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   Table of Contents - Current issue
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September-October 2018
Volume 22 | Issue 5
Page Nos. 577-717

Online since Tuesday, September 18, 2018

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EDITORIAL  

Pan-Indian reference database for the diagnosis of osteoporosis: A need indeed Highly accessed article p. 577
K V. S Hari Kumar
DOI:10.4103/ijem.IJEM_483_18  
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ORIGINAL ARTICLES Top

Influence of different reference databases on categorization of bone mineral density: A study on rural postmenopausal women from Southern India Highly accessed article p. 579
Kripa Elizabeth Cherian, Nitin Kapoor, Hesarghatta Shyamasunder Asha, Nihal Thomas, Thomas Vizhalil Paul
DOI:10.4103/ijem.IJEM_77_18  
Background and Objectives: Currently available DXA (Dual energy X-ray Absorptiometry) scanners utilise bone mineral density (BMD) of Caucasian population to calculate T scores and categorise BMD. We studied the influence of various databases on classification of BMD in south-Indian postmenopausal women aged above 50 years. Methodology: This was a cross-sectional study. Hologic DXA scanner was used to estimate BMD at lumbar spine (LS) and femoral neck (FN). T scores of ≤-2.5, -2.4 to -1, -0.9 to +1 were diagnostic of osteoporosis, osteopenia and normal respectively. Three reference databases(Italian, Korean and north Indian) were used to recalculate T scores. The agreement (K=kappa) between manufacturer provided database and the other databases was studied. The impact of different databases in diagnosing osteoporosis in subjects with FN fracture was assessed. Results: A total of 1956 postmenopausal women with mean (SD) age of 62 (4.3) years and 211 femoral neck(FN) fracture subjects with mean(SD) age of 68 (7.2) years were recruited. In subjects with fracture, osteoporosis at FN was found in 72% with Caucasian, 88% with North Indian, 56% with Italian, and 45% with Korean database. On comparing manufacturer provided database with the other population-specific reference, there was perfect agreement with north Indian (κ = 0.81 [FN], κ = 0.82 [LS]) and good agreement with the Italian database (κ = 0.78 [FN], κ = 0.74 [LS]). Conclusion: North-Indian database identified most of the participants with FN fracture as having osteoporosis and had perfect agreement with the manufacturer's database. Follow up studies will further validate the impact of utilizing this database in clinical practice.
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The effects of Vitamin D supplementation on thyroid function in hypothyroid patients: A randomized, double-blind, placebo-controlled trial p. 584
Afsaneh Talaei, Fariba Ghorbani, Zatollah Asemi
DOI:10.4103/ijem.IJEM_603_17  
Background: Data on the effects of vitamin D supplementation on thyroid function in hypothyroid patients are scarce. Objective: This study was done to evaluate the effects of vitamin D supplementation on thyroid function in hypothyroid patients. Material and Methods: This randomized double-blind, placebo-controlled trial was conducted on 201 hypothyroid patients aged 20–60 years old. Subjects were randomly assigned into two groups to intake either 50,000 IU vitamin D supplements (n = 102) or placebo (n = 99) weekly for 12 weeks. Markers of related with thyroid function were assessed at first and 12 weeks after the intervention. Results: After 12 weeks of intervention, compared to the placebo, vitamin D supplementation resulted in significant increases in serum 25-hydroxyvitamin D (+26.5 ± 11.6 vs. 0.0 ± 0.0 ng/mL, P < 0.001) and calcium (+0.4 ± 0.7 vs. 0.1 ± 0.6 mg/dL, P = 0.002), and a significant decrease in serum thyroid-stimulating hormone (TSH) levels (−0.4 ± 0.6 vs. +0.1 ± 2.0 μIU/mL, P = 0.02). A trend towards a greater decrease in serum parathyroid hormone (PTH) levels was observed in vitamin D group compared to placebo group (−3.8 vs. +1.9, P = 0.07). We did not observe any significant changes in serum T3, T4, alkaline phosphatase (ALP) and albumin levels following supplementation of vitamin D compared with the placebo. Conclusion: Overall, the current study demonstrated that vitamin D supplementation among hypothyroid patients for 12 weeks improved serum TSH and calcium concentrations compared with the placebo, but it did not alter serum T3, T4, ALP, PTH, and albumin levels.
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Ultrasound elastography is a useful adjunct to conventional ultrasonography and needle aspiration in preoperative prediction of malignancy in thyroid nodules: A Northern India perspective Highly accessed article p. 589
Monika Garg, Deepak Khandelwal, Vivek Aggarwal, Kiran B Raja, Sanjay Kalra, Bhoopendra Agarwal, Deep Dutta
DOI:10.4103/ijem.IJEM_634_17  
Introduction: Data on ultrasound elastography (USE) are scant from India. This study aimed to compare the sensitivity and specificity of USE with thyroid ultrasonography (USG) and fine-needle aspiration (FNA) as preoperative predictor of malignancy, using postoperative histopathology as gold standard. Materials and Methods: Consecutive patients with thyroid swelling/goiter underwent thyroid USG followed by USE. Patients with pure cystic nodules or eggshell calcification were excluded. Patients with nodules >10 mm with one or more high-risk USG features underwent FNA. Patients with no USG high-risk features, benign score on USE, and benign FNA were conservatively followed. All other patients underwent thyroidectomy. Results: 246 consecutive patients underwent USG. Data from 97 patients (117 nodules) were analyzed. Median age of patients was 43 years with 85.4% females. All patients with USE score-1 had benign USG and FNA characteristics. Of 86 nodules having USE score-2, 18.6% nodules were hypoechoic and 16.28% had microcalcification. Hypoechogenicity and microcalcifications were observed in 66.67% nodules with USE score-3. All nodules with USE score-4 and 5 were hypoechoic and had microcalcifications. Histopathology was benign in 84 and malignant in 33 patients. Occurrence of malignancy in USE scores 1–5 was 0, 4.65, 100, 90.5, and 100%, respectively. All eight nodules with diagnosis of follicular adenoma had preoperative USE score-2. The sensitivity of preoperative USG, USE, and FNA in picking up malignancy was 66.67, 87.88, and 69.70%, respectively. Specificity of USG, USE, and FNA in detecting thyroid malignancy was 88.10, 100, and 97.6%, respectively. False positivity rates for USG, USE, and FNA in diagnosing thyroid malignancy was 11.9, 0, and 2.4%, respectively. The overall diagnostic accuracy of USG, USE, and FNA cytology in this study was 82.05, 96.58, and 89.74%, respectively. Conclusion: USE may be better than USG for preoperative detection of malignancy in thyroid nodules.
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Ultrasound-guided fine-needle aspiration cytology along with clinical and radiological features in predicting thyroid malignancy in nodules ≥1 cm p. 597
N Siddhartha Chakravarthy, Anuradha Chandramohan, Anne Jennifer Prabhu, M Gowri, Pavithra Mannam, NK Shyamkumar, Dukhabandhu Naik, AJ Cherian, Nihal Thomas, MJ Paul, Deepak Abraham
DOI:10.4103/ijem.IJEM_1_18  
Aims and Objectives: The aim of the study is to examine the adequacy and accuracy of ultrasound-guided fine-needle aspiration cytology (US-FNAC) in thyroid nodules ≥1 cm and to analyze the clinical, sonological, and cytological features in predicting thyroid malignancy. Materials and Methods: US-FNAC was done on 290 patients from December 2013 to December 2014 by the radiologist. The Thyroid Imaging Reporting and Data System (TIRADS) was used to record the sonological features. FNAC samples were reported by a dedicated cytopathologist. Accuracy was calculated by comparing US-FNAC, clinical features and ultrasound (US) features for those who had final histopathology till April 2017. Results: The adequacy of US-FNAC in this study was 80.2%. Thyroidectomy was performed in 128/290 (44.1%). The sensitivity and specificity of US-FNAC in this study is 83.9 and 76.3%, respectively, with a positive predictive value of 85.2%, negative predictive value of 74.4%, and an accuracy of 81% in predicting malignancy in thyroid nodules ≥1 cm. The malignancy rate in benign FNAC sample was 25% (10/40), and was 69% (8/13) in those with a follicular lesion of undetermined significance (FLUS). Around 80% of benign and 89% of FLUS had follicular variant of papillary carcinoma of thyroid (FVPTC). US-FNAC, a high TIRADS score, and US features such as marked hypoechogenicity, taller than wide, irregular margins, microcalcification, and clinical features, such as hard in consistency and significant cervical lymph nodes, were important in predicting malignancy (P < 0.001). Conclusions: The accuracy of US-FNAC in this study is 81%. The US-FNAC, a high TIRADS score, a hard thyroid nodule, and significant cervical lymph nodes are important in predicting malignancy. The accuracy rate in benign and atypia undetermined significance categories needs to improve in this study. Further research to help in decreasing false negative rates of FVPTC will help in increasing the accuracy of US-FNAC in the present study.
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Study of pituitary morphometry using MRI in Indian subjects p. 605
Arun KC Singh, Devasenathipathy Kandasamy, Ajay Garg, Viveka P Jyotsna, Rajesh Khadgawat
DOI:10.4103/ijem.IJEM_199_18  
Aim: To establish normative measurements of pituitary gland in Indian population. Material and Methods: In this cross-sectional study, we measured dimensions of pituitary gland in 482 (213 females and 269 males) Indian subjects with apparently normal pituitary gland function. Mid-sagittal T1-weighted image (T1-WI) on magnetic resonance imaging (MRI) was used to measure height and length of pituitary gland. Pituitary gland width was measured using coronal T1-WI and pituitary gland volume was calculated. Results: Mean height, length and calculated volume of pituitary gland was significantly higher in females compared to males (p = <0.001, P = 0.03 and P = <0.001, respectively) when all age groups were combined but pituitary gland width was not statistically different in male and female subjects. When subjects were divided into different age groups, except for 10–14 years age group where pituitary height was significantly higher in females as compared to male, no significant difference was observed between male and female in any of the parameters (height, length, width and volume). The mean pituitary gland height was 5.80 ± 1.32 mm and 5.37 ± 1.25 mm in female and male subjects, respectively. Females achieved peak pituitary gland height in 10 to 14-year age group, while males achieved their peak pituitary gland height in 15 to 19-year age group. Conclusion: Our study provides age and sex wise normative data for pituitary measurements derived from Indian population.
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An observational prospective study to evaluate the preoperative risk factors of new-onset diabetes mellitus after renal transplantation in a tertiary care centre in Eastern India p. 610
Santosh Kumar, Debmalya Sanyal, Pratik Das, Kingshuk Bhattacharjee, Rohit Rungta
DOI:10.4103/ijem.IJEM_121_18  
Objectives: This study aimed to determine the pre-transplant risk factors as independent predictors on the new-onset of diabetes mellitus after renal transplants (NODATs). Materials and Methods: A single-centred prospective real-world observational study of 100 subjects who underwent renal transplantation over a period of 2 years. All known patients with diabetes were excluded from the study. NODAT was defined according to the American Diabetes Association definition. In addition to pre-transplant workup 2 days prior to transplant, post-transplant follow-up done on weekly basis for 1st month, every 15th day from 1st month to 3rd month, monthly from 3rd month to 12th month. Each transplant patient followed up for 1 year post-transplant or for 6 months post-development of NODAT, whichever was later. All the pre-transplant variables namely body mass index (BMI), family history of diabetes mellitus (DM), HbA1c, fasting insulin level, fasting c-peptide level, serology for hepatitis B, C, serum magnesium level and pre-operative insulin ressistance were further compared between NODAT and non-NODAT groups at the end of the study to assess their strength of associations. Results: Among the 100 subjects included in the study, 24 developed NODAT. Risk factors namely age, family history of DM, BMI, hepatitis B and C infection, total cholesterol, triglyceride level, pre-operative HbA1c, pre-operative insulin resistance and pre-diabetes were significantly higher, whereas beta-cell function, ABO compatibility and magnesium levels being significantly lower in NODAT cohort. Conclusion: The incidence of NODAT is quite high (24%). Risk of development of NODAT was related to traditional as well as novel risk factors. Key aspects lies in identifying patients at risk of developing NODAT, using traditional risk factors for early diagnosis and introducing interventions on modifiable risk factors for prevention and timely intervention.
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Effect of implementation of ADA/AACE guidelines on the management of hospitalized hyperglycemic patients through training of residents: A tertiary care center study p. 616
BP Amrith, Prayas Sethi, Manish Soneja, Naval Vikram, Arvind Kumar, Praveen Aggarwal, Viveka P Jyotsna, RM Pandey, Naveet Wig
DOI:10.4103/ijem.IJEM_698_17  
Background: Hyperglycemia is a common comorbidity in hospitalized patients and may add to adverse outcomes. Various associations have issued guidelines for optimal management of hyperglycemia in ill patients. This study aims to assess the adherence to current guidelines in inpatient setting and the impact of educational interventions on the improvement in adherence to guidelines as well as its effect on the level of blood sugar control and patient outcomes. Materials and Methods: It was a quasi-experimental pretest and posttest study and was done in three phases, viz., observation of current practices, intervention in the form of educational interventions, and its effect on change in practices and patient outcomes. Results: There was statistically significant 22% increase in the use of recommended insulin regimens (P = 0.028). The proportion of blood sugars within recommended range in the first 48 h, mean daily blood sugars, and the incidence of severe hyperglycemia improved in phase 3 vs phase 1 and was statistically significant. On comparing the subgroups, viz., those who followed and those who did not follow the guidelines, the results of the proportion of blood sugar in recommended range and proportions of blood sugar of more than 250 were found to be statistically significant. Conclusion: Dedicated educational interventions help in improving healthcare practices. According to current guidelines, rapid improvement in hyperglycemia and better glycemic control occur with adherence to protocol-based management of hyperglycemia.
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Neonatal glycemic status of infants of diabetic mothers in a tertiary care hospital p. 621
Suraiya Begum, Sanjoy K Dey, Kanij Fatema
DOI:10.4103/ijem.IJEM_689_17  
Background: Diabetes is a common medical complication during pregnancy that results in significant neonatal morbidities. In infants of diabetic mothers (IDMs), hypoglycemia is a common complication. Objective: To study the neonatal hypoglycemia in IDMs in a tertiary care hospital. Settings and Design: A cross-sectional study was done in postnatal ward in Bangladesh Institute of Research and Rehabilitation in Diabetic, Endocrine and Metabolic Disorders from January to December 2009. Subjects and Methods: The data of IDMs were collected from postnatal ward. All IDMs delivered during this period staying in postnatal ward were included in this study. The outcomes were compared between the hypoglycemic and normoglycemic IDMs and between gestational diabetes mellitus (GDM) and pre-GDM in hypoglycemic group using Chi-square test and Fisher's exact test. The data analysis was performed with Epi-enfo7 software. Statistical significance was set at P < 0.05. Results: A total of 363 IDMs were included in this study. Hypoglycemia developed in 38.3% IDMs and 43.2% mothers of hypoglycemic IDMs had GDM and 56.8% had pre-GDM. Duration of maternal diabetes (P = 0.04) and large for gestational age (P = 0.0001) were associated with hypoglycemia. Multigravidae (82.2% vs 68.3%, P = 0.03), prolonged duration of maternal diabetes (45.46 weeks vs 3.23 weeks, P = 0.00001), preterm babies (48.1% vs 28.3% P = 0.009), and control of diabetes by insulin (81% vs 46.7%, P = 0.001) were more in pre-GDM, and statistically significant. About 85% IDMs developed hypoglycemia within 6 h of birth (P-value 0.00001) and majority (68%) were at 2 h of age. Forty percent of hypoglycemic IDMs from postnatal ward were admitted in special care baby unit. Conclusion: Hypoglycemia observed in 38.3% IDMs and developed within 6 h of age and maximum were at 2 h. Early recognition and appropriate intervention are needed in IDMs.
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Comparison of efficacy and safety of fixed dose combination of rosuvastatin and choline fenofibrate to fixed dose combination of rosuvastatin and fenofibrate in patients of mixed dyslipidemia: A randomized, open-label, multicentre clinical trial in Indian population p. 627
Hanmant Barkate, Piyush Patel, Dimple Shah, Falgun Vyas
DOI:10.4103/ijem.IJEM_321_16  
Introduction: This study was conducted to evaluate the safety and efficacy of fixed-dose combination (FDC) of rosuvastatin and choline fenofibrate in comparison to rosuvastatin and fenofibrate FDC among Indian patients of mixed dyslipidemia. This would be a first study evaluating FDC of rosuvastatin and choline fenofibrate in Indian population. Methods: A multicenter, open-label, randomized, active controlled, comparative, parallel-design study was conducted at 12 centers spread all across India. Mixed dyslipidemic patients aged 18–70 years were randomized to FDC of rosuvastatin 10 mg and choline fenofibrate 135 mg (RCF group) and FDC of rosuvastatin 10 mg and fenofibrate 160 mg (RF group) once daily for approximately 180 days. The primary endpoint of study was percentage change in serum triglyceride level at the end of study from baseline. Results: Of 290 patients screened, 240 patients were enrolled in this study (120 patients in each group). At the end of 180 days, there was a significant reduction in triglyceride level in both the groups (−37.7% in RCF group and −37.8% reduction in RF group; P < 0.0001 for both); however, the difference between both the groups was not statistically significant (P = 0.94). Similarly, there was significant increase (P < 0.0001 for both) in high-density lipoprotein cholesterol (HDL-C) in both groups (+17.8% in RCF group and +14.9% in rosuvastatin fenofibrate RF group). Low-density lipoprotein cholesterol (LDL-C), very low-LDL (VLDL-C), and total cholesterol were also reduced significantly in both groups (P < 0.0001). However, the difference between two groups for increase in HDL-C and decrease in LDL-C, VLDL-C, and total cholesterol was not significant. Both the treatments were safe and well tolerated. Conclusion: Overall, FDC of rosuvastatin and choline fenofibrate is as safe and effective as rosuvastatin and fenofibrate combination in Indian patients with mixed dyslipidemia with added advantage improved patient compliance as it can be taken irrespective of intake of food.
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Effect of glycemic variability on mortality in ICU settings: A prospective observational study p. 632
Manjitpal Singh, Vimal Upreti, Yashpal Singh, Anand S Kannapur, Monish Nakra, Narendra Kotwal
DOI:10.4103/ijem.IJEM_11_18  
Background: Evidence suggests a role of glycemic variability in intensive care unit (ICU) mortality. Objective: To assess effect of glycemic variability and ICU/in-hospital mortality. Design: Prospective, observational study. Setting: A 20-bedded medical/surgical ICU in a tertiary care hospital. Patients: Critically ill patients requiring life-support measures admitted to the ICU between November 1, 2015 and December 30, 2016 with hyperglycemia [random blood sugar (RBS) ≥200 mg%] and sequential organ failure assessment (SOFA) scores ≤9. Patients were put on predefined insulin infusion protocol, multiple glucose values were obtained, and mean blood glucose level (MGL) was calculated as their simple arithmetic mean. Standard deviation (SD) of MGL and coefficient of variation (CV) of glucose (derived as a percentage of SD to mean blood glucose) were then calculated for each patient and analyzed for all-cause death during hospitalization period. Results: A total of 123 patients having a mean age of 65.12 ± 16.27 years, mean SOFA score of 5.76 ± 1.76, and mean HbA1c of 6.22 ± 0.73% were included. MGL was 160.65 ± 24.19 mg/dl, SD 33.32 ± 15.08 mg/dl, and CV 20.74 ± 8.43. Deceased as compared to survivors had higher MGL (163.76 ± 24.85 vs 155.62 ± 22.43 mg/dl, P = 0.068) and higher glycemic variability (SD 38.92 ± 14.44 vs 25.06 ± 12.27 mg/dl; P < 0.001 and CV 23.69 ± 7.9 vs 15.98 ± 6.87; P < 0.001). Interestingly, more patients having higher CV at lower MGL (85.7%) died as compared to those having lower CV at higher MGL (55.6%). Conclusions: High glycemic variability is associated with increased ICU/in-hospital mortality. Outcome of patients having less glycemic variability even with slight hyperglycemia may be better than those having tight glycemic control but higher glycemic variability. Insulin protocols need to be in place for management of hyperglycemia in critical care setting aiming for adequate glycemic control as well as minimizing glycemic variability.
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It is time to carpe diem with porcine ACTH – A comparison of porcine sequence corticotropin to tetracosactide hexaacetate in testing the hypothalamic pituitary adrenal axis in healthy individuals p. 636
Nalini B Wagmode, Vivek Mathew, Ganapathy Bantwal, Vageesh Ayyar, Belinda George, CP Patanjali, John Michael
DOI:10.4103/ijem.IJEM_114_18  
Context: Our literature search revealed that the use of porcine sequence corticotropin has not been validated against tetracosactide hexaacetate in a healthy population. Aims: To study the efficacy of using porcine sequence corticotropin in comparison with tetracosactide hexaacetate in the evaluation of hypothalamo pituitary adrenal (HPA) axis. Materials and Methods: Fifteen healthy volunteers were enrolled. Serum cortisol was measured at 0 minute in all subjects and at 30 and 60 minutes after tetracosactide hexaacetate 250 μg intravenously. Four weeks later, serum cortisol level was measured at 0 minute and at 30 and 60 minutes following 24 units of porcine sequence corticotropin given intramuscularly. Results: Mean serum cortisol values with tetracosactide were 30.3 (±7.83) μg/dl and 31.27 (±7.36) μg/dl at 30 and 60 minutes, respectively. The mean cortisol values with porcine sequence corticotropin were 26.33 (±5.47) μg/dl and 31.59 (±6.40) μg/dl at 30 and 60 minutes, respectively. All subjects had a response qualified as normal or adequate at 30 minutes itself. Mean peak serum cortisol response was 32.65 (±7.76) μg/dl in tetracosactide group and 31.59 (±6.4) μg/dl in porcine sequence corticotropin group, and the responses in two groups were comparable (P = 0.686). There were no immediate side effects in both groups, with a lower cost of procedure in the porcine corticotropin group. Conclusion: Our study established the efficacy of porcine sequence corticotropin in testing the adequacy of HPA axis in healthy individuals. Our study also revealed that, the intactness of the HPA axis could be confirmed as early as 30 minutes in healthy individuals.
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Epicardial adipose tissue thickness and its corelation with metabolic risk parameters in people living with HIV: A RIMS study p. 641
S Bhagyabati Devi, Keisham J Chanu, T Jeetenkumar, H Lalrinfela, Priscilla C Lalhmachhuani, Tutan Das
DOI:10.4103/ijem.IJEM_34_18  
Context: Epicardial fat envelopes the coronary vessel adventitia without fascial separation, thus pathologic inflammation in the fat may promote the growth of atherosclerotic plaque in coronary arteries in an 'outside-in' fashion. Epicardial fat is quantitatively increased in HIV compared to un-infected people. Aims: 1. To assess Epicardial Adipose tissue (EAT) by Computed tomography (CT) in PLHIV receiving first line ART (antiretroviral therapy) 2. To correlate EAT with metabolic risk parameters. Material and Methods: 215 HIV-infected patients aged >18 years on first line ART were included in the cross sectional study. EAT thickness were measured by CT scan. Metabolic parameters were measured based on metabolic syndrome criteria. Statistical Analysis Used: Data analysis was done using IBM SPSS version ver. 21. Probability value of less than 0.5 was taken as significant. Ethical Issues: The study was carried out after obtaining approval from the Institutional Ethical Committee (IEC), Regional Institute of Medical Sciences, Imphal. Results: Half of the patients were found to have EAT thickness of 8.1-9 mm and 12.6% of cases had EAT of >9 mm. Mean epicardial thickness was 8.3 mm ± 0.7 mm for whole population. Triglyceride and high density lipoprotein (HDL) were also found to have positive correlation with EAT thickness (rp= 0.364, P = 0.04 and rp= 0.343, P = 0.05 respectively). Conclusion: Epicardial adipose tissue thickness is increased in PLHIV receiving highly active anti retroviral therapy (HAART) and positively co-related with parameters of metabolic syndrome such as waist circumference, HDL cholesterol and triglyceride level.
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A study of thyroid dysfunction in cirrhosis of liver and correlation with severity of liver disease p. 645
P Punekar, Ashvanee Kumar Sharma, A Jain
DOI:10.4103/ijem.IJEM_25_18  
Introduction: Liver plays an important role in the metabolism of thyroid hormones, as it is the most important organ in the peripheral conversion of tetraiodothyronine (T4) to triiodothyronine (T3) by Type 1 deiodinase. Materials and Methods: This case–control study included 100 decompensated liver cirrhosis patients (71 males and 29 females) and 100 apparently healthy controls (71 male and 29 female). Serum FT3, FT4, and thyroid-stimulating hormone (TSH) levels were measured using electrochemiluminescence immunoassay and analyses between cases versus healthy controls (Group 1) and further analyses in subgroups, cirrhosis with hepatic encephalopathy (HE) cases (n = 38) versus cirrhosis without HE cases (Subgroup 1), cirrhosis survivors (n = 84) versus cirrhosis nonsurvivors (Subgroup 2), HE survivors (n = 23) versus HE nonsurvivors (Subgroup 3). Results were also analyzed for severity of liver disease according to Child–Turcotte–Pugh (CTP) (Class A, B, and C), model for end-stage liver disease (MELD) score, and HE grades. Results: Most common etiology was alcohol (46%) and presentation was gross ascites (74%). Cirrhosis patients had statistically significant lower level of FT3 (P < 0.0001) and FT4 (P < 0.0001) but had higher level of TSH (P < 0.0001) compared with the controls. Cirrhosis with HE (n = 38) had significantly lower lever of FT3 (P < 0.0001) compared with cirrhosis without HE (n = 62), whereas there was no statistically significant difference in FT4 (P < 0.09) and TSH (P < 0.60) levels. FT3 level significantly low in HE Grade 4 patients compared with HE Grade 1 patients (P = 0.0001). In all cirrhotic patients, FT3 and FT4 were negatively correlated, but TSH level was positively correlated with total leukocyte counts, serum total bilirubin, aspartate transaminase, alanine transaminase, globulin, prothrombin time (PT), blood urea, serum creatinine, CTP, and MELD score. Overall, the most common abnormality seen was low T3 (low FT3) syndrome 41% (41 out of 100) in cases, 50% (19 out of 38) in cirrhosis with HE, and 32% (5 out of 16) in Non-survivors cases. Conclusion: The mean FT3 and FT4 levels were significantly decrease and mean TSH levels were significantly increase in liver cirrhosis patients compared to healthy controls. Level of FT3, FT4, and TSH also correlate with the severity of liver disease, level of FT3 can be used as prognostic marker for liver cirrhosis patients.
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Correlation between ultrasound-based TIRADS and Bethesda system for reporting thyroid-cytopathology: 2-year experience at a tertiary care center in India p. 651
Gokulakrishnan Periakaruppan, Krishna G Seshadri, GM Vignesh Krishna, Rupesh Mandava, PM Venkata Sai, S Rajendiran
DOI:10.4103/ijem.IJEM_27_18  
Background: In recent times, high-resolution ultrasound thyroid imaging has paved the way for significant transformation in clinical approach to thyroid nodule. There are several risk stratification systems in thyroid imaging, developed with an aim, not only to reduce the inter-observer variability but also to establish effective communication system. Thyroid image reporting and data system (TIRADS) classification system, which is similar to breast imaging reporting and data system for breast lesion, is the most useful of all. To our knowledge, there is just a handful published research articles available based on Indian population in this regard. In this article, we study the thyroid nodules using high-resolution ultrasound in Indian population and we try to correlate the TIRADS and Bethesda system for reporting thyroid cytopathology. Materials and Methods: This prospective study includes 184 patients studied over a period of 2 years (April 2015–April 2017). Patients having thyroid nodule in B-mode ultrasound and are scheduled to get a fine-needle aspiration cytology (FNAC) done. Bethesda classification of these nodules is tabulated in follow-up period simultaneously. By comparing these data, efficacy of TIRADS in differentiating benign from malignant nodules are assessed finally using accuracy, positive predictive value (PPV), cross-tabulation, and Chi-square tests. Results: Out of the 117 TIRADS 2 nodules, none turned out to be Bethesda IV or higher, which means none of these nodules turned out to be malignant.The risk of malignancy for TIRADS 2, TIRADS 3, TIRADS 4, and TIRADS 5 was 0, 2.2, 38.5, and 77.8%, respectively. The risk of malignancy percentage in our study is similar to those values obtained in other prominent studies. Conclusion: The probability of a particular nodule being malignant can be effectively inferred from the ultrasound-based TIRADS system with a certain level of confidence. Considering our results and other literature reviews, it be can be safely assumed that FNAC can be at least deferred in patients having TIRADS 2 nodules, which contribute to majority of newly detected cases. In our experience, there is a remarkable correlation exists between TIRADS ultrasound classification and Bethesda cytology, especially for benign nodules.
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Association of hypomagnesemia with hypocalcemia after thyroidectomy p. 656
Shrikanth P Chincholikar, Sudha Ambiger
DOI:10.4103/ijem.IJEM_599_17  
Background: Hypocalcemia is one of the most common acceptable complications in postoperative period after thyroidectomy. Hypomagnesemia has been recognized after parathyroid surgery, and it has not been studied extensively after thyroidectomy. The aim of this study was to estimate magnesium and calcium ion levels in patients undergoing thyroidectomy and to evaluate the association of hypomagnesemia with hypocalcemia after thyroidectomy. A prospective study was conducted in Government Medical College, Calicut, from December 2012 to November 2013. Materials and Methods: all patients had undergone total/near-total/subtotal thyroidectomy. Pre- and postoperative at 24 h and serum calcium and magnesium were measured by automate electrolyte analyzer. Clinical findings of hypocalcemia were recorded. Statistical analysis was done using SPSS software, version 17.0. Unpaired student t-test was used. Pearson Chi-square test or Fisher's exact test was used to compare the percentage for categorical variables. Results: In our study, 58% of the patients developed hypocalcemia, biochemical and/or symptomatic (S. Ca <8.5). About 34% of patients developed hypomagnesemia, biochemical and/or symptomatic (S. Mg <1.7). About 30% of patients developed both hypocalcemia and hypomagnesemia. About 24% of patients developed symptoms of both hypocalcemia and hypomagnesemia. Discussion: Thyroidectomy patients were at a risk of transient and permanent hypoparathyroidism because of chances of parathyroid resection during operation. Transient hypocalcemia and hypomagnesemia occur frequently after total thyroidectomy. It is important to monitor both calcium and magnesium levels after total thyroidectomy and to correct deficiencies to facilitate prompt resolution of symptoms. Conclusion: There is an association of hypomagnesemia with hypocalcemia after thyroidectomy.
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Effect of physical activity during pregnancy on gestational diabetes mellitus p. 661
Surabhi Mishra, Surekha Kishore
DOI:10.4103/ijem.IJEM_618_17  
Aims: The present study evaluates association between physical activity and Gestational Diabetes Mellitus (GDM), for it can be an effective intervention for its management. Though physical activity helps maintain glucose homeostasis, evidences of GDM risk are less extensive. Therefore, this study also identifies its correlation with maternal blood glucose levels. Materials and Methods: A prospective case-control study was carried out among pregnant women attending regular antenatal clinic at two private hospitals. The study comprised of 100 cases and 273 matched controls. Data was collected by personal interviews using a standard questionnaire. Physical activity was assessed using long form of International Physical Activity Questionnaire (IPAQ) reported as Metabolic Equivalent-Minutes per week (MET-Minutes/Week). Statistical Package for Social Sciences (SPSS) was used for analysis. Results: Results shows high exposure rates for low-to-moderate physical activity among cases, across all domains and sub-activities. The odds of GDM engaged in domestic and gardening activities for <2999 MET-minutes per week are 10 times higher than involved for ≥3000 MET-minutes per week (P < 0.001). The study also shows poor or no correlation between physical activity during pregnancy and maternal blood glucose levels. Conclusion: Despite existence of poor or no relationship with maternal blood glucose levels, prolonged sedentary behavior and decreased physical activities, especially domestic, are potential risk factors for GDM, a major finding of the study.
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Impact of glycemic levels in Type 2 diabetes on periodontitis p. 672
Sangeeta Dhir, Subhash Wangnoo, Viveka Kumar
DOI:10.4103/ijem.IJEM_566_17  
Aim: The aim is to study the effect of glycemic level in Type 2 diabetes and cardiovascular risk factors on periodontal health. Materials and Method: Type 2 diabetic and nondiabetic patients in the age group of 35–80 years (n = 1700) were recruited for the study. Periodontal examination included as follows: Probing depth, clinical attachment level (CAL), gingival recession, and bleeding on probing. Periodontitis was diagnosed based on the CAL levels and diabetes was diagnosed based on glycated hemoglobin (HbA1c) levels. Body mass index, total cholesterol, triglyceride, and low-density lipoprotein (LDL) were assessed for cardiovascular risk. Patients were characterized into two groups as follows: diabetic (n = 1235) and nondiabetic (n = 465). Sociodemographic variables included were: age, sex, obesity, smoking, duration of diabetes, and periodontitis were assessed. SPSS version 20.0.1.0 was used for all the statistical assessments. Conclusion: HbA1c and lipid levels were statistically significant with the severity of periodontitis (odds ratio [OR] [95% confidence interval [CI]: HbA1c 1.34 [1.019–1.21]; Total cholesterol 1.01 [1.03–1.42]; triglycerides 1.01 [1.01–1.14]; LDL 1.028 [1.08–1.71]). Smoking and obesity were also found to be significantly associated with the presence of periodontitis [OR (95% CI): smoking 1.35 (1.10–1.67); obesity 1.23 (1.73–2.05)]. The study concluded that uncontrolled HbA1c levels and elevated cardiovascular risk factors significantly increase the severity of periodontitis in Type 2 diabetes mellitus.
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Serum uric acid levels in Type 2 diabetes mellitus: Is there a linear relationship with severity of carotid atherosclerosis? p. 678
Shantan Venishetty, Rama Bhat, KV Rajagopal
DOI:10.4103/ijem.IJEM_641_17  
Aims: The aim of this study was to correlate serum uric acid (SUA) levels and carotid intima-media thickness (CIMT) in patients with type 2 diabetes mellitus (DM). Settings and Design: This study was a cross-sectional observational study on 103 diabetic patients conducted from September 2015 to May 2017. Subjects and Methods: We screened 103 patients with type 2 DM between the ages of 30–65 years. SUA levels and the CIMT were measured. The patients were divided into quartiles based on uric acid level. The CIMT of the quartiles is compared and analyzed. Statistical Analysis Used: Chi-squared test, Analysis of Variance, and Pearson's correlation. Results: Uric acid levels were positively associated with CIMT (P = 0.001). The association remained significant after further adjustment for potential confounders. Strong correlation was found among them as depicted by correlation coefficient (r = 0.779). Conclusions: Carotid atherosclerosis as measured by IMT is associated with SUA levels in patients with type 2 DM.
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Serum amyloid P and endocrine markers in a cohort of obese children p. 683
Mehwish Anwer, Muhammad J Iqbal
DOI:10.4103/ijem.IJEM_66_18  
Objectives: Obesity in children can lead to morbidity and mortality due to metabolic and inflammatory comorbidities. Aims: The objective of the study was to investigate the alterations in acute inflammatory markers, serum amyloid P (SAP) and cortisol, and endocrine markers, leptin and insulin, in obese children. Materials and Methods: Serum leptin, insulin, cortisol, and amyloid P concentrations were measured in obese (BMI percentile >85, n = 17) and nonobese (BMI percentile < 75, n = 20) children using ELISA and Bio-Plex Bead-based assay. Statistical Analysis Used: Serum concentrations of analytes were compared between normal and obese groups using 2-tailed student's t-test. Results: Mean leptin, insulin, and SAP serum concentrations were significantly higher in obese children as compared to the controls (97.19 vs. 4.06, P < 0.05; 21.31 vs 3.56, P < 0.05; 46.77 vs. 17.89, P < 0.05; respectively). No difference was found in mean serum cortisol levels of the two groups. However, cortisol values were higher in obese subjects compared to the control group (7.89 vs 6.30, P = 0.15). Leptin corelated with insulin (r = 0.42, P = 0.043) and cortisol (r = 0.48, P = 0.025) levels in the obese group. Furthermore, leptin, insulin, and SAP levels were corelated with BMI (r = 0.80, P < 0.000; r = 0.67, P = 0.015, respectively) and body weight (r = 0.52, P = 0.01; r = 0.52, P = 0.002; r = 0.54, P = 0.01, respectively) in the obese group but did not demonstrate a significant relationship in the nonobese group. Conclusion: Elevated SAP levels and increase in leptin and insulin indicated a preeminent disposition of morbidly obese children to the development of low-grade inflammation and metabolic syndrome.
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REVIEW ARTICLES Top

A review on cardiovascular outcome studies of dipeptidyl peptidase-4 inhibitors p. 689
Maneesha Khalse, Amit Bhargava
DOI:10.4103/ijem.IJEM_104_18  
The U.S. Food and Drug Administration issued a guidance for pharmaceutical industry defining preapproval and postapproval requirements for the demonstration of cardiovascular (CV) safety for all new medications developed for glycemic management in type 2 diabetes. However, results published from the studies of dipeptidyl peptidase-4 (DPP-4) inhibitors are conflicting with regard to different CV endpoints. Upcoming CV outcome studies perhaps will be able to provide additional insights related to diabetes management and help to provide the answers to some of these concerns. This article provides a brief overview regarding how various CV safety evidence of DPP-4 inhibitor evolved over time that highlights possible implication in clinical practice and translates them into effective diabetes management.
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Emotional and psychological needs of people with diabetes p. 696
Sanjay Kalra, Biranchi Narayan Jena, Rajiv Yeravdekar
DOI:10.4103/ijem.IJEM_579_17  
Diabetes is a chronic metabolic disorder that impacts physical, social and mental including psychological well-being of people living with it. Additionally, psychosocial problems that are most common in diabetes patients often result in serious negative impact on patient's well-being and social life, if left un-addressed. Addressing such psychosocial aspects including cognitive, emotional, behavioral and social factors in the treatment interventions would help overcome the psychological barriers, associated with adherence and self-care for diabetes; the latter being the ultimate goal of management of patients with diabetes. While ample literature on self-management and psychological interventions for diabetes is available, there is limited information on the impact of psychological response and unmanaged emotional distresses on overall health. The current review therefore examines the emotional, psychological needs of the patients with diabetes and emphasizes the role of diabetologist, mental health professionals including clinical psychologists to mitigate the problems faced by these patients. Search was performed using a combination of keywords that cover all relevant terminology for diabetes and associated emotional distress. The psychological reactions experienced by the patient upon diagnosis of diabetes have been reviewed in this article with a focus on typical emotional distress at different levels. Identifying and supporting patients with psychosocial problems early in the course of diabetes may promote psychosocial well-being and improve their ability to adjust or take adequate responsibility in diabetes self-management – the utopian state dreamt of by all diabetologists !.
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CASE REPORT Top

PHPT masquerading as rickets in children and presenting with rare skeletal manifestations: Report of three cases and review of literature p. 705
Roma Pradhan, Amit Agarwal, Sushil Kumar Gupta
DOI:10.4103/ijem.IJEM_54_18  
Primary hyperparathyroidism (PHPT) is an uncommon condition in children and adolescents. However, rapid growth spurt during puberty may result in unmasking and development of certain skeletal manifestations of PHPT. We present three cases of PHPT associated with rare skeletal manifestations of rickets. All three patients had radiological evidence of rickets with primary hyperparathyroidism. All the three patients had single gland adenoma. Literature is sparse regarding reversal of features of rickets following parathyroidectomy. In all three patients of our series, there was a complete resolution of bone/joint pain. However, in two children only the genu valgum persisted but their growth was normal and they had no proximal muscle weakness. In another child multiple corrective surgeries were done to correct the deformities.
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LETTERS TO THE EDITOR Top

Bilateral femoral head avascular necrosis with physiological doses of steroids p. 710
Smit Rajput, Bindu Kulshreshtha
DOI:10.4103/ijem.IJEM_97_18  
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Triple ectopic thyroid on pertechnetate scintigraphy p. 712
Averilicia Passah, Saurabh Arora, Nishikant A Damle, Rajni Sharma
DOI:10.4103/ijem.IJEM_88_18  
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Occurrence of subacute thyroiditis following influenza vaccination p. 713
Averilicia Passah, Saurabh Arora, Nishikant A Damle, Konudula S Reddy, Deepak Khandelwal, Sameer Aggarwal
DOI:10.4103/ijem.IJEM_237_18  
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Vitamin D deficiency in children: Is there a need for routine supplementation? p. 714
Suresh K Angurana
DOI:10.4103/ijem.IJEM_215_18  
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Multiple impacted permanent Teeth—An indicator for early detection of hypoparathyroidism: A rare case report p. 715
B Suresh Babu, Thatapudi A Shankar, Moon Chattaraj, K Kongkana, S Venugopal, Abhishek Singh Nayyar
DOI:10.4103/ijem.IJEM_56_18  
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