A middle aged lady with recurrent low trauma fracture due to parathyroid adenoma.

A 48 year old lady was referred to BIRDEM Hospital, Dhaka, Bangladesh by her local physician for evaluation of hypercalcaemia and increased serum parathyroid hormone (PTH) in the background history of low trauma fracture. Ultrasound of neck and parathyroid scintigraphy with 99mTc-MIBI revealed a parathyroid adenoma. Parathyroidectomy was done. Histopathology report showed features consistent with parathyroid adenoma. Primary hyperparathyroidism should be kept in mind in all patients presenting with history of bone problems ranging from simple bone pain to spontaneous or low trauma fracture associated with hypercalcemia. By the help of appropriate localization technique it can be localized and cured by parathyriodectomy.

Clinical effectiveness and safety of vildagliptin in >19 000 patients with type 2 diabetes: the GUARD study.

The present GUARD study was a prospective, non-interventional study evaluating the clinical effectiveness, safety and tolerability of vildagliptin with or without metformin in adult patients with type 2 diabetes mellitus (T2DM) studied in routine clinical practice. Patients were enrolled from countries across four geographical regions. The primary endpoint was change in glycated haemoglobin (HbA1c) concentration from baseline after 24 weeks of treatment with vildagliptin with or without metformin. Of 19 331 patients analysed, 3511 received vildagliptin and 15 820 received vildagliptin plus metformin. At week 24, the mean HbA1c was reduced significantly from baseline by -1.27% (vildagliptin: -1.17%; vildagliptin plus metformin: -1.29%; p < 0.0001). Significant reductions in HbA1c from baseline were consistently reported regardless of patient age, body mass index (BMI) or baseline HbA1c. Weight and BMI were also significantly reduced from baseline. Vildagliptin treatment with or without metformin was generally well tolerated. It provided clinically relevant glycaemic and weight control, and was well tolerated in a large multi-ethnic population of patients with T2DM studied in routine clinical practice.

Clinical experience with BIAsp 30: Results from the Bangladesh cohort of the global A1chieve study.

The aim of A1chieve was to remedy the deficit of data on the efficacy and safety of insulin analogues in routine clinical care in less well-resourced developed countries. To present results from the Bangladesh cohort of the A1chieve study receiving BIAsp 30 ± oral anti diabetic drugs. A1chieve was a 6-month, observational study of 66,726 people with type 2 diabetes, started on insulin detemir, insulin aspart or biphasic insulin aspart (BIAsp 30) in 28 countries across four continents. A total of 1,093 subjects were recruited from 49 sites in Bangladesh and 580 subjects initiated on BIAsp 30 were studied. In the entire cohort, treatment with BIAsp 30 for 24 weeks significantly reduced mean HbA(1c) (2.8%, p < 0.001), fasting plasma glucose (4.0 mmol/L, p < 0.001) and post prandial plasma glucose (6.6 mmol/L, p < 0.001) levels from baseline. The rate of overall hypoglycaemic events in the entire cohort also reduced significantly at 24 weeks (1.86 to 0.02 events/person year, p < 0.0001). BIAsp 30 can be considered as a safe and effective option for initiating as well as intensifying insulin therapy for type 2 diabetes.

Androgen versus erythropoietin for the treatment of anaemia of pre-dialysis chronic kidney disease.

Chronic kidney disease is a microvascular complication of diabetes mellitus (DM). Anemia is an important clinical manifestation to treat chronic kidney disease. Many subjects with poor socio-economic status having chronic kidney disease (CKD) and anaemia in a developing country can not afford the treatment with erythropoietin. This study has designed to see the efficacy of Nandrolone, a cheaper alternative; in comparison with recombinant human erythropoietin for management of anemia of pre-dialysis diabetic chronic kidney disease. Sixty adult diabetic patients with anaemia of chronic kidney disease on conservative treatment [Not on Hemodialysis (HD)] were enrolled. Patients were divided into two groups (Group 1 and Group 2) of 30 patients each. Group 1 patients received nandrolone deaconate 50 mg deep intramuscular and Group 2 recombinant human erythropoietin 100 IU per kilogram of body weight subcutaneously once weekly. Patients of both group received oral supplements in order to maintain body iron stores. All the relevant haematological and renal parameters were evaluated at the end of 3rd & 6th months. There was a statistically significant rise in haemoglobin concentration, packed cell volume, in both groups. The rise in haemoglobin concentration, in Group 2 was more marked followed by Group 1, at the end of 3rd, and 6th months. Nandrolone, though not equally effective, may be considered as a valid alternative therapy for the treatment of anemia of pre-dialysis diabetic chronic kidney disease to that of erythropoietin.

Prevalence of diabetes among hypothyroid subjects.

Thyroid dysfunction affects a significant portion of the general population. Most studies have found a higher prevalence of hypothyroidism in women, increasing with age. Prevalence of hyperthyroidism has been found to range 0.5-3.0%. Type 2 diabetes is a major public health problem affecting approximately 4.8 percent of the Bangladeshi population. The study was designed to see the prevalence of type 2 diabetes in hypothyroid patients of any etiology. Four hundred forty two consecutive cases of diagnosed hypothyroidism were recruited in the study. All diagnosed hypothyroid subjects (sub-clinical or overt) reported in one year not known to be diabetic previously, underwent standard OGTT (FPG and 2-hour post 75 gram glucose) before initiation of thyroid hormone replacement. Newly detected diabetes among the subjects diagnosed as hypothyroidism is significantly higher 4.8 vs. 7.01% (p<0.01) and the prevalence of pre-diabetic state Impaired Glucose Tolerance (IGT) is also higher (11% vs. 12.6%) among hypothyroid subjects. Pure IFG (FPG ≥6.1 mmol/l but <7.0 mmol/l, and 2-PG <7.8 mmol/l) was found in 5.2% according to WHO criteria and the prevalence is higher (6.8%) with ADA criteria (considering normal FBG <5.6mmol/l). Diabetes was found in 7.01% among hypothyroid subjects which is higher than the existing known prevalence (4.8%). IGT was also found higher among hypothyroid subjects than population prevalence (8.6%). Further larger sample study is essential to establish the findings.

Practical management of diabetes during Ramadan fasting.

Diabetes mellitus is a global epidemic including Bangladesh. It is a chronic, costly and deadly disease. Recent advancement gives us the opportunity to control diabetes and offer the patient to have a normal or near normal life. Fasting during Ramadan is one of the five pillars of Islam. Recent studies show that most of the type-2 diabetic patients can fast during the holy month of Ramadan safely. But they need pre-Ramadan counseling for assessment, education, motivation, dietary and drug adjustment. Ramadan is beneficial for health. Fasting improves metabolic control, reduces weight and helps to control hypertension. Fasting also associated with some risks like-hypoglycemia, diabetic ketoacidosis, hyper osmolar non ketotic coma and dehydration. All of these risks can be significantly reduced by pre-Ramadan counseling. Those who are at very high risks of hypoglycemia and acute diabetic or other complications they should not fast. After recovery they should complete their fast with the consultation of Islamic scholars. If there is hypoglycemia while fasting, fast must be broken. Islam allows us to have a regular blood sugar test during fast. Patient should follow a highly individualized management plan. Close monitoring is essential to prevent complications for safe Ramadan.

Evaluation of management, control, complications and psychosocial aspects of diabetics in Bangladesh: DiabCare Bangladesh 2008.

DiabCare Bangladesh 2008 evaluated the current status of diabetes care in Bangladesh as a continuation of similar cross-sectional study conducted previously in 1998. The current study recruited 1952 patients from general hospitals, diabetes clinics and referral clinics to study current scenario of diabetes management from 01 March 2009 to 31 March 2009. We report the results of type 2 diabetic population who constituted 95.3% (n=1860). Results showed deteriorating glycaemic control with mean HbAlc of 8.6 +/- 2.0% with only 23.1% of the patients achieving American Diabetes Association (ADA) target of <7%. 896 (47.0%) patients were hypertensive and 850 (94.9%) were on antihypertensive medication. 70.8% of patients had LDL levels >2.6 mmol/L; 43.8% had triglycerides >2.2 mmol/L; 44.1% had HDL<1 mmol/L despite 48% of the patients being on lipid lowering agents. Microvascular, macrovascular and severe late complications were reported in 39.2%, 9.9% and 12.1% patients respectively. The rates of diabetic complications were cataract 12.9%, microalbuminuria 15.7%, neuropathy symptoms 31.7%, leg amputation 1.2% and history of angina pectoris was 6.6%. Quality of life evaluation showed that about half of patients have poor quality of life. Also, there was poor adherence to diet, exercise and self testing of blood glucose. In conclusion, majority of the patients were still not satisfactorily controlled. There is an urgent need for effective remedial measures to increase adherence to practice guidelines and to educate both patients and healthcare personnel on importance of achieving clinical targets for metabolic control.

Prevalence of diabetes and impaired fasting glucose in urban population of Bangladesh.

We investigated the prevalence of type 2 diabetes (T2DM) and impaired fasting glycemia (IFG) and their risk factors in the urban population of Bangladesh. The study was carried out in Dhaka City Corporation with a population of 99,12,908 in 20,89,336 households distributed in 95 wards. Using a multistage cluster sampling, we investigated 5265 eligible participants of 20 age years and above for height, weight, waist-girth, hip-girth, blood pressure and fasting blood glucose. Body mass index (BMI) and waist-to-hip ratio (WHR) were calculated. We used WHO diagnostic criteria of 1999. The overall prevalence of T2DM was 11.2% and IFG was 5.9%. The age-standardized prevalence of T2DM (95% CI) was 10.5% (9.37-11.13) and IFG was 5.2% (4.51-5.84). Compared with the slum dwellers, the non-slum dwellers had significantly higher prevalence of both T2DM (7.4 vs. 13.4%, p<0.001) and IFG (4.1 vs. 7.4%, p<0.001). Logistic regression analysis showed that family history of diabetes, higher family income, sedentary lifestyle and higher quartiles of age, BMI and WHR were significantly related to diabetes. The prevalence of diabetes in the urban population has increased alarmingly in recent years. Older age, obesity, higher income, family history of diabetes and reduced physical activity were proved to be the significant risk factors for diabetes and IFG.

Orlistat as an adjunct therapy in type 2 obese diabetic patients treated with sulphonylurea: a Bangladesh experience.

Co-existence of obesity and type 2 DM exacerbates metabolic and other remediable health consequences further. Various pharmacological therapies have been adopted when changing of lifestyle fail to achieve target glycaemic control. Our objective is to find out whether Orlistat can reduce both weight and need for oral hypoglycaemic agent (OHA) and improves glycaemic status,lipid disorders, blood pressure in Bangladesh type 2 DM with obesity. In this center, open-label, randomized, controlled pilot trial 36 type 2 patients with obesity were enrolled. All patients aged 40-65 years had BMI >25 kg/m2 taking sulfonylureas and hypocalorie diet. Twenty one randomly cases were treated with orlistat 120 mg three times daily for 6 months and 15 without orlistat as control. Body weight, waist circumferances, fasting blood sugar, HbAlc,serum lipids, blood pressure and dose of drugs were monitored at 0,12, 24 weeks. After 6 months, orlistat group showed non-significant weight loss than control group (3.95% vs 1.42% from base lines), but showed significant reduction of waist circumference (6 % vs 0.63 %, p<0.01 vs p>0.05 from base line). Orlistat group had significant improvement in glycaemic status (HbA1c changes: 22.37% vs 13.38%, p<0.001 vs p>0.05 and FBS changes: 21.76% vs 22.95%, p<0.01vs p<0.05). Lipid profile had reduced significantly from base lines (Chol: 19.31% vs 9.12%,p<0.001vs >0.05; LDL Chol: 24.99% vs 19.09%, p<0.001 vs p<0.01; Triglyceride: 34.48% vs 12.61%, p<0.001 vs p>0.05). Diastolic pressure had improved significantly in orlistat group (6.73% vs 3.70%, p<0.01 vs >0.05). Reduction of OHA doses were found in both groups. Thus orlistat can be used as an adjuvant therapy with other OHA in managing glycaemic control, lipid profiles and blood pressure.

Waist-to-height ratio is a better obesity index than body mass index and waist-to-hip ratio for predicting diabetes, hypertension and lipidemia.

Body mass index (BMI, kg/m.sq) and waist-to-hip ratio (WHR) are widely used as obesity indices for diabetes and cardiovascular risks. Lower adult height was related to diabetes and stroke. Waist-girth was proved important for visceral obesity. Incorporating waist-girth and height as waist-to-height ratio (WHtR), we reported earlier--"Waist-to-height ratio is an important predictor of hypertension and diabetes". We readdressed this index in a larger sample with two-sample OGTT and lipid profiles. In a cluster sampling of 16,818 rural inhabitants, considering age > or = 20 y, 5713 subjects were found eligible. Of them, 4923 (M/F=2321/2602) volunteered for height, weight, blood pressure, waist-girth and hip-girth. Fasting venous blood (5 ml) was drawn for plasma glucose, total cholesterol (T-chol), Triglycerides (TG) and high-density lipoprotien (HDL-c). Overall, 1565 participants were undertaken for OGTT. The mean (SD) values of BMI, WHR and WHtR for subjects with diabetes and hypertension were significantly higher in either sex. The level significance was highest for WHtR. The prevalence of diabetes and hypertension increased significantly with higher quintiles of BMI, WHR and WHtR (chi sq values were largest in WHtR for both events). Partial correlation coefficients, controlling for age and sex, showed that BMI, WHR and WHtR significantly correlated with systolic and diastolic BP, FBG, T-chol and TG. In the entire correlation matrix, the 'r' values were the highest for WHtR. Taking diabetes and hypertension as dependent variables, logistic regression also showed the highest odds ratio in higher WHtR than BMI and WHR. We conclude that WHtR was proved again a valuable obesity index for predicting diabetes, hypertension and lipidemia.

Diagnostic imaging modalities in parotid gland enlargement.

Twenty patients with various parotid gland enlargement were selected from outpatient dental clinic. The classical sign of the parotid enlargement is swelling which may by localized as inflammatory, cystic, neoplastic or associated with systemic diseases as diabetes mellitus, sjogren's syndrome and may occur after ingestion of certain drugs or metals. These heterogeneous pathological swellings have great morphological variation that need various diagnostic imaging modalities to be visualized. The favoured modality has been evolved from plain radiography, to sialography, scintigraphy, ultrasonography and to computed tomography. The application and limitation of each modality were presented.

Effect of GnRH agonists on the thymus in female rats.

The potential clinical applications of GnRH agonists are growing. We studied the effects of two GnRH agonists on the adult female rat thymus in 4 experiments. GnRH agonists administered sc and continuously significantly increased wet and dry thymic weights (absolute and relative). Thymic enlargement was related to the duration of treatment with GnRH agonists. The maximum increase in thymic weight occurred at approximately 18 days following initiation of treatment with GnRH agonists. Thymic enlargement does not appear to involve enhanced mitotic activity as measured by incorporation of tritiated thymidine into thymic tissue and thymic DNA. Histologic examination and computer-assisted morphometric analysis of thymuses indicated an increase in cortex to medulla ratio most pronounced at 10 and 18 days of GnRH agonist treatment. No consistent increases in splenic weight or bone marrow cell counts were observed. Thymosin alpha-1 but not thymosin beta-4 increased in GnRH agonist-treated rats. Thymic weight correlated negatively with ovarian and uterine weights, relative adrenal weight, serum estradiol, LH, and positively with thymosin alpha-1. Exogenous estrogen administration reversed GnRH agonist-induced thymic weight increase. Whether GnRH agonists have direct thymic effects remains to be determined.

Serodiagnosis of infectious mononucleosis with a bovine erythrocyte glycoprotein.

A glycoprotein from bovine erythrocyte membrane was evaluated in two immunoassays as a reagent for the serodiagnosis of infectious mononucleosis (IM). We previously reported that a partially purified preparation of this glycoprotein, when attached to latex beads, agglutinated in the presence of IM heterophile antibody. In the present study, we used a highly purified form of the glycoprotein both as an agglutinating reagent, covalently bound to latex, and in a solid-phase sandwich-type radioimmunoassay (RIA) for IM antibody detection in a larger population of patients. We tested serum samples from college students with symptoms suggestive of IM with the latex reagent (143 samples) and with the RIA (245 samples). Correlation of these two tests, both with each other and with the classical differentially absorbed, agglutination tests for Paul-Bunnell antibody in IM sera, using fresh sheep or horse cells, was excellent (greater than 97% agreement). The new tests also corresponded in most cases with a rapid, unabsorbed preserved horse erythrocyte slide test. However, in this study of 245 samples, both apparent false-positives (5 samples) and apparent false-negatives (3 samples) were observed with this slide test. In conclusion, we found that the bovine glycoprotein as a reagent can facilitate the diagnosis of IM, giving results comparable to those with erythrocyte agglutination tests on differentially absorbed sera. The advantages are ease and speed of performance (latex test), potential for automation (RIA test), stability and uniformity of the glycoprotein reagent (latex and RIA tests), and most importantly, the ability to use unabsorbed sera (latex and RIA tests).

Hypertension in the rural population of Bangladesh--a preliminary survey.

A total of 5,026 persons constituting 75% of the total population of a village of Bangladesh were screened for elevated blood pressure. Three hundred thirty seven (6.7%) showed diastolic blood pressure of 90 mm Hg or above. Those with diastolic blood pressure of 95 or above constituted 2% of the population. 74% of the hypertensives were asymptomatic while 86.3% of the cases were undetected and therefore remained untreated. Our findings indicate the need for early detection and control of elevated blood pressure to prevent complications. It is recommended that a large scale community survey programme may be undertaken for detection and early treatment of hypertension which helps prevention of total complications.

Immunochemical studies of infectious mononucleosis--XI. comparison of heterophile antibody inhibitors from the erythrocyte membranes of four mammalian species.

Immunochemical comparisons were made of the reactivity of membrane glycoproteins from horse, bovine, sheep and goat erythrocytes with heterophile antibodies of infectious mononucleosis. The four receptors were tested as competitive inhibitors of a sandwich-type solid-phase radioimmunoassay and of agglutination of glycoprotein-latex reagents by infectious mononucleosis serum. The results of this study showed that the bovine glycoprotein had a superior reactivity with this heterophile antibody system and sheep erythrocyte glycoprotein was the least reactive. The latter had negligible ability to displace 125I-bovine glycoprotein and was a very poor inhibitor of the agglutination of a bovine glycoprotein-latex reagent by infectious mononucleosis serum. Horse and goat glycoproteins were more efficient inhibitors than sheep glycoprotein but less active than the preparation from bovine red cells. All of the inhibitory activity of sheep, horse and goat glycoproteins, and a major portion of that of the bovine glycoprotein was destroyed by neuraminidase treatment. We have termed this receptor--shared by all four species--the Paul-Bunnell receptor, since by definition Paul-Bunnell antibody is a sheep erythrocyte agglutinin which is also reactive with horse, bovine and goat erythrocytes. The neuraminidase (and alkaline borohydride) resistant receptor of bovine glycoprotein has been designated the Bo receptor because it is not common to the other three species.

Immunochemical studies of infectious mononucleosis. VIII. A glycoprotein from sheep erythrocytes with sialic acid-dependent receptor properties.

A glycoprotein was solubilized from sheep erythrocyte membranes with hot aqueous ethanol. The glycoprotein was purified by phosphocellulose chromatography, ethanol precipitation, lipid solvent extraction, and DEAE chromatography. In water solution the glycoprotein existed as globular aggregates with a diameter of 7.1 +/- 2.2 nm. In the presence of sodium dodecyl sulfate, 80% of the material exhibited a subunit m.w.app of 27,000. Approximately 10% of the material had a m.w.app of only 9000 and another 10% had a m.w.app of 35,000. All three fractions were reactive with Paul-Bunnell heterophile antibody from the sera of patients with infectious mononucleosis and with Limulus polyphemus lectin. These activities were destroyed by neuraminidase treatment. Complete inhibition of the rosetting of sheep red blood cells by 4 X 10(5) human peripheral blood lymphocytes was seen at 100 to 200 micrograms glycoprotein/ml. Neuraminidase-treated glycoprotein was not inhibitory. Pronase-derived sialoglycopeptide was inhibitory. Most likely, the receptor for lymphocytes resides in the carbohydrate portion of the glycoprotein. By using 125I-glycoprotein, binding studies were carried out that yielded an estimate of approximately 2 X 10(5) binding sites for sheep erythrocyte glycoprotein per lymphocyte. Purified glycoprotein contained 44.4% amino acid. Carbohydrate components and their molar ratios were sialic acid (1.0): galactose (1.0):N-acetylglucosamine (1.3): N-acetylgalactosamine (1.2).

Evaluation of drug-antibody conjugates in the treatment of human myelosarcomas transplanted in nude mice.

Methotrexate, daunomycin, and chlorambucil were independently conjugated to immune goat gamma-globulins specifically raised to the Ph1 + chronic myelogenous leukemia cell line K-562. The drug-antibody conjugates were then tested against myelosarcomas made up of K-562 cells growing in nude mice and their efficacy was compared with that of the drug alone, gamma-globulins, a mixture of the two, or conjugates of drugs with normal goat gamma-globulin. Conjugation methods for methotrexate and daunomycin abrogate the antibody activity as indicated by the absence of complement-mediated cytotoxicity of the conjugates in vitro and the lack of effect on myelosarcomas in vivo. Simultaneous administration of either of these drugs and antibody partially abrogated the development of myelosarcomas. Chlorambucil-antibody conjugates, however, retained their cytotoxicity in vitro and were found effective in vivo. It is the first successful attempt to covalently bind chlorambucil to gamma-globulins without the loss of drug or antibody biological activity. Although the simultaneous administration of chlorambucil and gamma-globulins and conjugated drug gamma-globulins reduced the growth of myelosarcomas considerably, the immune gamma-globulins alone either reduced their weight to a larger degree or eliminated their growth completely. Results of this study indicate that myelosarcomas made up of K-562 cells grown in nude mice are good and reproducible models for testing various therapeutic agents. The advantage of using human cells proliferating in an in vivo environment brings experimental therapy one step closer to clinical trials.