Atin Kumar

CPAP for the Metabolic Syndrome in Patients with Obstructive Sleep Apnea

BACKGROUND Obstructive sleep apnea is associated with an increased prevalence of the metabolic syndrome and its components. It is unclear whether treatment of obstructive sleep apnea syndrome with continuous positive airway pressure (CPAP) would modify these outcomes. METHODS In our double-blind, placebo-controlled trial, we randomly assigned patients with obstructive sleep apnea syndrome to undergo 3 months of therapeutic CPAP followed by 3 months of sham CPAP, or vice versa, with a washout period of 1 month in between. Before and after each intervention, we obtained measurements of anthropometric variables, blood pressure, fasting blood glucose levels, insulin resistance (with the use of homeostasis model assessment), fasting blood lipid profile, glycated hemoglobin levels, carotid intima-media thickness, and visceral fat. The metabolic syndrome was defined according to National Cholesterol Education Program Adult Treatment Panel III criteria, with Asian cutoff values for abdominal obesity. RESULTS A total of 86 patients completed the study, 75 (87%) of whom had the metabolic syndrome. CPAP treatment (vs. sham CPAP) was associated with significant mean decreases in systolic blood pressure (3.9 mm Hg; 95% confidence interval [CI], 1.4 to 6.4; P=0.001), diastolic blood pressure (2.5 mm Hg; 95% CI, 0.9 to 4.1; P<0.001), serum total cholesterol (13.3 mg per deciliter; 95% CI, 5.3 to 21.3; P=0.005), non-high-density lipoprotein cholesterol (13.3 mg per deciliter; 95% CI, 4.8 to 21.8; P=0.009), low-density lipoprotein cholesterol (9.6 mg per deciliter; 95% CI, 2.5 to 16.7; P=0.008), triglycerides (18.7 mg per deciliter; 95% CI, 4.3 to 41.6; P=0.02), and glycated hemoglobin (0.2%; 95% CI, 0.1 to 0.4; P=0.003). The frequency of the metabolic syndrome was reduced after CPAP therapy (reversal found in 11 of 86 patients [13%] undergoing CPAP therapy vs. 1 of 86 [1%] undergoing sham CPAP). Accelerated hypertension developed 1 patient receiving CPAP therapy first, intolerance to CPAP developed in 2 others, and another patient declined to continue sham CPAP. CONCLUSIONS In patients with moderate-to-severe obstructive sleep apnea syndrome, 3 months of CPAP therapy lowers blood pressure and partially reverses metabolic abnormalities. (Funded by Pfizer; ClinicalTrials.gov number, NCT00694616.).

Prevalence of rheumatoid arthritis in the adult Indian population.

SummaryThe prevalence of rheumatoid arthritis was studied in the adult Indian population. As the first step, a house-to-house survey of a rural population near Delhi was conducted by two trained health workers. The target population comprised 44 551 adults (over 16 years old). The health workers identified the possible cases of rheumatoid arthritis (RA) using a questionnaire. These cases were then further evaluated by the authors using the 1987 revised ARA criteria for the diagnosis of RA. A response rate of 89.5% was obtained and 3393 persons were listed as possible cases of RA by the health workers. Of these, 299 satisfied the revised ARA criteria for the diagnosis of RA, giving a prevalence of 0.75%. Projected to the whole population, this would give a total of about seven million patients in India. The prevalence of RA in India is quite similar to that reported from the developed countries. It is higher than that reported from China, Indonesia, Philippines and rural Africa. These findings are in keeping with the fact that the north Indian population is genetically closer to the Caucasians than to other ethnic groups.

Whole-body MR imaging with the use of parallel imaging for detection of skeletal metastases in pediatric patients with small-cell neoplasms: comparison with skeletal scintigraphy and FDG PET/CT

BackgroundIn pediatric patients with small-cell tumors, there is an increasing demand for accurate and early detection of skeletal, especially bone marrow, metastases as new treatment protocols are introduced. Whole-body MR imaging (WB-MR) and 18F-fluorodeoxyglucose PET/CT (FDG PET/CT) are new promising imaging methods that can detect metastases before osteoblastic host response occurs, which is the basis for detection of metastases by skeletal scintigraphy (SSC).ObjectiveTo assess the ability of WB-MR to detect marrow metastases in children with small-cell neoplasms and compare its performance with that of FDG PET/CT and SSC.Materials and methodsDuring a 16-month period, 26 children and adolescents with histopathologically proven small-cell neoplasms underwent WB-MR, FDG PET/CT and Tc-phosphonate-based SSC in a random order within a 25-day period. Metastases were localized in relation to eight regions of the body.ResultsWB-MR revealed metastases in 39 out of a total of 208 regions in 26 patients (sensitivity 97.5%, specificity 99.4%, positive predictive value 97.5%, negative predictive value 99.4%), SSC in 12 regions (sensitivity 30%, specificity 99.4%, PPV 92.3%, NPV 85.6%) and FDG PET/CT in 36 regions (sensitivity 90.0%, specificity 100%, PPV 100%, NPV 97.7%). Both WB-MR and FDG PET/CT showed excellent agreement (kappa) with the final diagnosis (96.9% and 93.6% respectively), whereas SSC showed only moderate agreement (39.6%).ConclusionOur results suggest that WB-MR and FDG PET/CT studies are robust imaging modalities for screening for skeletal metastases, and are far more accurate than SSC. The lack of radiation is an additional advantage of WB-MR, especially in the pediatric population.

Survival in patients with systemic lupus erythematosus in India.

SummarySurvival in patients with systemic lupus erythematosus (SLE) in developed countries has improved considerably over the last 2 decades. In India, however, survival in patients with SLE reported 5 years ago from this tertiary referral centre was very poor. The present study was conducted to examine trends, if any, towards improvement in the survival of patients with SLE attending the same centre during the period 1981–1990. No statistically significant change in survival was noted. It appears that improvement in the survival of SLE patients would require an overall improvement in the standard of medical care in India.

Carcinoma of the Gallbladder: CT findings in 50 cases

Fifty patients with histologically proven carcinoma of the gallbladder were examined by computed tomography (CT). The gallbladder masses were categorized into two broad groups: group 1 (74%) included patients in whom the gallbladder was identified along with a mass lesion; and group 2 (26%), where a large mass was present in the gallbladder fossa with no identifiable gallbladder. Group 1 was further divided into three types according to the nature of the tumor: Type 1, mass almost filling the entire gallbladder lumen; Type 2, a polypoidal mass projecting into the lumen; type 3, an infiltrating tumor seen as focal or diffuse wall thickening. Liver involvement, in the form of localized invasion in the vicinity of the primary gallbladder malignancy, was the most common associated finding (80%). Other ancillary features included presence of calculi, lymphadenopathy, and biliary obstruction. CT was found useful for characterizing and defining the extent of carcinoma of the gallbladder. However, it may not consistently demonstrate involvement of the gastrointestinal tract, omentum, and abdominal wall. CT can also be used for aspiration/biopsy guidance of the gallbladder mass in selected cases.

Long-term outcome of undifferentiated spondylarthropathy.

Undifferentiated spondylarthropathy is one of the common disease subsets in the group of so-called seronegative spondarthritides. It is not exactly known how often it differentiates into ankylosing spondylitis or other well-defined disease subsets over time. The present study was designed to find out the long-term outcome in this subset. Thirty-five patients diagnosed with undifferentiated spondylarthropathy between January 1987 and December 1988 were recruited. Twenty-two (63%) of them were available for detailed assessment 11 years after the original diagnosis. Their baseline characteristics did not differ from those of the original cohort of 35 patients and were as follows: male:female ratio 19:3, median age of onset 17 years (range 8–39), and median duration of disease 8 months (range 4–24). Clinical features were enthesitis (45%) and inflammatory pain in the back (100%), buttock (77%), hip (64%), shoulder (18%), knee (82%), ankle (77%), and hand and wrists (50%). There was no restriction in spinal movement. Family history was positive in two cases. Radiologically, the only finding was grade I sacroiliitis in 17 patients (77%). Human leukocyte antigen (HLA)-B27 was positive in all. Functionally, all were in class I. During follow-up, one patient developed psoriatic skin lesions after 9 years. Uveitis developed in four patients (18%). After a median follow-up of 11 years, 15 (68%) had ankylosing spondylitis, one developed psoriatic arthritis, four remained undifferentiated, and two had natural remission. Functionally, 19 patients (86%) were in class I and three (14%) were in class III. No patient had bamboo spine, but three underwent total hip replacement. Thus, a majority of patients (68%) with undifferentiated spondylarthropathy gradually developed ankylosing spondylitis of mild severity.

Imaging in bronchopulmonary sequestration

Bronchopulmonary sequestration is an uncommon pulmonary disorder characterized by an area of non‐functioning abnormal lung tissue, which receives its blood supply from a systemic artery and characteristically has no connection with the tracheobronchial tree. The abnormal lung tissue is located within the visceral pleura of a pulmonary lobe in the intralobar variety, whereas the extralobar form has its own visceral pleura. The venous drainage of the extralobar type is usually into the systemic veins, whereas the intralobar type drains into the pulmonary veins. Radiological imaging plays a vital role in establishing the diagnosis, and even more importantly, in providing to the clinician a vascular roadmap essential for surgical planning. We present here a review of bronchopulmonary sequestration and also discuss the role of various imaging methods in the early diagnosis and management of these cases.

F-18 FDG PET-CT in patients with recurrent glioma: Comparison with contrast enhanced MRI

PURPOSE The purpose of the study was to compare the efficacies of FDG PET-CT and contrast enhanced MRI in detection of recurrent gliomas. METHODS Ninety histopathologically proven glioma patients with clinical suspicion of recurrence were evaluated. All patients underwent FDG PET-CT scan and contrast enhanced MRI. Combination of clinical follow up, repeat imaging and biopsy (when available) was taken as gold standard. RESULTS Based on gold standard criteria, 59 patients were positive and 31 patients were negative for recurrence. Overall sensitivity and specificity of FDG PET-CT were 70% and 97% respectively whereas that for contrast enhanced MRI was 95% and 23%. FDG PET-CT also has higher accuracy (80%) as compared to MRI (70%). FGD PET-CT has lower sensitivity than MRI in all grades, except for Grade II gliomas where their sensitivities are comparable (95% and 90%). Very low specificity of MRI was observed in all grades of tumour (18-33%). In contrast the specificity of FDG PET-CT was high across all grades (83-100%). CONCLUSION FDG PET-CT is a highly specific modality for detecting recurrence in patients with gliomas and can effectively exclude post therapy changes.

Intravenous dexamethasone pulse therapy in diffuse systemic sclerosis

Thirty-five patients with diffuse systemic sclerosis were studied in a randomized, placebo-controlled, double-blind study. Seventeen patients received intravenous dexamethasone “pulse” therapy, while 18 patients received placebo. Each “pulse” consisted of 100 mg dexamethasone in 250 ml 5% dextrose infused intravenously over 1 h. Pulse therapy was repeated every month for 6 months. Assessment of disease status with various parameters was done at entry and at completion of trial, i.e. after 6 months. Significant improvement in skin involvement was seen in the study group, with the total skin score (TSS) decreasing from 28.5±12.2 to 25.8±12.8, while in the control group, TSS increased from 30.6±13.2 to 34.7±10. Similarly, significant improvement was noted in the flexion index. Other parametres that included extension index, maximum oral opening, range of movement of joints, functional disability score, Raynauds phenomenon (frequency and duration), ESR, proteinuria, chest X-ray, ECG, lung function tests, barium swallow and antinuclear antibody were unchanged. Adverse effects of therapy were limited to an increased incidence of minor chest infections. It is concluded that intravenous pulse dexamethasone may be useful in the treatment of diffuse systemic sclerosis.

Ultrasound guided aspiration of endometrioma: a new therapeutic modality to improve reproductive outcome

Objective: To evaluate the therapeutic efficacy and reproductive outcome following ultrasound guided aspiration (UGA) of endometrioma in infertile patients. Method: This is a prospective non‐randomized clinical report of UGA in 22 infertile patients with endometrioma. The aspiration of endometriotic cysts was carried out transvaginally in nine and transabdominally in 13 patients. Following aspiration intranasal buserilin was given to eight and danazol to 14 patients. In the case of recurrence a reaspiration was done. Patients were allowed to conceive following medical therapy. Recurrence of endometrioma and conception rate was recorded and correlated with endometrioma size and volume aspirated. Result: A total of 47 aspirations were done. There were no procedure related complications. Reaspiration was required in six patients and one was operated (total recurrence 7/22 — 31.8%). During a mean follow‐up of 20±8.4 months nine patients (40.9%) conceived and eight have already delivered at term. The recurrence risk and the conception rate was not affected by the cyst size or volume aspirated. Conclusion: UGA of endometrioma can be an effective and safe alternative therapeutic procedure in infertile patients with endometrioma to improve their reproductive outcome.