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   Table of Contents - Current issue
January-February 2019
Volume 23 | Issue 1
Page Nos. 1-171

Online since Monday, March 18, 2019

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Anaplastic cancer of the thyroid: The viper in the pit p. 1
Krishna G Seshadri
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Stretched penile length and testicular size from birth to 18 years in boys from Western Maharashtra Highly accessed article p. 3
Vijay K Jaiswal, Vaman Khadilkar, Anuradha Khadilkar, Nikhil Lohiya
Background: Genital stage and testicular volume examination and assessment are essential for assessment of growth puberty in boys. There is paucity of Indian data for penile and testicular parameters particularly in pubertal years. Aim: The aim of this study is to present normative data for penile length, testicular volume, and testicular length from birth to 18 years in boys from western Maharashtra and to correlate these parameters with sexual maturity staging (SMR) (Tanner staging). Materials and Methods: A cross-sectional observational study was undertaken in apparently healthy boys from 0 to 18 years of age from western Maharashtra from October 2016 to October 2017. Age, anthropometric parameters, stretched penile length (SPL), testicular volume, and testicular length were measured. Pubertal stage was categorized using Tanner staging. Data were entered in Microsoft excel 2013 and using SPSS version 16. LMS method was used to construct age-specific Z-scores for SPL, testicular volume, and testicular length. Results: A total of 843 boys were enrolled in the study. Mean SPL was 4.1 ± 0.4, 5.4 ± 0.8, and 10.2 ± 1.7 cm at 1, 10, and 18 years of age, respectively, and showed a gradual rise from birth to 18 years. Mean testicular volume was 1.8 ± 0.5, 3.3 ± 1.2, and 24.1 ± 3.5 ml, whereas testicular length was 1.3 ± 0.4, 2.1 ± 0.5, and 4.4 ± 0.7 cm respectively, at 1, 10, and 18 years, respectively. The magnitude of increase for SPL and testicular volume was greater around 9–10 years. The increase in SPL and testicular size was hand in hand with SMR for genital development as well as for axillary and pubic hair stages. Conclusion: Normative data on SPL, testicular volume, and testicular length from western Maharashtra are presented. These data may be useful in disorders of puberty and genitalia in boys.
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High prevalence of genital mycotic infections with sodium-glucose co-transporter 2 inhibitors among Indian patients with type 2 diabetes p. 9
Ajay Aggarwal, Roopak Wadhwa, Dheeraj Kapoor, Rajeev Khanna
Introduction: Genital mycotic infections are common among patients with poorly controlled diabetes. Sodium-glucose co-transporter 2 inhibitors (SGLT2i) induced pharmacological glycosuria increases the risk of these infections (2–3 fold) among patients with type 2 diabetes (T2D). The data about incidence of these infections in Indian setting is unclear. Aim: To study the prevalence of genital mycotic infections caused by SGLT2i among Indian patients with T2D. Materials and Methods: We collected data of 205 patients with T2D on SGLT2i for more than 1-month duration. Patients with symptoms and/or signs suggestive of genital mycotic infections and who had positive response to antifungal treatment were considered to have infection. Data were collected for a period of 2 months from July to August 2017. Results: Among 205 patients, mean age was 52.4 ± 8.7 years and percentage of females was 52.2%. Among SGLT2i, empagliflozin, canagliflozin and dapagliflozin were prescribed to 50.7%, 30.2% and 19.1% patients, respectively. The mean duration of treatment with SGLT2i was 7.6 ± 5.9 months. At least, one episode of genital mycotic infection occurred in 53 (25.9%) patients and 25 (12.2%) had second episode. Incidence of these infections was marginally higher in females than males with no statistically significant difference (P = ns). There was no significant correlation between age, sex, duration of disease, duration of treatment, glycaemic control, type and dose of SGLT2i used with the incidence of genital mycotic infections (P = ns). The patients who had knowledge of side effects of the drug and observed precautions had significantly lesser incidence of infections (P < 0.001). Majority of the infections were mild in nature and responded well to treatment. Conclusion: There is a very high risk of genital mycotic among Indian patients with T2D on SGLT2i. All patients should be educated about the risk of genital mycotic infections when on SGLT2i and precautions needed to minimise the risk.
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Evaluation of changes in insulin sensitivity in prepubertal small for gestational age children treated with growth hormone p. 14
Carmen Sydlik, Claudia Weissenbacher, Julia Roeb, Susanne Bechtold-Dalla Pozza, Heinrich Schmidt
Background: Although growth hormone (GH) therapy for children born small for gestational age (SGA) has been approved for many years, there are still concerns about increasing their risk for insulin resistance and diabetes mellitus type 2. Monitoring of glucose homeostasis is therefore generally recommended, but there is no consensus on either the methods or consequences. Methods and Aims: The aim of our study was to analyze the oral Glucose Tolerance Tests (oGTTs) which were performed yearly from baseline to 4 years of GH therapy in a collective of 93 SGA children, who were prepubertal during the whole follow-up. We looked for correlations with auxological and laboratory data as well as predictive baseline results for glucose homeostasis during further treatment. Results: While glucose levels remained constant, insulin secretion increased from baseline to the first year of GH therapy. Insulin sensitivity index (ISI) showed no significant change afterwards; HOMA1, HOMA2, and QUICKI stabilized after the second year. For all indices mean values never reached pathological levels and no cases of diabetes mellitus were induced. Higher gestational age, lower birth length, and older age at start of GH therapy were associated with lower insulin sensitivity. No predictive factors for later insulin resistance could be found. Conclusion: As expected, in GH-treated prepubertal SGA children insulin resistance was induced, but not to pathological levels. No special risk factors for disturbed glucose homeostasis could be identified. Based on our opinion, performing oGTTs in GH-treated SGA children at baseline and in puberty should remain mandatory, but the current study recommendations regarding further surveillance of glucose homeostasis are questionable.
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Coexistence of autoimmune disorders and type 1 diabetes mellitus in children: An observation from Western Part of India p. 22
Balram Sharma, Hardeva R Nehara, Sanjay Saran, Vijay K Bhavi, Anshul K Singh, Sandeep K Mathur
Introduction: Type 1 diabetes mellitus (T1DM) is associated with various autoimmune disorders like celiac disease, thyroid disorder, adrenal failure, etc. However, how common is this association in Indian children is not clearly known. Objective: To assess the prevalence of other coexisting autoimmune disorders in children with T1DM. Materials and Methods: In this cross-sectional study, patients requiring insulin and ketosis-prone diabetic and with history of diabetic ketoacidosis/undetectable fasting C-peptide levels were included. Beside demographic and clinical data, detailed biochemistry evaluations were performed. Celiac disease was diagnosed as per the ESPGHAN diagnostic criteria. ACTH stimulation test was done to confirm the adrenal insufficiency in patients with basal serum cortisol <5 μg/dL. Thyroid function test (TSH) and anti-TPO antibody were assessed in all patients. Screening for other autoimmune disorders was done only when clinically indicated or symptoms or family history was suggestive of presence of such disorder. Results: Among 150 patients enrolled, 64.66% were males and mean age was 13.48 ± 3.29 years (range 3–18 years). Mean age at diagnosis of T1DM was 10.0 ± 3.63 years and duration of diabetes was 3.46 ± 3.18 years. The prevalence of antibodies positive against autoimmune diseases was anti-tTG IgA (20.7%), anti-TPO (33.7%), anti-CCP ab (1.3%), and ANA (0.7%). Significantly higher proportion of females had raised anti-TPO antibodies than males (47.2% vs. 25.8%, P = 0.006). Celiac disease was most common association (24.8%) followed by hypothyroidism (14.1%) and Grave's disease (3.3%). Significantly higher proportion of females had hypothyroidism than males (25.0% vs. 8.2%, respectively, P = 0.005). Prevalence of raised anti-tTG and anti-TPO did not differ significantly by the age (P = 0.841 and P = 0.067) or duration of T1DM (P = 0.493 and P = 0.399). Conclusion: In this part of country, celiac disease, hypothyroidism, and Graves's disease are common associations in children with T1DM.
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Effect of vitamin D supplementation on bone turnover markers in children and adolescents from North India p. 27
Raman K Marwaha, MK Garg, A Mithal, Sushil Gupta, Manoj Shukla, Aditi Chadha
Objectives: Vitamin D is known to play an important role in bone mineral metabolism. Its deficiency may affect growth and status of bone markers in children. Hence, we undertook to study the status of bone markers in children with vitamin D deficiency (VDD) and impact of vitamin D3 supplementation on them. Materials and Methods: Total 468 out of 615 children and adolescents with VDD, who were given either of the three doses (600, 1000, and 2000) of vitamin D supplementation, were included in the study. These 468 children with pre- and postsupplementation preserved samples with available anthropometry, serum biochemistry, 25-hydroxy-vitamin D, and parathormone were evaluated for bone formation (procollagen type 1 amino-terminal propeptide [P1NP]) and resorption (β-cross laps [CTx]) markers. Results: The mean age and body mass index of these children were 11.3 ± 2.3 years (boys: 11.5 ± 2.4; girls: 12.2 ± 1.2 years; P = 0.03) and 18.1 ± 3.8 kg/m2 (boys: 18.2 ± 3.9; girls: 17.6 ± 3.2 kg/m2; P = 0.208), respectively. There were 8.8% subjects with severe, 42.7% with moderate, and 48.5% with mild VDD. There was a significant decline in serum P1NP (from 691 ± 233 ng/ml to 640 ± 259 ng/ml, P < 0.001) and CTx (from 1.67 ± 0.53 ng/ml to 1.39 ± 0.51 ng/ml, P < 0.001) following supplementation. Though decline in serum P1NP and CTx levels was observed in both boys and girls, among all three supplementation groups and VDD categories, the effect was more marked in serum CTx than P1NP levels. Conclusions: Vitamin D supplementation in VDD children resulted in decrease in both bone formation (P1NP) and resorption (CTx). The impact, however, was more marked on bone resorption than bone formation.
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Evaluation of vitamin D status and its impact on thyroid related parameters in new onset Graves' disease- A cross-sectional observational study p. 35
Swayamsidha Mangaraj, Arun K Choudhury, Basanta M Swain, Pradosh K Sarangi, Binoy K Mohanty, Anoj K Baliarsinha
Aims and Objective: We aimed to compare serum vitamin D level in new onset Graves' disease versus age and sex matched controls. Furthermore, we assessed the correlation of vitamin D with hormonal parameters and antibody titers in Graves' disease. Materials and Methods: In total, 84 patients of new onset Graves' disease and 42 age and sex matched healthy individuals were recruited. Biochemical and hormonal investigations that included serum calcium, phosphorous, free triiodothyronine (FT3), free thyroxine (FT4), thyroid stimulating hormone (TSH), 25 hydroxy vitamin D (25(OH) D), and parathyroid hormone (PTH) were done for all subjects. Thyrotropin receptor antibody (TRAb) was measured only for Graves' disease patients. Results: The patients with Graves' disease had significantly lower 25(OH) D levels (19.2 ± 8.9 ng/ml) as compared to control subjects (23.8 ± 12.5 ng/ml) (P = 0.019). Thyroid hormone levels, thyroid volume, and TRAb titers did not differ significantly between vitamin D deficient Graves' disease group (25(OH)D <20 ng/ml) and vitamin D non deficient Graves' disease group (25(OH)D ≥20 ng/ml). Furthermore, serum vitamin D level did not correlate significantly with thyroid hormones, thyroid volume, or TRAb titers among Graves' disease. The odds ratio (OR) for association of vitamin D deficiency (VDD) state and Graves' disease was 1.62 (95% CI 0.77–3.41). Vitamin D sufficiency state was associated significantly with lower risk of Graves' disease (OR = 0.38, 95% CI 0.15–0.95). Conclusion: Serum vitamin D levels are significantly lower in new onset Graves' disease. No significant correlation between vitamin D and thyroid hormones, thyroid volume, or TRAb titers was found in these patients. VDD state is not associated with Graves' disease.
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Drug prescription patterns and cost analysis of diabetes therapy in India: Audit of an endocrine practice p. 40
Rajiv Singla, Jatin Bindra, Ankush Singla, Yashdeep Gupta, Sanjay Kalra
Drug therapy in diabetes care along the duration of diabetes has been documented scarcely in literature, especially from Indian subcontinent. An audit of an endocrine practice from New Delhi was conducted to understand the current diabetes practice and its direct cost to the patient. Aims: The aim of this study was to analyze the current trend in the use of antidiabetes as well as other drugs for comorbidities along the duration of diabetes. The study also aimed to analyze the direct drug cost to patients. Settings and Design: Retrospective cross-sectional study. Subjects and Methods: Data captured in clinic electronic medical records of an endocrine practice was analyzed. Statistical Analysis Used: Data was analyzed descriptively using machine learning codes on python platform. Results: Records of 489 people who attended the clinic during the 6-month period were retrieved. Data of 403 people with diabetes were analyzed after exclusion of incomplete data. Use of antidiabetic drug increased from 1.44 (0.78) [mean (standard deviation)] in people with a duration of diabetes <5 years to 3.18 (1.05) in people with 20+ years of diabetes. The mean number of antidiabetic drug usage seems to plateau at 15 years of diabetes. About 46% of people with 20+ years of diabetes required insulin therapy. Prescription patterns involving a combination of different drug classes in patients were also analyzed. The cost of diabetes therapy increases linearly along the duration of diabetes. Conclusion: This study provides valuable insights on temporal prescription patterns of antidiabetic drugs from an endocrine practice. Metformin remains the most preferred drug across the entire duration of diabetes. Dipeptidyl peptidase-4 inhibitors seem to be fast catching up with sulfonylureas as a second-line treatment after metformin. After 20 years or more of diabetes duration, 46% people would require insulin for glycemic control.
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A comparison between silent and symptomatic renal stones in primary hyperparathyroidism p. 46
Raiz Ahmad Misgar, Ashish Sehgal, Shariq Rashid Masoodi, Arshad Iqbal Wani, Mir Iftikhar Bashir, Ajaz Ahmad Malik, Munir Ahmad Wani, Muzaffar Maqsood Wani, Imtiyaz Ahmad Wani
Background: Nephrolithiasis is a common complication of primary hyperparathyroidism (PHPT), and in a subgroup of patients stones are clinically silent. Patients with silent and symptomatic stones may differ biochemically. There is a scarcity of data available comparing patients with silent and symptomatic renal stones in PHPT. Aims: To characterize patients with PHPT with nephrolithiais and to compare patients with silent and symptomatic stones. Materials and Methods: We reviewed clinical data of 186 patients with PHPT managed at our center from January 1996 to December 2017. Silent renal stones were defined as ultrasonography finding of renal stones without symptoms. Symptomatic renal stones were defined as those with symptoms or a history of graveluria or any procedure for nephrolithiasis. A 5-mm diameter was set as the cut-off between micro- and macrolithiasis. We compared those with (n = 95) and without (n = 91) stones, and, among stone formers, those with symptoms (n = 66) and silent (n = 29) were compared. Results: There was no significant difference between stone formers and nonstone formers with respect to biochemical parameters. Patients with silent renal stones had significantly lower serum calcium and higher phosphate, than those with symptomatic stones. Most (75%) patients with silent renal stones had microlithiais, while only a fifth (22%) with symptomatic renal stones had microlithiasis. Conclusion: Nephrolithiasis is a common complication of PHPT. Most patients with silent renal stones had microlithiasis and biochemical features of less severe disease. Patients with silent renal stones may represent early mild stage of PHPT.
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Adverse effect profile and effectiveness of sodium glucose co-transporter 2 inhibitors (SGLT2i) - A prospective real-world setting study p. 50
Harmandeep Kaur Gill, Parjeet Kaur, Shama Mahendru, Ambrish Mithal
Background: Clinical trials have shown promising results in terms of glycemic control and weight reduction with the use of sodium glucose co-transporter 2 inhibitors (SGLT2i) in type 2 diabetes mellitus (T2DM). However, real-world evidence from standard clinical practice especially from Asia is still limited. The aim of this study was to evaluate the safety and effectiveness of SGLT2i in patients with T2DM in real-world setting. Methods: This was a prospective observational longitudinal study involving consecutive patients with T2DM, initiated on SGLT2i from 1 April 2015 to 31 March 2016. The adverse effects and metabolic parameters were evaluated at 3 monthly intervals up to 1 year. Results: Total 486 patients were initiated on SGLT2i. At baseline, mean age, glycosylated haemoglobin (HbA1c), and weight was 51.03 ± 9.82 years, 8.76 ± 1.59%, and 89.32 ± 16.04 kg, respectively. Data of 388 patients were available at 6 months of follow-up for analysis of adverse effects profile. About 38.6% patients experienced adverse effects. Genitourinary tract infection was the most common adverse effect (20.6%) followed by generalized weakness (10.5%). Significant reduction in mean weight and HbA1c reduction seen at 6 months (n = 202): 3.2 kg and 1.26%, respectively, and at 12 months (n = 104): 3.9 kg and 1.27%, respectively. Conclusion: In this real-world study of patients with T2DM living in hot climate, use of SGLT2i was associated with adverse effects in higher proportion of patients than those reported in clinical trials, but effectiveness was comparable. Patient guidance regarding adequate hydration and hygiene can maximize the benefits of this promising class of drugs.
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Prolactin-adjusted ACTH ratio in predicting lateralization of acth source during simultaneous bilateral inferior petrosal sinus sampling in patients with Cushing's disease p. 56
Kush Dev Singh Jarial, Anil Bhansali, Kanchan K Mukherjee, Rimesh Pal, Vivek Gupta, Akhilesh Sharma, Rakesh K Vasishta, Suja P Sukumar, Naresh Sachdeva, Rama Walia
Introduction: Prolactin-adjusted adrenocorticotropic hormone (ACTH) ratio is used to improve the diagnostic accuracy of bilateral inferior petrosal sinus sampling (BIPSS) for lateralization of pituitary adenoma. Objective: To study the use of prolactin for successful catheterization during BIPSS, the role of prolactin-normalized ACTH ratio for confirmation of Cushing's disease (CD) and prolactin-adjusted ACTH ratio in predicting the lateralization. Patients and Methods: BIPSS was done in patients with CD; prolactin-adjusted ACTH ratio was compared with intersinus ACTH ratio, magnetic resonance imaging, and intraoperative findings for localization of pituitary adenoma. Histopathology was taken as “gold standard” for the diagnosis of CD. Results: Eight patients underwent BIPSS. All the patients underwent transsphenoidal surgery. All these patients had proper venous sampling during BIPSS as determined by inferior petrosal sinus (IPS):Peripheral prolactin ratio of ≥1.8. Prolactin-normalized ACTH ratio of ≥1.3 was achieved in all the eight patients, which was consistent with the diagnosis of CD. Concordance of intersinus ACTH ratio ≥1.4 with the intraoperative findings was found in five of eight (62.5%) patients depicting correct lateralization. Concordance of prolactin-adjusted ACTH ratio with intraoperative findings was found in four of eight (50%) patients. Seven of eight patients had concordance of intersinus ACTH ratio with prolactin-adjusted ACTH ratio. Conclusion: Prolactin is a useful marker for successful catheterization, confirming the diagnosis of CD during BIPSS, and prolactin-adjusted ACTH ratio does not add to the accuracy of lateralization of pituitary adenoma compared with intersinus ACTH ratio.
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Sex hormone levels – Estradiol, testosterone, and sex hormone binding globulin as a risk marker for atherosclerotic coronary artery disease in post-menopausal women p. 60
Darvin V Das, Uma K Saikia, Dipti Sarma
Context: Sex hormones levels determine the risk of occurrence of coronary artery disease (CAD) in post-menopausal (PM) women. Aims: To investigate the relationship between sex hormones (estradiol and testosterone)/sex hormone binding globulin (SHBG) and cardiovascular risk factors in PM women. In addition, we learned the association between these sex hormones/SHBG and the occurrence of atherosclerotic CAD event in PM women. Settings and Design: Cross-sectional case- control study. Subjects and Methods: Subjects recruited in the present study were from the cardiology outpatient clinic or Emergency department Guwahati Medical College and Hospital, Assam. The subjects were grouped into two categories after appropriate exclusion criteria: Cases – PM women with documented CAD (n = 40) and controls – Healthy PM women (n = 30). The medical history, clinical examination, and investigations including serum estradiol, total testosterone, SHBG, free testosterone index (FTI), high-sensitivity C-reactive protein (hs-CRP), lipid profile, carotid intima-media thickness (CIMT), fasting plasma glucose (FPG), and postprandial plasma glucose (PPPG) were done and analyzed. Statistical Analysis Used: Pearson correlation between sex hormones and CAD risk factors was done. The association between sex hormones and CAD risk factors among PM women was analyzed by multiple logistic regression. The statistical significance was set at the 0.05 level. Results: The mean age of all the subjects was 62.27 ± 6.9 years. Among the cases, a significant positive correlation was found between total testosterone/FTI and waist circumference, W/H ratio, triglyceride levels, hs-CRP, and CIMT (P < 0.01). In addition, a significant negative correlation was found between total testosterone and FTI with high-density lipoprotein-cholesterol levels (P < 0.01). The multiple logistic regression analysis showed that total testosterone levels (P < 0.01) and SHBG (P < 0.01) are independently associated with the occurrence of atherosclerotic CAD in PM. Conclusion: We conclude that increased serum testosterone levels and low SHBG in PM women are associated with the development of atherosclerotic cardiovascular risk factors.
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Focused parathyroidectomy under local anesthesia – A feasibility study p. 67
Supriya Sen, Anish Jacob Cherian, Pooja Ramakant, K Reka, MJ Paul, Deepak Thomas Abraham
Purpose: We conducted this study to evaluate the feasibility, patient satisfaction, and cost of performing focused parathyroidectomy under local anesthesia (LA) and mild sedation, administered and monitored by a surgeon. Materials and Methods: This was a prospective observational study of 30 patients with primary hyperparathyroidism (PHPT) undergoing a focused parathyroidectomy under LA and mild sedation at a single institution. The clinical features, gland weight, operating time, procedure time, postoperative pain scores, overall patient satisfaction, postoperative nausea and vomiting, analgesic requirements, complications, cost, and cure rates were documented. Data were analyzed using SPSS software version 17.0. Results: In two patients (6.7%), the procedure had to be completed under general anesthesia (GA). Postoperative temporary hypocalcemia was witnessed in 14 of 30 (46.7%), but only 1 required intravenous calcium infusion. About 21 of 30 (75%) were completely satisfied with LA, whereas 25 of 30 (89%) were completely satisfied with surgical procedure. Furthermore, all patients were keen to recommend this procedure under LA to their friends and family. Comparing the cost between performing the procedure under LA with that under GA, a significant difference was witnessed (P = 0.001). Among the 26 patients reviewed at 6 months, all had a normal serum calcium and parathyroid hormone levels indicating 100% cure rate. Conclusion: Performing focused parathyroidectomy under LA is feasible; additionally, this method can significantly reduce the cost of the procedure (P = 0.001).
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The effect of a high-intensity interval training on plasma vitamin D level in obese male adolescents p. 72
Rouhollah Haghshenas, Zahra Jamshidi, Saeid Doaei, Maryam Gholamalizadeh
Background: The worldwide increasing vitamin D deficiency in adolescents is alarming. The effect of high-intensity trainings on adolescent health is not clear. Object: This study aimed to examine the effect of a high-intensity interval training (HIIT) on plasma level of vitamin D in overweight male adolescents. Materials and Methods: About 96 overweight students aged 12–16 years from two high schools participated in the study. The schools were randomly assigned to the intervention group (n = 52) and the control group (n = 44). For the intervention group, HIIT was performed 3 days per week for 8 weeks, while the control group was asked to walk outdoors at the same time. Results: At the end of the study, the vitamin D level was increased to 1.21 ng/dl in the intervention group, whereas it decreased to 1.94 ng/dl in the control group (P = 0.003). Conclusion: About 8 weeks of HIIT improved plasma level of vitamin D in overweight male adolescents. More prolonged interventions consisted of both the sex and broader age ranges are warranted.
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Safety and efficacy of bipolar radiofrequency ablation device in hemostasis during thyroidectomy in comparison with ultrasonic scalpel: A comparative study p. 76
Sadeq G Kadem, Majid H Alabbood
Aim: Ultrasonic scalpel is one of the recent advances in surgical technology. The main limitation of their use is the cost. However, radiofrequency ablation device is a refined type of electrosurgical cautery that can be used with conventional reusable bipolar cautery forceps. This study aims to compare the efficacy of bipolar radiofrequency ablation device that can be used with conventional reusable bipolar cautery forceps for hemostasis and dissection during thyroidectomy with that of ultrasonic scalpel. Materials and Methods: Sixty patients underwent total thyroidectomy were recruited at Alshiffa General Hospital, Basrah, Iraq from March 2016 to June 2017. The participants were divided into two equal groups: in the first group thyroid dissection was done with ultrasonic scalpel, and in the second group thyroid dissection was done with bipolar radiofrequency ablation device. Outcome and complications of both procedures were analyzed statistically and compared. Results: The bipolar radiofrequency ablation device significantly reduced the mean operative time by (−15.35 min) in comparison to ultrasonic scalpel. The Bipolar Radiofrequency Ablation Device (BRFA) group reported a mean operative time of 50.13 ± 14.16 compared to 65.49 ± 7.78 in the US group with, P value = 0.001. There was no statistically significant difference in the other outcome parameters and the rate of complications reported between the two devices during this study. Conclusion: The bipolar radiofrequency ablation device that can be used with conventional reusable bipolar cautery forceps is a simple, safe, and time-saving adjunct for thyroid surgeries and equally effective as compared to costly instruments like ultrasonic scalpel.Clinical Significance: The bipolar radiofrequency device can be used in thyroid surgery to secure hemostasis, save time, and cost.
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Vitamin D status of school children in and around Guwahati p. 81
Dipti Sarma, Uma K Saikia, Abhamoni Baro
Context: Peripubertal and adolescent children are vulnerable to vitamin D deficiency as this is the period of rapid skeletal growth. Aims: This study was done to assess the vitamin D status in school children between the age of 8–14 years attending the government schools in rural and urban areas of Assam in Northeast India. Settings and Design: This was a cross-sectional observational study. Materials and Methods: About 500 students (350 from rural and 150 from urban areas) were recruited in the study. Serum 25-hydroxy vitamin-D [25(OH)D], parathyroid hormone (PTH), calcium, phosphorus and alkaline phosphatase were measured in fasting state. Daily nutrition intake and sunlight exposure were assessed. Statistical Analysis: Student's t-test and Pearson correlation test were done to assess the association between different variables. P value <0.05 was considered significant. Results: The prevalence of vitamin D deficiency was 8.4% and vitamin D insufficiency was 14.2%. There was no significant difference of mean 25(OH)D levels and sun exposure between rural and urban children. Out of 42 children with vitamin D deficiency, 36 (85.7%) had sun exposure <20% and 41 (97.6%) had calcium intake < 1000 mg/day. The rural children had a higher calcium intake as compared to urban children (P = 0.005). There was a significant positive correlation of mean 25(OH)D levels with serum calcium, sun exposure and calcium intake. Conclusion: The prevalence of vitamin D deficiency in peripubertal and adolescent age group children in and around Guwahati city of Assam is comparatively lower than that in other parts of the country.
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Risk assessment of diabetes using the Indian diabetes risk score: A study on young medical students from Northern India p. 86
Mongjam Meghachandra Singh, Vipra Mangla, Ruchira Pangtey, Suneela Garg
Context: Identification of risk factors of diabetes is required among youth as diabetes in young persons is now spreading in epidemic proportions. Indian Diabetes Risk Score (IDRS) is a validated and cost- effective tool to identify risk of diabetes among population. Aims: Present study was conducted among young medical students to assess risk of type 2 diabetes mellitus (T2DM) using the IDRS and to study association of risk of diabetes with other factors. Materials and Methods: A cross-sectional study was conducted among 290 first grade medical students from July 2017 to December 2017. A semi-structured interview schedule was developed for data collection. Written informed consent was taken. Statistical Analysis Used: SPSS version 25 was used for data analysis. 'P' < 0.05 was considered as statistically significant. Results: A total of 290 medical students were included in the study. IDRS categorization revealed 77%, 22% and 1% students in low-, moderate- and high-risk category, respectively. Statistically significant association of moderate-high diabetes risk with male gender, positive family history of diabetes, no/mild physical activity and body mass index (BMI) ≥23 kg/m2 was seen. Conclusion: Present study findings has brought forth that large number (23%) of young medical students were in moderate-high risk category of developing T2DM and health professionals should be more vigilant in young obese males with minimal physical activity and positive family history of disease. Hence, there is a pressing need for bringing out behaviour change communication among young medical students so that risk reduction strategies and lifestyle changes can be implemented in early years of their lives.
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Impact of anemia and red cell indices on the diagnosis of pre-diabetes and diabetes in Indian adult population: Is there a cut-off guide for clinicians? p. 91
Subramanian Kannan, Chinthala Jaipalreddy, Vellaichamy Muthupandi Annapandian, Bangalore Venkatraman Murali Mohan, Sharat Damodar, Kranti Shreesh Khadilkar, Kumbenahalli Siddegowda Shivaprasad
Background: It is well known that anemia and red cell turn over affects the HbA1c value. Iron deficiency anemia increases the HbA1c and haemolytic anemia lowers it. However, the cut-off of haemoglobin (Hb) or red-cell indices when the HbA1c value becomes unreliable is not known. Aim: We sought to find out values of HbA1c and red-cell indices where there is considerable discordance between HbA1c and plasma glucose (PG) values in the diagnosis of diabetes (DM) and pre-diabetes (Pre-DM) making HbA1c values unreliable. Methods: A cross-sectional study of 237 non-diabetic subjects who attended our out-patient division of preventive health check-up clinics, between November 2016 and December 2017. Data was collected only from relatively healthy subjects who had voluntarily opted for undergoing a preventative health check-up (including a diabetes screening). Patients were classified as concordant (fasting and 2-hr post meal glucose values are in agreement with HbA1c) and discordant (values are not in agreement with HbA1c). Results: A total of 237 patients (73% males) with mean age was 47.2±9.7 years (range 25-75) were included in the study. The HbA1c definition group had more diagnosis of DM (153 vs 96) and but lesser numbers of pre-DM (66 vs 102) compared to the PG group. Out of 237 patients, 133 (56%) showed concordance and 104 (44%) were discordant. The FPG, 2h-PPBG and HbA1c are significantly higher in the concordant group. The Hb value and MCV were significantly higher (p<0.05) in concordant group whereas, RDW and platelets are significantly higher (p<0.05) in discordant group. The highest rate of discordance was noted in the HbA1c strata of 6.5-7% (72%) followed by HbA1c of 5-6.4% (42%) and least in the HbA1c strata >7% (20%). While no single Hb or MCV value could predict discordance, a RDW value >17 was consistently associated with discordance across all the HbA1c strata. Conclusion: A HbA1c below 7% is significantly influenced by red-cell turn over indices and clinicians need to perform additional testing using plasma glucose levels to confirm the presence of diabetes or pre-diabetes. In patients whose RDW >17, HbA1c should be replaced by 75gm OGTT as a test of choice for diagnosis of diabetes or pre-diabetes.
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Utility of a commercially available blood steroid profile in endocrine practice p. 97
Vijaya Sarathi, Sridevi Atluri, TV S. Pradeep, Sindhu S Rallapalli, Chintala V Rakesh, Tirupati Sunanda, K Dileep Kumar
Background: A blood steroid profile has recently become available on commercial basis in India. In this study, we report our initial experience with the use of steroid profile in the evaluation of disorders of sex development (DSD) and suspected cases of congenital adrenal hyperplasia (CAH) and discuss the potential scenarios in endocrine practice that may benefit from this steroid profile. Materials and Methods: The study included six subjects. Patient 1 was a 46, XX girl who presented with peripubertal virilization, patient 2 was a girl who presented with normal pubertal development, secondary amenorrhea, and virilization, and patient 3 was a girl who presented with primary amenorrhea and virilization. These three patients were suspected to have CAH but had non-diagnostic serum 17 OH-progesterone levels. Patient 4 and 5 were 46, XY reared as girls who presented with primary amenorrhea alone and primary amenorrhea and virilization, respectively, and sixth subject was a heathy volunteer. All subjects were evaluated with blood steroid profile by Liquid chromatography tandem mass spectrometry (LC-MS/MS). Results: Patient 1 and 2 were diagnosed to have 11 β-hydroxylase deficiency by using the steroid profile. Patient 3 was suspected to have CAH, but the steroid profile excluded the diagnosis and helped to confirm the diagnosis as polycystic ovary syndrome. In patient 4 and patient 5, although steroid profile ruled out the possibility of steroidogenesis defects, it did not help to reach at the specific diagnosis. Conclusion: The blood steroid profile used in this study is most useful for the diagnosis of 11 β-hydroxylase deficiency. The utility of this test is limited in the evaluation of 46, XY patients with under-virilization.
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Development and validation of a questionnaire assessing knowledge, attitude, and practices about obesity among obese individuals p. 102
SR Reethesh, Piyush Ranjan, Charu Arora, GS Kaloiya, Naval K Vikram, Sada N Dwivedi, Viveka P Jyotsna, Manish Soneja
Aim: The objective of this study was to develop and validate a knowledge, attitude, and practice (KAP) questionnaire about obesity among obese individuals. Materials and Methods: The questionnaire was developed following a standardized protocol that consisted of literature review, focused group discussions, and expert opinion. A cross-sectional survey on 100 obese individuals was carried out to validate the tool. Exploratory factor analysis was performed, using principal component with varimax rotation, to establish the construct validity of the questionnaire. Internal consistency of the questionnaire was tested using Cronbach's α coefficient. Results: KAP questionnaire with 42 items categorized under three domains knowledge, attitude, and practices was developed. The KAP sections have 14, 15, and 13 items, respectively. Independent Cronbach's α for KAP domains were 0.75, 0.75, and 0.63, respectively, indicating good internal consistency. Conclusion: The developed questionnaire will be helpful in achieving better understanding of the patients' KAP about obesity. It has satisfactory validity and good internal consistency.
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Polymorphic analysis of leptin promoter in obese/diabetic subjects in Kashmiri population p. 111
Rubiya Dar, Shabhat Rasool, Ajaz Ahmad Waza, Gazalla Ayoub, Meenu Qureshi, Abdul Hamid Zargar, Iftikhar Bashir, Tariq Jan, Khurshid Iqbal Andrabi
Background: The role of common variants in leptin promoter has already been established to play a major role in obesity and diabetes in humans. The study was accordingly focused on leptin promoter variants and their potential association with diabetes and obesity in ethnic population from Kashmir, India. Methods: Allele frequencies of 620 Kashmiri subjects with diabetes (200), obese subjects (200), and ethnically matched healthy controls (200) were tested for the Hardy–Weinberg disequilibrium. Among 200 obese subjects, a total of 50 persons were with diabetes. The genotype and allele frequencies were evaluated using the Chi-square or Fisher's exact tests. Results: Sequence analysis revealed two reported variations i.e., rs72563764C>T and rs7799039G>A in promoter region. Both variants show homozygous as well as heterozygous genotypes. These variations indicated significant difference with respect to allelic and genotypic frequencies in all groups i.e., persons with diabetes, obese, and obese persons with diabetes (P < 0.05). We also analyzed the association of these variations with biochemical characteristics and found significant association of rs72563764C>T with triglycerides (TG) in obese patients and fasting plasma glucose (FPG) and random blood sugar (RBS) in obese/persons with diabetes. Also rs7799039G>A showed association with postprandial plasma sugar (PPPS) in obese patients and FPG and resting plasma glucose (RPG) in obese persons with diabetes. Conclusions: Our results are suggestive of the association of leptin promoter gene variations i.e., rs72563764C>T and rs7799039G>A with both diabetes and obesity.
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Response to zoledronic acid in patients with active Paget's disease of bone: A retrospective study p. 117
Harsh Durgia, Jayaprakash Sahoo, Sadishkumar Kamalanathan, Rajan Palui, Ritesh Kumar, Dhanapathi Halanaik, Ramesh Ananthakrishnan, Gowri Sankar, Kalyani Sridharan, Henith Raj
Background: Traditionally, bisphosphonates are used to treat active Paget's disease of bone (PDB). Intravenous zoledronic acid (ZA) is the most effective treatment option leading to sustained remission. Objective: The primary objective of this study was to analyze the effect of intravenous ZA in patients with active PDB in a tertiary care center of India. Materials and Methods: Retrospective data of 13 patients with active PDB who received a single dose of 4 mg intravenous ZA at our institute from January 2011 to June 2017 were reviewed. Response to therapy was monitored clinically, biochemically by serum alkaline phosphatase (ALP), and scintigraphically by 99m-Technetium methylene diphosphonate bone scan. Results: All of our patients reported relief of bone pain. The mean duration of follow-up in our study was 35.2 ± 16.8 months. Serum ALP levels reduced significantly from 1190.9 ± 666.1 IU/L (n = 13) at baseline to 200.5 ± 68.4 IU/L (n = 13) at 6 months (P < 0.001). ALP level at 1 year was 174 ± 33.6 IU/L (n = 12), which remained stable till 36 months at 176.5 ± 50 IU/L (n = 8). This indicates that remission achieved by 6 months post ZA is sustained for at least 3 years. Scintigraphic ratio reduced from 9.6 [interquartile range (IQR) 5.25–18.2] at baseline to 2.7 (IQR 1.20–4.05) at follow-up (P < 0.001). Similarly, scintigraphic index of involvement reduced from 9.9 (IQR 5.6–28.5) at baseline to 3 (IQR 2–4) at follow-up (P = 0.018). Conclusion: A 4 mg single dose of intravenous ZA results in clinical, biochemical, and scintigraphic response that is sustained for at least 3 years.
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Role of procalcitonin as a predictor of clinical outcome in acute diabetic foot infections: A prospective study p. 122
Adlyne R Asirvatham, Usha Menon, Praveen V Pavithran, Jayakumar R Vasukutty, Harish Kumar, Nisha Bhavani, Arun Menon, Vasantha Nair, Vivek Lakshmanan, Ajit K Varma, Mangalanandan T Sukumaran, Arun Bal
Background: Prediction of outcome in diabetic foot infection (DFI) remains difficult due to lack of active signs of infection, and apparently normal white blood cell (WBC) count. Erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) have been studied previously in this regard and were not useful. Hence, we evaluated procalcitonin (PCT) as a prognostic marker in this study. Objectives: We aimed to study the role of PCT, CRP, and ESR levels in predicting clinical outcome of acute DFI. Materials and Methods: A total of 250 subjects (197 men, 53 women) with acute DFI were enrolled. WBC count, ESR, CRP, and PCT were done for all subjects at admission after obtaining informed consent. Subjects were managed according to hospital protocol and followed up for 1 month. Clinical outcome was assessed based on mobility and morbidity status of the subject. Results: Old age, anemia, hyponatremia, hypoalbuminemia, and elevated serum creatinine were risk factors for poor outcome. Presence of cardiac failure, diabetic retinopathy, peripheral vascular disease, previous amputations, and positive bone culture had negative influence on clinical outcome. Elevated WBC count, ESR, CRP, and serum PCT were significantly associated with bad outcome. Elevated PCT (>2 ng/ml) [odds ratio (OR) (95% confidence interval (CI)), 2.03 (1.13–5.19), P < 0.001], gangrene [OR (95% CI), 2.2 (1.02–4.73), P = 0.04], and sepsis [OR (95% CI), 10.101 (4.34–23.25), P < 0.001] were good predictors of clinical outcome in acute DFI. Conclusion: PCT proved to be a reliable marker of acute DFI and good predictor of clinical outcome than existing markers WBC count, ESR, and CRP. Hence it should be useful for clinicians while managing acute DFI.
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Heart failure hospitalization with DPP-4 inhibitors: A systematic review and meta-analysis of randomized controlled trials p. 128
Awadhesh Kumar Singh, Ritu Singh
Background: Heart failure hospitalization (hHF) with dipeptyl-dipeptidase-4 inhibitors (DPP-4Is) remains at the center stage since the publication of Saxagliptin Assessment of Vascular Outcomes Recorded in Patients with Diabetes Mellitus – Thrombolysis in Myocardial Infarction (SAVOR-TIMI) in 2013 showing significant increase with saxagliptin, compared to placebo. This outcome led to additional label of hHF to both saxagliptin and alogliptin in April 2016 and eventual labelling of hHF to all the four approved DPP-4Is in United States in August 2017, by US Food Drug Administration. To note, neither Trial Evaluating Cardiovascular Outcomes with Sitagliptin (TECOS), nor Cardiovascular and Renal Microvascular Outcome Study with Linagliptin (CARMELINA), showed any signals of hHF with these two agents. These developments have seriously generated an uncertainty among clinicians with regards to hHF effect of DPP-4Is in type 2 diabetic patients with high risk of cardiovascular (CV) disease. Aims and Objectives: We systematically searched the database of PubMed, Embase, Cochrane Central library, ClinicalTrials.gov, and International conference presentation from the inception up to October 25, 2018 using MeSH and specific key words. We retrieved all those studies that explicitly looked for hHF as a prespecified end point and were conducted for ≥52 weeks. Subsequently, we conducted the meta-analysis using comprehensive meta-analysis software Version 3, using different sensitivity analysis to study the effect of DPP-4Is on hHF in both dedicated CV outcome trials as well as randomized controlled trials. Results: The meta-analysis of four exclusive dedicated CV outcome trials (N = 43,522) did not find significant increase in hHF with DPP-4 inhibitors (Fixed model Relative Risk [RR] 1.06; 95% Confidence Interval [CI], 0.96-1.17; P = 0.25; I2: 53.95%, tau2: 0.012, P = 0.089). Meta-analysis of all randomized controlled trials that explicitly looked for hHF for ≥52 weeks (N = 48,199) also did not show any significant increase in hHF (fixed model peto odds ratio 1.05; 95% CI 0.95–1.15, P = 0.36; I2: 43.74%, tau2: 0.016, P = 0.10). Conclusions: This meta-analysis suggests no significant increase in hHF with DPP-4 inhibitors, although a nonsignificant heterogeneity across the trials might limit this observation.
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Uric acid and its correlation with various metabolic parameters: A population-based study p. 134
Pradip Mukhopadhyay, Sujoy Ghosh, Kaushik Pandit, Purushottam Chatterjee, Bikash Majhi, Subhankar Chowdhury
Introduction: Uric acid, apparently an inert waste product, was found to have association with various metabolic disorders. The data regarding prevalence of serum uric acid (SUA) abnormalities and its correlation with other anthropo-metabolic parameters, however, are scanty. Materials and Methods: In all, 405 participants from a rural area were investigated for various metabolic parameters including uric acid. SUA level was evaluated for having any correlation with other anthropometric and metabolic disorders like obesity, dyslipidemia, metabolic syndrome (MetS), hypertension, calcium and vitamin D abnormalities, liver function, and glycemic alterations. Lean MetS is defined as those having waist criteria below the region specific waist criteria and even then satisfying the definition of MetS as per the National Cholesterol Education Program (NCEP) ATP-III (Adult Treatment Panel) criteria. Results: The mean uric acid was 4.2 mg/dL (±1.35), with 4.9 mg/dL (±1.28) for males and 3.7 mg/dL (±1.14) for females. Thirteen of 405 people (3.2%) found to have uric acid level of more than 7.0 mg/dL, and eight people out of 405 (2.0%) had hypouricemia. SUA showed correlation with age, blood pressure, and the anthropometric parameters for obesity, for example, weight, body mass index, waist circumference, waist hip ratio, waist height ratio, fasting insulin, Homeostatic Model Assessment of Insulin Resistance (HOMA-IR), low-density lipoprotein (LDL)-cholesterol, high-density lipoprotein (HDL)-cholesterol, and triglycerides. However, fasting glucose, calcium, phosphate, 25-hydroxy vitamin D3, and iPTH did not show any correlation with the SUA level. Compared to the healthy population, SUA level was elevated in MetS as defined by International Diabetes Federation (IDF) criteria. However, the SUA in healthy population was not significantly different from the Lean MetS, and SUA of Lean MetS was not significantly different from Obese MetS. Conclusion: SUA is elevated in MetS compared to the normal population. However, SUA in Lean MetS is not different from Obese MetS.
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Sodium glucose co-transporter-2 inhibitor: Benefits beyond glycemic control p. 140
Manash Pratim Baruah, BM Makkar, Vikrant B Ghatnatti, Kaushik Mandal
Type 2 diabetes mellitus (T2DM) is a family of metabolic disorders characterized by hyperglycemia as a consequence of abnormalities in insulin secretion and insulin sensitivity. It affects hundreds of millions of people worldwide and leads to increased morbidity, compromised quality of life, higher mortality sodium glucose co-transporter 2 (SGLT2) inhibitors, a new class of oral antidiabetic drugs, have garnered considerable attention in the recent past and are considered potential first-line candidates for the management of T2DM. This review outlines the evidence-based therapeutic efficacy, safety, limitations, and advantages of SGLT2 inhibitors in the management of T2DM. SGLT2 inhibitors work by preventing the kidneys from reabsorbing glucose back into the blood, leading to increase in excretion of glucose through urine, thereby lowering hyperglycemia. Treatment with SGLT2 inhibitors improves A1C levels, reduces blood pressure and body weight, and is overall well tolerated by patients with T2DM. However, additional data on long-term cardiovascular safety are still needed. Characteristic adverse events include mild genital - urinary tract infection more commonly seen in women than in men, but serious infection is uncommon. Their use should be exercised with extra caution in patients suffering from renal impairment. Further, advancing to dual/triple combinational therapies with SGLT2 inhibitors and existing oral antidiabetic options may prove to be a breakthrough in the management of T2DM.
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Cardiovascular effects of sodium glucose co-transporter-2 inhibitors in patients with type 2 diabetes mellitus p. 150
Surender Kumar, Pradeep G Talwalkar, Sambit Das, Soumik Goswami
Type 2 diabetes mellitus (T2DM), the leading type of diabetes, has a typical association with coronary heart disease. In India, patients with diabetes are at an increased risk of developing coronary disease as compared to people without diabetes and this suggests the requirement of intensive treatment of cardiovascular (CV) risk factors. Consequently, there is a need for an intervention that could target CV risk factors in multiple paths beyond hyperglycemic control alone. Although metformin is the mainstay of treatment in most of the patients with T2DM, a second line of treatment with anti-hyperglycemic agent is warranted in patients with T2DM in the management of CV risk factors beyond glycemic control. Sodium glucose co-transporter-2 (SGLT-2) inhibitors, the oral hypoglycemic drug, that act independent of insulin secretion are associated with a reduced risk of hypoglycemia which is associated with the increased risk of CV events. Moreover, it has been observed that the use of SGLT-2 inhibitors in patients with T2DM is associated with reductions in blood pressure and body weight beyond improved glycemic control. In this article, the clinical efficacy, safety, and tolerability of SGLT-2 inhibitors on glycemic, nonglycemic parameters, and CV outcome including data from the EMPA-REG OUTCOME study are discussed. The EMPA-REG OUTCOME study is the first CV outcome study that demonstrated the association of a glucose lowering agent with the reduced CV mortality and all-cause mortality, and reduced hospitalization for heart failure in patients with T2DM at high risk of CV events. Although the mode of action associated with the CV benefits remains unknown, data from ongoing trials including DECLARE-TIMI (Dapagliflozin Effect on CV Events) and CANVAS (Canagliflozin CV Assessment Study) trials potentially can validate the class-effect for SGLT-2 inhibitors regarding the CV outcomes.
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Endocrine manifestations of Von Hippel–Landau disease p. 159
Roma Pradhan, Nelson George, Kaushik Mandal, Amit Agarwal, Sushil K Gupta
Von Hippel–Lindau (VHL) disease is an autosomal dominant disorder characterized by various endocrine, nonendocrine, benign, and malignant tumors in various organs. VHL tumor suppressor gene, located on short arm of chromosome 3 is responsible for this. Pheochromocytoma (PCC) is one of the important endocrine manifestations that needs to be ruled out in case of VHL suspicion. In this review, we summarize the endocrine manifestations of VHL disease and their management while giving case history of five such cases.
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Fournier's gangrene and sodium-glucose co-transporter 2(SGLT2) inhibitors: Our experience p. 165
Ashwitha S Dass, Gloria Immaculate, Arpandev Bhattacharyya
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Juvenile autoimmune hypothyroidism and gender dysphoria: A causal relationship or a casual coincidence? p. 166
Anne Beatrice, K Sumana, Manoj Gopinath Mengade
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Low bone mass and Klinefelter syndrome p. 167
Kalyani Sridharan, Nitin Kapoor, Thomas Vizhalil Paul
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Hypokalemic periodic paralysis and spectrum of thyroid disorders: Analysis of 7 cases from Northern India p. 168
Ajay Aggarwal, Roopak Wadhwa, Arun Pande, Monashish Sahu, Dheeraj Kapoor, Rajeev Khanna
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Could the glycemic gap fill the unfilled gaps? p. 171
Francesco Gavelli, Filippo Patrucco
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