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   Table of Contents - Current issue
Coverpage
May-June 2020
Volume 24 | Issue 3
Page Nos. 233-292

Online since Tuesday, June 30, 2020

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EDITORIAL  

Current perspective on auto-antibodies in type 1 diabetes p. 233
Debmalya Sanyal
DOI:10.4103/ijem.IJEM_206_20  
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ENDOCRINOLOGY AND GENDER Top

Transsexualism in hindu mythology p. 235
Shiva Prakash Srinivasan, Sruti Chandrasekaran
DOI:10.4103/ijem.IJEM_152_20  
In spite of India showing progress in various medical, economic and social fronts, the care of the transgender individual is still encumbered by the various biases and taboos that people hold. But, this was not true in the antiquity. Hindu mythology holds transgender individuals in a status equal to other genders. This brief review of the various references of transgender individuals in Hindu mythology throws light on the various ways the topic of transsexualism and changing gender was addressed.
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REVIEW ARTICLES Top

Trabecular bone score—An emerging tool in the management of osteoporosis p. 237
Remya Rajan, Kripa E Cherian, Nitin Kapoor, Thomas V Paul
DOI:10.4103/ijem.IJEM_147_20  
Areal bone mineral density (aBMD) is currently the gold standard for the diagnosis of osteoporosis, however, it has its own pitfalls. Trabecular bone score (TBS), a novel tool in the evaluation of osteoporosis is an indirect indicator of bone microarchitecture. It is a textural index that evaluates pixel gray-level variations in the lumbar spine DXA (dual energy X-ray absorptiometry) image. Both cross-sectional and longitudinal studies have demonstrated that TBS may independently predict fragility fractures. TBS can also be used to adjust FRAX probabilities of fracture, though data available till date doesn't support any additional benefit. TBS also shows an improving trend with anti-osteoporotic treatment; however, the least significant change (LSC) is high that it takes more than 2 years for the change to manifest. TBS is also used in the evaluation of bone strength in cases of secondary osteoporosis. Though TBS predicts fracture risk independently in both genders, with the currently available data, it cannot be recommended as a standalone tool for decision regarding treatment of osteoporosis. TBS can be used as a tool to complement BMD in assessment of bone health. Additional studies are needed to assess its utility in clinical practice.
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”Orocrinology”: Seven easy steps! Highly accessed article p. 244
Julie Elizabeth Mathew, Beena Varma, Jubbin Jagan Jacob, Sanjay Kalra
DOI:10.4103/ijem.IJEM_119_20  
A complete examination of the oral cavity is a neglected part of physical examination and is not taught in both undergraduate and postgraduate medical training. We believe that a thorough oral examination helps in the identification of a variety of endocrine disorders and so to emphasize this, we have proposed the term “orocrinolgy.” Orocrinology is the art of using a Thorough oral cavity examination to diagnose a variety of adult and pediatric endocrine disorders. Under “orocrinology,” we have highlighted an easy to perform a seven-step technique to perform a complete examination of the oral cavity. The common endocrine-related abnormalities that you might encounter during each of these seven steps is summarized along with the steps. The seven steps start with the examination of the salivary glands, followed by the lips. This is followed by the examination of labial, buccal, alveolar, and gingival mucosa in two steps. The fifth step is the Inspection of the tongue and the base of the mouth followed by the sixth step, which is the evaluation of the palate, uvula, and tonsils. The final seventh step is the examination of the hard structures in the oral cavity, which includes the teeth, mandible, and the maxilla.
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ORIGINAL ARTICLES Top

Glycemic index of wheat and rice are similar when consumed as part of a North Indian mixed meal Highly accessed article p. 251
Shikha Nayar, SV Madhu
DOI:10.4103/ijem.IJEM_4_20  
Introduction: Wheat is preferable over rice due to its lower glycemic index (GI). It is not known if the same is true when these staples are a part of mixed meals, hence we compared the Glycemic responses of wheat/rice containing mixed meals. Materials and Methods: Glycemic responses of 2 mixed meals were compared with reference meal (glucose) where each was designed to provide a total of 50 g of available carbohydrate (AvCHO), in 10 healthy adult volunteers as per recent recommendations. Test meal 1 comprised of a pulse preparation (green gram dal), a vegetable (ladies' finger), and 2 wheat chapattis. In test meal 2 these wheat chapattis were replaced by cooked rice supplying an equal amount of AvCHO. After an overnight fast of 10- 14 h, capillary blood glucose estimations were done subsequent to eating each test meal or glucose. GI of test meals was calculated by comparing their area under curve (AUCs) with AUC for glucose. GI of test meals were compared using unpaired t test. Results: The study sample comprised of 7 males and 3 females with mean age 30.9 ± 5.1y. The GI of test meal 1 (85.5 ± 11.8%) and test meal 2 (83.6 ± 11.4%) was not significantly different (P = 0.7095). Conclusion: The present study found no differences in glycemic index of wheat chapatti and rice based mixed meals with equivalent AvCHO content of the staple.
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Profile of auto-antibodies (Disease related and other) in children with type 1 diabetes p. 256
Madhurima Basu, Kaushik Pandit, Mainak Banerjee, Samim Ali Mondal, Pradip Mukhopadhyay, Sujoy Ghosh
DOI:10.4103/ijem.IJEM_63_20  
Background: Type 1 diabetes is associated with several disease-related and other organ-specific autoimmune disorders. Data related to various auto-antibodies in Type 1 diabetes in India is limited. Materials and Methods: In this cross sectional study, 92 subjects with T1DM (33 males, 59 females) were evaluated for T1DM related antibodies (autoantibodies to glutamic acid decarboxylase (anti-GAD), autoantibodies to protein tyrosine phosphatise (anti-IA2), anti-islet cell antibody (ICA), insulin autoantibody (IAA), anti-Zinc Transporter(ZnT8) and other organ specific auto antibodies like anti–thyroid peroxidase (anti-TPO), anti-thyroglobulin (TgAb), IgA anti-tissue transglutaminase (IgA anti-tTG), anti-21-hydroxylase, and anti-ovarian antibody (in females). Results: Anti-GAD, IA-2, islet cell antibody, insulin autoantibodies (IAA), ZnT8 antibody were present in 79.3%, 32.6%, 61.9%, 63%, and 20.65% subjects, respectively. Only 2.2% patients with Type 1 diabetes were antibody negative. At least one antibody was found in 97.8% and at least two antibodies in 67.3%. The presence of anti-TPO, anti-thyroglobulin, IgA anti-tissue transglutaminase, anti 21-hydroxylase were found in 51%, 25%, 22.8%, and 2.1%, respectively. Anti-ovarian antibody was absent in all females of our study population. The duration of diabetes positively correlated with the number of T1DM specific antibody and also with GAD antibody positivity. Anti TPO positivity correlated with the age of onset of T1DM, but not with the duration of disease or presence of other T1DM specific autoantibody. Conclusions: T1DM is associated with a high prevalence of autoantibodies and antibody negative T1DM is rare. The association with other organ specific antibody (especially thyroid and adrenal glands) and celiac disease is also substantial, which reinforces the importance of regular thyroid and celiac disease screening in T1DM subjects. The duration of diabetes positively correlated with number of T1DM specific antibodies.
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Juvenile hypothyroidism: A clinical perspective from Eastern India p. 260
Moutusi Raychaudhuri, Debmalya Sanyal
DOI:10.4103/ijem.IJEM_627_19  
Introduction: Juvenile hypothyroidism (JH) can have deleterious effects on growth, pubertal development, and scholastic performance of children. In India, there is a paucity of data on acquired hypothyroidism in children, in contrast to congenital hypothyroidism. Our objective was to assess the profile of JH in a referral clinic from eastern India. Materials and Methods: For this study, 100 patients with documented acquired hypothyroidism (subclinical and overt) (aged <18 years), from eastern India, were evaluated retrospectively. Evaluation included history as well as clinical, biochemical, and ultrasonography parameters. Results: Out of the 100 participants, 74% had overt hypothyroidism (OH), while 26% had subclinical hypothyroidism (SCH). The majority of the participants were females (66%). The mean age at detection was 8.95 ± 3.96 years in the SCH group and 8.38 ± 3.29 years in the OH group. A family history of thyroid disorder and/or goiter was present in 35% of the patients. Goiter was the most common presentation in both SCH and OH, with overall prevalence of 58%. Height below 3rd percentile was significantly higher (28%) in OH group compared to 4% in SCH group. Five percent of OH subjects were obese. Worsening school performance was reported in only 9% of subjects. Only 4% (all males) presented with delayed puberty, while one female (1%) presented with precocious puberty. Sixty-four percent of OH group were TPOAb positive compared to only 15% in SCH group. Five percent of our study population had type-1 diabetes mellitus (T1DM) and 7% had Down syndrome (DS). Conclusion: In our study, JH showed significantly higher female preponderance and TPOAb positivity in OH group, in comparison to SCH group. Family history of thyroid disorder and/or goiter was present in a significant proportion of patients. Goiter was the most common presentation of JH. Height deceleration, weight gain, and fatigue were the other common presentations. Prevalence of short stature was significantly higher in OH group. Interestingly, in contrast to prevalent notion, only 5% of OH were obese and worsening school performance was observed to be rare. Puberty disorders (both delayed and precocious) may occur in JH as seen here. Because of strong association, those with T1DM or DS should be screened for JH and vice versa in TIDM.
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Effect of thyroxine replacement on leydig cell and sertoli cell function in men with hypothyroidism p. 265
Jayakumar S Ambigapathy, Sadishkumar Kamalanathan, Jayaprakash Sahoo, Ritesh Kumar, Nandhini Lakshmana Perumal
DOI:10.4103/ijem.IJEM_69_20  
Context: Thyroid hormones play an important role in reproductive and sexual function in both sexes. Comprehensive information on the ill-effects of hypothyroidism on Leydig cell, Sertoli cell and germ cell function is lacking in the existing literature. Aims: To investigate the effect of primary hypothyroidism and its treatment on testicular function – Sertoli cell, Leydig cells, seminal fluid and spermatozoa. Methods and Material: This study was carried out as a descriptive study with a before-after study design in the endocrine department of a tertiary care hospital in South India. Forty treatment naïve, overtly primary hypothyroid, consenting male patients were included. Hormones assessed were free T3, free T4, thyroid stimulating hormone, follicle stimulating hormone [FSH], luteinizing hormone [LH], prolactin, testosterone, inhibin B[INHB], and insulin like factor 3[INSL3]. Semen analysis was done according to WHO 2010 guidelines in 37 subjects. Sexual function questionnaires like Androgen Deficiency in Aging Male [ADAM], and Arizona Sexual Experience Scale [ASEX] were used. After ensuring euthyroid state for consecutive 6 months with adequate dose of thyroxine sodium, reassessment of all parameters was done. Results: At baseline, 72.5 % had a low serum testosterone value (&lt; 230 ng/dl), 67.56 % had low total sperm motility, 72.97% had low total progressive sperm motility, 80% had low ADAM score and 72.72% had low ASEX score. A raised prolactin level was seen in 32.5% of study subjects. Hypogonadotropic hypogonadism was more common than hypergonadotropic hypogonadism (89.66% vs. 10.34%). On restoration of euthyroidism, all these parameters improved. Serum INSL3 and LH increased significantly after thyroxine replacement, unlike FSH and INHB. Conclusions: Leydig cell function seemed more severely affected by hypothyroidism as compared to Sertoli cell function. Among sperm function parameters, motility was predominantly affected.
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Perioperative glycemic control in patients who underwent cardiac transplantation and effect on the outcome at discharge in a tertiary care centre p. 270
Lohit Kumbar, Sandeep Donagaon, UM Nagamalesh, Ravi Shankar Shetty, Pramila Kalra
DOI:10.4103/ijem.IJEM_121_20  
Objectives: To study the glycemic status and insulin requirements in patients who underwent cardiac transplantation and to compare it among patients with and without diabetes mellitus. To compare preoperative glycemic status and perioperative insulin requirements with the outcome. Methods and Materials: The retrospective data of the glycemic status of patients before and after cardiac transplantation were collected and analyzed. Different variables like HbA1c, creatinine, age, BMI, and glycemic status were compared with the outcome. Results: A total of 18 patients with a mean age of 46.72 ± 16.94 years (mean ± SD) and a median age of 48.5 years underwent cardiac transplantation. The mean preoperative glycosylated hemoglobin (HbA1c) was 8.75 ± 2.15% (72 ± 2.36 mmol/mol) and 5.82 ± 0.45% (40 ± 4.89 mmol/mol) in patients with and without diabetes mellitus, respectively. The mean insulin requirement of insulin on postoperative days 0, 1, 2, and 3 was 1.396, 0.503, 0.490, and 0.537 (IU/kg/day) in patients with diabetes, whereas in patients without diabetes mellitus it was 1.955, 0.561, 1.19, and 0.61 (IU/kg/day), respectively. The mean insulin requirement at the time of discharge was 0.698 ± 0.43 IU/kg/day (mean ± SD) and 1.285 ± 1 IU/kg/day (mean ± SD) (p = 0.36) in patients with and without diabetes mellitus, respectively (p = 0.53, 0.11, 0.41, and 0.32, respectively). There was no association with the outcome when analyzed with different variables like HbA1c, creatinine, BMI, age, hemoglobin, insulin requirements, and glycemic status. Conclusions: Perioperative glycemic control is crucial for successful cardiac transplantation irrespective of diabetic status.
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Does bone mineral apparent density facilitate accurate identification of osteoporosis in the short postmenopausal women? p. 275
Karthik Subramaniam, Tom Babu
DOI:10.4103/ijem.IJEM_101_20  
Objective: Height is one of the most important aspects affecting the areal bone mineral density (BMD). There are several height adjustments in children but none in widespread use for adults. This is specifically a problem in ethnic groups where mean height is substantially lower. We hypothesized that height adjustment of areal BMD would reduce the misclassification in short individuals. Materials and Methods: This is a retrospective study involving 373 postmenopausal women. Their records were reviewed and bone mineral apparent density (BMAD) were calculated. Areal BMD T-scores and BMAD T-scores were then compared. Results: The mean height of the cohort was 154.4 cm. There were 47 women who were defined as short (≤147 cm). In short women, BMAD neither showed improvement nor decrement in T-scores, and BMAD T-scores predicted more number of osteoporosis than BMD T-scores. When divided into height ranges, taller women (>160 cm) showed worsening of BMAD T-scores as compared to BMD T-scores (Chi-square test for trend P < 0.001). Hence, BMAD might actually “correct” for larger bone and not shorter bones. Conclusion: BMAD was not found to be a suitable alternative in short postmenopausal women to accurately determine whether the low bone density in them is because of dual-energy X-ray absorptiometry artifact or whether they truly have a low density.
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Serum CCL 18 levels in women with polycystic ovarian syndrome p. 280
Justin Easow Sam, KM Suryanarayana, Mala Dharmalingam, Pramila Kalra, Chitra Selvan
DOI:10.4103/ijem.IJEM_650_19  
Background: Polycystic ovarian syndrome (PCOS) is one of the most common metabolic disorders seen in women of the reproductive age group, with the majority of them having insulin resistance. There is a need to identify sensitive markers of insulin resistance. CC chemokine ligand 18 (CCL 18) secreted from white adipose tissue is upregulated in individuals with insulin resistance. Objectives: To study the correlation between serum CCL 18 levels and insulin resistance in PCOS. Materials and Methods: This case-control study included 45 PCOS women and an equal number of age and body mass index (BMI) matched controls. Estimation of serum CCL 18, serum testosterone, fasting plasma glucose, fasting insulin, HbA1c, and ultrasonography of abdomen and pelvis was done and HOMA IR was calculated. Results: Serum CCL 18 level was higher in women with PCOS when compared to controls. The mean level of serum CCL 18 (ng/mL) in the PCOS group and control group was 28.32 ± 4.17 and 11.90 ± 4.91, respectively (P < 0.001). Blood pressure, waist circumference, waist-hip ratio, modified Ferriman Gallway score (FG) score serum total testosterone, fasting serum insulin, and HOMA IR showed a relationship with serum CCL 18 levels. Serum CCL 18 was an independent predictor of PCOS (P < 0.05). A serum CCL 18 cutoff level of 18.84 ng/mL showed 93.3% sensitivity and 91.7% specificity in distinguishing PCOS subjects from healthy individuals. Conclusion: There is a significant correlation of serum CCL 18 level with insulin resistance in PCOS subjects and serum CCL levels can be considered as a marker of PCOS.
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LETTERS TO THE EDITOR Top

Transgender health care status in Kerala p. 286
Suja Sukumar, Vivek Ullatil, Arjun Asokan
DOI:10.4103/ijem.IJEM_146_20  
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Successful retrieval of oocytes followed by surrogacy in hypogonadotropic hypogonadism p. 287
Kaberi Banerjee, Bhavana Singla, Priyanka Verma
DOI:10.4103/ijem.IJEM_134_20  
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Large mediastinal parathyroid adenoma presenting with acute pancreatitis p. 288
Aman Kumar, Nishikant Avinash Damle, Deepak Khandelwal, Vivek Aggarwal
DOI:10.4103/ijem.IJEM_160_20  
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An unforeseen complication of diabetes therapy: Skin revelations p. 289
Pragya Gupta, Kripa E Cherian, Nitin Kapoor, Thomas V Paul
DOI:10.4103/ijem.IJEM_268_20  
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Unmasking of hypoparathyroidism by zoledronic acid infusion in a patient with sheehan syndrome p. 291
S Arun Viswanath, Bashir Ahmad Laway
DOI:10.4103/ijem.IJEM_253_20  
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