey, n = 10 442 for biochemical investigations); mean age was 40 years. The overall prevalence of most risk factors was high, with 50.9% of men and 51.9% of women being overweight, central obesity was observed among 30.9% of men and 32.8% of women, and 40.2% of men and 14.9% of women reported current tobacco use. Self-reported prevalence of diabetes (5.3%) and hypertension (10.9%) was lower than when measured clinically and biochemically (10.1% and 27.7%, respectively). There was marked heterogeneity in the prevalence of risk factors among the study centres. CONCLUSION: There is a high burden of CVD risk factors among industrial populations across India. The surveillance system can be used as a model for replication in India as well as other developing countries.

A rare case of human trypanosomiasis caused by Trypanosoma evansi.

Human trypanosoma infections like the ones seen in Africa and South America are unknown in India. The only exception in literature is of two documented cases of a self-limiting febrile illness, being attributed to Trypanosoma lewisi like parasites. We are reporting an unusual case of trypanosomiasis from the rural parts of Chandrapur district in Maharashtra. An adult male farmhand who used to practice veterinary medicine also, presented with history of febrile episodes on and off since five months and drowsiness before admission to this Institute. Though routine blood and other investigations were within normal limits, the peripheral smear showed a large number of trypanosomes which morphologically resembled the species Trypanosoma evansi, the aetiological agent of surra - a form of animal trypanosomiasis. A battery of assays covering the spectrum of parasitology, serology, and molecular biology confirmed the infecting parasite to be T. evansi. Failure to demonstrate the central nervous system (CNS) involvement, as evidenced by the absence of parasite in cerebrospinal fluid (CSF) advocated the use of suramin - the drug of choice in early stage African trypanosomiasis without any CNS involvement. Suramin achieved cure in our patient. The case is being reported because of its unique nature as the patient was not immunocompromised and showed infestation with a parasite which normally does not affect human beings.

Treatment and follow-up of the first case of human trypanosomiasis caused by Trypanosoma evansi in India.

The first reported human case of trypanosomiasis caused by Trypanosoma evansi was treated using suramin. Patient follow-up indicates that the drug and specific regimen used were well tolerated. Clinical, serological and parasitological investigations at 6 months indicate complete cure of the patient. Suramin should be considered in the treatment of other cases of human T. evansi infection, if they occur.

Effect of passive smoking on endothelial function in: healthy adults.

BACKGROUND: Active smoking predisposes to atherosclerotic vascular disease but recent evidence that inhalation of environmental tobacco smoke (passive smoking) may also have deleterious cardiovascular effects, has enormous public health implications. Endothelial dysfunction is an important early feature of atherogenic process, which may occur due to passive smoking. OBJECTIVE: To assess the effect of passive smoking on endothelial function (measured by flow-mediated dilatation, a marker of endothelium-dependent arterial dilatation) and compare it with non-smokers. STUDY DESIGN: Case control study. SETTING: Out-Patient Department of Medicine, Government Medical College, Nagpur. PARTICIPANTS: Seventy-five young, healthy, male adults between 15-30 years age were studied. There were three groups: (a) Non smokers (n = 25) (b) Passive smokers (n= 25) and (c) Active smokers (n = 25). Subjects with diabetes mellitus, hypertension and ischemic heart disease were excluded. Lipid profile was measured in all. Endothelial function was tested non-invasively by using high frequency linear vascular probe on brachial artery. Resting brachial artery lumen, flow at rest and after hyperemia, flow-mediated dilatation and nitroglycerine-induced dilatation were measured. RESULTS: The mean brachial artery lumen dilatation and flow at rest were similar in all the three groups. Flow-mediated dilatation (FMD%, a marker of endothelium-dependent dilatation and endothelial function) was significantly higher in non-smokers than passive smokers (8.9 +/- 4.8 Vs 5 +/- 2.3, p < 0.01) and also as compared with active smokers (8.9 +/- 4.8 Vs 6.6 +/- 2.2, p < 0.05). Nitroglycerine-induced dilatation, (a marker of endothelium-independent dilatation ) was similar in all the three groups. Serum lipids (mean cholesterol, LDL, and mean LDL/HDL ratio) were statistically significantly higher in passive and active smokers as compared with non-smokers (p < 0.05). CONCLUSION: Like active smoking, passive smoking was also associated with impaired endothelial function, (a key early event in atherogenesis) and altered lipid profile, in healthy young adults.

Reversible myocarditis in a patient receiving clozapine.

Myocarditis is a rare and potentially life-threatening complication of clozapine. We report the case of a 2 6-year-old patient who developed reversible myocarditis during treatment with clozapine for chronic resistant schizophrenia. The patient recovered rapidly on withdrawal of clozapine and with supportive management.

Factors precipitating congestive heart failure--role of patient non-compliance.

OBJECTIVE: This study was aimed to identify systematically the precipitating factors causing decompensation of heart failure and subsequent hospitalisation. We specially assessed the role of patient non-compliance with therapy as an important precipitating factor for heart failure, since it has not been systematically studied previously in an Indian setting where rheumatic heart disease is common. METHODS: In this cross-sectional analytical study, 125 cases of congestive heart failure hospitalized in Government Medical College, Nagpur, were studied. All the patients were thoroughly evaluated and investigated to identify the precipitating factors for heart failure. A patient was categorized as being non-compliant with therapy if he/she was consuming less than 80% prescribed drugs (assessed by pill count) or was non-compliant with dietary advice (assessed by an interviewer-administered questionnaire). RESULTS: Rheumatic heart disease was the commonest underlying heart disease (52.8%) followed by ischemic and/or hypertensive heart disease (27.2%). The most common precipitating factor was patient non-compliance with diet or drug therapy (49.6%) followed by arrhythmias (16.8%), uncontrolled hypertension (14.4%), infective endocarditis (13.6%), anemia (14.4%) and infections (11.2%). CONCLUSION: The results emphasize the importance of patient non-compliance with prescribed therapy as a leading precipitating factor for congestive heart failure in an Indian setting, which can be prevented by appropriate cost-effective strategies aimed to improve patient compliance.