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   Table of Contents - Current issue
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November-December 2017
Volume 21 | Issue 6
Page Nos. 791-935

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EDITORIALS  

Endocrinology and the nudge hypothesis Highly accessed article p. 791
AG Unnikrishnan, Sujoy Ghosh, Subhankar Chowdhury
DOI:10.4103/ijem.IJEM_630_17  PMID:29285435
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Pentads and hexads in diabetes care: Numbers as targets; Numbers as tools p. 794
Sanjay Kalra, Manash P Baruah, Rakesh Sahay, Kamal Kishor
DOI:10.4103/ijem.IJEM_281_17  PMID:29285436
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ORIGINAL ARTICLES Top

The effect of electromagnetic radiation due to mobile phone use on thyroid function in medical students studying in a medical college in South India Highly accessed article p. 797
Nikita Mary Baby, George Koshy, Anna Mathew
DOI:10.4103/ijem.IJEM_12_17  PMID:29285437
Background: Enormous increase in mobile phone use throughout the world raises widespread concerns about its possible detrimental effect on human health. Radiofrequency waves are emitted by cell phones. They are non-ionising and the effect on the thyroid gland is part of their non thermal effects. The thyroid gland may be particularly vulnerable to this effect because of its normal anatomical position. Materials and Methods: The study was done to explore the association between radiation exposure and thyroid dysfunction among mobile phone users. It had an exploratory design and unit survey method to collect information from all medical students in a medical college in South India. Inclusion criteria included active use of mobile phone prior to and during the study period. Criteria for exclusion was presence of pre-existsting thyroid disease,thyroid nodule,thyroid goitre/nodule and altered thyroid function. Results: The sample size was 83 undergraduate students. 71% of respondents had no family history of thyroid illness. Among the remainder,20.5% had a first degree relative with thyroid dysfunction,8.4% had a second degree relative affected. Clinical examination revealed that 79.5% of the respondents were normal,13.6% had thyroid swelling,3.6% had symptoms of thyroid dysfunction and 3.6% had both thyroid swelling and symptoms of thyroid dysfunction. 53% of the respondents spent 0.5 hrs on an average talking on the phone daily,28.9% spent 1.5 hrs daily and 10.8% of respondents spent over 3.5 hours. We found there was a significant correlation between total radiation exposure and an increase in TSH among both groups –in those with and without family history of thyroid illness. Conclusion: In our study there was a significant correlation between total radiation exposure and increasing TSH values among both all respondents.
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Neck circumference as a marker of overweight and obesity and cutoff values for Bangladeshi adults p. 803
Nazmul Kabir Qureshi, Tanjina Hossain, Mohammed Imrul Hassan, Nazma Akter, Md Mubinur Rahman, Moushumi Moriam Sultana, SM Ashrafuzzaman, Zafar Ahmed Latif
DOI:10.4103/ijem.IJEM_196_17  PMID:29285438
Objective: There are several methods of assessing overweight and obesity. Several studies conducted in different populations indicate that neck circumference (NC) can be used as a simple measure of overweight and obesity. This study was conducted to evaluate NC as a marker of overweight and obesity and to determine respective cutoff values for Bangladeshi male and female participants. Research Design/Materials and Methods: This cross-sectional observational study was conducted with during July 2013–June 2014 among randomly selected 871 Bangladeshi participants (male = 496 [56.9%], female = 375 [43.1%], aged >18 years) who visited Outpatient Department of United Hospital, Bangladesh Institute of Research and Rehabilitation in Diabetes, Endocrine and Metabolic disorders, primary health-care centers located in Dhaka, Savar, Gazipur. NC of participants was taken in centimeter to the nearest 1 mm, using plastic tape measure. Main outcome included NC, waist circumferences (WC), body mass index (BMI), and waist: hip ratio (WHR). Results: Pearson's correlation coefficients indicated a significant association between NC and height (men, r = 0.33; women, r = 0.28; P < 0.0001), weight (men, r = 0.61; women, r = 0.55; P < 0.0001), BMI (men, r = 0.51; women, r = 0.41; P < 0.0001), WC (men, r = 0.61; women, r = 0.46; P < 0.0001), hip circumference (men, r = 0.61; women, r = 0.44; P < 0.0001), WHR (men, r = 0.22; women, r = 0.18; P < 0.0001). Receiver operating characteristic curve analysis showed that NC ≥34.75 cm in men (area under curve [AUC]: 0.77; P < 0.001) and ≥31.75 cm in women (AUC: 0.62; P < 0.001) were the best cutoff value for BMI ≥23 (overweight). NC ≥35.25 cm in men (AUC: 0.82; P < 0.001) and NC ≥34.25 cm in women (AUC: 0.76; P < 0.001) were the best cutoff value for BMI ≥27.5 (obesity). NC ≥35.25 cm in male (AUC: 0.83; P < 0.001) and NC ≥31.25 cm in women (AUC: 0.65; P < 0.001) were the best cutoff value for WC >90 cm in men and > 80 cm in women, respectively. NC ≥34.45 cm in male (AUC: 0.59; P= 0.001) and NC ≥31.25 cm in women (AUC: 0.66; P = 0.008) were the best cutoff value for WHR >0.9 in men and >0.8 in women, respectively. Conclusion: NC measurement is a simple, convenient, inexpensive screening measure to identify overweight and obese participants. Men with NC ≥34.75 cm and women with NC ≥31.75 cm are to be considered overweight while men with NC ≥35.25 cm and women with NC ≥34.25 cm are to be considered obese. NC ≥35.25 cm in male and NC ≥31.25 cm in women were the best cutoff value for abdominal obesity.
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Incidence of endocrine disorders in Indian adult male population p. 809
K. V. S. Hari Kumar, SK Patnaik
DOI:10.4103/2230-8210.219335  PMID:29285439
Background: The comprehensive epidemiology of endocrine disorders is lacking from our country. Most of the available data pertain to the prevalence of diabetes and thyroid disorders only. We studied the incidence of endocrine disorders in a cohort of service personnel followed for a long duration. Materials and Methods: The data for this descriptive epidemiologic study were derived from the electronic medical records of the male service personnel enrolled between 1990 and 2015. They were recruited between the ages of 17 and 20 years in good health, and their morbidity data were derived from the medical records. We calculated the incidence rates as per person-years (py) using appropriate statistical methods. Results: Our analysis includes 51,217 participants (median: age 33 years, range: 17–54) with a mean follow-up of 12.5 years. Yearly evaluation of the data gave a cumulative follow-up duration of 613,925 py. The incidence of diabetes, obesity, and dyslipidemia was 0.41, 0.23, and 0.12 per 1000 py, respectively. The incidence of thyroid, parathyroid, pituitary, adrenal, and metabolic bone disorders was 3.9, 8.6, 1.6, 0.81, and 0.97 per 100,000 py, respectively. Conclusion: Our cohort had lower incidence rates of endocrine disorders when compared with the Western population. Long-term epidemiological studies are essential to identify the demographic trends of the endocrine disorders in India.
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Verbal episodic memory in young hypothyroid patients p. 812
Vatsal Priyadarshi Pandey, Tara Singh, SK Singh
DOI:10.4103/ijem.IJEM_170_17  PMID:29285440
Context: Hypothyroidism affects cognitive functions especially memory. However, most of the previous studies have generally evaluated older hypothyroid patients and sample size of these studies varied in terms of age range. Aims: To see whether hypothyroidism affects memory in young patients. Settings and Design: The sample consisted of 11 hypothyroid patients with an age of 18–49 and 8 healthy controls matched on age and education. Subjects and Methods: Verbal episodic memory was assessed using Hindi adaptation of Rey-Auditory Verbal Learning Test. Statistical Analysis Used: An independent t-test was used to see the difference between mean performance of the patient group and healthy control on memory measures. Results: Results indicated nonsignificant difference between verbal episodic memory of patient group and healthy controls. Conclusions: On the basis of these findings, it was concluded that hypothyroidism may not affect younger patients in terms of episodic verbal memory the same way as it does in the older patients.
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High-dose Vitamin D supplementation precipitating hypercalcemic crisis in granulomatous disorders p. 815
Vijaya Sarathi, Hareeshababu Karethimmaiah, Amit Goel
DOI:10.4103/ijem.IJEM_577_16  PMID:29285441
Background: Vitamin D supplementation precipitating hypercalcemic crisis is often the first manifestation in patients with granulomatous disorders. Methods: We report our experience on patients presenting with hypercalcemic crisis due to granulomatous disorder and the role of Vitamin D supplementation in the precipitation of hypercalcemic crisis in them. Results: The study included five patients with granulomatous disorders who presented with hypercalcemic crisis. All patients initially presented with nonspecific constitutional symptoms to other health-care centers to receive high-dose Vitamin D supplementation (60,000 U/week or 600,000 U intramuscular single dose). All of these patients presented with hypercalcemic crisis (serum calcium: 16.04 ± 0.3 mg/dl) to our centers after a period of 32.8 ± 9.62 days. Three patients were diagnosed to have sarcoidosis, and two were diagnosed to have tuberculosis. All five patients had parathyroid hormone-independent hypercalcemia with elevated serum 1,25-dihydroxy Vitamin D. Serum angiotensin-converting enzyme level was elevated in all the three patients with sarcoidosis. Fluorine-18-fluorodeoxyglucose positron emission tomography/computed tomography was performed in two patients with sarcoidosis which demonstrated diffusely increased tracer uptake in liver. In these two patients, liver biopsy confirmed the diagnosis. Conclusions: High-dose Vitamin D supplementation is most often the underlying cause of hypercalcemic crisis in patients with granulomatous disorders. Hence, high-dose Vitamin D supplementation should be used judiciously.
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Prevalence and etiological profile of short stature among school children in a South Indian population p. 820
Kumaravel Velayutham, S Sivan Arul Selvan, RV Jeyabalaji, S Balaji
DOI:10.4103/ijem.IJEM_149_17  PMID:29285442
Background and Objectives: Short stature (SS) is a common pediatric problem and it might be the first sign of underlying illness. Studies documenting the burden and etiological profile of SS are scarce from India and are mostly limited to data obtained from referral centers. Due to the lack of large-scale, community-based studies utilizing a standard protocol, the present study aimed to assess the prevalence and etiological profile of SS in school children of a South Indian district. Materials and Methods: In this cross-sectional study, children aged 4–16 years from 23 schools in Madurai district, Tamil Nadu, underwent anthropometric measurements and height was plotted in Khadilkar et al. growth chart. The cause of SS was assessed using clinical and laboratory evaluations in assigned children with a height less than third centile. Results: A total of 15644 children belonging to 23 schools were evaluated, and 448 (2.86%) children had SS. Etiological evaluation was further performed in 87 randomly assigned children, and it is identified that familial SS or constitutional delay in growth was the most common cause of SS in the study population (66.67%). Hypothyroidism and growth hormone deficiency were the two most common pathological causes of SS seen in 12 (13.79%) and 8 (9.20%) children, respectively. Malnutrition was the cause of SS in 6 (6.9%) children and cardiac disorders, psychogenic SS, and skeletal dysplasia were other identified causes of SS in the study. Interpretation and Conclusions: The overall prevalence of SS in school children was 2.86% and familial SS or constitutional delay in growth was the most common cause of SS. As a significant percentage of children with SS had correctable causes, monitoring growth with a standard growth chart should be mandatory in all schools.
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Cardiovascular risk factors in children and adolescents with subclinical hypothyroidism p. 823
Yogesh Yadav, Uma Kaimal Saikia, Dipti Sarma, Manoj Hazarika
DOI:10.4103/ijem.IJEM_153_17  PMID:29285443
Background: Subclinical hypothyroidism (SCH) is a commonly encountered entity in day-to-day clinical practice and has been associated with adverse cardiovascular risk profile in adults and children. Data on children and adolescents with SCH, from India, are limited. Materials and Methods: This study was a cross-sectional case–control study, conducted at a tertiary care center in Northeast India. Twenty-seven children and adolescents aged 11 ± 2.4 years with SCH and thyroid-stimulating hormone >7.5 mIU/L were included in the study along with 20 age-, gender-, and height-matched controls. Multiple clinical, biochemical, and radiological cardiovascular risk factors were assessed and compared between the two groups. Results: Body mass index (BMI) (P = 0.048), waist circumference (P = 0.008), waist to height ratio (P = 0.007), low-density lipoprotein cholesterol (P = 0.04), triglycerides (TGs) (P = 0.038), TGs to high-density lipoprotein (HDL) cholesterol ratio (P = 0.005), non-HDL cholesterol (P = 0.019), fasting insulin (P = 0.006), and homeostasis model assessment of insulin resistance (P = 0.007) were found to be significantly higher while free T4 (P = 0.002) and HDL cholesterol (P = 0.019) were found to be significantly lower in SCH subjects compared to controls. On multiple regression analysis, BMI was found to have significant association with multiple cardiovascular risk factors. Conclusion: Children and adolescents with SCH were found to have adverse cardiovascular risk profile. Long-term follow-up studies are required to assess the clinical significance of these findings and requirement for therapy.
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Optimal levothyroxine replacement adequately improves symptoms of hypothyroidism; Residual symptoms need further evaluation for other than hypothyroidism causation p. 830
Rekha Singh, Ashwani Tandon, Sushil Kumar Gupta, K Saroja
DOI:10.4103/ijem.IJEM_165_17  PMID:29285444
Objectives: Many patients with hypothyroidism complain of persistent residual symptoms, despite optimal treatment, although the similar prevalence is seen in patients with documented absence of thyroid disorder in primary health-care setup. We aimed to investigate symptomatic relief in new cases of primary hypothyroidism and compare with controls with other chronic conditions. Methods: This prospective case–control follow-up study enrolled patients from July 2014 to May 2015 in an endocrine outpatient clinic of a tertiary hospital. Controls were age- and gender-matched ambulatory individuals with well-controlled other chronic diseases and no major comorbidity. Thyroid symptom questionnaire (TSQ) was administered at pretreatment to all the cases and then they were started on levothyroxine (LT). At euthyroidism, TSQ was readministered. For controls, TSQ was administered only once. TSQ was measured on Likert scale 1-4 for lack of energy, dry skin, constipation, aches and pains, cold intolerance, poor memory, depression, weight gain, tiredness after walking, and difficulty in getting up (DGU). P < 0.05 was considered statistically significant. Results: A total of 194 cases (147 females and 47 males) and 259 controls (187 females and 72 males) were analyzed. A significant difference in the symptoms prevalence was seen between controls and pretreatment cases, except for DGU, and between subclinical and overt hypothyroidism. Pretreatment serum thyroid-stimulating hormone in cases correlated significantly with all their pretreatment symptoms score. All symptoms prevalence decreased significantly posttreatment. At euthyroidism, the mean symptoms score in posttreatment cases was similar or lower than the controls. Conclusion: LT effectively improves the symptoms of hypothyroidism in newly diagnosed cases of primary hypothyroidism. The residual symptoms need an alternation explanation other than hypothyroidism.
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Comparison of two protocols in the management of glucocorticoid-induced hyperglycemia among hospitalized patients p. 836
Om J Lakhani, Surender Kumar, Sudhir Tripathi, Mitali Desai, Chandani Seth
DOI:10.4103/ijem.IJEM_226_17  PMID:29285445
Context: There is limited literature focusing on the management of glucocorticoid-induced hyperglycemia (GCIH). Aims: The primary objective was to compare the mean blood glucose between the experimental group (new protocol) and the control group (standard protocol) in the management of GCIH. The secondary objective was to compare other parameters of glycemic efficacy, variability, and safety parameters. Methods: This was a randomized, open-labeled, parallel arm trial. Adult patients who were given glucocorticoid (minimum dose equivalent to prednisolone 10 mg) in the past 24 h and had 2 h postmeal plasma glucose ≥200 mg/dl were included in the study. Patients randomized to control group received standard basal-bolus insulin. In the experimental group, a “correctional insulin” matching the glycemic profile of the glucocorticoid administered was provided with or without “background” basal-bolus insulin. The parameters of glycemic efficacy, variability, and safety were compared. P < 0.05 was considered statistically significant. Results: Data of 67 patients included in the study were analyzed, of which 33 patients were in the experimental group and 34 patients in the control group. The mean blood glucose in the experimental and the control group was 170.32 ± 33.46 mg/dl and 221.05 ± 49.72, respectively (P = 0.0001). The parameters for glycemic variability were all significantly lower in patients in the experimental group. The hypoglycemia event rate was low in both the groups. Conclusion: When compared to the standard basal-bolus insulin protocol, the new protocol showed lower mean blood glucose and lower glycemic variability.
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Correlation between the cernea classification of external branch of superior laryngeal nerve in relation to the ultrasound-based volume of thyroid gland p. 845
Riju R Menon, Sreedutt Murali, C Gopalakrishnan Nair, Misha J. C. Babu, Pradeep Jacob
DOI:10.4103/ijem.IJEM_230_17  PMID:29285446
Introductíon: Goiter is a very common problem dealt with by surgeons. Surgical treatment of thyroid requires removal of a part (hemi) or whole of the gland (total thyroidectomy). The external branch of the superior laryngeal nerve (EBSLN) is an important but less researched structure to be preserved during surgery. Various studies have described the incidence of different types of EBSLN, but have not described regarding the relationship between the change in volume of the gland to the nerve. Materials and Methods: A prospective analysis of 100 patients who underwent total thyroidectomy in our department was done. All patients underwent preoperative ultrasonography and the volume of the gland was calculated. Intraoperatively, the EBSLN was identified and preserved prior to ligating the superior thyroid vessels. The nerve was classified as per the Cernea classification. The gland was divided into high and low volume, taking 20 ml as the cutoff. The incidence of Type 2 nerve in a low-volume gland was compared with that of a high-volume gland. Results: In 100 patients (200 nerves), 191 nerves were identified. The nerve was type 1 in 56/200 (28%), Type 2a in 116/200 (58%), and Type 2b in 19/200 (9%) patients. In large-volume glands, Type 2 nerve was more common (87%). Conclusion: Dissection of thyroid gland requires expertise to preserve the EBSLN. Large volume glands pose a more difficult challenge, as the gland is more closer to the nerve.
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Role of parathyroid hormone in determination of fat mass in patients with Vitamin D deficiency p. 848
Raman K Marwaha, MK Garg, Namita Mahalle, Kuntal Bhadra, Nikhil Tandon
DOI:10.4103/ijem.IJEM_42_17  PMID:29285447
Background: Obesity has become a global epidemic and it is rising is Asia. Vitamin D deficiency (VDD) is widely prevalent in the Indian subcontinent. Studies have linked VDD to obesity and shown correlation between parathyroid hormone (PTH), 25-hydroxy Vitamin D (25(OH)D), and fat mass (FM). However, studies on the role of PTH among subjects with VDD are lacking. Objective: The objective of this study is to study the role of PTH in the determination of FM in participants with VDD. Subjects: Five hundred and fifty-one adults (m:247, f:304) were included in this study. Materials and Methods: Total and regional (trunk, arm, and leg) FM was assessed by dual X-ray absorptometry. Biochemical and hormonal parameters such as calcium, phosphorus, alkaline phosphatase, ionic calcium, 25(OH)D, and PTH were also analyzed. Results: The mean age of the study population was 58.8 ± 15.8 years (Male: [63.3 ± 13.1], Female: [55.2 ± 16.9]). FM and body mass index were significantly lower in females with higher levels of serum 25(OH)D. Total FM was negatively correlated with serum 25(OH)D (r = −0.363, P < 0.0001) and positively correlated with serum PTH (r: 0.262, P < 0.0001) in females only. Females with VDD and secondary hyperparathyroidism had higher FM than those with normal PTH. Conclusions: Females with VDD had higher total and regional FM. However, this correlation was evident only in those with high serum PTH levels, suggesting a potential role of PTH in the accumulation of FM.
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Maternal and neonatal outcome in mothers with gestational diabetes mellitus p. 854
G Thiruvikrama Prakash, Ashok Kumar Das, Syed Habeebullah, Vishnu Bhat, Suryanarayana Bettadpura Shamanna
DOI:10.4103/ijem.IJEM_66_17  PMID:29285448
Introduction: Gestational diabetes mellitus (GDM) is common and is accompanied with other comorbidities. Challenges to treatment exist at our institute as it serves women with low income. This study assessed the burden of comorbidities and the outcome of GDM. Methods: This was a prospective, observational study of women with gestational diabetes attending the obstetrics department from September 2012 to April 2014. GDM was diagnosed based on the International Association of Diabetes and Pregnancy Study Groups criteria. Medical comorbidities were noted, and lipid profile was done. All the women were followed up till delivery, and the complications were recorded. Age- and parity-matched pregnant women with normal oral glucose tolerance test were recruited as controls. Results: One hundred and thirty-nine women were followed up till delivery. The average age was 28 years. Eighteen percent had bad obstetric history. The average body mass index was 28.8. Twenty-five percent had gestational hypertension (HTN), and 6.4% had chronic HTN. Thirty percent had hypothyroidism. 65% women received insulin. The glucose values were within the recommended range in 60% of the women. Maternal hypoglycemia occurred in 7 (5%) women. Forty-four percent of the women required cesarean section and 34% had complications either during pregnancy or labor. Three neonates had macrosomia. Twenty-six neonates (20%) required admission to the Neonatal Intensive Care Unit. Four neonates (3%) died. Newborns of mothers whose GDM optimally treated had less complications. Conclusion: Gestational diabetes is associated with HTN, hypothyroidism, obesity, and lipid abnormalities. The majority of women required insulin for treatment and optimal control of blood glucose resulted in lower neonatal complications.
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Carotid intima-medial thickness and glucose homeostasis in Indian obese children and adolescents p. 859
Aashima Dabas, Thushanth Thomas, Monita Gahlot, Nandita Gupta, K Devasenathipathy, Rajesh Khadgawat
DOI:10.4103/ijem.IJEM_112_17  PMID:29285449
Objective: To evaluate for subclinical atherosclerosis and its risk factors in Indian obese children. Materials and Methods: A cross-sectional, case–control study was conducted to recruit 80 children aged 6–17 years with constitutional obesity as cases and 23 age- and gender-matched controls with normal body mass index (BMI). Anthropometric and clinical evaluation was followed by biochemical analysis and body fat estimation by dual-energy X-ray absorptiometry in cases. Similar evaluation was performed for controls except laboratory parameters. Carotid intima-media thickness (CIMT) was measured with B-mode ultrasonography in both cases and controls to evaluate subclinical atherosclerosis. Results: The mean age of cases was 12.8 ± 3 years, with mean BMI of 29.2 ± 4.8 kg/m2. The mean CIMT was significantly higher in cases than controls (0.54 ± 0.13 vs. 0.42 ± 0.08; P < 0.001 across all ages). CIMT was significantly higher in participants who were hypertensive than nonhypertensive (0.6 ± 0.11 vs. 0.53 ± 0.11 mm; P = 0.04). CIMT showed a positive correlation with BMI (r = 0.23, P = 0.02), percentage body fat and fat mass index (r = 0.28 and 0.3 respectively; P < 0.001), but not with waist: hip ratio. CIMT showed significant positive correlation with blood glucose at 60 min (r = 0.22; P = 0.04), serum insulin at 60 min (r = 0.28; P = 0.01) while negative correlation with whole body insulin sensitivity (r = −0.27; P = 0.01). Conclusion: CIMT correlated significantly to blood pressure, insulin sensitivity, and body fat in Indian obese children.
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Neutrophil-lymphocyte ratio is a novel reliable predictor of nephropathy, retinopathy, and coronary artery disease in Indians with type-2 diabetes p. 864
Sachin Chittawar, Deep Dutta, Zahran Qureshi, Vineet Surana, Sagar Khandare, Tribhuvan Nath Dubey
DOI:10.4103/ijem.IJEM_197_17  PMID:29285450
Background and Aims: Neutrophil-lymphocyte ratio (NLR) has been suggested to be a predictor of coronary artery disease (CAD), and end-organ damage in type-2 diabetes mellitus (T2DM). Similar data are lacking from Indians with T2DM. Hence, this study aimed to evaluate the role of NLR as a predictor of microvascular complications and CAD in T2DM. Subjects and Methods: Consecutive T2DM patients attending the outpatient services of 2 different hospitals, who gave consent, underwent clinical, anthropometric evaluation, and evaluation for the occurrence of retinopathy, nephropathy, neuropathy, and CAD. Results: A total of 298 patients were screened of which 265 patients' data were analyzed. Occurrence of hypertension, neuropathy, nephropathy, retinopathy, and CAD was 12.8%, 18.5%, 41.5%, 62.3%, and 3.8%, respectively. Patients in higher NLR quartiles had significantly higher diabetes duration, occurrence of nephropathy, albuminuria, retinopathy, CAD and lpwer glomerular filtration rate. Patients with more microvascular complications had significantly longer diabetes duration, blood pressure, NLR, creatinine, and urine albumin excretion. Binary logistic regression revealed NLR followed by body mass index were best predictors of microvascular complications. NLR had areas under the receiver operating characteristic curve (AUC) of 0.888 (95% CI: 0.848–0.929; P < 0.001), 0.708 (95% CI: 0.646–0.771; P < 0.001), and 0.768 (95% CI: 0.599–938; P = 0.004) in predicting albuminuria, retinopathy, and CAD, respectively. NLR of 2.00 had sensitivity and specificity of 86.4% and 69% in predicting albuminuria; sensitivity and specificity of 64.2% and 63% in predicting retinopathy; sensitivity and specificity of 80% and 47.1% in predicting CAD. Conclusion: NLR is inexpensive, easy to use, reliable predictor of nephropathy, retinopathy, and CAD in Indian T2DM.
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The prevalence of new onset diabetes mellitus after renal transplantation in patients with immediate posttransplant hyperglycemia in a tertiary care centre p. 871
Saba Samad Memon, Nikhil Tandon, Sandeep Mahajan, VK Bansal, Asuri Krishna, Arunkumar Subbiah
DOI:10.4103/ijem.IJEM_309_17  PMID:29285451
Objectives: This study aimed to determine the prevalence of immediate posttransplant hyperglycemia and new onset diabetes after renal transplantation (NODAT). It also aims at answering whether posttransplant hyperglycemia per se is a risk factor for future development of NODAT. Methods: A retrospective study was conducted among patients undergoing kidney transplantation under a single surgical unit in a tertiary care hospital in the past 5 years. All known patients with diabetes were excluded from the study. Immediate postoperative hyperglycemia was defined as random blood sugar (RBS) ≥200 mg/dl or requirement of insulin. NODAT was defined as fasting plasma glucose ≥126 mg/dl or RBS ≥200 mg/dl or if the patient is receiving therapy for glycemic control at 6 weeks or 3 months posttransplantation. Results: The study population included 191 patients. The overall prevalence of posttransplant hyperglycemia and NODAT was 31.4% and 26.7%, respectively. NODAT developed in 28 patients (46.7%) of those who had posttransplant hyperglycemia. Thus, posttransplant hyperglycemia was associated with a fourfold increased risk of NODAT (P = 0.000). Posttransplant hyperglycemia was associated with increased infections (P = 0.04) and prolonged hospital stay (P = 0.0001). Increased age was a significant risk factor for NODAT (P = 0.000), whereas gender, acute rejection episodes, cadaveric transplant, hepatitis C virus status, human leukocyte antigen mismatch, and high calcineurin levels were not significantly associated with the future development of NODAT. Conclusion: The significant risk of NODAT posed by posttransplant hyperglycemia makes it prudent to follow up these patients more diligently in a resource-limited setting wherein routine monitoring in all patients is cumbersome.
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Validity of madras diabetes research foundation: Indian diabetes risk score for screening of diabetes mellitus among adult population of urban field practice area, Indira Gandhi Medical College, Shimla, Himachal Pradesh, India p. 876
Kanica Kaushal, Anjali Mahajan, Anupam Parashar, Dineshwar Singh Dhadwal, V. M. S. Jaswal, Pramod Jaret, Salig Ram Mazta
DOI:10.4103/ijem.IJEM_361_16  PMID:29285452
Introduction: IDRS is based on four simple parameters derived from known risk factors for diabetes; two modifiable risk factors (waist circumference and physical inactivity) and two non-modifiable risk factors (age and family history of diabetes), which may be amenable to intervention. The present study has been planned as the region specific validation is important before it can be used for screening in this part of the country. Aims: The aim of the present study was to validate MDRF-IDRS for screening of diabetes mellitus among adult population of urban field practice area, IGMC, Shimla, Himachal Pradesh, India. Methods: The present community based cross sectional study was conducted among 417 adults fulfilling the eligibility criteria using a two stage sampling design. Results: In the present study IDRS value ≥70 had an optimum sensitivity of 61.33% and specificity of 56.14% for detecting undiagnosed type 2 diabetes in the community. At an IDRS score of ≥70, the PPV was 23.47%, NPV as 86.88%, the diagnostic accuracy as 57.07%, LR for positive test as 1.398, LR for negative test as 0.69 and Youden's index as 0.17. However Youden's index was 0.19 at a cut of ≥60 i.e. higher than what was at ≥70. Higher IDRS scores increased the specificity but the sensitivity dramatically decreased. Conversely, lower IDRS values increased the sensitivity but the specificity drastically decreased. Area under the curve = 0.630 and a P value < 0.001. Conclusions: MDRF IDRS is user friendly screening tool but the criteria of including the parameter of physical activity for the calculation of the risk score needs to be clearly defined. In the present study the maximum sensitivity of 100% was seen at a cut off of ≥30. Hence we would recommend that all those in the medium and high risk group should be screened for type 2 Diabetes.
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Predisposition of angiotensin-converting enzyme deletion/deletion genotype to coronary artery disease with type 2 diabetes mellitus in South India p. 882
Dhivakar Mani, Rathika Chinniah, Padmamalini Ravi, Krishnan Swaminathan, RA Janarthanan, Murali Vijayan, Kamaraj Raju, Balakrishnan Karuppiah
DOI:10.4103/ijem.IJEM_215_17  PMID:29285453
Background: Worldwide, South Asians contribute to a high proportion of coronary artery disease (CAD) burden, mainly attributed to a high prevalence of diabetes. Early identification of such high-risk individuals would enable aggressive disease modification and prevention of complications. Definition of susceptible genotypes early in the course of disease may be one such avenue for reduction in morbidity and mortality from CAD. Aim: Our study was aimed to investigate the insertion/deletion polymorphism of angiotensin-converting enzyme (ACE I/D) gene and susceptibility to CAD in patients with type 2 diabetes mellitus (T2DM) in a South Indian population. Subjects and Methods: ACE (I/D) genotyping was performed by polymerase chain reaction specific primer for 187 CAD patients and 185 age- and sex-matched controls. Results: We observed that the ACE“II” genotype was found to be significantly associated with CAD patients (odds ratio [OR] = 1.689; P = 0.028). However, multiple logistic regression analysis revealed that ACE “DD” genotype was found to be most predominant risk factor for CAD patients with T2DM (OR = 6.118; P = 0.001). Conclusion: Our results showed that ACE (I/D) genotypes and alleles presented functional dimorphism in the development of CAD and CAD with T2DM patients in South India. This finding may be extremely useful in identifying subsets of patients where early aggressive treatment of risk factors is warranted.
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Hypothyroidism and depression: Are cytokines the link? p. 886
Parimal S Tayde, Nikhil M Bhagwat, Pragya Sharma, Bharat Sharma, Pradip P Dalwadi, Ashutosh Sonawane, Alka Subramanyam, Manoj Chadha, Premlata K Varthakavi
DOI:10.4103/ijem.IJEM_265_17  PMID:29285454
Context: Primary hypothyroidism has been thought of as an inflammatory condition characterized by raised levels of cytokines such as C-reactive protein (CRP), interleukin-6 (IL-6), and tumor necrosis factor-alpha (TNF-α). Depression is also well known to occur in hypothyroidism. Depression is also characterized by elevated inflammatory cytokines. We planned to study whether cytokines play an important part in linking these two conditions. Objectives: (1) To know the prevalence of depression in overt hypothyroidism due to autoimmune thyroid disease. (2) To correlate the levels of inflammatory markers with the occurrence of depression. (3) To study the effect of levothyroxine on inflammatory markers and depression. Materials and Methods: In this longitudinal, case–controlled study, 33 patients with autoimmune hypothyroidism (thyroid-stimulating hormone >10 uIU/ml) were included with 33 age-, sex-, and body max index-matched healthy controls. Individuals were tested for Serum TNF-α, IL-6, high-sensitivity-CRP (hs-CRP). They were assessed for depression using Montgomery Asberg Depression Rating Scale (MADRS) and World Health Organization Quality of Life (QOL) Scale. Patients received L Thyroxine titrated to achieve euthyroidism and were reassessed for inflammatory markers and cognitive dysfunction. Results: Nineteen patients (57%) had mild to moderate depression (MADRS >11). After 6 months of treatment, eight patients (42%) had remission of depression with significant improvement in QOL scores (P < 0.05). TNF-α, IL-6, and hs-CRP were significantly elevated in patients compared with controls and reduced with therapy but did not reach baseline as controls. The change in inflammatory markers correlated with improvement in QOL scores in social and environmental domains (P < 0.01). Conclusions: Primary autoimmune hypothyroidism is an inflammatory state characterized by elevated cytokines which decline with LT4 therapy. It is associated with depression and poor quality of life. Treatment of hypothyroidism results in alleviation of depression in the majority of patients. Similarly, patients with mild to moderate depression should be tested for hypothyroidism as simple treatment may ameliorate their depression and improves MADRS score and QOL.
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REVIEW ARTICLES Top

Bhagavad gita for the physician p. 893
Sanjay Kalra, Ameya Joshi, Bharti Kalra, Vivekanand G Shanbhag, Rajib Bhattacharya, Komal Verma, Manash P Baruah, Rakesh Sahay, Sarita Bajaj, Navneet Agrawal, Ashim Chakraborty, Yatan Pal Singh Balhara, Sandeep Chaudhary, Deepak Khandelwal, Sameer Aggarwal, Nanik Ram, Jubbin Jacob, Sandeep Julka, Gagan Priya, Shelley Bhattacharya, Komal Dalal
DOI:10.4103/ijem.IJEM_259_17  PMID:29285455
This communication presents verses from the Bhagavad Gita which help define a good clinician's skills and behavior. Using the teachings of Lord Krishna, these curated verses suggest three essential skills that a physician must possess: Excellent knowledge, equanimity, and emotional attributes. Three good behaviors are listed (Pro-work ethics, Patient-centered care, and Preceptive leadership) and supported by thoughts written in the Gita.
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Gemigliptin: Newer promising gliptin for type 2 diabetes mellitus p. 898
Manish Gutch, Abhay Joshi, Sukriti Kumar, Avinash Agarwal, Rajendra Kumar Pahan, Syed Mohd Razi
DOI:10.4103/ijem.IJEM_20_17  PMID:29285456
The dipeptidyl peptidase-4 (DPP-4) inhibitors have facilitated the management of type 2 diabetes mellitus (T2DM) owing to their superior efficacy and safety with low incidence of adverse effects. Gemigliptin is a new member of this family of drugs, and studies have revealed certain advantages of gemigliptin use compared to its previous congeners. Besides, this drug has also been studied for the treatment of T2DM as monotherapy, in combination with metformin or other oral antidiabetic drugs and in T2DM with moderate-to-severe renal failure. In this review, we explore the published data highlighting the pharmacology, efficacy, and safety of gemigliptin along with its recommendations for use in patients with T2DM.
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Osteogenesis imperfecta p. 903
Justin Easow Sam, Mala Dharmalingam
DOI:10.4103/ijem.IJEM_220_17  PMID:29285457
Osteogenesis imperfecta is a common heritable connective tissue disorder. Nearly ninety percent are due to Type I collagen mutations. Type I-IV are autosomal dominant, and Type VI–XIII are autosomal recessive. They are Graded 1-5 based on severity. Genomic testing is done by collagen analysis from fibroblasts. The mainstay of treatment is bisphosphonate therapy. The prognosis is variable.
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Sodium-glucose cotransporter-2 inhibitors: Moving beyond the glycemic treatment goal p. 909
Vishal Gupta, William Canovatchel, BN Lokesh, Ravi Santani, Nishant Garodia
DOI:10.4103/ijem.IJEM_85_17  PMID:29285458
Revelations of the multifactorial pathogenesis of type 2 diabetes mellitus (T2DM) that extend beyond the role of insulin and glucose utilization have been crucial in redefining the treatment paradigm. The focus of treatment is currently directed towards achieving wide-ranging targets encompassing the management of cardiovascular comorbidities that have been evidenced as indispensable aspects of T2DM. While most currently prescribed antihyperglycemic agents have little or no effect on reducing cardiovascular risks, some have been associated with undesirable effects on common risk factors such as weight gain and cardiovascular sequelae. Sodium-glucose cotransporter-2 inhibitors (SGLT2i) are newer additions to the array of therapeutic agents for T2DM that have demonstrated robust glycemic control as mono and add-on therapies. Their unique renal mode of action, independent of insulin modulation, confers complementary metabolic benefits. By virtue of these effects, SGLT2i may have a distinct role in the revised treatment recommendations by established working groups such as the American Diabetes Association and the American Association of Clinical Endocrinologists that advocate a more comprehensive management of T2DM, not restricting to glycemic targets. The current review gives an overview of the changing treatment needs for T2DM and discusses the nonglycemic effects of SGLT2i. It provides an updated summary on the efficacy of canagliflozin, dapagliflozin, and empagliflozin in promoting weight loss, stabilizing blood pressure, and other favorable metabolic effects.
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The heart of the matter: Cardiac manifestations of endocrine disease p. 919
Aditya John Binu, Kripa Elizabeth Cherian, Nitin Kapoor, Sujith Thomas Chacko, Oommen George, Thomas Vizhalil Paul
DOI:10.4103/ijem.IJEM_212_17  PMID:29285459
Endocrine disorders manifest as a disturbance in the milieu of multiple organ systems. The cardiovascular system may be directly affected or alter its function to maintain the state of homeostasis. In this article, we aim to review the pathophysiology, diagnosis, clinical features and management of cardiac manifestations of various endocrine disorders.
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BRIEF COMMUNICATION Top

Prevalence of pharamcologically-treated diabetes in term pregnancies in Haryana, India p. 926
Bharti Kalra, Sanjay Kalra, Meenu Choudhary, Meenakshi Thakral
DOI:10.4103/ijem.IJEM_205_17  PMID:29285460
Gestational diabetes mellitus (GDM) is common in pregnancy. Epidemiological studies have described the prevalence of GDM in the antenatal period, but do not assess the number of women who require pharmacological therapy at term. This information is important for obstetric care providers and health planners. We reviewed indoor charts of all women admitted for delivery at a maternity center in Karnal, Haryana, India. Of the 569 participants, 0.87% had preexisting diabetes, while 1.93% were being treated with drugs for GDM (0.70% insulin, 1.23% metformin). The overall prevalence of diabetes needing drug therapy at time of delivery in pregnant women was 2.81%.
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LETTERS TO THE EDITOR Top

Sulfonylureas: Scoring beyond START STUDY p. 928
Altamash Shaikh
DOI:10.4103/ijem.IJEM_322_17  PMID:29285461
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Leptin receptors can be an alternative target for new anti-hypertensive drug development p. 929
Mridula Ramkumar, SK Kanthlal
DOI:10.4103/ijem.IJEM_564_17  PMID:29285462
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Karma and diabetes mellitus p. 930
Jan Brož
DOI:10.4103/ijem.IJEM_313_17  PMID:29285463
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Preservation of thyrotroph function in Sheehan's syndrome p. 931
Bashir Ahmad Laway, Sajad Sumji
DOI:10.4103/ijem.IJEM_346_17  PMID:29285464
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Primary antiphospholipid antibody syndrome presenting as unilateral adrenal hemorrhage p. 932
Shruti Khare, Hardik Patel, Gargey Sutaria, Reena Sharma
DOI:10.4103/ijem.IJEM_474_17  PMID:29285465
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Gestational diabetes mellitus training: A well-grounded approach for safeguarding two generations p. 934
Ranjit Unnikrishnan, Suganthi Jaganathan, Pallavi Wadhwani, Sandeep Bhalla, Pushkar Kumar, Sourabh Sinha, Neerja Bhatla, Padmalatha Venkatram, Kusagradhi Ghosh, Ambrish Mittal, Dorairaj Prabhakaran, Nikhil Tandon, Viswanathan Mohan, Uma Ram
DOI:10.4103/ijem.IJEM_221_17  PMID:29285466
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