Double Trouble Research Articles

Double trouble for CML.

Combining two BCR-ABL1 inhibitors with nonoverlapping mechanisms of action eradicates CML and prevents recurrence.

(574) - Acute Cellular Rejection (ACR) ± Antibody Mediated Rejection (AMR) - Double Trouble or Overrated?

(574) - Acute Cellular Rejection (ACR) ± Antibody Mediated Rejection (AMR) - Double Trouble or Overrated?

Double Trouble: an observational study of thyroid dysfunction in South Indian subjects with type 2 diabetes

Objective: Studies conducted in subjects with type 2 diabetes have shown increased prevalence of overt hypothyroidism and subclinical hypothyroidism. Hence, we designed a study to find out the prevalence of thyroid dysfunction in south Indian subjects with type 2 diabetes. Research Design and Methods: 400 subjects with type 2 diabetes attending the out-patient department of Karnataka Institute of Endocrinology and Research, Bangalore were randomly selected. 200 relatives who accompanied the subjects without diabetes were recruited as controls. BMI, waist circumference, blood pressure, fasting plasma glucose, post prandial plasma glucose, HbA1c, lipid profile, and thyroid profile of these subjects were determined. Results: 400 subjects with type 2 diabetes and 200 subjects without diabetes were included in the study. They were in the age group of 25 to 75 years. Thyroid dysfunction was present in 13% of non diabetic controls. Subclinical hypothyroidism was present in 7%, overt hypothyroidism in 5% and hyperthyroidism in 1% of the controls. Thyroid dysfunction was present in 24% of subjects with type 2 diabetes. Subclinical hypothyroidism was present in 11.25%, overt hypothyroidism in 12% and hyperthyroidism in 0.75% of the 400 subjects with type 2 diabetes. Conclusions: Hypothyroidism especially subclinical hypothyroidism is more common in south Indian subjects with type 2 diabetes. Hence, it is indispensable to investigate for thyroid dysfunction in subjects with type 2 diabetes. Failure to recognize the presence of thyroid dysfunction may be a primary cause of poor glycemic control often encountered in some subjects with type 2 diabetes, despite appropriate anti diabetic therapy. This highlights the need for the routine evaluation of thyroid function in subjects with type 2 diabetes.

Double trouble: hoarseness and Horner’s after supraclavicular brachial plexus block

Supraclavicular brachial plexus block is a popular procedure for surgeries of the upper limb. Although separate instances of Horner’s syndrome and recurrent laryngeal nerve palsies have been previously reported with this approach and one combined incidence has been reported following an interscalene approach, a combined incidence following a supraclavicular approach has not been previously documented. A 21-year-old male patient, who presented with a laceration and suspected vascular injury over his right palm, had a supraclavicular block placed with a tourniquet inflated to minimise bleeding. He developed Horner’s syndrome and hoarseness of voice in the immediate postoperative period. There was complete resolution of symptoms after eight hours. The presence of an external force in the form of a tourniquet may influence the spread of the local anaesthetic due to compressive effects on the axillary fascial sheath. However, further studies are required to prove this.

Double Trouble: Synchronous Adenocarcinoma of Gallbladder and Pancreas

Double Trouble: Synchronous Adenocarcinoma of Gallbladder and Pancreas

Double Trouble: SRK, Fandom, and Special Effects

Double Trouble: SRK, Fandom, and Special Effects

Double trouble: psychology and psychologization under the spotlight

Double trouble: psychology and psychologization under the spotlight

Fish Fauna Faces Anthropogenic Double Trouble: Erosion of Fish Diversity in Tropical Oxbow Lake of the Ganga River Basin in Eastern India

Fish diversity in Oxbow lake is adversely impacted due to diverse anthropogenic activities like over-exploitation, indiscriminate use of fine meshed fishing gears, jute retting etc. To quantify the impact of such anthropogenic activities on fish diversity and aquatic health, a survey with seasonal analysis of diversity indices, relative frequencies and abundance status of native fish populations was conducted from April 2013 to March 2014 in a semi closed Oxbow lake in Nadia district in eastern India. The level of p<0.05 was accepted as statistical significance. Of the 33 native fish species recorded 33% belonging to 8 orders and 17 families fell under vulnerable or endangered categories. Native species like Amblypharyngodon mola, Chanda nama, Pethia ticto and Notopterus notopterus, Colisa fasciata, P. ticto, were the most dominant and frequent fishes. Shannon-Weiner diversity index was decreased by 41% by precipitating impact of monsoonal anthropogenic activities during post-monsoon. Low native fish diversity indices are pointers to poor ecosystem health status owing to intense adverse activities like jute retting, indiscriminate fishing aggravated by influx of turbid water from the river Ganga following episodic flood events during monsoon. Regulation and prevention of such anthropogenic activities are urgently warranted for sustainable conservation and management of the Oxbow lake.

654: Out of hospital twin births: double trouble or reasonable option?

654: Out of hospital twin births: double trouble or reasonable option?

Double trouble: tPA-induced angioedema

Angioedema results from the release of one or more mediators, most often histamine and bradykinin, in the deeper layers of the skin and mucous membranes. There is an increase in...

Double Trouble: Prevalence and Factors Associated with Tuberculosis and Diabetes Comorbidity in Bangladesh.

BackgroundDiabetes among tuberculosis patients increases the risk of tuberculosis treatment failure, death, and development of multidrug-resistant tuberculosis. Yet, there is no data is available in Bangladesh on the prevalence of diabetes among tuberculosis patients. The objective of the current study was to estimate prevalence and identify factors associated with tuberculosis-diabetes co-morbidity among TB patients enrolled in the Directly Observed Treatment, Short course program.MethodsA community based cross-sectional quantitative study was conducted among 1910 tuberculosis patients living in six urban and eleven rural areas among whom Oral Glucose Tolerance Test (those who fasted) and Random Blood Sugar test (those who did not fast) were performed. Besides glucose levels, data on socio-demographic information, family history of diabetes and anthropometric measurements (height and weight) were also collected.ResultAmong the 1910 TB patients who participated in screening for diabetes, 245 (12.8%) were found to have diabetes and 296 (15.5%) to have pre-diabetes. Out of those who had diabetes, 34.7% were newly diagnosed through the current study and 65.3% already knew their status. Among those who were found to have prediabetes, 27 (9.1%) had impaired Fasting Blood Glucose (FBG), 230 (77.7%) had Impaired Glucose Tolerance (IGT), and 39 (13.2%) had both Impaired FBG and IGT. Older age, higher BMI, higher education (secondary level and above), being married, participation in less active work, and family history of diabetes are associated with higher prevalence of diabetes.ConclusionWe observed a higher prevalence of diabetes and pre-diabetes in TB patients than reported previously in Bangladesh among the general population which may challenge TB and diabetes control in Bangladesh. Diabetes diagnosis, treatment and care should be integrated in the National TB Program.

Double Trouble: A Case of Double Bumper in a Gastrostomy Patient

Percutaneous endoscopic gastrostomy (PEG) was developed by Gauderer in 1980. Placement could be accomplished by the pull (Ponsky), push (Sachs-Vine), introducer (Russell) and T-fastener (Versa) methods. Indications include inability to consume sufficient nutrition for longer then one month (despite functional GI tract), hydration, medications administration and gastric decompression. Complications associated with PEG tube placement can be divided into three categories, occurring at: any time, early or late. Complications occurring at any time include tube dysfunction, peristomal wound infection, necrotizing fasciitis, intra-abdominal bleeding, peritonitis, peristomal ulceration and gastric outlet obstruction. Early complications include pneumoperitoneum, ileus and perforation. Late complications include tube deterioration/migration, tract tumor seeding and fistula formation. A rare complication is buried bumper syndrome (BBS) which is a slow erosion of internal bolster into the gastric wall caused by tight apposition of the external bolster against the abdominal wall, and ultimately leads to pain and the inability to infuse feedings. We present a case of a 74 year old female with past medical history of end-stage Alzheimer's dementia who presented with PEG tube blockage. Original PEG tube was placed 1 year prior to admission in El-Salvador. Attempted removal of the PEG tube using traction technique caused breakage of the tube at the internal bolster. EGD was performed and showed extrinsic compression at insertion site, however, bolster was not identified. Abdominal CT scan was performed and showed bolster buried in-between the abdominal wall and peritoneum. As patient's family refused any surgical intervention, a decision was made to insert a new PEG tube through existing stoma and buried internal bumper. Repeat CT scan confirmed position of the PEG tube with retained internal bumper anchored between new internal bumper and abdominal wall (“Double Bumper”). Tube feeds were started and patient was discharged home. On 3 months follow-up, stoma site appeared healthy and PEG tube appeared functional. This case demonstrates a new non-surgical management of BBS. Anchoring the retained bumper prevents migration which could potentially result in small bowel obstruction (has been reported in literature). We propose that the “Double Bumper” method should be the new standard in managing the BBS in high risk surgical patient who need continued enteral feeding.Figure 1Figure 2Figure 3

Double Trouble Bubble: Autoimmune Overlap Syndrome Causing Portal Gastropathy, with Review of Current Literature

A 57 year old female with a past medical history of cirrhosis and high elevation of SM-Ab titer, elevated actin IGG, and anti-mitochondrial antibody significantly increased presented to the emergency department with hematemasis and bright red blood per rectum. After admission to the ICU she received 2 units packed red blood cells and was started on intravenous antibiotics, protonix, and octreotide. An esophagogastroduodenoscopy revealed esophageal and gastric varices extending into the stomach with gastropathy, not amenable to banding. A Trans-Jugular Intrahepatic Portosystemic Shunt (TIPS) was performed after resolution of bleeding. The patient was discharged with follow up for transplant evaluation while being treated with ursodiol, rifaximin, lactulose, pantoprazole, and diuretics. Autoimmune hepatitis (AIH) is a liver disease characterized by inflammatory liver histology, elevated transaminase levels, circulating autoantibodies, and increased levels of immunoglobulin G in the absence of a known etiology. Two types of AIH are recognized according to seropositivity: smooth muscle antibody and/or antinuclear antibody (AIH type 1) and antibodies to liver-kidney microsome type 1 and/or liver cytosol type 1 (AIH type 2). There is mounting evidence that genetic susceptibility, molecular mimicry, and impaired immunoregulatory networks contribute to the initiation and perpetuation of the autoimmune attack. Liver damage is thought to be mediated primarily by CD4 T-cells. The histological findings of lymphocytes, plasma cells, and macrophages is non-specific but consistent with the diagnosis of AIH. A massive recruitment of activated inflammatory cells is likely to cause damage and eventually leads to portal hypertension; this prolonged elevated portal pressures then can lead to progressive congestion and eventually gastropathy. Due to large heterogeneity of the disease AIH may be unrecognized, and the clinical manifestation of AIH can range from mild or severe symptoms to fulminant hepatic failure. Growing insights into the clinical presentation of AIH highlights the importance of evaluation of the current diagnostic criteria and development of new treatment strategies to identify patients who would benefit from more efficient therapy. We present a patient in which liver transplant would be the only viable option for long term therapeutic benefit due to the untreated progression of her disease.

First Introduction of Two Australian Temnocephalan Species into Africa with an Alien Host: Double Trouble.

The redclaw crayfish, Cherax quadricarinatus (Decapoda: Parastacidae), is native to Australia but has been introduced to South Africa as a warm-water aquaculture species. In a South African natural waterbody, examined crayfish had high-intensity infections of 3 temnocephalan species on their body surfaces and within the branchial chambers. Temnocephalans were characterized using light and scanning electron microscopy and identified as Craspedella pedum, Diceratocephala boschmai, and Didymorchis sp. This is the first report of the introduction of Australian temnocephalans, C. pedum and Didymorchis sp., to Africa and expands the known distribution of these species beyond their presumptive native range. The present study also documents a naturalized population of C. quadricarinatus from a natural water body in South Africa, comprising a new geographical locality record.

Antibody double trouble for HIV

Antibody double trouble for HIV

Bentall Surgery in a Patient with Cold Agglutinin and Antiphospholipid Antibody: Double Trouble

Cold agglutinin disease is an uncommon disease with potential to cause hemolysis and thrombosis during hypothermic cardiac surgery. Antiphospholipid syndrome is also rare disease with hypercoagulation tendacy. Perioperative management of both these diseases is challenging. We present successful perioperative management of high risk Bentall surgery in patient with both these dreadful diseases.

Double Trouble: Parafictional Personas and Contemporary Art

Across the news and entertainment media there is an increasingly prevalent phenomenon: actors, performers and artists who play “versions of themselves”. This paper explores the entertaining and critical potentials of this strategy, which I term “parafictional personas”. I draw upon Carrie Lambert-Beatty’s theorisation of the parafictional as a critical mode that has developed out of (and in tension with) the “historiographic turn”. Parafictional personas are a specific iteration, characterised by two key components: they compulsively imbue every opportunity with layers of interconnections and self-reflexive moments; and they involve artists and performers appropriating their own “proper name”, constructing fictionalised doubles of themselves. While found widely across media, my central focus is contemporary visual art, analysing two key examples, Israeli–American artist Omer Fast and Lebanese artist Walid Raad.These artists are significant because their personas are not simply means of performing themselves as individuals; they are integrated into the ways the artists approach contentious, still unfolding events of contemporary history. Parafictional personas have the potential to thoroughly embed fictional constructs within reality, because of the difficulties in separating elements represented by the same proper name. Their critical potential lies in the ways that they make visible the difficulties of maintaining clear distinctions between historical and fictional, social and individual narratives. Parafictional personas confound cultural desires to order, categorise and “make sense” of historical narratives. They reveal how much we as viewers (and societies) search for ideas of truth and resolution, even if such truths are presented as incomplete, questionable, or irresolvable.

Common bile duct duplication: double bile ducts, double trouble

Common bile duct duplication: double bile ducts, double trouble

Diagnosis of non-alcoholic fatty liver disease (NAFLD).

Non-alcoholic fatty liver disease (NAFLD) increases risk of mortality from liver and cardiovascular disease (CVD) and is the major cause of hepatocellular carcinoma (HCC), which may develop without cirrhosis. NAFLD predicts type 2 diabetes, even independently of obesity. Globally, the prevalence of NAFLD averages 25% and is as common as the metabolic syndrome. The majority of patients with type 2 diabetes have NAFLD. The challenge for the diabetologist is to identify patients at risk of advanced liver disease and HCC. At a minimum, liver function tests (LFTs), despite being neither specific nor sensitive, should be performed in all patients with the metabolic syndrome or type 2 diabetes. Increases in LFTs, for which the updated reference values are lower (serum ALT ≈30U/l in men and ≈20U/l in women) than those hitherto used in many laboratories, should prompt assessment of fibrosis biomarkers and referral of individuals at risk to a NAFLD/hepatology clinic. Preferably, evaluation of NAFLD should be based on measurement of steatosis biomarkers or ultrasound if easily available. A large number of individuals carry the patatin-like phospholipase domain containing 3 (PNPLA3) I148M variant (30-50%) or the transmembrane 6 superfamily member 2 (TM6SF2) E167K variant (11-15%). These variants increase the risk of advanced liver disease and HCC but not of diabetes or CVD. Genotyping of selected patients for these variants is recommended. Many patients have 'double trouble', i.e. carry both a genetic risk factor and have the metabolic syndrome. Excess use of alcohol could be a cause of 'triple trouble', but such patients would be classified as having alcoholic fatty liver disease. This review summarises a presentation given at the symposium 'The liver in focus' at the 2015 annual meeting of the EASD. It is accompanied by two other reviews on topics from this symposium (by Kenneth Cusi, DOI: 10.1007/s00125-016-3952-1 , and by John Jones, DOI: 10.1007/s00125-016-3940-5 ) and a commentary by the Session Chair, Michael Roden (DOI: 10.1007/s00125-016-3911-x ).

Double trouble: subsidence and CO2 respiration due to 1,000 years of Dutch coastal peatlands cultivation

Coastal plains are amongst the most densely populated areas in the world. Many coastal peatlands are drained to create arable land. This is not without consequences; physical compaction of peat and its degradation by oxidation lead to subsidence, and oxidation also leads to emissions of carbon dioxide (CO2). This study complements existing studies by quantifying total land subsidence and associated CO2 respiration over the past millennium in the Dutch coastal peatlands, to gain insight into the consequences of cultivating coastal peatlands over longer timescales. Results show that the peat volume loss was 19.8 km3, which lowered the Dutch coastal plain by 1.9 m on average, bringing most of it below sea level. At least 66 % of the volume reduction is the result of drainage, and 34 % was caused by the excavation and subsequent combustion of peat. The associated CO2 respiration is equivalent to a global atmospheric CO2 concentration increase of ~0.39 ppmv. Cultivation of coastal peatlands can turn a carbon sink into a carbon source. If the path taken by the Dutch would be followed worldwide, there will be double trouble: globally significant carbon emissions and increased flood risk in a globally important human habitat. The effects would be larger than the historic ones because most of the cumulative Dutch subsidence and peat loss was accomplished with much less efficient techniques than those available now.