INTRODUCTION: Diabetic Ketoacidosis (DKA) is a metabolic state developing in diabetic patients whenever a stressor shifts the metabolism towards ketogenesis with resultant metabolic acidosis. Common ...stressors for DKA are infections and medication non-compliance. We present a peculiar case of DKA which was precipitated by thyrotoxicosis. CASE DESCRIPTION: 32-year-old female with past medical history of Type 1 Diabetes Mellitus presented for evaluation of nausea, vomiting and chest pain. She reported as being compliant with her insulin regimen. Physical examination showed rapid breathing and acetone breath. Initial blood tests revealed elevated blood sugars at 745 MG/DL with a high anion gap metabolic acidosis. Beta hydroxybutyrate levels were elevated suggesting diabetic ketoacidosis. Rest of the workup to identify the precipitating cause, including urinalysis, EKG, Chest X ray had been negative. Another striking feature noted on patient's examination was bilateral exophthalmos. No thyroid enlargement was appreciated. A thyroid function panel was ordered which demonstrated elevated free T4 at 3.42 NG/DL (normal range 0.7-1.9 NG/DL), T3 at 26.01 PG/ML (normal range 1.7-3.71 PG/ML) and a depressed TSH level <0.01 mcIU/mL (normal range 0.35-.5 mcIU/ml) suggesting primary hyperthyroidism. Our patient improved upon administration of IV fluids and insulin with resultant closure of anion gap and resolution of DKA. Tachycardia persisted despite the resolution of DKA. Treatment was begun with propylthiouracil and propranolol to control thyrotoxicosis with remarkable improvement at the time of discharge. DISCUSSION: Treatment of Diabetic Ketoacidosis requires a thorough investigation of the precipitating event. In clinical practice, the most common triggers are noted to be infections like pneumonia and urinary tract infections, missed or inadequate insulin dose and myocardial infarction. Hyperthyroidism is rarely considered as a culprit for the same. In literature, there is only mention of few cases of hyperthyroidism causing DKA. Hyperthyroidism affects glucose and insulin metabolism in multiple ways. In untreated hyperthyroidism, proinsulin processing becomes abnormal resulting in a reduced C peptide to pro insulin ratio. Hyperthyroidism also leads to increased glucose absorption in the intestinal tract. Lastly, excessive thyroid hormone activity reduces the half-life of insulin via increased degradation into biologically inactive molecules. Our case emphasizes the need to consider thyrotoxicosis as an independent risk factor for development of DKA in appropriate clinical settings, especially when tachycardia persists despite resolution of DKA and infection has been ruled out. Women with Type 1 Diabetes have been found to have a higher prevalence of Graves’ disease. Correction of underlying hyperthyroidism decreases the insulin requirements in these patients.
Plaque‐like myofibroblastic tumor is a rare and benign pediatric soft tissue tumor. It presents as a slowly growing plaque reaching several centimeters in diameter, made up of multiple nodules. The ...clinical and histological features of this benign entity are similar to other fibrohistiocytic or myofibroblastic tumors occurring in childhood, so the diagnosis can be difficult. The correlation between clinical data, histopathology, and immunohistochemistry is necessary for the correct diagnosis.
Background: Chronic pancreatitis is a heterogeneous disease. More research efforts are needed to clarify further whether individuals with chronic pain due to pancreatitis report a poor quality of ...life that necessitates intervention services. In this study, we sought to ascertain the clinical profile of subjects with chronic pancreatitis in India, especially with regard to risk factors, clinical features and therapeutic modalities.Methods: 50 patients of chronic pancreatitis were studied, both prospectively and retrospective. Investigations and interventions details were noted. Questionnaire for pain scoring was prepared. Persistent pain or recurrent episodes of acute pain interfering with normal lifestyle were the criteria for intervention.Results: The most common symptom of chronic pancreatitis is long-standing pain in the middle of the abdomen. 25 patients underwent intervention in view of severe pain. In our study improvement in endocrine function after intervention was observed in 27% of patients and improvement in exocrine function was seen in 60% patients after intervention at 2 yearly follow up.Conclusions: Surgical method and ERCP guided intervention gives superior results as compared to conservative method in management of chronic pancreatitis.
Nontuberculous mycobacteria (NTM) are environmental organisms that can cause opportunistic pulmonary disease with species diversity showing significant regional variation. In the United States, ...Hawai'i shows the highest rate of NTM pulmonary disease. The need for improved understanding of NTM reservoirs led us to identify NTM from patient respiratory specimens and compare NTM diversity between outdoor and indoor locations in Hawai'i. A total of 545 water biofilm samples were collected from 357 unique locations across Kaua'i (
= 51), O'ahu (
= 202), Maui (
= 159), and Hawai'i Island (
= 133) and divided into outdoor (
= 179) or indoor (
= 366) categories.
sequence analysis was used to determine NTM species and predictive modeling applied to develop NTM risk maps based on geographic characteristics between environments.
was frequently identified from respiratory and environmental samples followed by
and
yet significantly less NTM were consistently recovered from outdoor compared to indoor biofilms, as exemplified by showerhead biofilm samples. While the frequency of
recovery was comparable between outdoor and indoor showerhead biofilms, phylogenetic analyses demonstrate similar
gene sequences between all showerhead and respiratory
isolates, supporting outdoor and indoor environments as possible sources for pulmonary
infections.
Objectives
To assess change in functional outcomes after a second focal high‐intensity focused ultrasonography (HIFU) treatment compared with outcomes after one focal HIFU treatment.
Patients and ...Methods
In this multicentre study (2005–2016), 821 men underwent focal HIFU for localized non‐metastatic prostate cancer. The patient‐reported outcome measures of International Prostate Symptom Score (IPSS), pad usage and erectile function (EF) score were prospectively collected for up to 3 years. To be included in the study, completion of at least one follow‐up questionnaire was required. The primary outcome was comparison of change in functional outcomes between baseline and follow‐up after one focal HIFU procedure vs after a second focal HIFU procedure, using IPSS, Expanded Prostate Cancer Index Composite (EPIC) and International Index of Erectile Function (IIEF) questionnaires.
Results
Of 821 men, 654 underwent one focal HIFU procedure and 167 underwent a second focal HIFU procedure. A total of 355 (54.3%) men undergoing one focal HIFU procedure and 65 (38.9%) with a second focal HIFU procedure returned follow‐up questionnaires, respectively. The mean age and prostate‐specific antigen level were 66.4 and 65.6 years, and 7.9 and 8.4 ng/mL, respectively. After one focal HIFU treatment, the mean change in IPSS was −0.03 (P = 0.02) and in IIEF (EF score) it was −0.4 (P = 0.02) at 1–2 years, with no subsequent decline. Absolute rates of erectile dysfunction increased from 9.9% to 20.8% (P = 0.08), leak‐free continence decreased from 77.9% to 72.8% (P = 0.06) and pad‐free continence from 98.6% to 94.8% (P = 0.07) at 1–2 years, respectively. IPSS prior to second focal HIFU treatment compared to baseline IPSS prior to first focal HIFU treatment was lower by −1.3 (P = 0.02), but mean IPSS change was +1.4 at 1–2 years (P = 0.03) and +1.2 at 2–3 years (P = 0.003) after the second focal HIFU treatment. The mean change in EF score after the second focal HIFU treatment was −0.2 at 1–2 years (P = 0.60) and −0.5 at 2–3 years (P = 0.10), with 17.8% and 6.2% of men with new erectile dysfunction. The rate of new pad use was 1.8% at 1–2 years and 2.6% at 2–3 years.
Conclusion
A second focal HIFU procedure causes minor detrimental effects on urinary function and EF. These data can be used to counsel patients with non‐metastatic prostate cancer prior to considering HIFU therapy.
Metal-on-metal prostheses undergo wear and corrosion, releasing soluble ions and wear particles into the surrounding environment. Reports described early failures of the metal-on-metal prostheses, ...with histologic features similar to a Type IV immune response. Mechanisms by which metal wear products and metal ion causing this reaction are not completely understood, and the effects of metal ions on osteocytes, which represent more than 95% of all the bone cells, have not been also studied. We hypothesized that soluble metal ions released from the cobalt-chromium-molybdenum (Co-Cr-Mo) prosthesis may have cytotoxic effect on osteocytes.
MLO-Y4 osteocytes were treated with various metal ion solutions for 24 and 48 h. The effect of ion treatment on cytotoxicity was assessed by WST-1 reagents and cell death ELISA. Morphological changes were analyzed by a phase-contrast microscope or fluorescent microscope using Hoechst 33342 and propidium iodine staining.
Cr and Mo ions did not cause cell death under 0.50 mM, highest concentration studied, whereas Co and Ni ions had significant cytotoxic effect on MLO-Y4 cells at concentrations grater than 0.10 mM and at 0.50 mM, respectively, in a dose-dependent manner. According to the ELISA data, osteocytes treated with Co ions were more susceptible to necrotic than apoptotic cell death, while Ni ions caused osteocyte apoptosis. The morphological assays show that cells treated with Co and Ni ions at high concentration were fewer in number and rounded. In addition, fluorescent images showed a marked reduction in live cells and an increase in dead osteocytes treated with Co and Ni ions at high concentration.
Metal ions released from metal-on-metal bearing surfaces have potentially cytotoxic effects on MLO-Y4 osteocytes, in vitro.
The present paper investigated and analyzed swirler material consisting of mild steel which was subjected to service for the period of one year in a 30 MW marine boiler. Due to the presence of high ...temperatures in the furnace coupled with the corrosive marine environment swirler material showed accelerated degradation and material wastage. An investigation into the feasibility of manufacturing the existing swirler with an alternate material or coating the swirler material with a thermal barrier coating was undertaken. Based on their properties and performance, SS 304 and SS 316 were proposed as the replacement materials for the swirler. The other alternative of coating the existing swirlers with a form thermal barrier coating to observe for any improvement in their performance at elevated temperatures was also tested. Stellite, which is a Ni-Co based coating, was carried out on the MS samples and the same were exposed to same temperatures mentioned above. The performance of the available options was evaluated with respect to the grain structure of the material, the hardness value of the materials and deterioration at elevated temperatures. Investigation showed the proposed materials/ coatings like SS 304, SS 316 and Stellite coating revealed that SS 316 is the material best suited for high temperature application.
Patients who are being investigated for recurrent prostate cancer after previous radiotherapy should undergo prostate magnetic resonance imaging (MRI) with both systematic and MRI-targeted biopsies ...to optimise cancer detection. Subsequent treatment with focal ablation offers a means for cancer control while preserving urinary continence in the majority of patients.
Recurrent prostate cancer after radiotherapy occurs in one in five patients. The efficacy of prostate magnetic resonance imaging (MRI) in recurrent cancer has not been established. Furthermore, high-quality data on new minimally invasive salvage focal ablative treatments are needed.
To evaluate the role of prostate MRI in detection of prostate cancer recurring after radiotherapy and the role of salvage focal ablation in treating recurrent disease.
The FORECAST trial was both a paired-cohort diagnostic study evaluating prostate multiparametric MRI (mpMRI) and MRI-targeted biopsies in the detection of recurrent cancer and a cohort study evaluating focal ablation at six UK centres. A total of 181 patients were recruited, with 155 included in the MRI analysis and 93 in the focal ablation analysis.
Patients underwent choline positron emission tomography/computed tomography and a bone scan, followed by prostate mpMRI and MRI-targeted and transperineal template-mapping (TTPM) biopsies. MRI was reported blind to other tests. Those eligible underwent subsequent focal ablation. An amendment in December 2014 permitted focal ablation in patients with metastases.
Primary outcomes were the sensitivity of MRI and MRI-targeted biopsies for cancer detection, and urinary incontinence after focal ablation. A key secondary outcome was progression-free survival (PFS).
Staging whole-body imaging revealed localised cancer in 128 patients (71%), with involvement of pelvic nodes only in 13 (7%) and metastases in 38 (21%). The sensitivity of MRI-targeted biopsy was 92% (95% confidence interval CI 83–97%). The specificity and positive and negative predictive values were 75% (95% CI 45–92%), 94% (95% CI 86–98%), and 65% (95% CI 38–86%), respectively. Four cancer (6%) were missed by TTPM biopsy and six (8%) were missed by MRI-targeted biopsy. The overall MRI sensitivity for detection of any cancer was 94% (95% CI 88–98%). The specificity and positive and negative predictive values were 18% (95% CI 7–35%), 80% (95% CI 73–87%), and 46% (95% CI 19–75%), respectively. Among 93 patients undergoing focal ablation, urinary incontinence occurred in 15 (16%) and five (5%) had a grade ≥3 adverse event, with no rectal injuries. Median follow-up was 27 mo (interquartile range 18–36); overall PFS was 66% (interquartile range 54–75%) at 24 mo.
Patients should undergo prostate MRI with both systematic and targeted biopsies to optimise cancer detection. Focal ablation for areas of intraprostatic recurrence preserves continence in the majority, with good early cancer control.
We investigated the role of magnetic resonance imaging (MRI) scans of the prostate and MRI-targeted biopsies in outcomes after cancer-targeted high-intensity ultrasound or cryotherapy in patients with recurrent cancer after radiotherapy. Our findings show that these patients should undergo prostate MRI with both systematic and targeted biopsies and then ablative treatment focused on areas of recurrent cancer to preserve their quality of life.
This trial is registered at ClinicalTrials.gov as NCT01883128.
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