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   Table of Contents - Current issue
November-December 2018
Volume 22 | Issue 6
Page Nos. 719-868

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Fracture liaison service: Prevention by coordination p. 719
Manoj Chadha, Awesh Shingare, Amritha Prasanth, Phulrenu Chauhan, Nishit F Shah
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The relation of the non-modifiable (destiny) and modifiable (free will) factors in metabolic derangements p. 722
Ameya S Joshi, Nikhil M Bhagwat
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Measurement Of 2D:4D ratio and neck circumference in adolescents: Sexual dimorphism and its implications in obesity – A cross sectional study Highly accessed article p. 724
Saravanakumar Jeevanandam, KM Prathibha
Introduction: A bidirectional relationship between testosterone and obesity is explained by the hypogonadal obesity cycle and evidence from reports stating that weight loss leads to increased testosterone levels. There is an alarming rise in the prevalence of obesity among children and adolescents. The objectives of the present study were to measure the 2D:4D ratio of adolescent students and study its association with neck circumference (NC). Materials and Methods: After obtaining ethical clearance, the study was conducted on 168 adolescents pursuing their undergraduate education in a South Indian university. 2D:4D ratio and NC were measured using Digital Vernier Calipers and plastic inch tape, respectively. All the participants were divided into three groups (normal, overweight, and obese) on the basis of their BMI. Mean 2D:4D ratio and NC were compared between the three groups using one-way ANOVA. Results: Mean right and left hand ratios of the study population were 0.973 ± 0.030 and 0.975 ± 0.069, respectively. Comparison of 2D:4D ratios between the sexes revealed statistical significance (males = 0.966, females = 0.977, and P value = 0.019). There was no significant correlation between 2D:4D ratios and BMI. There was a significant negative correlation between NC and 2D:4D ratios of the individuals with normal BMI. However, no statistically significant correlation between NC and 2D:4D ratios was observed in overweight and obese individuals. Conclusion: 2D:4D ratio and NC could be used as simple measures for screening of people at higher risk for heart disease and metabolic syndrome. However, studies on a larger sample might help us reveal the association between NC and 2D:4D ratios.
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Once weekly dulaglutide therapy in type 2 diabetic subjects, real-world evidence from a tertiary care diabetes center in India Highly accessed article p. 728
Jasjeet S Wasir, Ambrish Mithal, Paras Agarwal, Apeksha Mittal
Aims: To evaluate the real-world efficacy, durability, and side-effect profile of once weekly GLP1RA: dulaglutide in Indian type 2 diabetes mellitus (T2DM) patients. Materials and Methods: A retrospective observational study. Data for efficacy (HbA1c and weight), adherence/discontinuation and patient reported side-effects, of 117 patients who were prescribed dulaglutide were analyzed. Results: Final analysis was done on complete data of 74 patients (6 months follow-up), this indicated that dulaglutide is effective (mean-reduction at 6 months of: HbA1c; 0.87% and weight; 3.8 kg). Subjects with a poorer glycemic control (greater HbA1c) or greater weight at initiation had a better fall in HbA1c and weight reduction at the end of the study. The most common side-effects were gastrointestinal (15% nausea and 6% loose motions). Also, 25% (n = 19) of our study subjects discontinued dulaglutide because of gastrointestinal side-effects. Conclusion: Our real-world experience is well aligned to systematic data of the randomized controlled trials (RCTs) regarding the efficacy of dulaglutide in the treatment of T2DM (our study vs. RCTs; HbA1c reduction: 0.87% vs. 0.78% to 1.64%, weight reduction: 3.8 vs. 0.3 to 3 kg). The most common side-effects and reason for discontinuation were gastrointestinal side-effects. Finally, by virtue of their observed benefit, we expect a superior cardiovascular risk-reduction with dulaglutide use in our population.
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Correlation of parathyroid hormone levels with mineral status in end-stage renal disease patients Highly accessed article p. 735
Kirti Arora, Gitanjali Goyal, Divya Soin, Sumit Kumar, Hobinder Arora, Cheenu Garg
Parathyroid hormone (PTH) is the main regulator of calcium, phosphate, magnesium, sodium, and potassium homeostasis. Therefore, this study was conducted to evaluate the relationship between PTH and aforementioned minerals in end-stage renal disease (ESRD) patients. Aim: The aim of this study was to estimate serum intact parathormone (iPTH) and other biochemical parameters in ESRD patients and to find correlation between serum iPTH and biochemical parameters in the study group. Results: This cross-sectional study included 60 clinically diagnosed patients of ESRD of age (>18 years), either sex. Disordered mineral metabolism is common complications of ESRD patients. The mean value of calcium, phosphorus, and magnesium was 7.90 ± 1.16 mg/dL, 6.44 ± 1.72 mg/dL, and 2.57 ± 0.62 mg/dL, respectively, indicating hypocalcemia, hyperphosphatemia, and hypermagnesemia in ESRD patients. To compensate the deranged mineral status, increased levels of PTH were seen in ESRD patients with mean value of 173.93 ± 62.62 pg/mL. There was a statistically significant positive correlation found between PTH and S. creatinine (P ≤ 0.001; r = 0.596), whereas the statistically significant negative correlation found between PTH and eGFR (P ≤ 0.001; r = −0.525). A significant positive correlation found between PTH and phosphorous (P = 0.003; r = 0.378) and potassium (P ≤ 0.001; r = 0.421). On the other hand, significant negative correlation found with calcium (P ≤ 0.001; r = −0.805) and corrected calcium (P = <0.001; r = −0.769). But nonsignificant association was found with magnesium, sodium, and calcium × phosphorous (P > 0.05). Conclusion: It was concluded that PTH is playing crucial role in mineral metabolism; it should be frequently assessed in order to prevent any untoward mineral decompensation and to prevent complications like bone disease and extra skeletal calcification, and decrease cardiac disease risk in ESRD patients.
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Unusual sites of metastatic and benign I 131 uptake in patients with differentiated thyroid carcinoma p. 740
Shanmuga S Palaniswamy, Padma Subramanyam
Introduction: Differentiated thyroid carcinoma (DTC) is the most common pathological type of thyroid carcinoma, which includes papillary and follicular subtypes. DTC is usually indolent, characterized by good prognosis, and long-term survival. Total thyroidectomy is the mainstay of treatment in DTC which is followed by diagnostic whole body 131I (WBI) scan. Like other primary malignancies of the head and neck, DTC follows a consistent pattern of spread in the cervical LNs. The central compartment, level VI and VII, is the first sentinel node followed by spread to the lateral compartments levels II–V, followed by the contralateral side. Inspite of nodal involvement, DTC usually have a favourable outcome. Presence of extrapulmonary distant metastases could predict a poor prognosis for high-dose 131I therapy. However, distant metastasis occurs often as a grave event and mortality rates vary depending on metastatic sites. Aim and Objectives: A range of rare 131I concentrating DTC deposits in sella, orbit, choroid, skeletal muscles, liver, skin, costochondral soft tissue, pancreas and kidney, and a few benign 131I concentrating sites are being depicted. Materials and Methods: Metastatic sites from DTC can be easily identified by performing a whole body 131I (WBI) scan along with a stimulated thyroglobulin (Tg) estimation (TSH >30 uIU/ml). Apart from thyroid and thyroid-related diseases, certain benign non-thyroidal pathologies can concentrate radioiodine (131I). From 13,000 of our patients who underwent radioiodine scan for thyroid cancer, we have selected a few cases of 131I concentrating benign and malignant lesions for illustration. Results: Out of 13000 DTC patients who underwent whole body 131I scintigraphy in our department from Jan 2007 till Mar 2018, 25 patients revealed benign sites of 131I uptake. 61 % patients had residual thyroid tissue with or without associated nodal involvement. Remaining patients had distant metastases. Rare sites of functioning thyroid metastases and benign sites of I 131 uptake have been selected for illustration. Conclusion: Apart from the WBI (two-dimensional, planar) images, single-photon emission computed tomography-computed tomography (SPECT-CT) has been incremental in localizing benign lesions which greatly depends on their location. This pictorial review highlights the need to create an awareness to detect metastatic deposits of DTC at unexpected sites. Otherwise patients will need further investigation to rule out unsuspected sites of functioning distant metastases.
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Evaluation of proinflammatory cytokines in obese vs non-obese patients with metabolic syndrome p. 751
Hamid Ashraf, Bashir Ahmad Laway, Dil Afroze, Arshad Iqbal Wani
Background: Obesity is one of the most common yet neglected public health problems in both the developed and developing countries. Metabolic syndrome (MS) is a multiplex of risk factor for the development of type 2 diabetes (T2D) and cardiovascular disease (CVD) and it reflects the clustering of multiple risk factors resulting from obesity and insulin resistance. Despite its predominance in obese individuals, MS does occur in non-obese individuals. Many individuals characterised as normal weight as per their body mass index (BMI), have increased visceral adiposity thereby leading to an unfavourable inflammatory cytokine profile. There are limited studies from India with respect to inflammatory cytokines in obesity and MS in general and non-obese patients with MS in particular. Materials and Methods: An observational cross-sectional study was carried out in patients with MS with or without obesity. Anthropometric parameters such as height, weight and waist girth were measured and BMI was calculated. Serum levels of TNF-α, IL-6 and adiponectin were measured by using the enzyme-linked immunosorbent assay. Results: A significant proportion of individuals categorised as normal weight had an increased waist circumference which correlated with BMI, acanthosis nigricans (AN) and fatty liver. There was no statistically significant difference in the cytokine levels in obese and non-obese patients with MS; similarly among non-obese patients with MS, cytokine levels were comparable in patients with or without abdominal obesity. However, triglycerides inversely correlated with adiponectin levels and there was no significant correlation between the cytokines and other parameters of MS. Conclusion: There was no significant difference in various metabolic and inflammatory parameters between obese and non-obese patients with MS. Even in non-obese group, there were no differences in metabolic and inflammatory markers between individuals with or without abdominal obesity. This finding indicates that apart from adipose tissue, other factors are also responsible for the development of MS and its associated proinflammatory profile. There could be a significant contribution of genetic and epigenetic factors which needs to be further explored.
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FRAX first – Pragmatic approach in resource poor settings p. 757
Adlyne Reena Asirvatham, Karthik Balachandran, Subramanian Kannan, Satish K Balasubramaniam, Shriraam Mahadevan
Background: Fracture Risk Assessment Tool (FRAX) is a fracture prediction tool that uses clinical risk factors with or without bone mineral density (BMD). BMD is difficult to obtain in resource-limited setting. Hence, we aimed to compare fracture risk prediction by FRAX without BMD (FRAX) and FRAX with BMD (FRAX/BMD). Objective: We intended to determine if FRAX and FRAX/BMD would produce identical predictions for 10-year probability of hip fracture and major osteoporotic fracture (MOF). We also desired to study the risk factors that could help to identify the similarity of risk prediction. Materials and Methods: A retrospective review of patients who underwent BMD measurement and FRAX assessment was conducted. Men and women >50 years of age with osteopenia and osteoporosis according to the World Health Organization (WHO) definition at one or more sites were included. FRAX prediction scores were calculated with and without BMD using the FRAX India tool. Results: Of 239 subjects, 207 (86.61%) had identical fracture risk predictions with or without BMD in FRAX estimation. Mean age was lower (P = 0.009), whereas body mass index (BMI), hip BMD, spine BMD, and history of previous fracture were higher (P = 0.005, P < 0.001, P < 0.001, and P = 0.02, respectively) in the identical prediction group. Conclusion: In our study, FRAX provided fracture risk prediction alike FRAX/BMD in most of the cases. FRAX is a good predictor of fractures especially in younger patients with higher BMI. Therefore, we conclude that FRAX is an effective tool to predict osteoporotic fracture risk and would be an inexpensive alternative when access to dual-energy X-ray absorptiometry (DXA) is limited.
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Efficacy and safety of 90,000 IU versus 300,000 IU single dose oral Vitamin D in nutritional rickets: A randomized controlled trial p. 760
Medha Mittal, Vineeta Yadav, Rajesh Khadgawat, Manish Kumar, Poonam Sherwani
Aim: To compare efficacy and safety of 90,000 IU versus 300,000 IU oral single dose vitamin D for treatment of nutritional rickets. Study Design: Randomized controlled trial. Setting: Tertiary care hospital. Participants: One hundred ten children (6 months to 5 years, median age 10.5 months) with rickets. Exclusion criteria were disease affecting absorption, intake of calcium/vitamin D preparation in last 6 months, abnormal renal function, and rickets other than nutritional. Intervention: Vitamin D3 as a single oral dose 90,000 IU (group A, n = 55) or 300,000 IU (group B, n = 55). Methodology: Severity of rickets was scored on knee and wrist X-ray as per Thacher's radiographic score. Baseline serum levels of calcium, SAP, 25(OH)D, iPTH were measured. Follow up was done at 1 week, 4 weeks, and 12 weeks. Outcome Variable: Primary – Radiographic score at 3 months. Secondary – Serum levels of 25(OH)D, SAP, and iPTH at 3 months, clinical and biochemical adverse effects. Results: Eighty-six subjects (43 in each group) completed the study. The radiographic score reduced from 6.90 to 0.16 in group A and from 6.93 to 0.23 in group B. The levels of 25(OH)D, ALP, and PTH were similar between the groups at baseline and follow up. Hypercalciuria and hypercalcemia were seen more often in group B as was hypervitaminosis D. There were no clinical adverse events. Conclusions: Single oral dose vitamin D3 90,000 IU is safe and effective in achieving healing of rickets.
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Bone health in patients with Cushing's syndrome p. 766
Sk Hammadur Rahaman, Viveka P Jyotsna, Devasenathipathy Kandasamy, V Shreenivas, Nandita Gupta, Nikhil Tandon
Introduction: Osteoporosis is a well-recognized complication of Cushing's syndrome (CS). Data on bone health in patients with CS from south Asian countries, which are vitamin D deficient, are scarce. Aims: We assessed bone mineral density (BMD) in patients with CS in comparison to controls. We also looked into how BMD differs in different types of endogenous CS. Materials and Methods: Thirty-seven cases of CS and 48 matched controls were studied for clinical, biochemical, hormonal, and bone densitometry parameters. Results: BMD (both total lumbar spine (LS) and hip) as well as Z scores were significantly lower in CS patients as compared to controls. Neither LS nor hip BMD was significantly different among different etiological groups of CS. The difference in BMD was also not significant between eumenorrhoeic and oligo-/amenorrhoeic patients with CS. Conclusion: Patients with CS are at increased risk of having fracture secondary to osteopenia and osteoporosis. There is no significant association of vitamin D and intact parathormone with low BMD in patients with CS.
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The role of circulating microRNA in the regulation of beta cell function and insulin resistance among Indians with type 2 diabetes p. 770
S Sucharita, V Ashwini, JS Prabhu, ST Avadhany, V Ayyar, G Bantwal
Background: Circulating microRNA (miRNA/miR) levels are emerging out as markers of tissue level changes; however, their role in type 2 diabetes (T2D) needs to be explored. The study aimed to compare the circulating levels of the miRNA (miR9, miR30d, miR1, miR133a, miR29a, miR143) between T2D and gender matched controls and also to evaluate the strength of association between circulating miRNAs and beta cell function/insulin resistance among Indians with T2D. Subjects and Methods: Thirty T2D (25–60 years) and their gender matched controls (n = 30) were recruited. Plasma glucose and insulin, HbA1c, lipid profile, and miRNA levels were estimated. Insulin resistance and beta cell function (HOMA IR and %B) were derived. Body composition was assessed by Dual-energy-x-ray absorptiometry (DXA). Comparison between the study groups was performed using independent “t” test and strength of association by Pearson's correlation. Results: There was a significant difference in HOMA IR (P = 0.03) and %B (P = 0.001) between the two study groups. The muscle mass, percent body fat, and muscle to fat ratio were comparable between the two study groups. miRNA 30d was significantly higher in the T2D compared to control group even after controlling for age (P = 0.005). There was a significant positive association between miR30d with HOMA-IR (r = 0.26, P = 0.04). Conclusion: The current study demonstrated that miR30d (insulin gene transcription in pancreatic beta cell and regulator of insulin sensitivity in skeletal muscle) was overexpressed among T2D. Further role of other miRNA and their interaction in regulation of beta cell function and insulin resistance needs to be studied.
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Clinical spectrum of disorders of sex development: A cross-sectional observational study p. 774
Sheeraz A Dar, Mudasir Nazir, Roumissa Lone, Duri Sameen, Ikhlas Ahmad, Wasim A Wani, Bashir A Charoo
Objective: Disorders of sex development (DSD) constitutes a small but difficult and equally important area of endocrinology. It is often a social emergency as the decision regarding sex assignment in these cases is extremely disturbing and difficult to both families and healthcare professionals. Our study was devised to assess the clinical and chromosomal profile of patients with suspected DSD and classify them according to the new DSD consensus document. Subjects and Methods: This study was a cross-sectional observational study carried out in the department of pediatrics of a tertiary care hospital from August 2012 to August 2014. All patients with suspected DSD in the age group of 0–19 years were included. After detailed history and examination, karyotyping, abdominal sonography, and hormonal analysis were done. Additional studies like gonadal biopsy, laparoscopy, and hormone stimulation tests were done in selected cases. Results: About 41 patients were included in the study. The mean age of presentation was 87 months (1 day to 16 years). Only seven (13.7%) patients presented in neonatal period. In total, 25 patients had ambiguous genitalia; 46, XX DSD were diagnosed in 24 (58.5%) patients, 46, XY DSD in 10 (24.4%) patients, and sex chromosome DSD in 7 (17.1%). Congenital adrenal hyperplasia (CAH) was the commonest disease diagnosed in 21 (51.2%) patients. Turner syndrome, Klinefelter syndrome, androgen insensitivity syndrome, 46, XX ovotesticular disorder, and 46, XY gonadal dysgenesis were diagnosed in 3, 3, 4, 3, and 5 patients, respectively. Eleven patients with CAH presented in shock and six had history of sib deaths. Conclusion: 46, XX DSD were the commonest etiological group in our study and CAH was the commonest individual disease. There is a need for educating general public and practitioners regarding DSD to allow early intervention. Moreover, there is a need to introduce routine neonatal screening for CAH in our country.
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Mild cognitive impairment in young type 1 diabetes mellitus patients and correlation with diabetes control, lipid profile, and high-sensitivity c-reactive protein p. 780
Naveen Kumar, Veer B Singh, Babu L Meena, Deepak Kumar, Harish Kumar, Makhan Lal Saini, Arun Tiwari
Background: It has been an established fact that diabetes mellitus (DM) is associated with lower levels of cognitive function and may be a risk factor for the development of mild cognitive impairment (MCI) and dementia. Most of these studies involved elderly diabetes patients and aging itself may contribute to cognitive impairment. Since a majority of the individuals with DM are between the ages of 40 and 59 years, it is crucial to determine the factors that contribute to cognitive impairment in these patients. So this study was done to correlate the various physical and metabolic parameters with MCI in young individuals with type 1 DM. Materials and Methods: In this cross-sectional study, 126 patients with type 1 DM underwent cognitive assessment by the Montreal Cognitive Assessment test and their cognitive levels were correlated with their HbA1c, lipid profile, and high-sensitivity C-reactive protein (hs-CRP). Results: The prevalence of MCI was 71.42%. MCI was significantly correlated with HbA1c, serum triglycerides, low-density lipoprotein, very low-density lipoprotein, and hs-CRP levels. The factors that were statistically insignificant were the duration of diabetes, body mass index, and high-density lipoprotein levels. Conclusion: Cognitive impairment is seen even in type 1 DM patients. It should be considered along with the other complications of DM.
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Presurgical screening of fine needle aspirates from thyroid nodules for BRAF mutations: A prospective single center experience p. 785
Ramamoorthy Hemalatha, Rekha Pai, Marie T Manipadam, Grace Rebekah, Anish J Cherian, Deepak T Abraham, Simon Rajaratnam, Nihal Thomas, Pooja Ramakant, Paul M Jacob
Objective: Analysis of BRAF V600E mutation in thyroid fine needle aspirates (FNA) is an important adjunct to cytology, particularly among FNA placed in the “indeterminate category.” However, such a prospective evaluation of FNA obtained from patients with thyroid nodules has been lacking from India. Material and Methods: FNA from 277 patients were prospectively evaluated for BRAF mutations by Sanger's sequencing. A subset of 30 samples was also analyzed by pyrosequencing using the PyroMark BRAF mutation kit. Results: Overall, 27.2% of FNA samples were positive for mutations including 19 (35.8%) of the 53 histologically confirmed papillary thyroid carcinoma (PTC), 2 of the 25 follicular variants of PTC, and 1 anaplastic thyroid carcinoma. Only 1 (2.7%) of the 37 samples in the atypia of undetermined significance/follicular lesion of unknown significance category was BRAF positive. The sensitivity of cytology improved marginally from 67.1% to 68.3% when evaluated with BRAF. Further, a comparison of the clinicopathological characteristics of BRAF positive and negative PTCs showed a significant association (P = 0.05) between lymph node metastasis and BRAF positivity. Conclusion: BRAF positivity was lower than that reported from East Asia with the test being useful in confirming malignancies among the suspicious of malignancy and malignant categories.
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Clinico-pathological profile of anaplastic thyroid carcinoma in an endemic goiter area p. 793
Roma Pradhan, Amit Agarwal, Punita Lal, Niraj Kumari, Manoj Jain, Gyan Chand, Anjali Mishra, Gaurav Agarwal, Ashok K Verma, Saroj K Mishra
Introduction: Anaplastic thyroid cancers (ATCs) usually present in the sixth to seventh decades of life and little is known about the disease in young patients. The aim was to analyze the clinicopathological characteristics diagnosed with ATC in an iodine-deficient area. Material and Methods: The medical records of 100 patients diagnosed with ATC at a tertiary care hospital between 1991 and 2013 were reviewed. Results: The mean age of patient was 58 years. About 34 patients were ≤50 years. The common presentation was that of a rapidly growing fixed and hard mass (64%). Due to rapid expansion, 27% patients experienced severe pain. About one-third presented as sudden enlargement of pre-existing goiter over few weeks. The median duration of symptoms before diagnosis was 3 months. About 41% presented with lymph node enlargement and 31% with distant metastasis. The diagnosis was established with fine-needle aspiration or core biopsy. Histopathology was available in 32 patients and showed four major patterns: spindle cell (9), giant cell (7), epithelioid (5), squamoid (1), mixed type in 10 patients. Eight patients presenting with stridor required emergency tracheostomy for airway control. Total thyroidectomy with or without lymph node dissection was possible in 21 patients. Patients received radiotherapy with or without chemotherapy. Median overall survival was 3 months. Overall survival was significantly better in patients receiving some form of treatment. Conclusion: ATC in endemic goiter areas presents at an earlier age. One-third of ATC is due to anaplastic transformation of pre-existing goiter and majority of the patients refuse treatment due to dismal outcome.
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Pregnancy outcomes in women with strictly controlled type 1 diabetes mellitus p. 798
Işıl Gülizar Uzun Çilingir
Objective: To evaluate the pregnancy outcomes in mothers with controlled Type 1 diabetes mellitus (T1DM). Materials and Methods: Thirty seven pregnant patients with controlled T1DM were included in the study. Results: Twenty (54%) out of 37 patients had preterm delivery (<37 weeks of gestation). The type of delivery was induced vaginal delivery in 9 (24.3%) patients and cesarean section in 27 (72.9%) patients. Preeclampsia developed in 6 (16.2%) patients. Macrosomia was found in 9 (24%) patients. Two antenatal death occured. Conclusion: Even in the most favorable conditions, the pregnant patients with T1DM would have a great risk for preterm delivery and cesarean section, moderate risk for macrosomia, preeclampsia, and an undefined risk for antenatal death.
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Correlation of serum Vitamin D levels in lactating mothers and their infants p. 801
Minhaz Husain, Manish Verma, Rakesh Jora, Jai Prakash Soni, Pramod Sharma
Background: Although Vitamin D deficiency is highly prevalent in Indians, data on Vitamin D eficiency in lactating mothers and exclusively breast fed infants is inadequate. Objective: This study was done to evaluate the prevalence of Vitamin D deficiency in lactating mothers and their infants and to find out any correlation between them. Materials and Methods: This hospital based, cross sectional study included 200 healthy infants between 1-30 days and their mothers. Serum sample was collected from both for Ca, inorganic phosphate (IP), alkaline phosphatase (ALP), and 25(OH)D. Results: Mean serum 25(OH)D level of mothers was 11.33 ± 5.86 ng/ml with a range of 2–37 ng/ml. Hypovitaminosis D was defined as serum 25(OH)D level <10 ng/ml. Almost 94 (47%) of mothers were having hypovitaminosis D. Mean serum 25(OH)D level of infants was 11.92 ± 7.89 ng/dl with a range of 2.5–68 ng/dl. Ninety (45%) infants were having hypovitaminosis D. There was a moderate positive correlation between individual mothers' and infants' serum 25(OH)D values (Pearson coefficient = 0.516, P < 0.001). Using logistic regression, it was found that infants born to mothers with hypovitaminosis D carry a 4.47 times more risk of developing hypovitaminosis D as compared to infants born to mothers with normal serum 25(OH)D (Odds ratio = 4.47, P < 0.001). Conclusion: This study shows a high prevalence of Vitamin D deficiency in lactating mothers and their breastfeeding infants with a positive correlation between them. These results provide a justification for adequate Vitamin D supplementation of all exclusively breastfeeding infants and highlight the urgent need to improve maternal Vitamin D status.
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Diabetes management and the buddhist philosophy: Toward holistic care p. 806
Sanjay Kalra, Gagan Priya, Emmy Grewal, Than Than Aye, BK Waraich, Tint SweLatt, Touch Khun, Menh Phanvarine, Sun Sutta, Uditha Kaush, Manilka , Sundeep Ruder, Bharti Kalra
Buddhist philosophy is a way of life that transcends the borders of religion and focuses on the alleviation of suffering. The core teaching of Buddha was the Four Noble Truths: there is suffering, suffering is caused by clinging and ignorance, there is a way out of suffering and that way is the Noble Eightfold Path. The medical analogy in diabetes care would include identification of diabetes, understanding its etiopathogenesis, and how prognosis can be improved with appropriate care and management of this chronic disorder. Gaining awareness about the cause of illness and conducting our lives in a manner that nourishes and maintains long-term good health leads to improved outcomes for individuals living with diabetes and improve their overall well-being. The Noble Eightfold Path in Buddhism constitutes of right view, right resolve, right speech, right action, right livelihood, right effort, right mindfulness, and right concentration. These elements of the Eightfold Path can be taken as guiding principles in diabetes care. Buddhist meditation techniques, including mindfulness meditation-based strategies, have been used for stress reduction and management of chronic disorders such as chronic pain, depression, anxiety, hypertension, and diabetes. In this article, we focus on how Buddhist philosophy offers several suggestions, precepts, and practices that guide a diabetic individual toward holistic health.
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Lessons for the health-care practitioner from Buddhism p. 812
Sanjay Kalra, Gagan Priya, Emmy Grewal, Than Than Aye, BK Waraich, Tint SweLatt, Touch Khun, Menh Phanvarine, Sun Sutta, Uditha Kaush, Manilka , Sundeep Ruder, Bharti Kalra
From its earliest days, Buddhism has been closely intertwined with the practice of medicine, both being concerned in their own way in the alleviation and prevention of human suffering. However, while the connection between Buddhism and healthcare has long been noted, there is scarce literature on how Buddhist philosophy can guide health-care practitioners in their professional as well as personal lives. In the sutras, we find analogies that describe the Buddha as a doctor, knowledge of Dharma as the treatment, and all lay people as patients. The occurrence of disease is closely related to one's mental, physical and spiritual health, society, culture, and environment. It is not enough to approach medicine in a manner that simply eradicates symptoms; the psychosocial aspects of disease and its mind based causes and remedies must be a primary consideration. Holistic care involves harmonization of all these elements, and the Buddhist philosophy offers great insight for the physician. The Buddhist medical literature lays out moral guidelines and ethics for a health-care practitioner and this has corollaries in the principles of medical ethics: nonmaleficence, benevolence, justice, and autonomy. There is emphasis on loving-kindness, compassion, empathy, and equanimity as key attributes of an ideal physician. The practice of medicine is a stressful profession with physician burnout an often neglected problem. Mindfulness meditation, as developed in Buddhism, can help health-care professionals cope up with the stress and develop the essential attributes to improve patient care and self-care. This article outlines the spiritual and ethical values which underlie Buddhist concern for the sick and gives an overview of lessons which health-care practitioners can imbibe from Buddhism.
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Liraglutide – Indian experience p. 818
Majumder Anirban, Roy Chaudhri Soumyabrata, Sanyal Debmalya, Kingshuk Bhattacharjee
Liraglutide is an effective drug for the treatment of type 2 diabetes mellitus (T2DM). The aim of this review is to collate evidence on the real-world clinical effectiveness of liraglutide from the published Indian studies. A review of publications was conducted to identify observational studies that assessed the effectiveness of liraglutide among Indian T2DM. Total ten publications were retrieved and these observational studies are compared with the results of the liraglutide randomized controlled trial (RCT) program (Liraglutide Effect and Action in Diabetes [LEAD]). Liraglutide therapy demonstrated HbA1c reduction in the Indian population up to 2.26% and 2.54%, over 24 and 52 weeks, respectively. Among the LEAD trials, the HbA1c reduction at 24 weeks was maximum in LEAD-4 with 1.5% reduction at both doses used (1.2 and 1.8 mg) and up to 1.14% in LEAD-3 with a dose of 1.8 mg. The weight loss among Indian subjects was generally around 5 kg or more with maximum weight loss of 8.6 kg over 24 weeks. The maximal weight loss in LEAD studies was less than 3 kg with an exception of 3.24 kg in LEAD-6. In over 52 weeks of liraglutide therapy among Indian subjects, mean weight loss was 7.4 kg, which was 3.5 times more than of LEAD program. Two Indian observational studies also demonstrated significant weight loss among nondiabetic obese subjects at a much lower than that of 3 mg anti-obesity dose. Gastrointestinal (GI) events are the commonly reported adverse events with Indian studies as well as LEAD program. Liraglutide therapy produces better glycemic control and more weight loss among Indian T2DM subjects compared with RCTs conducted in western population with almost similar adverse consequences.
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Sodium-glucose cotransporter-2 inhibitors in combination with other glucose-lowering agents for the treatment of type 2 diabetes mellitus p. 827
Sanjay Kalra, Jothydev Kesavadev, Manoj Chadha, G Vijaya Kumar
Involvement of multiple physiological pathways and complex pathogenesis is responsible for the onset and progression of type 2 diabetes mellitus (T2DM). Since it is difficult to manage multiple pathophysiological defects by monotherapy, a combination therapy with two or more oral antidiabetic agents (OADs) may help achieve euglycemia in T2DM patients. Choice of OADs is difficult with growing armamentarium of antidiabetic therapy. Ideally, drug combination should aim at reversal of known pathogenic abnormalities and demonstrate improvement in the overall metabolic health rather than simply reduce glycosylated hemoglobin (HbA1c) levels. Increased glucose reabsorption, a faulty pathological mechanism, is targeted by a novel class of drugs, namely, the sodium-glucose cotransporter-2 (SGLT2) inhibitors. Combination of SGLT2 inhibitors and other OADs complement each other due to their unique mechanism of action. In addition, the glucose-lowering effect of SGLT2 inhibitors remains independent of β-cell function and insulin sensitivity which reduces the chances of severe hypoglycemia in patients receiving these agents. Clinical studies from the past favor the use of SGLT2 inhibitors in combination with other agents to achieve better HbA1c levels, weight loss, and blood pressure control. In this review, we have made an attempt to explore the recommended guidelines for combination therapy, its advantages as either combination therapy or fixed-dose combinations therapy, and the role of SGLT2 inhibitors as a choice of drug as a combination with other OADs.
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Genital infections with sodium glucose cotransporter-2 inhibitors: Occurrence and management in patients with type 2 diabetes mellitus p. 837
AG Unnikrishnan, Sanjay Kalra, Vedavati Purandare, Hardik Vasnawala
Diabetes is a metabolic disorder characterized by hyperglycemia and is associated with several comorbidities and complications. Genital infection is one such complication that is often associated with diabetes mellitus (DM). Even though abnormalities in immune system, high urine glucose, and bladder dysfunction are important contributors for the increased risk of genitourinary symptoms, yet the possible role of pharmacologically induced glucosuria cannot be completely overlooked in such patients. There are various classes of medications to control blood glucose levels. A new therapeutic option to manage hyperglycemia is to increase renal glucose excretion by inhibiting sodium-glucose cotransporter-2 (SGLT2) glucose transport proteins. SGLT2 inhibitors (SGLT2i) represent a novel class of oral antidiabetic drugs which are associated with drug-induced glucosuria. Currently, canagliflozin, dapagliflozin, and empagliflozin are the three SGLT2i approved for therapy in Type 2 DM (T2DM). Safety studies with these three SGLT2i have reported events of mild-moderate genital infections in patients on SGLT2i therapy. However, most of the reported infections responded to standard treatment. Apart from SGLT2i, factors including personal hygiene, menopause, and circumcision might have a possible role in reported events of genital infections among T2DM patients on SGLT2i therapy. The present review identifies the occurrence of genital infections in diabetic patients on SGLT2i therapy, factors affecting the incidence of genital infections, and management strategies in patients with T2DM on SGLT2i therapy.
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ACTH resistance syndrome: An experience of three cases p. 843
Alpesh Goyal, Hiya Boro, Deepak Khandelwal, Rajesh Khadgawat
The term adrenocorticotropin (ACTH) resistance syndrome is used for a group of rare inherited disorders, which present with primary adrenal insufficiency during childhood. The syndrome includes two disorders inherited in an autosomal recessive fashion – familial glucocorticoid deficiency and triple A syndrome. Herein, we report our experience of three cases with ACTH resistance syndrome, highlighting the approach to diagnosis and management in such patients.
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Flash glucose monitoring in subjects with diabetes on hemodialysis: A pilot study p. 848
Rajesh S Javherani, Vedavati B Purandare, Anjali A Bhatt, Suganthi S Kumaran, Mehmood G Sayyad, Ambika G Unnikrishnan
Background: In patients with diabetes related end-stage renal disease (ESRD) on hemodialysis, blood glucose management can be challenging due to the kinetics of glucose and insulin in addition to other factors. The glucose monitoring systems which measure glucose levels continuously may be useful to study the glucose profile of patients with diabetes undergoing hemodialysis. Our study is designed to use ambulatory glucose profile to study the glucose pattern – during, before, and after a session of hemodialysis. Materials and Methods: Ten patients with type 2 diabetes with ESRD undergoing hemodialysis were recruited. Forty-eight glucose readings were recorded in a 12-h period which included 4 h each prior, during, and after the dialysis session with a flash glucose monitor (FreeStyle Libre-pro). The same 12 h time frame was also monitored on a non-dialysis day. Results: On the day of dialysis, the mean glucose level was significantly lower (P = 0.013) compared to the day without dialysis (95 ± 12.7 mg/dl vs 194 ± 76.8 mg/dl). As compared to the pre-dialysis period, the mean blood glucose levels during dialysis were lower (P = 0.004). As compared to the dialysis period, the mean blood glucose levels in the post-dialysis period were higher but did not reach statistical significance. Conclusion: In our study, subjects with type 2 diabetes on hemodialysis had lower glucose levels on the day of dialysis compared to non-dialysis day. Glucose levels showed a fall during hemodialysis and then a rise to higher levels after dialysis.
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Diagnosing post-transplant diabetes – The need for capillary glucose monitoring p. 852
Krithika D Muralidhara, Subramanian Kannan
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Bilateral medullary nephrocalcinosis secondary to Vitamin D toxicity: A 14-year follow-up report p. 853
Alpesh Goyal, Sk Hammadur Rahaman, Nishant Raizada, Devasenathipathy Kandasamy, Ajay Prakash Mehta, Rajesh Khadgawat
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Exposure to sunlight and Vitamin D synthesis p. 854
Srinivasa P Munigoti
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Which criteria to use to identify metabolic syndrome among patients with addictive disorders? Observations among patients with alcohol and opioid dependence syndrome p. 856
Mahmood Dhahir Al-Mendalawi
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Unilateral bluish sclera p. 857
K V. S Hari Kumar, Mandeep Sharma
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Central precocious puberty complicating congenital adrenal hyperplasia: North Indian experience p. 858
Devi Dayal, Anshita Aggarwal, Keerthivasan Seetharaman, Balasubramaniyan Muthuvel
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Chorea associated with nonketotic hyperglycemia (diabetic striatopathy) in an elderly male p. 859
Vishnu Vasudevan, Bashir Ahmad Laway, Arshad Iqbal Wani, Mohammad Maqbool Wani
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Severe hypercortisolism with hypokalemic alkalosis mimicking ectopic cushing syndrome in a patient with cushing disease due to pituitary microadenoma p. 860
Alpesh Goyal, Uttio Gupta, Devasenathipathy Kandasamy, Rajesh Khadgawat
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Localization of the parathyroid adenoma in mibi-negative cases: The value of a dedicated sonologist p. 863
Sushma Mehta, Vidita Powle, Naveen H Chandrasekhar, Vijay Pillai, Vidya Bushan, Vivek Shetty, Moni A Kuriakose, HV Sunil, KS Shivaprasad, Kranti S Khadilkar, Subramanian Kannan
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Erratum: Effect of physical activity during pregnancy on gestational diabetes mellitus p. 866

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Erratum: Occurrence of subacute thyroiditis following influenza vaccination p. 867

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Erratum: Lean metabolic syndrome: A concept or a reality? p. 868

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