Secret History: Return of the Black Death Channel 4, 7-8pm In 1348 the Black Death swept through London, killing people within days of the appearance of their first symptoms. Exactly how many died, and why, has long been a mystery. This Secret History documentary follows experts as they pick through the evidence and reveal why the plague killed on such a scale. And they ask, what might be coming next?

Medscape

Vitamin B12 deficiency.

Importance Psychiatric reactions to life stressors are common in the general population and may result in immune dysfunction. Whether such reactions contribute to the risk of autoimmune disease remains unclear. Objective To determine whether there is an association between stress-related disorders and subsequent autoimmune disease. Design, Setting, and Participants Population- and sibling-matched retrospective cohort study conducted in Sweden from January 1, 1981, to December 31, 2013. The cohort included 106 464 exposed patients with stress-related disorders, with 1 064 640 matched unexposed persons and 126 652 full siblings of these patients. Exposures Diagnosis of stress-related disorders, ie, posttraumatic stress disorder, acute stress reaction, adjustment disorder, and other stress reactions. Main Outcomes and Measures Stress-related disorder and autoimmune diseases were identified through the National Patient Register. The Cox model was used to estimate hazard ratios (HRs) with 95% CIs of 41 autoimmune diseases beyond 1 year after the diagnosis of stress-related disorders, controlling for multiple risk factors. Results The median age at diagnosis of stress-related disorders was 41 years (interquartile range, 33-50 years) and 40% of the exposed patients were male. During a mean follow-up of 10 years, the incidence rate of autoimmune diseases was 9.1, 6.0, and 6.5 per 1000 person-years among the exposed, matched unexposed, and sibling cohorts, respectively (absolute rate difference, 3.12 [95% CI, 2.99-3.25] and 2.49 [95% CI, 2.23-2.76] per 1000 person-years compared with the population- and sibling-based reference groups, respectively). Compared with the unexposed population, patients with stress-related disorders were at increased risk of autoimmune disease (HR, 1.36 [95% CI, 1.33-1.40]). The HRs for patients with posttraumatic stress disorder were 1.46 (95% CI, 1.32-1.61) for any and 2.29 (95% CI, 1.72-3.04) for multiple (≥3) autoimmune diseases. These associations were consistent in the sibling-based comparison. Relative risk elevations were more pronounced among younger patients (HR, 1.48 [95% CI, 1.42-1.55]; 1.41 [95% CI, 1.33-1.48]; 1.31 [95% CI, 1.24-1.37]; and 1.23 [95% CI, 1.17-1.30] for age at ≤33, 34-41, 42-50, and ≥51 years, respectively;Pfor interaction  Conclusions and Relevance In this Swedish cohort, exposure to a stress-related disorder was significantly associated with increased risk of subsequent autoimmune disease, compared with matched unexposed individuals and with full siblings. Further studies are needed to better understand the underlying mechanisms.

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Association of Stress-Related Disorders With Subsequent Autoimmune Disease.

Objectives To examine four key areas: (1) the effectiveness and cost-effectiveness of spinal fixation surgery, (2) the consequences of immediate versus delayed referral to a spinal injuries unit (SIU), (3) the number of people with a new spinal cord injury (SCI) who are discharged from hospital without ever being transferred to an SIU, and (4) the effectiveness and cost-effectiveness of steroids for people with SCI Data sources Searches were carried out on several databases and also on the Internet Specialist SCI and spinal injury related websites were searched, specifically the Spinal Injuries Association, the British Association of Spinal Cord Injury Specialists and the National Spinal Cord Injury Association Review methods Three separate search strategies were devised to find studies relating to the four key areas Two reviewers independently screened all study citations for inclusion The lists of all retrieved studies were scanned for additional studies Quality of studies was assessed and data were extracted by one reviewer then checked by the second Data from included studies were summarised within each key area For dichotomous data, relative risks were calculated with 95% confidence intervals Pooled relative risks were calculated as appropriate For continuous data, mean differences with 95% confidence intervals were calculated and, if data were pooled, weighted mean differences were calculated Searches were carried out to identify economic evaluations, details of these together with a critical appraisal of quality are presented in structured tables Quality was assessed using a checklist supplemented with additional comments on the adequacy of methodology where appropriate Results For spinal fixation versus no fixation, 68 retrospective observational studies were found that suggested some benefits of fixation surgery Only four studies were found on fixation surgery in SIUs compared with non-SIU hospitals and no significant differences were seen All 28 studies concerning delayed referral to a SIU were retrospective observational studies In most, study details were poorly reported and there was doubt over the comparability of groups at baseline and on confounding factors Times of referral and transfer were not reported separately Evidence suggested an effect in favour of the SIU group for neurological improvement No relevant published studies of any design were found regarding how many people with a new SCI are discharged from hospital without ever being transferred to an SIU Two systematic reviews were found that assessed the effectiveness of steroids No studies were identified that considered both costs and the impact on patient outcomes of a given intervention Conclusions Although there was evidence to suggest some benefits of fixation surgery and also a benefit of immediate referral to SIUs compared with delayed or no referral, owing to the limitations of the data these should be interpreted with caution Not enough data were found to assess whether surgery is more beneficial when carried out in SIUs and further research is required in this area Well-designed prospective observational studies with appropriately matched controls are needed High-dose methylprednisolone steroid therapy may be effective in promoting some degree of neurological recovery if given within 8 hours of injury There is a need for more randomised controlled trials (RCTs) of pharmacological therapy for acute SCI No published studies of any design were found to answer the question of how many people with acute SCI are discharged from hospital without ever being transferred to an SIU Primary research involving audit of selected hospital records should be commissioned and published The search strategy did not identify any full economic evaluations Future research should include full economic evaluations, possibly alongside a large RCT, which fully consider the costs and consequences of implementing interventions

Effectiveness and cost-effectiveness of acute hospital-based spinal cord injuries services: systematic review

Although both SLC30A8 rs13266634 single nucleotide polymorphism and plasma zinc concentrations have been associated with impaired glucose regulation (IGR) and type 2 diabetes (T2D), their interactions for IGR and T2D remain unclear. Therefore, to assess zinc-SLC30A8 interactions, we performed a case-control study in 1,796 participants: 218 newly diagnosed IGR patients, 785 newly diagnosed T2D patients, and 793 individuals with normal glucose tolerance. After adjustment for age, sex, BMI, family history of diabetes, and hypertension, the multivariable odds ratio (OR) of T2D associated with a 10 µg/dL higher plasma zinc level was 0.87 (95% CI 0.85-0.90). Meanwhile, the OR of SLC30A8 rs13266634 homozygous genotypes CC compared with TT was 1.53 (1.11-2.09) for T2D. Similar associations were found in IGR and IGR&T2D groups. Each 10 µg/dL increment of plasma zinc was associated with 22% (OR 0.78 [0.72-0.85]) lower odds of T2D in TT genotype carriers, 17% (0.83 [0.80-0.87]) lower odds in CT genotype carriers, and 7% (0.93 [0.90-0.97]) lower odds in CC genotype carriers (P for interaction = 0.01). Our study suggested that the C allele of rs13266634 was associated with higher odds of T2D, and higher plasma zinc was associated with lower odds. The inverse association of plasma zinc concentrations with T2D was modified by SLC30A8 rs13266634. Further studies are warranted to confirm our findings and clarify the mechanisms underlying the interaction between plasma zinc and the SLC30A8 gene in relation to T2D.

https://diabetes.diabetesjournals.org/content/diabetes/63/5/1796.full.pdf

Interactions Between Zinc Transporter-8 Gene (SLC30A8) and Plasma Zinc Concentrations for Impaired Glucose Regulation and Type 2 Diabetes

Objective: To assess serum zinc and magnesium level in type-2 diabetic patients and the effect of age, gender, glycemic control and duration of diabetes on these trace elements in comparison with those of control subjects. Study Design: Non-interventional case control study. Place and Duration of Study: Department of Medicine, Liaquat University of Medical and Health Sciences, Jamshoro, Hyderabad, from October 2007 to March 2008. Methodology: There were 42 diabetic patients and 42 age matched non-diabetic (control) subjects included in this study. Serum zinc, serum magnesium and fasting blood sugar measured among the diabetic and control groups and association of both trace elements were assessed with glycemic status, age, gender and duration of diabetes using SPSS version 16.0 for analysis. Results: Serum zinc level was significantly lower (mean 2.03+0.39 mg/dL) in diabetic patients as compared to control subjects (4.84+4.217 mg/dL, p = < 0.001). No significant difference was found in serum magnesium level with mean of 22.67+24.5 mg/dL in diabetic patients as compared to controls (18.3+3.4 mg/dL, p = 0.26). Conclusion: Serum zinc level was significantly lower in type-2 diabetics, whereas no significant difference was found in serum magnesium level when compared with control subjects. There was no association of age, gender, glycemic status and duration of diabetes on the serum concentration of these trace elements in type-2 diabetic patients.

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Serum zinc and magnesium in type-2 diabetic patients.

Objective: The objective of this study was to assess the frequency of thyroid dysfunction in response to combination of interferon and ribavirin therapy in chronic hepatitis C (CHC) patients and HCV outcome. Study Design: Descriptive study.

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Frequency of thyroid disorders during interferon and ribavirin therapy in chronic hepatitis C infection.

Various autoimmune diseases have association with each other but it is very rare to see multiple autoimmune diseases in one patient. Presence of more than two autoimmune diseases in one patient is known as multiple autoimmune syndrome (MAS). We report the case of an 11 years old girl who presented with history of swelling in front of the neck along with constipation, anorexia, weight gain and increasing pallor over a period of six months. Additionally she had an episodic history of joint pains and abdominal pain with no specific relation to diet, time, other gastrointestinal or genitourinary symptom. Hypothyroid goiter (Autoimmune thyroiditis, Hashimoto's thyroidits) was diagnosed by raised thyroid stimulating hormone (TSH), low T4 and presence of thyroid specific antibodies in blood. Patient was discharged on tablet Levothyroxine to which she responded well with reduction in size of the swelling and relief of the symptoms except for the joint pains and abdominal pain. To evaluate the persistent symptoms she was investigated further for other autoimmune diseases and was diagnosed to be having systemic lupus erythematosus (SLE) and Coeliac disease also. The final diagnosis was multiple autoimmune syndrome (Hashimoto's thyroiditis, Coeliac disease and SLE).

Multiple autoimmune syndrome: Hashimoto's thyroiditis, coeliac disease and systemic lupus erythematosus (SLE).

Objective To analyze the frequency and causes of anaemia in systemic lupus erythematosus (SLE) patients attending in department of medicine at tertiary care hospitals. Methods This retrospective, descriptive and analytical study was planned to analyze the frequency and causes of anaemia in SLE patients attending the department of medicine at (MMC) and (LUMHS) hospitals during the period of Jan 2006 to Nov 2008. The criteria used in this study were from the American College of Rheumatology. Investigations recorded were blood complete picture, absolute values, peripheral smear, and reticulocyte count in all patients of anaemia. These investigations were necessary to analyse the cases of anaemia in SLE. All investigations were not done in all cases. Patients with hypochromic microcytic anaemia were advised to have serum iron and ferritin levels, seven patients with macrocytic anaemia were advised to have direct and indirect coomb's test, LFTs, serum LDH, serum B12 and folate levels. Patients with normochromic and normocytic anaemia were considered to have anaemia of chronic disease. Bone marrow aspiration and Hb electrophoresis were done in two patients with anaemia of chronic disease. Thirty adult patients were included in this study. Special proforma were prepared to record the information from case sheets of patients including basic information, symptomatology and laboratory investigations. Severity and various types of anaemias were recorded. Anaemia was graded according to severity, as mild (Hb 10-12 G/dl), Moderate (Hb 8-10 G/dl) and severe (Hb Results Thirty adult diagnosed patients of SLE, were included. Their ages ranged from twenty years to fifty years at time of presentation. The mean age +/- SD (range) was 28 +/- 6.22 (20-50) years and median age was 31 years. Out of thirty patients, twenty seven (90%) were females and three (10%) were males. Twenty eight (93.33%) patients presented with anaemia, 14 (46.66%) patients were of mild anaemia, 8 (26.66%) patients were of moderate grade anaemia and 6 (20%) patients had severe anaemia. Iron deficiency anaemia was found in 9 (30%) patients, 12 (40%) patients had anaemia of chronic disease and 7 (23.33%) patients had haemolytic anaemia, out of theses 7 patients, 5 (16.66%) patients had Coomb's positive haemolytic anaemia. All thirty patients had ANA positive titres > 1:80; and nineteen (63.33%) patients had anti ds DNA positive, titres > 1:10. Conclusion Haematologic abnormalities are common manifestations in patients with SLE. Most patients exhibit anaemia at some point during their disease course.

Frequency of anaemia in patients with systemic lupus erythematosus at tertiary care hospitals.

Nine patients with traumatic fractures of dorsolumbar spine leading to pain and neurological deficit are presented. All had radiological evidence of spinal cord or quada equina compression, with either monoparesis, paraparesis or sphincter dysfunction alone. All patients underwent anterolateral decompression through a transpleural or retroperitoneal approach. Seven patients had bone grafting and spinal stabilization with Webb-Morley system. Two patients had decompression only. The results were favourable. This approach is safe and effective and allows early mobilization and functional recovery.

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Iqbal Ahmed Memon

Papers

Serum zinc and magnesium in type-2 diabetic patients.

Frequency of thyroid disorders during interferon and ribavirin therapy in chronic hepatitis C infection.

Multiple autoimmune syndrome: Hashimoto's thyroiditis, coeliac disease and systemic lupus erythematosus (SLE).

Frequency of anaemia in patients with systemic lupus erythematosus at tertiary care hospitals.

Anterolateral decompression for traumatic spinal cord compression