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   Table of Contents - Current issue
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March-April 2019
Volume 23 | Issue 2
Page Nos. 173-270

Online since Tuesday, May 21, 2019

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EDITORIAL  

Zinc and Glycemic Control p. 173
Mala Dharmalingam, Justin Easow Sam
DOI:10.4103/2230-8210.258696  
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REVIEW ARTICLE Top

SAVOR-TIMI to DECLARE-TIMI: A review on cardiovascular outcome trials of incretin-modulators and gliflozins Highly accessed article p. 175
Awadhesh K Singh, Ritu Singh
DOI:10.4103/ijem.IJEM_12_19  
Introduction: Since 2008 United State (US) food drug administration mandate, several newer anti-diabetic drugs (ADD) have undergone a mandatory cardiovascular (CV) outcome trial (CVOT) in type diabetes (T2DM) patients with high CV risk. These includes CVOT done with dipeptidyl-peptidase-4 inhibitors, sodium-glucose co-transporter-2 inhibitors and glucagon-like peptide-1 receptor agonist (GLP-1RAs). Several double-blind, randomized, placebo-controlled CVOT have been presented and published in the last decade (2008-2018). Aims and Objectives: We systematically searched the database of PubMed and ClinicalTrials.gov from January 1, 2008 to December 31, 2018 using specific key words. Subsequently, we pooled the data of different cardiovascular endpoints and made a comparative forest plot using GraphPad software Inc. Prism Version 8, US. Results and Conclusion: Saxagliptin, alogliptin, sitagliptin and linagliptin are CV neutral drugs. Saxagliptin showed a significantly higher hospitalization due to heart failure (HHF). Empagliflozin and canagliflozin have shown a significant reduction in composite of 3-point major cardiac adverse events (3P-MACE). Additionally, empagliflozin, canagliflozin and dapagliflozin significantly reduced the HHF and the composite of CV death or HHF. Moreover, empagliflozin showed significant reduction in CV- and all-cause death in patients with T2DM with established CV disease. While both exendin-backbone-based GLP-1RAs such as lixisenatide and extended-release exenatide were CV neutral; GLP-1-backbone-based GLP-1RAs such as liraglutide, semaglutide and albiglutide shown a significant reduction in the composite of 3-P MACE. Additionally, liraglutide shown a significant reduction in CV- and all-cause death. Moreover, semaglutide reduced non-fatal stroke and albiglutide reduced myocardial infarction, while extended-release exenatide reduced all-cause death; however, P value of significance for these outcomes should be considered nominal.
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ORIGINAL ARTICLES Top

Relationship between Salivary Alpha-2 Macroglobulin and HbA1c among Patients with Type-2 Diabetes Mellitus: A Cross-sectional Study p. 184
Vanshika Rastogi, Pramila Kalra, MN Vanitha Gowda
DOI:10.4103/ijem.IJEM_40_19  
Context: Type-2 diabetes mellitus (DM2) requires an adequate glycemic control to avoid diabetic complications. The best parameter available is glycosylated hemoglobin (HbA1c), as it gives us an overview of an individuals' glycemic control of the previous 4 months. Salivary biomarkers used as a diagnostic tool can indicate the control or degree of progression of diseases. Studies indicate that salivary alpha-2-macroglobulin (A2MG) levels are elevated in diabetes patients. Aims: To study the relationship of salivary A2MG with glycosylated Hba1c among patients with DM2. Settings and Design: A total of 87 patients of DM2, age 35–65 years were recruited. Materials and Methods: The routine oral cavity examination and dental check-up was done to rule out any dental disease. The patients with hepatic diseases and inflammatory diseases of oral cavity and body were excluded. The values of HbA1c were collected from the records of patients. Salivary A2MG levels were estimated by enzyme-linked immunosorbent assay. Levels of fasting and postprandial blood sugar, serum creatinine, and A2MG were compared with the HbA1c groups (<7 and ≥ 7). Statistical Analysis Used: Descriptive statistics (Software SPSS version 20.0). Nonparametric Pearson correlation test was used to assess the correlation between HbA1c and A2MG. Results: A positive correlation between salivary levels of A2MG and blood levels of HbA1c in blood was observed in this study. Results showed that there was also a significant correlation in mean values of fasting and postprandial blood sugar, serum creatinine, and salivary A2MG in diabetic subjects. Conclusion: Measurement of A2MG in saliva represents a promising noninvasive alternative method to evaluate glycemic index and consequently avoiding comorbidities.
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A medley correlation of serum zinc with glycemic parameters in T2DM patients p. 188
Santosh K Naik, Sunita J Ramanand, Jaiprakash B Ramanand
DOI:10.4103/ijem.IJEM_7_19  
Background: Studies in diabetic have reported zinc deficiency due to zincuria. Effective treatment of oral antidiabetic drugs should improve glycemic status correcting serum zinc levels. This study evaluated serum zinc level and its correlation with glycemic parameters in type 2 Diabetes Mellitus (T2DM) patients receiving oral antidiabetics. Aim: To study correlation of serum zinc and glycemic parameters in patients receiving oral antidiabetics. Materials and Methods: It was a prospective cross sectional pilot study, conducted for 1 year, with the approval of IEC. Patients of T2DM satisfying inclusion/exclusion criteria were enrolled. Serum zinc and glycemic parameters were estimated. The data was stratified into- Group A: Metformin (n = 20), Group B: Metformin and glimiperide (n = 13). Correlation analysis of serum zinc and glycemic parameters was carried. Result: The mean age and duration of 33 patients was 57 ± 9.1 and 6.30 ± 6.52 years respectively. The mean FBG, PPBG, HbA1c and zinc were 164 ± 35, 257 ± 63 mg/dL, 9.3 ± 2.2% and 58 ± 23 ug/dL respectively. Thirty patients had HbA1c >6.5%. The percentage of zinc deficiency was 76.92 and 90 in group A and B, respectively. Correlation of serum zinc and glycemic parameters was insignificant in overall group. It varied at different HbA1c levels and in different groups. A positive correlation existed between serum zinc level and HbA1c at ≥9.5%. Conclusion: Zinc deficiency was common in T2DM and to a greater extent in combination group. Correlation of serum zinc levels with glycemic parameters varied at different HbA1c and treatment groups.
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Outcomes of Bilateral Adrenalectomy in Cushing's Syndrome p. 193
Lakshmi Nagendra, Nisha Bhavani, Praveen V Pavithran, Ginil P Kumar, Usha V Menon, Arun S Menon, Lakshmi Kumar, Harish Kumar, Vasantha Nair, Nithya Abraham, Prem Narayanan
DOI:10.4103/ijem.IJEM_654_18  
Context: The literature on outcomes of bilateral adrenalectomy (BADx) in Cushing's syndrome (CS) is scant. Aims: The aim of this study is to analyze the short- and long-term outcomes of patients who underwent BADx and to compare the outcomes among different etiologies of CS. Settings and Design: This is a retrospective analysis of patients who underwent BADx for CS at our center between 2005 and 2018. Materials and Methods: In all, 33 patients were studied for clinical outcomes, survival rates, and long-term complications. Statistical Analysis: All analyses were performed with SPSS software (version 21.0). Results: The mean age at surgery was 39.33 ± 15.67 years. The primary etiology for CS was Cushing's disease (CD) in 42.42%, ectopic source in 36.36%, primary pigmented nodular adrenocortical disease (PPNAD) in 12.12%, and adrenocorticotrophin hormone–independent macronodular adrenal hyperplasia (AIMAH) in 9.09% of patients. The median follow-up time was 72.77 months. Improvement in hypertension and diabetes status after surgery was seen in 78% and 76.19% of patients, respectively. Proximal myopathy improved in 68% of patients. Nelson's syndrome and adrenal crisis were seen in 21.4% of patients each on long-term follow-up. Total mortality after BADx was 33.3%. Mortality in the first 30 days after surgery was seen in five patients (15.15%). Higher cortisol levels at presentation and age more than 40 years were predictors of mortality. Among the Cushing's subtypes, PPNAD had the best prognosis followed by CD. Perioperative Infections were a major cause of mortality. Conclusion: BADx is an effective treatment for CS especially in patients with PPNAD and CD but carries a significant mortality rate too.
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Bone mass in newborns assessed by DXA – A systematic review and meta-analysis p. 198
Rekha Ramot, Garima Kachhawa, Vidushi Kulshreshtha, Shweta Varshney, M Jeeva Sankar, K Devasenathipathy, V Sreenivas, Rajesh Khadgawat
DOI:10.4103/ijem.IJEM_681_18  
Purpose: Peak bone mass - a key determinant of osteoporotic fractures result from bone accretion starting form intrauterine life to early adulthood. Optimal skeletal growth in-utero and infancy may offer protection against osteoporosis in adult life. We attempted to pool the data from available literature to get a consensus on average bone mass among healthy newborns (age ≤30 days after birth). Methods: Systematic review was conducted (PRISMA guidelines) to generate pooled estimates of bone mass parameters at whole body (WB) and lumbar spine (LS), based on both fixed and random effect models of meta-analyses. Two investigators independently carried out a comprehensive literature search using PubMed, Google Scholar and Embase. Meta-regression was applied to further explore causes of heterogeneity. Results: Out of a total 2703 studies, 2682 was excluded leaving 21 studies for final analysis. Thirteen studies reported bone mass by Hologic® and eight by Lunar®. The pooled WBBMC was 66.2g (95% CI 65.4 to 67.05 by fixed effect model, while the corresponding parameter for LS was 2.3g (95% CI 2.2 to 2.4). The subgroup and meta-regression analyses done for controlling potential confounders did not significantly affect heterogeneity. Conclusion: We generated the pooled estimate of bone mass (WBBMC) among healthy newborn subjects. There was high degree of heterogeneity among studies.
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Platelet Indices as a Predictor of Microvascular Complications in Type 2 Diabetes Highly accessed article p. 206
Rajas S Walinjkar, Satish Khadse, Sunil Kumar, Shilpa Bawankule, Sourya Acharya
DOI:10.4103/ijem.IJEM_13_19  
Background: Type 2 diabetes mellitus (T2DM) patients have a higher risk of developing micro- and macrovascular complications, which lead to decrease in the quality of life and increase in morbidity. Platelet indices have been available in the laboratory routine using blood cell counters for several years. These indices could alert us regarding endothelial dysfunction and in turn regarding the microvascular complications. Hence, this study was done to prove the correlation between platelet indices and microvascular complications in T2DM. Materials and Methods: In total, 125 diabetic patients attending diabetes OPD and admitted in medicine department along with age and sex-matched non-diabetic controls were studied. A detailed history was taken regarding duration of diabetes, medication, past history of stroke, IHD, and hypertension. Patients with T2DM were specially evaluated for microvascular complications. Platelet indices, fasting blood glucose, Post prandial blood glucose, HbA1C, and Sr. Creatinine were obtained from venous blood samples. All parameters were then subjected to statistical analysis using SPSS 17.0. Results: Platelet indices, namely MPV, PCT, PDW, and P/LCR were significantly higher in diabetic individuals than those in age and gender-matched controls. Moreover, the increase in MPV, PDW, and P/LCR was more significant in diabetic subjects with microvascular complications when compared with those without microvascular complications. Platelet dysfunction also showed a positive association with HbA1C, retinopathy, nephropathy, and neuropathy individually. Conclusions: Changes in platelet indices were found to be statistically associated with diabetes and its complications.
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Vitamin B12 deficiency is endemic in Indian population: A perspective from North India p. 211
Rajiv Singla, Arpan Garg, Vineet Surana, Sameer Aggarwal, Geetu Gupta, Sweta Singla
DOI:10.4103/ijem.IJEM_122_19  
Background: Vitamin B12 deficiency is believed to be widespread in Indian population. However, more data is needed to fuel a meaningful debate on preventive and therapeutic strategies. Aims and Objectives: Objective of the current study is to evaluate status of vitamin B12 levels in people from a tier 3 city and among people living in an urban area with or without diabetes. Settings and Design: Retrospective, cross-sectional study. Methodology: Data captured in electronic medical records (EMR) of an endocrine practice and from a diagnostic laboratory was analysed. Statistical Analysis Used: Statistical analysis was done using open source software “Jamovi”. Results: Prevalence of vitamin B12 deficiency (Vitamin B12 levels <200 pg/ml) in tier 3 city was 47.19% (n = 267). From an urban endocrine practice, database of 11913 patients was searched for reports of vitamin B12 levels. Prevalence of vitamin B12 deficiency was 37.76% in people with pre-diabetes (n = 92), 31.23% in people with endocrine problems other than diabetes and pre-diabetes (n = 285) and 18.25% in people with diabetes (n = 378). Tier 3 city population had significantly lower vitamin B12 levels than people living in an urban area and attending an endocrine clinic. Vitamin B12 levels were significantly higher in people with diabetes as compared to people with other endocrine problems. Conclusion: Prevalence of vitamin B12 deficiency is 47% in north Indian population. People with diabetes have higher vitamin B12 levels than general population though still have high prevalence of deficiency. This data shows that Vitamin B12 deficiency is widespread in Indian population.
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Pandemic of Vitamin D deficiency: Cardiometabolic concern or skeletal biochemical abnormality? p. 215
Pradip Mukhopadhyay, Sujoy Ghosh, Kaushik Pandit, Purushottam Chatterjee, Partha Sarathi Mukherjee, Subhankar Chowdhury
DOI:10.4103/ijem.IJEM_59_19  
Context: Biochemical Vitamin D deficiency is said to be present universally in recent times. However, its effect is more profound in modulation of anthropometric and biochemical risk factors of various chronic metabolic disorders rather than its influence on bone mineral abnormalities. The present study was undertaken to compare various anthropometric and biochemical parameters including basic bone mineral biochemistry in various strata of Vitamin D status. Materials and Methods: A population based study was done in the rural area of West Bengal comprising 405 people (initially targeted 400) to look for various anthropometric and biochemical parameters. Results: Anthropometric metabolic markers like BMI, WC, waist to height ratio and biochemical parameters like total cholesterol, LDL, TG, insulin, ALT, FPG were statistically significantly higher in vitamin D deficient (<20 ng/ml) (n = 228) subjects compared to Vitamin D non-deficient subjects (≥20 ng/ml) (n = 177) which persisted even after adjustment for BMI except for FPG. The difference was similarly present when severely Vitamin D deficient (<10 ng/ml) (n = 39) subjects were compared to Vitamin D sufficient subjects (≥30 ng/ml) (n = 38) and persisted after adjustment for BMI except for FPG. However, WHR, blood pressure (both systolic and diastolic), HbA1c, HDL, AST, Uric acid, freeT4, TSH, HOMA-IR were not different in both the above-mentioned comparisons. Metabolic syndrome was statistically significantly lower in vitamin D non-deficient subjects. Though iPTH was statistically significantly higher in the low vitamin D cohorts in both the comparisons, bone mineral markers like serum calcium, phosphorus and alkaline phosphatase were not different even when severely vitamin D deficient subjects were compared to vitamin D sufficient subjects. Conclusion: Pandemic of vitamin D deficiency is more likely to be associated with cardio-metabolic risk factors than biochemical bone mineral abnormality.
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Body mass composition among underweight type 2 diabetes mellitus patients—A cross-sectional comparative study p. 222
Deepak Kumar Garg, Manoj Kumar Dutta
DOI:10.4103/ijem.IJEM_331_18  
Background: Over the past decades, various epidemiological data have shown that the pattern and profile of diabetes mellitus in India are different. The present study was carried out with an aim to study body mass composition in underweight type 2 diabetics and to compare with the normal population. Materials and Methods: The cross-sectional comparative study was conducted between January 2015 and December 2016 and included 60 participants who were selected using the convenient sampling technique. Newly diagnosed patients with type 2 diabetes mellitus and BMI less than 18.5 kg/m2 were considered for the study. Chi square test and Independent student t test were used for finding the statistically significant difference in proportions and between means, respectively; Pearson correlation coefficient was estimated for finding the linear association between two continuous variables. Results: No statistically significant difference was observed between the two groups in terms of age, waist-hip ratio, and BMI. Higher amount of fat mass and percentage were observed among the patients with diabetes as compared to that of the control group (P value < 0.05). However, there was no statistically significant difference between the underweight and the control group patients (P value > 0.05). A significant positive correlation was observed between HbA1c values and body fat mass values (P value < 0.05). Conclusion: Underweight type 2 diabetic patients were found to have high body fat mass as compared to healthy controls and the HbA1C values of the study participants were found to be positively correlated with fat mass.
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Socio-cultural dimensions of congenital adrenal hyperplasia: An ethnographic study from Chennai, South India p. 227
Mounika Pellur, Haripriya Narasimhan, Shriraam Mahadevan
DOI:10.4103/ijem.IJEM_177_18  
Aim: This study aims to provide a medical anthropological perspective on how congenital adrenal hyperplasia (CAH) is perceived and constructed by parents and doctors in India. It aims to put forth the complexities that are associated with CAH and the various experiences that parents and doctors share as a result, while also exploring the influences that culture and medicine have on each other. Methods: An ethnographic approach was taken to understand CAH in this study, in which families and doctors of children with CAH were interviewed. Fieldwork was done for 2 months in Chennai, Tamil Nadu. Results: A major finding of this study was the faith that parents had on biomedicine in general and doctors in particular. While parents continued to follow the instructions provided by the doctors, they also exercised their agency by questioning the decisions taken by the doctors. The research also revealed that there is constant worry and fear in parents about the future of their children due to the stigma attached to CAH. Conclusion: A constant discourse between medicine and culture can be noticed while analyzing the complexities associated with CAH. The study tries to show that medical decisions that doctors take in matters concerning CAH are culturally driven. Surgical corrections done in order to categorize the child into one of the two sexes is an example for the same. Similarly, various structures of family, marriage, and kinship have been medicalized owing to the strong influence medicine and culture have on each other.
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Visceral adiposity index: Simple Tool for assessing cardiometabolic risk in women with polycystic ovary syndrome p. 232
Hiya Agrawal, Kiran Aggarwal, Anju Jain
DOI:10.4103/ijem.IJEM_559_18  
Aim: To study visceral adiposity index (VAI) and its association with cardiometabolic risk in different phenotypes of polycystic ovary syndrome (PCOS). Materials and Methods: It is a case–control cross-sectional study where 100 reproductive age (18–35 years) women with PCOS were classified in different phenotypes as per Rotterdam criteria and compared with age and Body mass index (BMI) matched 50 eumenorrheic and nonhirsute women. Various anthropometric, clinical, biochemical, and hormonal parameters were measured in both women with PCOS and controls. VAI was calculated using waist circumference (WC), BMI, serum triglyceride, and High density lipoprotein (HDL) cholesterol levels in all the subjects and compared between cases and controls. Subsequently, women with PCOS were assessed for cardiometabolic risk according to androgen excess society statement 2010 as “at risk” and “at high risk.” Finally, risk was correlated with VAI for all the phenotypes of PCOS. Results: Mean VAI was significantly higher (P < 0.001) in cases than controls (2.07 vs. 1.27). Mean VAI in phenotype A (O+P+HA), B (O+HA), C (P+HA), and D (O+P) was 2.46, 2.48, 1.47, and 1.70, respectively. A total of 56% of women with PCOS were at risk and 12% at high risk for cardiometabolic disease. Metabolic syndrome was prevalent in 11% of cases and 1% had type 2 diabetes mellitus. Phenotypically, 88% of women with PCOS with phenotype A (O+P+HA), 67% of B (O+HA), 67% of C (P+HA), and 55% of D (O+P) were at increased risk. VAI was found to be positively correlated with WC (r, 0.550), waist to hip ratio (r, 0.295), Homeostasis model assessment of insulin resistance (HOMA IR) (r, 0.455), and cardiometabolic risk (r, 0.399). Also, it was the best factor associated with cardiometabolic risk (area under curve, 0.793). Conclusion: This study concluded that visceral adiposity index can be used as simple and effective tool for assessing the cardiometabolic risk in women with PCOS as higher VAI values were observed in those cases who were at high risk for developing cardiometabolic disorder in future.
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Levothyroxine dosing after delivery in women diagnosed with hypothyroidism during pregnancy-A retrospective, observational study p. 238
Kudugunti Neelaveni, Rakesh Sahay, K V. S Hari Kumar
DOI:10.4103/ijem.IJEM_609_18  
Background: Pregnancy leads to profound alteration in thyroid function and dysthyroidism contributes to adverse pregnancy outcomes. Though the management of hypothyroidism during pregnancy is highlighted, the same is often neglected during postpartum. We have evaluated the postpartum levothyroxine (LT4) dose change in patients with new onset hypothyroidism. Methods: We conducted this retrospective, observational study between 2014 and 2016 using the medical records of patients with new onset hypothyroidism during pregnancy. We included patients who continued with LT4 after delivery (as per predetermined protocol) and the availability of 2-year follow up record. We excluded patients who stopped LT4 and use of other drugs that affect the thyroid function tests (TFT) after delivery. The patients were divided into 2 groups for comparison [Group 1-Overt hypothyroidism (OH) and Group 2-Subclinical hypothyroidism (SCH)] based on the initial TFT reports. The data were analyzed using appropriate statistical methods and a P value of less than 0.05 was considered significant. Results: A total of 159 women continued using LT4 after delivery and the final follow up data were available for 130 patients only. LT4 dose up titration was observed more in group 1 than in group 2 (P = 0.0336). In both the groups, the presence of goitre, thyroid autoimmunity and a repeat pregnancy are associated with increasing LT4 requirement. Conclusion: Majority of patients with OH during pregnancy require more than half of the final dose after delivery. Goitre and autoimmunity are associated with higher LT4 dose after delivery.
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Breaking socioeconomic barriers in diabetes technologies: Outcomes of a pilot insulin pump programme for the underprivileged in Rural India p. 242
Krishnan Swaminathan, Vinaykumar Mukhekar, Ohad Cohen
DOI:10.4103/ijem.IJEM_645_18  
Aim: To assess whether the socioeconomic and stereotypical barriers for the adoption of advanced diabetes technologies can be overcome in the underprivileged children and their families in India, predominantly from the rural areas, by providing insulin pump therapy (CSII) to deserving patients. Materials and Methods: All patients were selected from the type 1 diabetes mellitus (T1DM) database of the Kovai Medical Center and Hospital, Coimbatore. Sixteen people with type 1 diabetes (PWD) were chosen due to poor control or an urgent situation like pregnancy or renal failure. Demographic data along with variables such as age, sex, time of diagnosis of T1DM, duration of CSII therapy, total daily insulin dose, hypoglycaemias, hospitalisations, glycosylated haemoglobin pre- and post-pump were collected. The glycosylated haemoglobin values were collected at 3, 6 and 12 months, post-CSII hypoglycaemia was defined as self-reported hypoglycaemia by the patient. Results: During 12 month follow-up, all 16 PWD were using the insulin pump with significant reductions in HbA1c from 11.4% at baseline to 8.0% (P < 0.001) and 7.6% at the end of 3 and 6 months, respectively. Discussion: Our results indicate that the CSII therapy without prejudice can lead to significant reductions in glycaemic control, hospitalisations and quality of life. This pilot work will help us lobby government policy makers to ensure policy changes that help the underprivileged with T1DM in India.
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A study of cardiac autonomic neuropathy in patients with type 2 diabetes mellitus: A Northeast India experience p. 246
Ashok K Bhuyan, Abhamoni Baro, Dipti Sarma, Bipul Choudhury
DOI:10.4103/ijem.IJEM_336_18  
Aim: To investigate the prevalence and the risk factors for cardiac autonomic neuropathy (CAN) in type 2 diabetes mellitus (DM) patients. Study Design: Cross-sectional cohort study. Place and Duration of Study: This study was conducted in the Department of Endocrinology, Gauhati Medical College and Hospital, Assam, India between December 2016 to March 2018. Methodology: We included 100 patients (60 males and 40 females; age range: 36–72 years) with type 2 DM. Their clinical, biochemical, and metabolic parameters were analyzed and assessment of CAN were done based on the Ewing's criteria. Results: Out of 100 patients, 60 were males and 40 were females. The mean age of the patients was 53.3 ± 10.37 years (36–72 years) and the mean duration of diabetes was 9.03 ± 6.4 years (6 months–25 years). Patients were divided into two groups: “without CAN” (CAN−) and “with CAN” (CAN+). The prevalence of CAN was 70%, with early CAN in 25%, definite CAN in 24%, and severe CAN in 21% cases The patients with CAN were older (P = 0.0005), had longer diabetes duration (11.56 vs. 3.13; P = 0.0001), higher creatinine (P < 0.0001), and lower estimated glomerular filtration rate (eGFR) (P = 0.0001) compared to patients without CAN. Retinopathy, peripheral neuropathy, and nephropathy were common in CAN + patients. On multiple logistic regression analysis, duration of diabetes [odds ratio (OR); 6.7, P < 0.0001), older age (OR; 1.07, P < 0.016), and lower eGFR (OR; 0.97, P < 0.03) were risk factors for CAN. Conclusion: CAN is a common microvascular complication in type 2 DM with duration of diabetes, age, and severity of nephropathy being its significant determinants.
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Sertoli cell function in young males with metabolic syndrome p. 251
Uma Kaimal Saikia, Kunjan Saikia, Dipti Sarma, Sonali Appaiah
DOI:10.4103/ijem.IJEM_574_18  
Context: The last few decades have witnessed an alarming increase in the prevalence of the metabolic syndrome (MetS) worldwide including India. Apart from the known risks of MetS in terms of cardiovascular risk and mortality, there is increasing evidence that it also leads to alteration in testicular function and fertility. Aims: To assess the presence of hypogonadism and Sertoli cell dysfunction in young adult males with MetS and correlate these parameters with different components of the MetS. Settings and Design: Cross-sectional study conducted in the Department of Endocrinology, Gauhati Medical College, a tertiary care hospital in North East India. Subjects and Methods: Young adult males with MetS aged 20–40 years and age-matched healthy males who served as controls were examined clinically. Laboratory investigations done in the fasting state included blood glucose, lipid profile, serum follicle-stimulating hormone (FSH), inhibin B and total testosterone (Te). Semen was collected after 3 days abstinence and analysis done. Statistical Analysis: Baseline parameters were presented as median and 'Kruskal–Wallis' test was used to compare them. Pearson test and multiple regression analysis were used to assess the correlation and association between variables. Results: Fifty cases with MetS and 30 controls were included in the study. Subjects with MetS had significantly lower levels of total Te, FSH and inhibin B. They also had significantly lower semen volume, sperm count and total as well as progressive motility. There was a significant negative correlation of waist circumference and positive correlation of inhibin B with total sperm count. A significant negative association of serum triglycerides with semen volume was also found. Conclusion: MetS is a state of hypogonadotropic hypogonadism as reflected by low total Te, FSH and inhibin B levels with semen abnormalities reflecting Sertoli cell dysfunction.
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Obese and non-obese polycystic ovarian syndrome: Comparison of clinical, metabolic, hormonal parameters, and their differential response to clomiphene p. 257
Garima Sachdeva, Shalini Gainder, Vanita Suri, Naresh Sachdeva, Seema Chopra
DOI:10.4103/ijem.IJEM_637_18  
Objective: To study the clinical, metabolic, hormonal parameters, and differential response to clomiphene among the obese and non-obese PCOS (polycystic ovarian syndrome). Design: Prospective observational study. Setting: Infertility OPD, a government hospital. Sample Size: About 164 women with PCOS-related infertility. Study Groups: Obese PCOS group [body mass index (BMI) ≥23 kg/m2) and non-obese PCOS group (BMI <23 kg/m2). Results: Of the total 164 PCOS women, 124 (75.61%) were in the obese group with BMI ≥23 kg/m2 and 40 (24.39%) were in the non-obese PCOS group. The prevalence of menstrual irregularity, hypertension, insulin resistance (IR), metabolic syndrome, endometrial hyperplasia, and clomiphene resistance in the PCOS women were 82.34%, 3.66%, 59.76%, 24.39%, 7.93%, and 53.7%, respectively. The Ferriman–Gallwey score, menstrual irregularity, IR [fasting insulin and Homeostatic Model Assessment of Insulin Resistance (HOMA-IR)], metabolic syndrome, deranged lipid profile, and clomiphene resistance were statistically more common in the obese PCOS group (P < 0.05). Hypertension, deranged blood sugar profile, testosterone, androstenedione levels, and endometrial hyperplasia were more common in obese PCOS group but the results were not statistically significant. No significant differences were found in the luteinizing hormone (LH), follicle-stimulating hormone (FSH), LH–FSH ratio, and 17-hydroxyprogesterone (17-OHP) levels between the two groups. Conclusion: Obese PCOS have a higher risk of adverse outcomes like hypertension, IR, metabolic syndrome, and endometrial hyperplasia. So, targeting obesity in PCOS women will not only help to prevent adverse outcomes but also improve responsiveness to clomiphene citrate.
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Klinefelter Syndrome: Clinical Spectrum Based on 44 Consecutive Cases from a South Indian Tertiary Care Center p. 263
Adlyne R Asirvatham, Praveen V Pavithran, Aswin Pankaj, Nisha Bhavani, Usha Menon, Arun Menon, Nithya Abraham, Vasantha Nair, Harish Kumar, MV Thampi
DOI:10.4103/ijem.IJEM_582_18  
Background: Klinefelter syndrome (KFS) is the commonest chromosomal abnormality, yet remains largely underdiagnosed due to its varied clinical presentation. This study was done to understand the clinical spectrum in our population. Aim: We intended to study the clinical characteristics of children and adults with KFS in our population. We also desired to identify any special features of Klinefelter variants. Methods: Forty-four patients with karyotype diagnosis of KFS during the time period 2007-2015 were included in this retrospective study. Clinical details and hormonal profile were obtained from hospital information system. Results: Our study population consisted of 17 (38.6%) participants in pediatric age group (age <18 years) and 27 (61.4%) adults. Clinical presentation prompting evaluation in the former group included cardiac anomalies (29.4%), dysmorphism (23.5%), hypogonadism (17.6%), developmental delay (11.8%), tall stature (11.8%), and cryptorchidism (5.9%). Among adults, 16 (59.2%) presented with hypogonadism and 9 (20.4%) had primary infertility. Six children (35.3%) had micropenis and four (three children, one adult) had unilateral undescended testis. Behavioral problems were detected in 19 (43.2%) subjects. Mean follicle stimulating hormone (FSH) and luteinizing hormone (LH) values were 38 IU/mL and 18 IU/mL, respectively. The classical 47 XXY karyotype was detected in 38 (86.4%) subjects and 6 (13.6%) had karyotype consistent with Klinefelter variants. Conclusion: KFS was diagnosed only after 18 years of age in two-thirds of patients. Developmental delay, cardiac anomalies, behavioral abnormalities, and intellectual disabilities were the common presentations in pediatric subjects. Adults predominantly presented with hypogonadism. Individuals with Klinefelter variant karyotype sought medical attention predominantly for non-gonadal concerns.
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Stress dose causing distress p. 267
Karthik Balachandran, Adlyne R Asirvatham, Shriraam Mahadevan
DOI:10.4103/ijem.IJEM_119_19  
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Myxedema coma, pancytopenia, and hypocoagulopathy: A rare presentation of Sheehan's syndrome p. 268
Badari Mylliemngap, Satish Swain, Surabhi Vyas, Prabhat Kumar
DOI:10.4103/ijem.IJEM_120_19  
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Denosumab as a bridge to surgery in a patient with severe hypercalcemia due to primary hyperparathyroidism in the setting of renal dysfunction p. 269
Remya Rajan, Kripa Elizabeth Cherian, Nitin Kapoor, Thomas V Paul
DOI:10.4103/ijem.IJEM_678_18  
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