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   Table of Contents - Current issue
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May-June 2019
Volume 23 | Issue 3
Page Nos. 271-386

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COMMENTARY  

New-onset diabetes after renal transplantation – A clinical insight p. 271
Debmalya Sanyal
DOI:10.4103/ijem.IJEM_248_19  
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ORIGINAL ARTICLES Top

Prevalence and predictors of “New-onset diabetes after transplantation” (NODAT) in renal transplant recipients: An observational study p. 273
Partha Sarathi Choudhury, Pradip Mukhopadhyay, Arpita Roychowdhary, Subhankar Chowdhury, Sujoy Ghosh
DOI:10.4103/ijem.IJEM_178_19  
Objective: New-onset diabetes after transplantation (NODAT) develops frequently after renal transplant. The study aims at the prevalence of NODAT , predictors for developing it and therapeutic glycemic responses in NODAT. Materials and Methods: Consecutive renal transplant recipients excluding Diabetic Kidney Disease (DKD) or pretransplant diabetes were evaluated. Forty-three out of 250 persons were found to have NODAT. Ninety age-matched transplant recipients from the rest were recruited as control. Fasting blood sugar (FBS), HbA1c, lipid profile, and trough tacrolimus level (T0) were examined in all. HOMA IR C-peptide and HOMA-beta C-peptide were calculated. Results: Prevalence of NODAT in renal transplant recipients was 17.2% (43/250). Twenty-four (55.8%) developed early NODAT (<1 year) and 19 (44.2%) developed late NODAT (>1 year). Significantly higher pretransplant body mass index (BMI) (kg/m2) (P < 0.001), waist circumference (WC) (cm) (P < 0.001), pretransplant cholesterol (mg%) (P = 0.04), triglyceride (mg%) (P < 0.001), and FBS (mg%) (P < 0.001) were found in NODAT compared with non-NODAT. Trough tacrolimus (ng/mL) was found to be higher in NODAT (10.2 vs. 5.37, P < 0.001). Though HOMA IR was not found to be different between groups, HOMA-beta C-peptide was low in NODAT compared with non-NODAT (P = 0.03). Predictors of NODAT were WC [odds ratio (OR) = 01.15] and trough tacrolimus level (OR = 1.316). Best cut-off of WC for predicting NODAT was 87.5 cm for male and 83.5 cm for female. Best cut-off of T0 was 8.5 ng/mL. In NODAT, 9.3% were treated by lifestyle modification, 67.4% by oral hypoglycemic agents, 11.6% by insulin, and 11.6% by combined insulin and oral antidiabetic agents with HbA1c <7%. Conclusion: NODAT in renal transplant recipients is more common in those with higher pretransplant BMI, WC, pretransplant total cholesterol, triglyceride, and FBS. Beta-cell secretory defect is more relevant as etiological factor rather than insulin resistance. Higher WC and trough tacrolimus level above 8.5 ng/mL may be important factors for predicting NODAT.
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Prospective study of bethesda categories III and IV thyroid nodules: Outcomes and predictive value of BRAFV600E mutation p. 278
Shiga Rappai Chirayath, Praveen V Pavithran, Nithya Abraham, Vasantha Nair, Nisha Bhavani, Harish Kumar, Usha V Menon, Arun S Menon
DOI:10.4103/ijem.IJEM_635_18  
Introduction: Atypia of undetermined significance or follicular lesion of undetermined significance (AUS/FLUS) of The Bethesda System for Reporting Thyroid Cytopathology (TBSRTC) has emerged as the most controversial category because of its heterogeneity and inconsistent reporting. There is a definite paucity in data available from the Indian subcontinent about the outcome of nodules carrying Bethesda category III or Bethesda category IV diagnoses. Aims and Objectives: The primary objective of our study was to determine the malignancy rate in Bethesda categories III and IV nodules. The secondary objectives were to determine predictive value of BRAFV600E mutation analysis on indeterminate thyroid nodules, predictive value of Thyroid image reporting and data system (TI-RADS) in malignancy prediction and to study the common histological variants in indeterminate nodules. Materials and Methods: This prospective study included 176 consecutive nodules of Bethesda categories III and IV, diagnosed over a period of 2 years from August 2015 to August 2017. A part of the fine needle aspirate was used to perform the BRAFV600E mutation analysis. The malignancy risk associated with these Fine needle aspiration Cytology categories were discussed with the patients. Those with Bethesda category IV diagnosis was advised surgery, whereas those with Bethesda category III were given the options of close follow-up with repeat FNA in 3 months or immediate surgery. Results: In our prospective study, there were 176 consecutive samples of categories III (140/79.5%) and IV (36/20.5%). Seventy-five (53.6%) category III nodules and 29 (80.6%) category IV nodules underwent immediate surgical excision. Fifty-five consecutive indeterminate cytology nodules were subjected for BRAFV600E. One of the samples was found to be positive for BRAF T1799A (V600E) mutation. The second sample harboured a missense mutation at position 1819 (TCC--GCC), wherein the codon 607 (TCC) coding for serine was substituted by alanine (GCC) which is a variant of unknown significance. In our study, the malignancy rate of Bethesda categories III and IV, which were triaged for immediate surgery were 54.6% and 72.4%, respectively. Conclusion: Malignancy rate in Category III at our center was much higher than that described by ATA and by other studies published from centers around the world, including the only two studies from India. In view of the strikingly high malignancy rate in these indeterminate nodules, strong consideration to surgery should be given to patients with FNA results suggesting these two categories. BRAFV600E mutation analysis in FNA specimen has limited utility in improving the preoperative diagnostic rate for malignancy.
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Predictors and outcome of fragility hip fracture: A prospective study from North India p. 282
Deba Prasad Dhibar, Yashpal Gogate, Sameer Aggarwal, Sudhir Garg, Anil Bhansali, Sanjay Kumar Bhadada
DOI:10.4103/ijem.IJEM_648_18  
Introduction: Fragility hip fracture is a useful surrogate marker of the burden of osteoporosis. With improving life expectancy and progressive ageing of population, the global burden of osteoporotic fracture is increasing. Despite this, there is paucity of data regarding epidemiology, predictors, and outcomes of fragility hip fractures in the Indian population. Methods: In this multicenter, prospective observational study, 264 patients of fragility hip fracture were followed up for 12 months. Results: Men (46.2%) and women (53.8%) had a nearly equal distribution of fragility hip fracture. Mean (±SD) age of study population was 65.9 ± 12.6 years and men had earlier age (64.7 ± 12.6 years) of fracture as compared to women (66.9 ± 12.6 years). Out of these, 89.7% patients had osteoporosis, 7.6% had osteopenia, and 2.7% patients had normal bone mineral density (BMD). Fractures predominantly occurred inside the home (229, 86.7%) as compared to outside (35, 13.3%). Female gender, hypertension, diabetes, anemia, smoking, and alcohol were associated with lower BMD, but not a predictor of morbidity. Aging (P = 0.000), osteoporosis (P = 0.012), and diabetes (P = 0.008) were predictors of increased mortality. A total of 243 (92%) patients underwent surgery with a mean hospital stay of 13.5 ± 2.9 days and 34 (12.9%) patients died. Maximum death (73.5%) occurred in first 3 months and the commonest cause of death was cardiovascular (44.1%) related. Conclusion: The majority of fragility hip fractures occurred inside the home. Distribution of fractures in either gender is comparable. Aging, osteoporosis, and diabetes are predictors of poor outcome. We recommend development of newer strategies that target male as well as female patients with osteoporosis with particular attention to prevent in-house falls and fractures.
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Rural childhood obesity – An emerging health concern p. 289
Sarala Premkumar, Padmasani Venkat Ramanan, J Dhivya lakshmi
DOI:10.4103/ijem.IJEM_649_18  
Background: Childhood obesity is growing globally as an epidemic. It is the most common metabolic disease identified in children. Objective: To assess the nutritional status of school going children in Poonamallee, Tamil Nadu and to compare the nutritional status between urban and rural school children. Methods: A retrospective review of the school health records over a period of 9 months was done with Institutional Ethics Committee (IEC) approval for a total of 1,803 children aged 5 to 18 years (916- rural, 887-urban). Revised IAP growth charts (2015) were used to classify their nutrition status. Results: The overall prevalence of overweight/obesity and thinness/severe thinness in our study was 20% and 9.4%, respectively. In the rural schools, the prevalence of overweight/obesity and thinness was 16.2% and 12.2%, respectively, whereas in the urban schools, it was 24% and 6.4%, respectively. The rural school children had lower mean Z scores of weight for age, height for age, and BMI for age compared to urban children (P < 0.001). Conclusion: Among rural school children overweight/obesity is more prevalent than undernutrition. There is an urgent need for nutrition education for the school children and community.
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Clinical profile of asymptomatic bacteriuria in type 2 diabetes mellitus: An Eastern India perspective p. 293
Mainak Banerjee, Manidipa Majumdar, Prabir K Kundu, Indira Maisnam, Apurba K Mukherjee
DOI:10.4103/ijem.IJEM_674_18  
Introduction: Asymptomatic bacteriuria (ASB), believed to precede symptomatic urinary tract infection (UTI) in diabetes mellitus, has geographical variation in microbial pattern and risk factors. However, data from the Eastern part of India are still lacking. Materials and Methods: A prospective longitudinal study was performed over 80 otherwise healthy type 2 diabetes patients with a follow-up for one year to (1) estimate the prevalence of ASB and its association with age, gender, duration of diabetes, and renal and glycemic status; and (2) identify the antibiotic sensitivity pattern of uropathogens as well as evaluate the usefulness of microbial pattern as a predictor of symptomatic UTI. Results: ASB was prevalent in 21.25% of type 2 diabetes population in our study. Klebsiella sp emerged as the commonest cause among males. The only risk factor for ASB was found to be long-standing type 2 diabetes. There was no association with age, gender, or recent glycemic status. Bacteriuric patients with worse baseline HbA1C values were at greater risk of UTI. Female diabetic patients with ASB due to Escherichia coli had significantly greater risk of developing UTI within one year. Conclusion: A large-scale prospective study reproducing similar findings will genuinely obviate the need to review recommendations on screening of ASB due to E. coli in females with long-standing diabetes and poor glycemic control. Early adoption of stringent HbA1C lowering strategy and measures to improve genital hygiene can help prevent symptomatic UTI in these patients.
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Clinical patterns and linear growth in children with congenital adrenal hyperplasia, an 11-year experience p. 298
Adnan Al Shaikh, Yasser AlGhanmi, Saniah Awidah, Abdullah Bahha, Mohamed E Ahmed, Ashraf T Soliman
DOI:10.4103/ijem.IJEM_99_19  
Objective: An important goal in treating children with congenital adrenal hyperplasia (CAH) is to achieve a normal final adult height (FH). The aim of this study was to describe the clinical presentations and evaluate linear growth and possible factors affecting it in children with CAH. Methods: This is a retrospective study of 56 patients with CAH followed up in a tertiary center for 11 years. Patient's data including demographics, clinical, anthropometric, and laboratory information at presentation and during follow-up period were collected from medical records. Results: Fifty-six children (31 females) with CAH were seen at KAMC-Jeddah over 11-year period and 91% were 21-hydroxylase deficient. Of these, 46.4% had hyponatremia and 28.6% had hyperkalemia (21.4% had hyponatremia and hyperkalemia) at presentation. Positive family history was documented in 53.6%. Ambiguous genitalia were present in 72% of females and the majority required corrective surgery. Males had significantly decreased HtSDS versus females and females had significantly higher body mass index. The HtSDS of children who had had higher 17OHP or salt-losing crisis during treatment was significantly lower than those who had normal 17OHP and those who did not have salt-losing crisis, respectively. Conclusion: The final height outcome in our patients with CAH treated with glucocorticoids is lower than the population norm. Proper control of the disease clinically and biochemically through strict compliance to medical therapy as well as close clinical and laboratory monitoring is an important key to achieve normal final adult height in these patients. Side effects, including overweight, obesity, and hypertension are true risk associations and need timely diagnosis and early management.
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Efficacy and safety of canagliflozin 300 mg in overweight and obese type 2 diabetes mellitus patients in a real-world setting: COLOR study p. 307
Pankaj Aneja, Gaurav Bhalla, Neeti Parvesh, Kunal Aneja, Kashish Aneja
DOI:10.4103/ijem.IJEM_55_19  
Background and Aims: To assess the efficacy and safety of canagliflozin (CANA, 300 mg/d) in overweight and obese patients with type 2 diabetes mellitus (T2DM). Methods: In a single centre, retrospective, observational study, we included overweight or obese patients with T2DM who had HbA1c >7% and received CANA as addition to existing therapy for at least 24 weeks. Primary endpoint assessed was changes in HbA1c, fasting and post-prandial plasma glucose (FPG and PPG), and secondary endpoints included changes in weight, waist circumference (WC), systolic blood pressure (SBP) and diastolic BP (DBP) over 12 and 24 weeks. Results: Among 90 patients, mean age was 53.5 ± 10.8 years and 42.2% were females. Majority of the patients (46.7%) were receiving two antidiabetic drugs. Significant reduction in HbA1c from baseline to week 24 (9.1 ± 1.8% vs. 7.5 ± 1.1% respectively, mean difference: -1.6 ± 0.9%, P < 0.0001) was seen. Reduction in FPG (mean difference: -63.0 ± 45.2 mg/dL, P < 0.0001) and PPG (mean difference: -97.7 ± 54.3 mg/dL, P < 0.0001) was also significant. Mean reduction in weight was -4.3 ± 2.2 kg (P < 0.0001) at 24 weeks. Reductions in WC, SBP and DBP were also significant at week 24 (P < 0.0001 for all). Changes in all these parameters were also significant at week 12. Proportion of patients achieving the target HbA1c of <7% was 28.9% and 52.2% at week 12 and week 24, respectively. Genital mycotic infections were seen in 20% patients and was present in higher proportion of females than males (28.9% vs. 13.5%, P = 0.070). No episodes of hypoglycaemia were found. Conclusion: Canagliflozin should be considered from among the various antidiabetic drugs in overweight and obese patients with T2D in India.
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Therapeutic experience of saxagliptin as first add-on after metformin in Indian type 2 diabetes patients: A non-interventional, prospective, observational study (ONTARGET-INDIA) p. 312
Sanjay Kalra, Sarita Bajaj, AG Unnikrishnan, Manash P Baruah, Rakesh Sahay, V Hardik, Amit Kumar
DOI:10.4103/ijem.IJEM_56_19  
Introduction: Dipeptidyl peptidase 4 (DPP4) inhibitors are widely used in type 2 diabetes mellitus (T2DM) patients but the data available in existing clinical trial programmes on DPP4 inhibitors include limited number of patients from India. Hence, this study attempted to understand usage, efficacy and safety of saxagliptin as first add-on after metformin in Indians with T2DM. Methodology: It was a multicenter, prospective, non-interventional and observational study planned to enrol T2DM patients who were inadequately controlled with metformin alone and had been recently (i.e., within past 15 days) prescribed saxagliptin as an add-on to metformin. Type 1 diabetes mellitus, use of glucose lowering drugs apart from metformin or saxagliptin, pregnancy, lactation, and medical condition, which could interfere with safe completion of the study were excluded. Results: A total of 1109 participants (658 men and 451 women) with mean ± SD age of 51.17 ± 11.85 years were enrolled from 50 centres throughout India. Significant reduction was observed in mean ± SD change of HbA1c as − 0.86% ± 1.76 from baseline to after 3 months of therapy (P < 0.0001). The quality of life assessed by World Health Organization Quality of Life-BREF (WHOQOL-BREF) questionnaire was reported to be “good” or “neither good nor bad” by majority of the participants at baseline and after 3 months of treatment. A total of 15 adverse events (AEs) were reported in the study, however, no serious adverse event (SAE) occurred during the study. All AEs were of mild intensity and did not require any intervention. Conclusion: Overall, saxagliptin in combination with metformin was generally well-tolerated in Indian T2DM patients and new or unexpected safety events were not identified. This study is also registered on Clinicaltrials.gov (NCT02588859).
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Prevalence of diagnostic methods and treatment modalities in vipoma patients: A rare cause of hormone-mediated diarrhea p. 318
Fateme Shamekhi Amiri
DOI:10.4103/ijem.IJEM_105_19  
Introduction: VIPoma is a neuroendocrine tumor that secrets vasoactive intestinal peptide and produces a well-defined clinical syndrome characterized by watery diarrhea, hypokalemia, hypochlorhydria and metabolic acidosis. The aim of this study to investigate clinical studies about diagnostic and therapeutic modalities of vipoma patients. In this retrospective study, all patients of vipoma were investigated. Clinical features, laboratory data at initial presentation, management and outcomes were collected. Subjects and Methods: The paper has written based on searching PubMed and Google Scholar to identify potentially relevant articles or abstracts. Categorical variables as percentage and continuous variables were reported as mean ± standard deviation (SD). Results: All the patients presented with watery diarrhea (30/30, 100%) and dehydration was reported in 33.3% of them. Prevalence of laboratory findings in these patients were assessed for hypokalaemia (25/30, 83.3%), metabolic acidosis (9/30, 33.6%), hypochloremia and achlorhydria (2/30, 6.6%). Elevated VIP levels have been seen in 73.3% patients with mean values of 882.85 ± 1134.87 pg/ml. Prevalence of diagnostic methods included CT scan in 19 patients (19/30, 63.3%), ultrasonography (15/50, 50%), and somatostatin receptor scintigraphy (8/30, 26.6%). Medical treatments included somatostatin and analogues in 18 patients (18/30, 60%). Surgery included less percentage of treatment in these patients. Conclusion: CT scan can be used as a reliable modality for diagnosis of vipoma and somatostatin analogues can be used as the most effective treatment in vipoma patients. Surveillance of these patients needs to close monitoring of patients via history, physical examination, laboratory and imaging.
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Comparison of the different PCOS phenotypes based on clinical metabolic, and hormonal profile, and their response to clomiphene p. 326
Garima Sachdeva, Shalini Gainder, Vanita Suri, Naresh Sachdeva, Seema Chopra
DOI:10.4103/ijem.IJEM_30_19  
Objective: To compare the different polycystic ovarian syndrome (PCOS) phenotypes based on their clinical, metabolic, hormonal profile, and their differential response to clomiphene. Design: Prospective observational study. Setting: Infertility clinic, a government hospital. Sample Size: 164 women with PCOS-related infertility. Materials and Methods: Sample population was divided into four phenotypes based on the NIH (National Institute of Health) consensus panel criteria. The incremental dose of clomiphene from 50 to 150 mg/day over three cycles was given. Outcome Measures: Clinical history, metabolic, hormonal profile, and ultrasound features of each phenotype. Also, the response to clomiphene citrate was studied as presence or absence of ovulation. Results: The prevalence of phenotypes A, B, C, and D were 67.7%, 11%, 17.7%, and 3.6%, respectively. Phenotype A had significantly higher weight, body mass index, clinical, and biochemical hyperandrogenism, menstrual irregularities, ovarian reserve parameters, fasting insulin, HOMA-IR, and more deranged lipid profile (P < 0.05). Clomiphene resistance was significantly more common in phenotype A (P < 0.05). No significant differences were noted in the waist circumference, waist-hip ratio, blood pressure and blood sugar values (fasting, 1-hour postprandial, 2-hour postprandial). Also, the Follicle Stimulating Hormone (FSH), Luteinizing Hormone (LH), LH-FSH ratio, 17-hydroxyprogesterone, and vitamin D levels were not significantly different among various PCOS phenotypes. Conclusion: Full-blown PCOS (phenotype A) is at a higher risk of adverse metabolic and cardiovascular outcomes as compared with the others, and phenotype D is the least severe phenotype. Thus, the phenotypic division of patients with PCOS-related infertility can help in prognosticating the patients about the severity of the disease and the fertility outcome.
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Nonfunctioning and subclinical cortisol secreting adrenal incidentalomas and their association with metabolic syndrome: A systematic review p. 332
Uzma Khan
DOI:10.4103/ijem.IJEM_52_19  
Background: A growing body of evidence suggests that nonfunctioning and subclinical cortisol secreting adrenal incidentalomas (AIs) are associated with several components of metabolic syndrome resulting in increased cardiometabolic risk. The long-term metabolic outcome of these AIs is largely unknown and their most appropriate management remains controversial. Objectives: To undertake a systematic review of the prevalence of cardiometabolic abnormalities in nonfunctioning and subclinical cortisol secreting AIs and long-term outcome of conservative treatment and adrenalectomy. Methods: MEDLINE, Cochrane Controlled Trials Register, and EMBASE were searched for relevant studies and systematic review was performed. National Institutes of Health (NIH) quality assessment tool for observational cohort and cross-sectional studies was used to assess the risk of bias in the studies. Results: Of the 65 studies screened, 18 (10 retrospective, 5 prospective, 2 cross-sectional studies, and 1 randomized controlled trial) were included in the systematic review. Prevalence of hypertension (HTN), impaired glucose metabolism, dyslipidaemia, and raised body mass index (BMI) was higher in subclinical cortisol secreting AIs as compared with nonfunctioning AIs. Surgical intervention had a beneficial effect on blood pressure, glucometabolic control, and obesity in patients with subclinical Cushing's syndrome. The results for lipid metabolism were equivocal. There was no significant improvement in cardiometabolic risk factors after adrenalectomy in nonfunctioning AIs. The quality of evidence was found to be low to moderate. Conclusions: The systematic review demonstrated increased prevalence of components of metabolic syndrome in patients with subclinical cortisol secreting and nonfunctioning AIs. A beneficial role of adrenalectomy on HTN, glucometabolic control, and BMI was observed in patients with subclinical cortisol secreting AIs.
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Focused parathyroidectomy using accurate preoperative imaging and intraoperative PTH: Tertiary care experience p. 347
Roma Pradhan, Sushil Gupta, Amit Agarwal
DOI:10.4103/ijem.IJEM_20_19  
Introduction: The cure rate after focused parathyroidectomy (FP) is dependent upon two critical adjuncts- concordant preoperative imaging and intraoperative parathyroid hormone (PTH), a technique which can reliably determine whether any other hyperfunctioning gland or glands are still present after resection of the lesion shown by imaging. We wanted to see the cure rate of FP by using these two adjuncts. We also sought to discern whether utilizing the central lab rapid PTH assay will lead to wider acceptance of this FP with intraoperative PTH in resource-constrained countries. This analysis was also undertaken to find out cost-effective way of doing intraoperative PTH by minimizing the samples for intraoperative PTH study. Result: Data were collected on 83 patients with sporadic primary hyperparathyroidism (PHPT) who underwent parathyroidectomy in two tertiary centers between '2009 and 2017'. A total of 75 patients had concordant imaging, while seven had discordant imaging. The sensitivity and specificity of intraoperative PTH in FP was 100%. All the 78 patients who had fall in intraoperative PTH (50%) at 10 min also had fall of more than 50% at 5 min except one patient (98.7%). Conclusion: We strongly advocate routine use of intraoperative PTH in all patients undergoing minimally invasive parathyroidectomy, as this adjunct offers maximum safety for the patient and confidence for the surgeon. Cost can be minimized by utilizing the central laboratory and reducing the number of samples.
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Cognitive impairment and its association with glycemic control in type 2 diabetes mellitus patients p. 353
Coredath Venugopal Lalithambika, Chankramath S Arun, Lakshmi Ammal Saraswathy, Renjitha Bhaskaran
DOI:10.4103/ijem.IJEM_24_19  
Introduction: Type 2 diabetes mellitus is one of the major causes of increasing morbidity worldwide. Effective screening is carried out routinely for diabetic retinopathy, neuropathy, and nephropathy. Of late, studies have reported that cognitive decline can occur in people with diabetes, which could go undetected for a long period, and hence routine screening could be warranted. Methodology: Our objective was to study the prevalence of previously unknown mild cognitive impairment (MCI) in type 2 diabetic patients visiting a tertiary care center with the Montreal Cognitive Assessment (MoCA) test and to study the correlations of HbA1c, fasting blood sugar (FBS), postprandial blood sugar (PPBS), age, and duration of diabetes with the MoCA scores. Seventy patients with type 2 diabetes mellitus were included in the study. Patients with MoCA scores ≥26 were considered to have normal cognition (NC) and those with <26 MCI. Results: MCI was noted in 38 (54.29%) type 2 diabetes mellitus patients and NC in 32 (45.71%). Those with MCI had higher HbA1c (8.79 ± 1.85 vs. 7.78 ± 1.60), higher FBS (177.05 ± 62.48 vs. 149.38 ± 54.38), and PPBS (282.03 ± 85.61 vs. 214.50 ± 82.43), which were statistically significant. The cognitive domains of executive function, naming, attention, language, and memory showed a statistically significant difference between those with MCI and NC. There were no differences in the mean age, duration of diabetes, and educational status between the groups. Conclusion: The high prevalence of MCI in type 2 diabetic patients highlights the importance of implementing routine cognitive testing. The correlation of cognitive impairment with poor glucose control needs further studies to find out whether improving glycemic control will help improve cognition.
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Effect of sertraline as an add-on therapy in T2DM patients with comorbid depression: An open label randomized controlled trial p. 357
Padala R Kumar, Anindita Chatterjee, Jayanti P Behera, Sudhiranjan Patnaik
DOI:10.4103/ijem.IJEM_67_19  
Objectives: To study the effect of sertraline on depression in type 2 diabetes mellitus (T2DM) patients with comorbid depression. Materials and Methods: An open label randomized control study. Patients with T2DM and moderate to severe depression were randomized to sertraline or control therapy for six months. The primary objective was the change in depression score and the secondary objectives were changes in glycemic parameters, wellbeing, and drug adherence scores at three and six months. Results: The present study includes 160 T2DM patients with moderate to severe depression. Depression in these patients was evaluated using a self-reporting version of Patient Health Questionnaire (PHQ-9). A total of 80 patients each were randomized to sertraline and control groups. Sertraline significantly improved depression scores in patients with T2DM and moderate to severe depression both at 3 months and 6 months compared to the control group. The wellbeing and treatment adherence scores improved significantly in the sertraline group at 6 months. However, sertraline had no significant effect on glycemic parameters when compared to control group both at 3 months and 6 months. Conclusion: Sertraline significantly improves depression and drug adherence in T2DM patients with depression but has no effect on glycemic parameters.
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Vitamin D toxicity: A prospective study from a tertiary care centre in Kashmir Valley p. 363
Raiz A Misgar, Danendra Sahu, Moomin H Bhat, Arshad I Wani, Mir I Bashir
DOI:10.4103/ijem.IJEM_116_19  
Background: Vitamin D toxicity (VDT), a “not uncommon” cause of hypercalcemia, can be life-threatening and cause substantial morbidity, if not treated promptly. Aims: To describe presentation, management, and outcome in 32 patients with VDT diagnosed over 3 years. Materials and Methods: Patients presenting with VDT at a tertiary care centre in Srinagar Kashmir India were included. Evaluation included detailed history and biochemical tests including serum calcium, phosphate, creatinine, intact parathyroid hormone (iPTH), 25-hydroxy Vitamin D (25-OHD), and 24-hour urinary calcium. Results: The clinical manifestations of the 32 patients (median age 65; range 3–77 years) included gastrointestinal symptoms (constipation and vomiting), polyuria/polydipsia, altered sensorium, pancreatitis, acute kidney injury, and nephrocalcinosis. The median total serum calcium level was 13.95 (range 11.10-17.20) mg/dl and median 25-OHD level was 306 (range 105–2800) ng/ml. All patients had suppressed or low normal iPTH and hypercalciuria and 78% had azotemia. All patients had received multiple intramuscular injections of vitamin D3. The median cumulative dose was 4,200,000 (range, 1,800,000-30,000,000) IU. The median time to resolution of hypercalcemia was 7 months (range 4–18 months). Conclusion: We conclude that VDT is an increasingly common cause of symptomatic hypercalcemia. VDT needs prolonged follow up as it takes months to abate its toxicity. Enhancing awareness among general practitioners regarding the toxicity resulting from high doses of vitamin D is the key to prevent VDT. We suggest that VDT be considered in patients, especially the elderly, presenting with polyuria, polydispsia, vomiting, azotemia, or encephalopathy.
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Correlation of olfactory phenotype by Indian smell identification test and quantitative MRI of olfactory apparatus in idiopathic hypogonadotropic hypogonadism p. 367
Hardeva Ram Nehara, Balram Sharma, Anshul Kumar, Sanjay Saran, Naresh Kumar Mangalhara, Sandeep Kumar Mathur
DOI:10.4103/ijem.IJEM_28_19  
Objectives: Idiopathic hypogonadotropic hypogonadism (IHH) can be associated with anosmia/hyposmia. The objective of this study is to evaluate olfaction by Indian smell identification test (INSIT) and measure olfactory bulbs (OBs) and sulci using dedicated magnetic resonance imaging (MRI) in patients with IHH and correlate MRI findings with INSIT. Methods: Forty patients with IHH underwent (a) brief smell identification test (INSIT) and (b) MRI of the olfactory apparatus. The size of olfactory sulcus and bulb was quantified and compared with the normative data obtained in 22 controls. The agreement between INSIT and MRI was assessed using Kappa index. Results: Of the 40 patients, 8 patients who reported abnormal smell sensation and 12 of the remaining 32 patients who reported normal smell sensation historically had a low score on INSIT. Thus, there were 20 patients with Kallmann syndrome (KS) and the rest 20 were normosmic IHH (nIHH). Of 40 patients with IHH, MRI finding was suggestive of normal (n = 16), hypoplastic (n = 12), and aplastic (n = 12) olfactory apparatus. All 20 patients with KS have olfactory abnormalities (n = 12 aplastic, n = 8 hypoplastic), and 4 of 20 nIHH have olfactory abnormalities (hypoplastic only) on MRI. There is (a) significant positive correlation (r = 0.54, P = 0.013) between the OB volume (MRI) and smell test scores and (b) moderate agreement (Kappa index: 0.49) between smell defect (INSIT score ≤ 4) and aplastic olfactory apparatus. Conclusion: Self-reporting of smell significantly underestimates olfactory phenotype, and hence we recommend an objective smell test to differentiate KS from nIHH. Olfactory phenotype significantly correlates with MRI quantification of olfactory apparatus in IHH.
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Thyroid symptomatology across the spectrum of hypothyroidism and impact of levothyroxine supplementation in patients with severe primary hypothyroidism p. 373
Deep Dutta, Aakash Garg, Deepak Khandelwal, Sanjay Kalra, Suresh Mittal, Sachin Chittawar
DOI:10.4103/ijem.IJEM_78_19  
Objective: This study aimed to determine the clinical and biochemical profile of patients with severe primary hypothyroidism (SPH) (TSH ≥40 μIU/ml) as compared to milder forms of hypothyroidism and document improvement in hypothyroidism symptoms in SPH. Methods: Thyroid symptomatology and biochemistry were evaluated in SPH, non-severe overt primary hypothyroidism (NSOPH; TSH <40 μIU/ml), subclinical hypothyroidism (ScH) and healthy controls. A total of 598 consecutive patients of hypothyroidism were screened of which 461 patients' data were analyzed (91 SPH, 130 NSOPH and 240 ScH). Thyroid symptomatology was re-evaluated at 12 weeks follow-up in SPH following restoration of euthyroidism with levothyroxine. Results: The median (interquartile range) age of patients was 35 (28-42) years with 91.6% female. The commonly noted symptomatology were shortness of breath (93.4%) and fatigueability (91.2%) in SPH, fatigueability (68.46%) and limbs swelling (43.07%) in NSOPH, and fatigueability (56.67%) and shortness of breath (32.92%) in ScH. All symptomatology were significantly higher in SPH. Delayed tendon reflex, carpel tunnel syndrome and meno-metrorrhagia were exclusive in SPH. Occurrence of menstrual irregularities was 73.62%, 28.46% and 16.25% in SPH, NSOPH and ScH, respectively. SPH patients had significantly higher cholesterol and triglycerides. There was significant improvement in symptomatology, reduction in body weight (−2.11 kg), improvement in hemoglobin (+0.64 g/L) with fall in total cholesterol (−18.96%), LDL-cholesterol (−23.46%) and triglycerides (−13.53%) following euthyroidism restoration in subjects with SPH. Common residual symptoms were fatigue (10%), poor memory (8%) and menstrual irregularities (6%). Conclusion: Thyroid symptomatology differs significantly across spectrum of hypothyroidism, being significantly worse in SPH. Euthyroidism restoration is associated with reversal of majority of thyroid symptomatology.
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LETTER TO THE EDITOR Top

Cold chain and insulin: Should we follow the polio vaccine example? p. 379
Karthik Balachandran
DOI:10.4103/ijem.IJEM_211_19  
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Litchi-related hypoglycemia: A public health challenge, an endocrine opportunity p. 380
Deep Dutta, Deepak Khandelwal, Sanjay Kalra
DOI:10.4103/ijem.IJEM_235_19  
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LETTERS TO THE EDITORS Top

Pituitary abscess mimicking as sellar mass p. 381
Danendra Sahu, Altaf U Ramzan, Masood Laharwal, Bashir A Laway
DOI:10.4103/ijem.IJEM_146_19  
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Reversible kallmann syndrome: Rare yet real p. 382
Sudarsanababu Lalitha Soumya, Kripa Elizabeth Cherian, Nitin Kapoor, Thomas V Paul
DOI:10.4103/ijem.IJEM_199_19  
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Hypercalcemic encephalopathy as the presenting manifestation of sarcoidosis p. 384
B Saroj Kumar Prusty, Kiran Kumar Ramineni, G Krishna Mohan Reddy, Ravi Kanth Jakkani, Ugandhar Bhattu Chakrahari
DOI:10.4103/ijem.IJEM_206_19  
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ERRATUM Top

Erratum: Pandemic of Vitamin D deficiency: Cardiometabolic concern or skeletal biochemical abnormality? p. 386

DOI:10.4103/2230-8210.263698  
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