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   Table of Contents - Current issue
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March-April 2020
Volume 24 | Issue 2
Page Nos. 123-231

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EDITORIALS  

Endocrinology, epidemics and ethics Highly accessed article p. 123
Sanjay Kalra, Ganapathy Bantwal, Rakesh Sahay
DOI:10.4103/ijem.IJEM_151_20  
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Transgender endocrinology p. 126
Anirban Majumdar, Debmalya Sanyal, Suja Sukumar, Sanjay Kalra
DOI:10.4103/ijem.IJEM_177_20  
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ENDOCRINOLOGY AND GENDER Top

IDEA group consensus statement on medical management of adult gender incongruent individuals seeking gender reaffirmation as female Highly accessed article p. 128
Anirban Majumder, Sudip Chatterjee, Debasis Maji, Soumyabrata Roychaudhuri, Sujoy Ghosh, Chitra Selvan, Belinda George, Pramila Kalra, Indira Maisnam, Debmalya Sanyal
DOI:10.4103/ijem.IJEM_593_19  
Cross sex hormone therapy (CSHT) is a strongly desired medical intervention for gender incongruent individuals. The goal is to change secondary sex characteristics to facilitate gender presentation that is consistent with the desired sex. When appropriately prescribed CSHT can greatly improve mental health and quality of life for gender incongruent individuals. Appropriate care for gender incongruent individuals in India is almost absent due to lack of country specific guideline and lack of training amongst the medical professionals. This document is intended to assist endocrinologists and physicians whose adult gender incongruent client is seeking gender reaffirmation as female (transfeminine). These individuals require a safe and effective CSHT regimen that will suppress endogenous male hormone secretion and maintain physiologic levels of female sex hormone. In this document, we offer suggestions based on an in-depth review of Guidelines of Endocrine Society, The World Professional Association for Transgender Health guidelines, the Sappho Good Practice Guide of India and collegial meetings with expert Indian clinicians working in this field. Clinicians represented in our expert panel are not gender specialists by training but have developed expertise due to the volume of gender incongruent individuals they manage. This consensus statement on medical management provides protocols for the prescribing clinician relating to diagnosis, baseline evaluation and counselling, prescription planning for feminizing hormone therapy and anti-androgen therapy, targets for monitoring hormone therapy, choice of therapy, clinical and biochemical monitoring, recommending sex reaffirmation surgery and peri-operative hormone therapy. The recommendations made in this document should not be perceived as a rigid set of guidelines and the treating clinicians are encouraged to modify our suggested protocols to address emerging issues.
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ENDOCRINOLOGY AND THE ARTS Top

Hormones p. 136
Narendra Kotwal
DOI:10.4103/ijem.IJEM_44_20  
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ORIGINAL ARTICLES Top

Parathyroid carcinoma—An experience of the enigma over 10 years p. 137
Supreet Singh Nayyar, Shivakumar Thiagarajan, Devendra Chaukar, Sarbani Ghosh Laskar, Asawari Patil, Abhishek Mahajan, Snehal Shah
DOI:10.4103/ijem.IJEM_588_19  
Introduction: Parathyroid carcinoma (PC) is an uncommon clinical entity. Identification and appropriate treatment of PC remains a challenge. In this study, we explore clinico-radiological features suggestive of PC, the utility of Castleman's histopathological criteria for the diagnosis of PC and discuss the MD-Anderson prognostic stratification system for PC. Methods: Retrospective analysis (case series) of patients who were treated at our tertiary oncology institution between January 2009 and December 2018 with an eventual diagnosis of PC. Results: The study group comprised 15 patients. The most common presentation was related to the musculoskeletal system (n = 9, 60%). In one of the cases, ultrasound features were recorded to be suspicious of PC. The highest histopathological correlation with PC was found with capsular and vascular invasion (n = 12, 80%). The primary tumor was found in inferior parathyroid glands in most cases (n = 12, 80%). The average tumor size was 2.47 cm. Six patients (40%) received adjuvant radiotherapy (RT). Three patients (20%) developed recurrence, all having distant metastasis. Overall survival (OS) at 3 years was 92.31% and disease-free survival (DFS) of 76.61%. Conclusion: The presence of certain features on ultrasonography might suggest PC preoperatively. Among Castleman's criteria, capsular invasion and vascular invasion had a maximum association with PC in our series. At present, there is no evidence to routinely give adjuvant RT to all patients with PC.
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Effect of dipeptidyl peptidase 4 inhibitors on cardiovascular events in type-2 diabetes patients with renal impairment: A systematic review and meta-analysis p. 143
Maneesha Khalse, B Ganapathy
DOI:10.4103/ijem.IJEM_568_19  
Background: Recent studies suggested that the increased risk of heart failure by DPP-4 inhibitors may have an interconnection with patients' baseline eGFR. We decided to investigate the effect of DPP-4 inhibitors and the degree of renal function on cardiovascular (CV) safety in type 2 diabetes (T2D) patients. Materials and Methods: Systemic search of literature that examined the DPP-4 inhibitors and reported cardiovascular outcomes in diabetes patients with renal impairment were performed. Studies were examined for inclusion criteria: Randomized controlled trials with reduced renal function taking DPP-4 inhibitors alone or in combination with other anti-diabetes agents reporting evaluable CV events for at least 24 weeks. Result: Analysis of four CV outcome studies (11,789 patients with eGFR ≤60 ml/min/1.73m2) did not find any increase in primary composite endpoints with DPP-4 inhibitors in patients stratified by baseline renal function. Rate of hospitalization due to heart failure (hHF) is found to be non-inferior to placebo group in patients with renal insufficiency (RR 1.07; 95% CI, 0.96-1.20 P = 0.26). In moderate renal dysfunction, there is a significant increase in heart failure risk compared to placebo. (RR 1.27; 95% CI, 1.033 -1.5 8; P = 0.024). Conclusion: Treatment with DPP-4 inhibitors did not affect the risk of cardiovascular events regardless of baseline renal function, however, an increase in the risk of hHF in moderate renal function in T2D patients with high CV risk merits careful consideration. Further research would be necessitated to reach definitive conclusion to understand the effect of declining renal function on CV safety of DPP-4 inhibitors.
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Changing trend in vitamin D status from 2008 to 2016: An experience from a tertiary care institute in North India p. 150
Nishant Raizada, Alpesh Goyal, Rajiv Singla, Vishnubhatla Sreenivas, Nandita Gupta, Rajesh Khadgawat
DOI:10.4103/ijem.IJEM_634_19  
Background: Serum 25-hydroxyvitamin D (25(OH)D) assays have become readily available in India over the past decade. A large number of cross-sectional studies have been performed on the vitamin D status and the prevalence of vitamin D deficiency (VDD) in India. However, seasonal and long-term trends in serum 25(OH)D levels have been reported less frequently. Aim: To determine the seasonal and year-wise variation in vitamin D status at a tertiary care hospital in north India. Materials and Methods: Using hospital records, the data on serum 25(OH)D assays performed in its endocrinology laboratory between 2008 and 2016 were obtained. For analysis of seasonal trends, the months of a year were divided into following seasons: March to June (summer season), July to October (rainy season), and November to February (winter season). VDD was defined as serum 25(OH)D concentration ង ng/mL. Results: A total of 26,339 assays of serum 25(OH)D were analyzed in the study. The year-wise assay numbers increased steadily from 2008 to peak in the year 2012, followed by a decline and a second smaller peak in the year 2016. The mean serum 25(OH)D concentration increased from 19.1 ± 16.4 ng/mL in 2008 to 21.7 ± 17.1 ng/mL in 2016 (P = 0.02). Between 2008 and 2016, the prevalence of VDD decreased from 71.9% to 54.3% in females, and from 56.7% to 52.1% in males. The levels in rainy season were significantly higher as compared to winters and summers (P < 0.05 for both). Hypervitaminosis D (serum 25(OH)D >100 ng/mL) and vitamin D toxicity (serum 25(OH)D >150 ng/mL) were seen in 319 (1.2%) and 27 (0.1%) assays, respectively. Conclusions: This study provides data on seasonal and year-wise trends in vitamin D status over a long period of time at a tertiary care hospital in north India. A long-term trend toward improving vitamin D status, especially in females, was noted in the study. The prevalence of VDD was found to decrease in the analyzed samples during the study period.
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Obesity and its link to undiagnosed diabetes mellitus and hypertension in rural parts of western India p. 155
Meenakshi Kalyan, Prasanna Dhore, Vedavati Purandare, Shailesh Deshpande, AG Unnikrishnan
DOI:10.4103/ijem.IJEM_582_19  
Background: Obesity and overweight are becoming major health concerns worldwide. Hence, we studied the association between overweight and obesity with new-onset diabetes and hypertension in a selected rural population. Methodology: Community health workers made house-to-house visits, inviting adults >20 years of age who were at a higher risk of diabetes, from a predefined rural area of Maharashtra, to visit a mobile diabetes clinic operating in a hub and spoke manner. Sociodemographic data and anthropometric measurements were recorded. BMI and waist circumference was classified according to the WHO recommended cutoffs for Asians. Subjects with capillary blood fasting glucose of ≥126 mg/dL or random glucose of ≥200 mg/dL by glucometer were diagnosed as diabetes and blood pressure of ≥140/90 mmHg by sphygmomanometer were diagnosed as hypertension. Subjects with a known history of diabetes mellitus and hypertension were excluded. Results: Out of 29,324 total population, 16.5% of subjects were overweight and 26.4% were obese. Mean ± SD of BMI of the participants was 22.9 ± 4.1 kg/m2 in males and 22.4 ± 4.2 kg/m2 in females. Around 35% of males and 30.5% of females had a high waist circumference of ≥90 cm and ≥80 cm, respectively, 20.5% of subjects had newly diagnosed hypertension, and 11.4% of subjects had newly diagnosed diabetes mellitus. The occurrence of newly diagnosed hypertension and diabetes showed an increasing trend with increasing BMI. Conclusion: Our community-based screening suggested a high prevalence of overweight and obesity in rural India. There was a high prevalence of newly diagnosed hypertension and diabetes in this population.
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Trimester-specific reference intervals for thyroid function parameters in Indian pregnant women during final phase of transition to iodine sufficiency p. 160
Subhadip Pramanik, Pradip Mukhopadhyay, Kingshuk Bhattacharjee, Rana Bhattacharjee, Bidisha Mukherjee, Samim Ali Mondal, Sandip Bandhopadhay, Subhas Biswas, Subhankar Chowdhury, Sujoy Ghosh
DOI:10.4103/ijem.IJEM_561_19  
Background: Interpretation of thyroid function tests during pregnancy depends on gestational age, method, and population-specific reference intervals. Therefore, there is a worldwide trend to establish trimester-specific levels for different populations. The aim of this study was to establish a trimester-specific reference range for thyroid function parameters during pregnancy in Indian women.Materials and Methods: Thyroid function tests (TSH, FT4, TT4, TT3) of 80, 76, and 73 women at 1st, 2nd, and 3rd trimester, respectively, and 168 nonpregnant women were analyzed after exclusion of low UIC( μg/L) and anti-TPO positivity(>35 IU/ml). Urinary iodine excretion (UIC) was assessed in all. The 2.5th and 97.5th percentile values were used to determine the reference ranges for thyrotropin (TSH), free thyroxine (FT4), total thyroxine (TT4), and total triiodothyronine (TT3) for each trimester of pregnancy. Results: The reference range for TSH for first trimester was 0.19–4.34 μIU/ml, for second trimester 0.46–4.57 μIU/ml, and for third trimester 0.61–4.62 μIU/ml. The reference range during three trimesters for FT4 (ng/dl) was 0.88–1.32, 0.89–1.60, and 0.87–1.54, for total T4 (μg/dl) was 5.9–12.9, 7.4–15.2, and 7.9–14.9. In nonpregnant women, FT4 was 0.83–1.34, total T4 was 5.3–11.8, and TSH was 0.79–4.29. The mean UIC in nonpregnant women was 176 ± 15.7 μg/L suggesting iodine-sufficiency in the cohort. Conclusion: The trimester-specific TSH range in pregnant women in this study is not significantly different from nonpregnant reference range in the final phase of transition to iodine sufficiency in India.
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Incidence of new-onset diabetes and posttransplant metabolic syndrome after liver transplantation - A prospective Study From South India p. 165
Tittu Oommen, Chankramath S Arun, Harish Kumar, Vasantha Nair, RV Jayakumar, S Sudhindran, VP Praveen, Nisha B Nithya Abraham, Usha Menon
DOI:10.4103/ijem.IJEM_602_19  
Background and Aims: Liver transplantation has become an effective therapy for patients with end-stage liver disease. The risk of new-onset diabetes after transplantation (NODAT) and posttransplant metabolic syndrome (PTMS) is high among patients after liver transplantation. These are thought to be associated with increased risks of graft rejection, infection, cardiovascular disease, and death. Our study aimed to document the incidence of NODAT and PTMS and analyze pre and posttransplant predictive factors for their development in patients undergoing a liver transplant. Methods: This was a prospective comparative study on 51 patients who underwent live donor liver transplantation. They were evaluated at baseline, 3 and 6 months after transplantation with fasting glucose, lipids, serum insulin levels, C-peptide, and HbA1C. They were followed up at 5 years to document any cardiovascular events or rejection. Results: The incidence of preoperative diabetes mellitus (DM) in the study group was 25/51 (49%). The incidence of NODAT was 38.5% (10/26 patients) and PTMS 29% (10/35), respectively. Age (47.7 ± 5.4 vs 41.5 ± 12.7 years), HOMA2 -IR (2.3 ± 1.8 vs 2.1 ± 1.6), serum insulin (16.1 ± 12.0 vs 17.9 ± 14.5), and C-peptide (4.6 ± 0.5 vs 4.8 ± 0.7) were similar at baseline in the NODAT group compared to those who did not develop it. Mean tacrolimus levels were higher in PTMS group (6.8 ± 2.9 vs 5.0. ± 2.0 P value = 0.042). By the end of 5 years, 7 patients expired; 6 due to rejection and one due to cardiovascular disease. Moreover, 2 of these patients had preexisting DM and 2 had NODAT. Conclusions: None of the baseline metabolic factors in patients undergoing liver transplant were predictive of the development of NODAT or PTMS. Mean tacrolimus levels were significantly higher in the PTMS group. A 5-year follow-up showed no excess risk of cardiovascular events or rejection in those with preexisting DM or in those who developed NODAT.
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Approaching indeterminate thyroid nodules in the absence of molecular markers: “The BETH-TR score” p. 170
Sushma Mehta, Subramanian Kannan
DOI:10.4103/ijem.IJEM_620_19  
Context: Given the lack of easy access to molecular markers for indeterminate thyroid nodules (Bethesda (BETH) category III, IV), the clinician can either decide to get a second opinion from an expert high-volume thyroid cytopathologist, redo the FNAC after a period of 3–6 months, or send the patient for a diagnostic hemithyroidectomy. Reviewing the sonographic risk features is also one way of triaging these nodules. The ACR-TIRADS (TR) is an objective method of sonographic risk assessment and is superior to other forms of sonographic classification. Aim: We propose combining the scoring of the TR category and BETH category (both expressed as a numerical value and summated) and look at the score which could potentially guide the clinician in deciding whom to send for surgery. Settings and Design: Observational prospective collection of consecutive patient data from the thyroid FNAC clinic. Statistical Analysis Used: The BETH categories were represented numerically and summated with the TR category. The categorical outcome variables of benign and malignant nodules and the summated score was analyzed using the Kruskal-Wallis test. Results: We analyzed 450 FNAC data, out of which 403 were thyroid nodule aspirates. Out of these nodules, 96 of them underwent surgery and 64% of these nodules were malignant on final histopathology (malignant = 62 and benign = 34). The mean size of the benign nodules was 3.6 ± 2.2 cm compared to 2.8 ± 1.8 cm of the malignant nodules. After excluding those with BETH 1 (n = 4), the mean BETH-TR score for benign nodules was 6 ± 1.4 and malignant nodules 9.4 ± 2.1 (P < 0.0001). The BETH-TR score progressively increased from 7.3 ± 0.92 in follicular thyroid cancers (FTC) to 8.6 ± 1.4 in follicular variant papillary thyroid cancer (FVPTC) to 10 ± 1.3 in classic papillary thyroid cancers (PTC). Among the indeterminate nodules (BETH III and IV; n = 40), the BETH-TR score of benign nodules was 6.75 ± 1 and malignant nodules was 7.5 ± 0.72 (P value = 0.01). A BETH-TR score ≥7 gave a sensitivity of 92% specificity of 74% and correctly identified malignant nodules in 86% of cases (likelihood ratio 3.5; ROC area: 0.8841; CI 0.79–0.94). Conclusion: A combined sonocytological BETH-TR score is one way to triage the management of indeterminate thyroid nodules. A BETH-TR score ≥7 gave a sensitivity of 92% specificity of 74% and correctly identified malignant nodules in 86% of cases.
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Growth parameters of under 2-year-old Indian children: A comparison to WHO MGRS 2006 charts p. 176
Venkat Sandeep Reddy, Rahul Jahagirdar, Ruma Deshpande
DOI:10.4103/ijem.IJEM_570_19  
Context: Growth is an important biological process by which an individual reaches a point of complete physical development. Growth monitoring of a child is a very important utility to detect the deviation from normal growth. In India, for children below 2 years of age WHO multicentre growth reference study (MGRS) 2006 charts are being used for growth monitoring, which were prepared by measuring children from six different countries who were raised in optimum conditions of health and nutrition. Aim: This study was carried out to verify the appropriateness of the WHO MRGS 2006 charts to monitor the growth of Indian children who are below 2 years of age. Settings and Design: The study was carried out in a tertiary care hospital in Pune, Maharashtra. Materials and Methods: A total of 1947 children [1089 boys (55.9%)] were measured for weight, length and head circumference. Z score for each observed value was calculated according the similar but gender-specific WHO MGRS 2006 growth charts. Statistical Analysis Used: The age- and sex-specific Z-scores or standard deviation scores along with prevalence were obtained for each study parameter using WHO standards. Results: A total of 24.08%, 21.31%, and 20.54% of the children were classified as underweight, stunted and microcephalic respectively when compared to the WHO MGRS 2006 growth charts. Conclusion: The WHO MGRS 2006 charts may not be appropriate for growth monitoring of Indian children below 2 years of age and there is a need formulate growth charts which can reflect the growth of Indian children.
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Surveillance accuracy of smartphone-dependent glucose meters in the measurement of plasma glucose p. 181
Shaikat Mondal, Himel Mondal, Sairavi Kiran Biri
DOI:10.4103/ijem.IJEM_580_19  
Background: Along with stand-alone glucose monitors, smartphone-dependent glucose meters (SDGM) are available for self-monitoring of blood glucose (SMBG). These display-less devices, connected to a smartphone, measure glucose and display report on a smartphone screen, which can be easily shared with doctors. Aim: The aim of this study was to check the accuracy of the available SDGMs in relation to the laboratory reference method. Materials and Methods: Two available SDGMs: BeatOTM and GlucoMeTM were tested. A total of 104 venous blood samples were tested for glucose in SDGMs and by the reference method. The accuracy of the report was checked by the International Standards Organization (ISO), American Diabetes Association (ADA), and Clinical Laboratory Improvement Amendments (CLIA) criteria. Clarke error grid analysis (CEGA) was carried out to find the suitability of SDGM in clinical usage. Results: Mean plasma glucose (n = 104) level from laboratory report was 106.48 ± 44.58 mg/dL, that from BeatOTM was 105.78 ± 52.6, and GlucoMeTM was 99.72 ± 51.22. The accuracy was lower than that recommended by ISO 2013 (29.8% and 30.77% error in BeatOTM and GlucoMeTM, respectively), ADA (63.46% and 74% error in BeatOTM and GlucoMeTM, respectively), and CLIA (42.31% and 46.15% error in BeatOTM and GlucoMeTM, respectively) criteria. According to CEGA, BeatOTM and GlucoMeTM can guide correct treatment in diabetes mellitus patients for 74% and 71% of measurement, respectively. Conclusion: The accuracy of both the SDGMs was lower than that suggested by ISO, ADA, and CLIA criteria. The result of this study would help patients and doctors in informed choice for the procurement of glucose monitors.
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Effect of jain fasting on anthropometric, clinical and biochemical parameters p. 187
Pratap Sanchetee, Prakash Sanchetee, MK Garg
DOI:10.4103/ijem.IJEM_601_19  
Background and Aims: Fasting has a long tradition in most cultures and has many health benefits. Most of the studies are from daytime fasting or intermittent fasting. There is paucity of data from complete fasting (no food and fruits, water only). This prospective study is conducted with aims to study impact of complete fasting on clinical and biochemical parameters. Methods: One hundred ten participants of either gender who voluntarily fasted (3-30 days) were included and underwent clinical and biochemical examination before and after fasting. Results: A total of 110 healthy volunteers (M: 27, F: 83) with mean age 51 ± 16 years (range 18-86) and body mass index 27.1 ± 4.9 kg/m2 (16.1-45.2) were studied. They had undergone fast for varying duration between 3-30 days (short fast: 3-7 days = 72; prolong fast: >7 days = 38). There were significant decrease in weight (66.8 ± 11.0 to 64.7 ± 11.1 kg, P < 0.0001), BMI (27.1 ± 4.9 to 26.2 ± 4.9 kg/m2, P < 0.0001), systolic blood pressure (130 ± 17 to 128 ± 15 mmHg, P = 0.012), serum globulin (3.10 ± 0.42 to 3.01 ± 0.41 mg/dl, P = 0.024), and serum high density lipoprotein (48.3 ± 12.2 to 45.7 ± 12.6 mg/dl, P < 0.0001) post fasting. However, significant increase was observed in pulse rate (81 ± 10 to 83 ± 11 beat/min, P = 0.001), fasting plasma glucose (102.9 ± 35.0 to 132.0 ± 42.0 mg/dl, P < 0.0001), serum triglycerides (137.6 ± 68.3 to 149.0 ± 67.1 mg/dl, P = 0.031), very low density lipoprotein (22.0 ± 10.5 to 24.2 ± 11.1 mg/dl, P = 0.010), and serum cortisol levels (13.5 ± 5.9 to 17.2 ± 6.3 μg/dl, P < 0.0001). These changes were more pronounced with prolong fasting, but were not affected by gender. Conclusions: Fasting results in improvement in anthropometric, physical and biochemical parameters related to physical health. It can be recommended as a mean for improving quality of life.
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Serum Anti-Müllerian hormone in polycystic ovary syndrome and its relationship with insulin resistance, lipid profile and adiponectin p. 191
Thien Jun Jun, Aniza Mohammed Jelani, Julia Omar, Rahimah Abdul Rahim, Najib Majdi Yaacob
DOI:10.4103/ijem.IJEM_305_19  
Objectives: This study was done to estimate serum anti-Müllerian hormone (AMH) level in polycystic ovary syndrome (PCOS) patients and to correlate serum AMH level with insulin resistance, lipid profile, and adiponectin levels. Materials and Methods: A cross-sectional study was conducted at Hospital Universiti Sains Malaysia (Hospital USM), Health Campus, Kubang Kerian, Kelantan, Malaysia. Thirty newly diagnosed patients with PCOS attending gynecology clinic between July 2016 and April 2017 were recruited. Fasting venous blood samples were collected from the subjects. Serum AMH, insulin, adiponectin, triglycerides, high-density lipoprotein cholesterol (HDL-C), and plasma glucose levels were measured, and insulin resistance was calculated based on homeostasis model of assessment-insulin resistance (HOMA-IR). The serum AMH level was estimated, and the correlation of serum AMH level with the metabolic parameters was analyzed. Results: The median of serum AMH levels in women with PCOS was 6.8 ng/mL (interquartile range: 7.38 ng/mL). There was a significant negative correlation between serum AMH and HOMA-IR or triglyceride levels (r = −0.49, P = 0.006 and r = −0.55, P = 0.002, respectively). A significant positive correlation was observed between serum AMH and serum HDL-C or serum adiponectin levels (r = 0.56, P = 0.001 and r = 0.44, P = 0.014, respectively) in all study subjects. Conclusion: The serum AMH level is associated with HOMA-IR, triglycerides, HDL-C, and adiponectin levels, and hence it may be used as a potential cardiometabolic risk marker in women with PCOS.
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Neonatal severe primary hyperparathyroidism: A series of four cases and their long-term management in India p. 196
Dhalapathy Sadacharan, Shriraam Mahadevan, Smitha S Rao, A Prem Kumar, S Swathi, Senthil Kumar, Subramanian Kannan
DOI:10.4103/ijem.IJEM_53_20  
Context: Neonatal severe primary hyperparathyroidism (NSPHPT) is an extremely rare autosomal recessive disorder, requiring a high index of suspicion. Infants affected with this disorder present with severe life-threatening hypercalcemia early in life, requiring adequate preoperative medical management followed by surgery. Aims: We report four newborns with NSPHPT who were managed over 10 years. Subjects and Methods: Demography, clinical presentation, treatment, and follow-up data were retrospectively studied with descriptive analysis to highlight the utility of long-term medical management, surgery, and genetic testing reported in the literature. Statistical Analysis Used: Descriptive Analysis. Results: We had three males and one female infant with a mean age of diagnosis at 28.7 days, calcium 29.2+/-2.8 mg/dL, and parathormone (PTH) 1963+/-270.4 pg/mL. All four infants presented with failure to thrive, hypotonia, and respiratory distress. All infants were treated medically followed by total parathyroidectomy plus transcervical thymectomy, with an additional hemithyroidectomy in one of them. Imaging was negative in all four cases. Three babies became hypocalcemic while the fourth infant had a drop in PTH and is on the tab. cinacalcet 30 mg/day. CaSR mutation was positive in three infants. Conclusions: Diagnosing NSPHPT needs expert clinical acumen. It requires emergency medical management to control calcium levels. The crisis may present later, necessitating parathyroidectomy in these cases once the child is fit for surgery. Surgery offers a cure for this unusual lethal hypercalcemia while the role of cinacalcet needs a special mention. Sound knowledge in endocrinology with parathyroid embryology and morphology is of paramount importance. Our case series might add a few insights into managing this unusual genetic disorder.
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Goiter prevalence and thyroid autoimmunity in school children of Delhi p. 202
Puneet Gupta, Nishant Raizada, Subhash Giri, AK Sharma, Sandeep Goyal, Nishesh Jain, SV Madhu
DOI:10.4103/ijem.IJEM_645_19  
Introduction: Several studies from India, performed prior to 2010, have reported a goiter prevalence of greater than five per cent in school going children. There has been considerable success in universal salt iodization efforts in the past decade. We studied the prevalence of goiter and thyroid autoimmunity in school going children in Delhi between 2010 and 2014 to assess the impact of salt iodization. Materials and Methods: The study employed the population proportionate to size (PPS) cluster sampling methodology to select subjects between the age of six and 14 years, from all 34 wards of 9 districts of Delhi. Cluster randomization sampling design was followed and in this way we identified 30 wards, from each of which 90 children were recruited for the study. The total sample size was 2700 children. Estimation of fT3, fT4, TSH, anti-TPO antibodies and urine iodine concentration (UIC) was done for 10% of the study population. Results: The prevalence of goiter in this study in the 6–14 years age group was 6.4%. The prevalence of goiter was higher in females (7.7% compared to 5.3% in males, P = 0.01). In the 270 subjects who were selected for biochemical evaluation, subclinical hypothyroidism was seen in 18.4% and positive anti-TPO antibodies were seen in 14.8%. The median UIC was 150 μg/L. Conclusions: There is improvement in goiter prevalence in the post-iodization period in Delhi. But still, residual goiter rates are above five per cent suggesting presence of other causes of goiter in this area. There is a high prevalence of thyroid autoimmunity in this population.
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Parathyroid hormone replacement versus oral calcium and active vitamin D supplementation in hypoparathyroidism: A meta-analysis Highly accessed article p. 206
Rajan Palui, Rashmi Ranjan Das, Ayan Roy, Sadishkumar Kamalanathan, Sitanshu Sekhar Kar, Jayaprakash Sahoo, Sandhiya Selvarajan, Amit Kumar Satapathy
DOI:10.4103/ijem.IJEM_579_19  
Objectives: Chronic hypoparathyroidism is treated conventionally with active vitamin D and high doses of calcium. Recombinant human parathyroid hormone (PTH) replacement is an attractive option for treating patients with hypoparathyroidism since it can replace the physiological action of native PTH. The aim of our study was to perform a comprehensive evaluation of the effects of PTH replacement on calcium homeostasis, bone metabolism, and daily requirement of calcium and active vitamin D. Materials and Methods: Randomized controlled trials done in chronic hypoparathyroid patients were included in this meta-analysis. The PTH group included subjects receiving a subcutaneous injection of either PTH (1-84) or PTH (1-34) with oral calcium and/or active vitamin D. The control group included those receiving oral calcium and active vitamin D with/without subcutaneous placebo injection. The primary outcome of this meta-analysis was to compare serum calcium, 24-h urinary calcium, and severe adverse effects among PTH and control groups. Results: In this meta-analysis, we did not find any difference in serum calcium level between PTH and control groups [mean difference (MD) -0.01; 95% confidence interval (CI) -0.09, 0.06; P = 0.71]. Although there was a trend towards low 24-h urinary calcium in the PTH group, the difference was not statistically significant (MD -1.43; 95% CI -2.89, 0.03; P = 0.06). The incidence of serious adverse events was also similar in both groups (RR 1.35; 95% CI 0.58, 3.16; P = 0.49). Conclusion: Both PTH and active vitamin D therapies are associated with comparable serum and urine calcium levels with a similar incidence of serious adverse events in patients with chronic hypoparathyroidism.
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LETTERS TO THE EDITOR Top

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DOI:10.4103/ijem.IJEM_646_19  
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DOI:10.4103/ijem.IJEM_86_20  
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Paradoxical cortisol response to dexamethasone in corticotroph microadenoma: A useful feature of underlying cyclic hormonogenesis p. 220
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DOI:10.4103/ijem.IJEM_95_20  
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DOI:10.4103/ijem.IJEM_636_19  
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DOI:10.4103/ijem.IJEM_664_19  
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DOI:10.4103/ijem.IJEM_647_19  
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DOI:10.4103/ijem.IJEM_3_20  
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Diagnosis of TIO: Is serum FGF23 Measurement always the answer? p. 230
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DOI:10.4103/ijem.IJEM_640_19  
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