The 11th edition of Harrison's Principles of Internal Medicine welcomes Anthony Fauci to its editorial staff, in addition to more than 85 new contributors. While the organization of the book is similar to previous editions, major emphasis has been placed on disorders that affect multiple organ systems. Important advances in genetics, immunology, and oncology are emphasized. Many chapters of the book have been rewritten and describe major advances in internal medicine. Subjects that received only a paragraph or two of attention in previous editions are now covered in entire chapters. Among the chapters that have been extensively revised are the chapters on infections in the compromised host, on skin rashes in infections, on many of the viral infections, including cytomegalovirus and Epstein-Barr virus, on sexually transmitted diseases, on diabetes mellitus, on disorders of bone and mineral metabolism, and on lymphadenopathy and splenomegaly. The major revisions in these chapters and many

Harrison's Principles of Internal Medicine

Global estimates of the prevalence of diabetes for 2010 and 2030.

Global estimates of diabetes prevalence for 2013 and projections for 2035.

1. Type 1 diabetes (due to b-cell destruction, usually leading to absolute insulin deficiency) 2. Type 2 diabetes (due to a progressive insulin secretory defect on the background of insulin resistance) 3. Gestational diabetes mellitus (GDM) (diabetes diagnosed in the second or third trimester of pregnancy that is not clearly overt diabetes) 4. Specific types of diabetes due to other causes, e.g., monogenic diabetes syndromes (such as neonatal diabetes and maturity-onset diabetes of the young [MODY]), diseases of the exocrine pancreas (such as cystic fibrosis), and drugor chemical-induced diabetes (such as in the treatment of HIV/AIDS or after organ transplantation)

Classification and diagnosis of diabetes

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Nepal lies in an area of endemic iodine deficiency. Thyroid dysfunction, along with a higher than average prevalence of goiter, is a major public health problem among the local population. The present study was undertaken to investigate the prevalence of thyroid dysfunction among the hill and terai (low land) castes of eastern Nepal that attended the thyroid clinic at the BP Koirala Institute of Health Sciences (BPKIHS), Dharan. A total of 599 cases were studied during a single year. The distribution of hyperthyroid and hypothyroidism was 13.68% and 17.19% respectively. The majority of the thyroid dysfunction was seen in the 21-40 year age group. The prevalence of hypothyroidism was slightly higher among terai castes (17.66%) when compared with hill castes (15.17%). There was a similar distribution of thyroid dysfunction among the male and female populations of the goitrous subjects (n=157), most were euthyroid (58.59%); hyperthyroidism affected (27.38%). Since, it was a hospital-based study, the prevalence of thyroid dysfunction may not be applicable to the general population. Extensive field-based countrywide epidemiological studies are necessary to provide data about thyroid dysfunction in the community.

Thyroid dysfunction in eastern Nepal.

Deficiencies of iodine and iron may have adverse effect on thyroid function. This study was undertaken to investigate the association between iron status and thyroid function in Nepalese children living in hilly regions. A cross-sectional study was conducted among 227 school children aged 6–12 years living in hilly regions of eastern Nepal. Urine and blood samples were analyzed for urinary iodine concentration, free thyroxine, free triiodothyronine, thyroid stimulating hormone, hemoglobin, serum iron and total iron binding capacity, and percentage transferrin saturation was calculated. The cohort comprised euthyroid (80.6 %, n = 183), overt hypothyroid (1.3 %, n = 3), subclinical hypothyroid (16.3 %, n = 37) and subclinical hyperthyroid (1.8 %, n = 4) children respectively. About 35.2 % (n = 80) children were anemic, 43.6 % (n = 99) were iron deficient and 19.8 % (n = 45) had urinary iodine excretion < 100 μg/L. Hypothyroidism (overt and subclinical) was common in anemic and iron deficient children. The relative risk of having hypothyroidism (overt and subclinical) in anemic and iron deficient children was 5.513 (95 % CI: 2.844−10.685, p < 0.001) and 1.939 (95 % CI: 1.091-3.449, p = 0.023) respectively as compared to non-anemic and iron sufficient children. Thyroid stimulating hormone had significant negative correlation with hemoglobin (r = −0.337, p < 0.001) and transferrin saturation (r = −0.204, p = 0.002). Thyroid dysfunction, iron deficiency and anemia are common among Nepalese children. In this cohort, anemic and iron deficient children had poor thyroid function.

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Association between iron status and thyroid function in Nepalese children.

Anemia is one of the most common public health problems in developing countries like Nepal. This study was done to find the prevalence of anemia among the children aged 4-13 years in eastern Nepal. A cross-sectional study was conducted in 2012 in four districts (Morang, Udayapur, Bhojpur and Ilam) of eastern Nepal to find the prevalence of anemia among the school children of eastern Nepal. Children aged 4-13 years were selected randomly from different schools of above districts and 618 venous blood samples were collected. Hemoglobin level was estimated by using cyanmethemoglobin method. The mean hemoglobin level was 12.2 ± 1.82 gm/dl. About 37.9% (n = 234) children were found anemic. Anemia prevalence was 42.4% (n = 78), 31.6% (n = 60), 45.3% (n = 48) and 34.8% (n = 48) among school children of Morang, Udayapur, Bhojpur and Ilam district, respectively. The study finds anemia as a significant health problem among the school children of eastern Nepal.

Anemia among school children in eastern Nepal

Chronic kidney disease (CKD) is becoming a serious health problem; the number of people with impaired renal function is rapidly rising. Progression of CKD is associated with having a number of complications, including thyroid dysfunction, dyslipidemia and cardiovascular diseases. This study was conducted to investigate thyroid function and lipid profile in CKD patients. A cross-sectional study was conducted among 360 chronic kidney disease patients at B P Koirala Institute of Health Sciences, Dharan, Nepal. Demographic features (age and sex) and medical history of diabetes mellitus, hypertension and cardiovascular diseases of each patient were noted, and blood samples (5 ml) were analyzed for serum urea, creatinine, glucose, free triiodothyronine (T3), free thyroxine (T4), thyroid stimulating hormone (TSH), total cholesterol, high density lipoprotein (HDL) cholesterol, low density lipoprotein (LDL) cholesterol and triglyceride. Thyroid dysfunction was found in 38.6 % CKD patients, the most common being subclinical hypothyroidism (27.2 %), followed by overt hypothyroidism (8.1 %) and subclinical hyperthyroidism (3.3 %). Hypercholesterolemia, low HDL cholesterol, undesirable LDL cholesterol and hypertriglyceridemia were observed in 34.4, 34.1, 35 and 36.6 % patients respectively. Stage 4 and 5 CKD patients had significantly higher risk of having thyroid dysfunction as compared to stage 3 patients. Significant risk factors for cardiovascular disease in CKD patients included presence of diabetes mellitus, hypercholesterolemia, undesirable LDL cholesterol and being in stage 4 and 5 (as compared to stage 3). Thyroid dysfunction, hypercholesterolemia, low HDL cholesterol, undesirable LDL cholesterol and hypertriglyceridemia are common in CKD patients. Progression of CKD is accompanied by rise in hypothyroidism and cardiovascular disease.

/pdf/thyroid-dysfunction-and-dyslipidemia-in-chronic-kidney-1lta6841cj.pdf

Thyroid dysfunction and dyslipidemia in chronic kidney disease patients

This case-control study followed by a longitudinal cohort study was undertaken to evaluate the level of lipid peroxidation product malondialdehyde (MDA) and nitrite as an indirect measurement of nitric oxide vis-a-vis the levels of antioxidants vitamin C and vitamin E in pulmonary tuberculosis. Fifty-six sputum smear-positive cases of pulmonary tuberculosis based on Ziehl-Neelsen (ZN) staining and 50 healthy controls without any systemic disease were included in this study. Thirty-five cases were longitudinally followed up with standard antituberculosis chemotherapy (ATT) for two months. Serum levels of malondiadehyde (MDA), nitrite, and plasma levels of vitamins C and E were measured. The mean serum MDA level was significantly higher (8.1 +/- 1.61 nmoles/ml) in PTB patients before commencement of ATT as compared to healthy controls (3.45 +/- 1.7 nmoles/ml) (p=0.0001) and decreased significantly after 2 months of ATT (3.84 +/- 1.28 nmoles/ml) (p=0.0001). The mean serum nitrite level (47.19 +/- 18.44 micromol/l) was significantly elevated before ATT compared to healthy controls (32.89 +/- 11.94 micromoles/l) and decreased significantly after 2 months of ATT (27.71 +/- 11.97 micromoles/l) (p=0.0001). The mean plasma levels of vitamins C (0.88 +/- 0.33 mg/dl) and E (0.79 +/- 0.24 mg/dl) in PTB patients before commencement of ATT were lower than healthy controls (1.42 +/- 0.38 mg/dl) and (1.35 +/- 0.35 mg/dl), respectively (p=0.001). There was a significant increase in vitamin C levels after 2 months of ATT (1.19 +/- 0.40 mg/dl) compared to before ATT (0.83 +/- 0.31 mg/dl) (p=0.0001), but no significant change in mean plasma vitamin E level before and after 2 months on ATT was found. Elevated malondialdehyde and nitrite levels with concomitant depressed vitamin C and E levels are indicative of lipid peroxidation and oxidative stress. The decrease in levels of malondialdehyde and nitrite with subsequent increase in vitamin C levels after two months of follow-up indicate a good response to treatment with standard ATT. Hence, the extent of oxidative stress in PTB can be evaluated by analyzing lipid peroxidation product, antioxidant and nitric oxide levels.

Evaluation of lipid peroxidation product, nitrite and antioxidant levels in newly diagnosed and two months follow-up patients with pulmonary tuberculosis.

Madhab Lamsal

Papers

Thyroid dysfunction in eastern Nepal.

Association between iron status and thyroid function in Nepalese children.

Anemia among school children in eastern Nepal

Thyroid dysfunction and dyslipidemia in chronic kidney disease patients

Evaluation of lipid peroxidation product, nitrite and antioxidant levels in newly diagnosed and two months follow-up patients with pulmonary tuberculosis.