Suja Sukumar

The microbiology of diabetic foot infections in patients recently treated with antibiotic therapy: A prospective study from India

AIM Clinicians often treat clinically infected diabetic foot ulcers without information from cultures of the wound. The results of wound cultures may also be affected by previous antibiotic therapy. Thus, we aimed to study the microbial isolates, and antimicrobial sensitivity of previously treated patients with a clinically infected DFU. RESEARCH DESIGN AND METHODS 293 consecutive patients with clinically infected DFU on prior antimicrobial treatment within the immediate past few days for a duration greater than one week were evaluated for microbial etiology, antibiotic sensitivity and final outcomes. Appropriate tissue samples i.e. purulent drainage, soft-tissue and/ or bone were obtained for aerobic/anaerobic cultures and antimicrobial sensitivities. 71 patients with missing prior antibiotic data were excluded. RESULTS 313 tissue samples obtained from 222 patients isolated 317 causative organisms. Most of the culture results from tissue specimens were mono-microbial (93.2%) compared to 37% in our previous cohort of 60 patients. Pseudomonas aeruginosa was the most common organism isolated on culture of bone (26.9%) or soft tissue (23.2%) specimen, respectively. Only 23% and 64% of P. aeruginosa isolates and 5.6% and 44% of Acinetobacter sp. were sensitive to quinolones and cephalosporins, respectively. CONCLUSIONS Clinically infected DFU recently treated with antibiotics have predominant monomicrobial and multi drug-resistant infection. Quinolones as an empirical antibiotic choice may not be appropriate in this setting.

Zebra lines in osteogenesis imperfecta on bisphosphonate therapy

A 7-year-old girl presented with a history of recurrent fractures since the age of 1 month. She was born out of a non-consanguineous marriage and had short stature with macrocephaly and triangular facies. Her sclera and teeth were normal. She did not have any hearing defect or a family history of frequent fractures. Her biochemical metabolic profile was normal except for vitamin D deficiency which was corrected. She was provisionally …

Acute lymphocytic leukaemia presenting as a metabolic bone disease

A 7-year-old boy presented with the acute onset of low backache of 2 months duration. An x-ray of thoracolumbar spine revealed multiple vertebral fractures, and biochemical evaluation showed hypercalcaemia with a suppressed parathyroid hormone which raised the possibilities of malignancy, granulomatous conditions or vitamin D toxicity. Despite the absence of blast cells in his blood, the bone marrow biopsy was unequivocally diagnostic of acute lymphoblastic leukaemia.

Maternal Mild Thyroid Insufficiency and Risk of Attention Deficit Hyperactivity Disorder: Evidence-based Medicine Viewpoint.

SummaryThis study was embedded within the Generation R, a population-based birth cohort in the Netherlands where children were followed up from birth until young adulthood. Of the 4997 eligible mother-child pairs with data on maternal thyroid levels (excluding twins), 3873 pairs of children and caregivers (77.5%) were included in the main analyses. Maternal hypothyroxinemia, characterized by low levels of free thyroxine coexisting with reference thyrotropin levels, and children’s symptoms of attention-deficit hyperactivity disorder (ADHD) were the main outcome measures. Maternal thyroid hormone levels (thyrotropin, free thyroxine, thyroid peroxidase antibodies) were measured at a mean (SD) of 13.6 (1.9) weeks of gestation. Children’s ADHD symptoms were assessed at 8 years of age using the Conners’ Parent Rating Scale-Revised Short Form; higher scores indicate more ADHD symptoms (possible range, 0–36). Maternal hypothyroxinemia (n=127) in early pregnancy was associated with higher scores for ADHD symptoms in children at 8 years of age after adjustments for child and maternal factors (increase in ADHD scores, 7% [95% CI, 0.3%, 15%]). The results remained essentially unchanged when women with elevated levels of thyroid peroxidase antibodies were excluded. The authors concluded that children exposed to maternal hypothyroxinemia in early pregnancy had more ADHD symptoms, independent of confounders. This finding suggests that intrauterine exposure to insufficient thyroid hormone levels influences neurodevelopment in offspring.

UTILITY OF A SINGLE LATE-NIGHT PLASMA CORTISOL AND ACTH FOR THE DIAGNOSIS OF CUSHING SYNDROME

OBJECTIVE To evaluate the diagnostic efficacy of various screening tests for the diagnosis of Cushing syndrome (CS). METHODS Thirty-five patients with CS and 16 patients of pseudo-CS were enrolled. Assessment of 24-h urinary free cortisol (UFC), late-night salivary cortisol (LNSC), overnight dexamethasone suppression test (ONDST), late-night plasma cortisol (LNPC), and adrenocorticotropic hormone (ACTH) on outpatient basis, and during sleep as well as in awake state after 48 hours of hospital admission. RESULTS We found that 24-h UFC performed the best among the screening tests with sensitivity, specificity and areas under the curve (AUCs) of 96.0%, 99%, and 0.988, respectively, at a cut-off of 144.6 μg/24 h. A cut-off of 10.5 nmol/L for LNSC had sensitivity 85.7%, specificity 88.2%, and an AUC of 0.897. A cut-off of 412.4 nmol/L for LNPC on outpatient basis had sensitivity 88.2%, specificity 91.2%, and an AUC of 0.957. Cut-offs of 215 and 243.3 nmol/L for LNPC during sleep and awake states after acclimatization had sensitivity, specificity, and an AUC of 94.1%, 88.2%, and 0.958, respectively. An ONDST cut-off of 94.6 nmol/L provided sensitivity, specificity, and an AUC of 96.0%, 99.03% and 0.995, respectively. A cut-off of 30.3 pg/mL for late-night ACTH on outpatient basis had sensitivity 67.6%, specificity 99.9%, and an AUC 0.796.A cut-off of 22.6 pg/mL for ACTH during sleep state after acclimatization had sensitivity, specificity, and an AUC of 73.5%, 99.2%, and 0.827, respectively. CONCLUSION UFC is the best screening test for CS. Furthermore, single measurements of LNPC and ACTH help to establish the diagnosis and ACTH dependency of CS in the majority of patients with CS. ABBREVIATIONS ACTH = adrenocorticotropic hormone AUC = area under the curve CRH = corticotropin-releasing hormone CS = Cushing syndrome ECLIA = electrochemiluminescence immuno-assay LDDST = low-dose dexamethasone suppression test LNPC = late-night plasma cortisol LNSC = late-night salivary cortisol ONDST = overnight dexamethasone suppression test RIA = radio-immuno assay UFC = urinary free cortisol.

Diagnostic utility of testosterone priming prior to dynamic tests to differentiate constitutional delay in puberty from isolated hypogonadotropic hypogonadism

Differentiation between constitutional delay in puberty (CDP) and isolated hypogonadotropic hypogonadism (IHH) during adolescence is a great clinical challenge, and the available diagnostic tests are of limited value.

Rat bite ulcer in an insensate foot

A 60-year-old man, a known case of type 2 diabetes mellitus for the past 20 years noticed sudden development of an ulcer on the plantar aspect of both great toes on waking up in the morning. The patient had examined his feet the previous night and it was free from any fissures, callosities or ulcers. There was no previous history of diabetic foot ulcer. The ulcer on right great toe was 3×2 cm, …