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   Table of Contents - Current issue
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March-April 2018
Volume 22 | Issue 2
Page Nos. 179-297

Online since Monday, May 14, 2018

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EDITORIAL  

Extending the clinician's hand through thyroid ultrasound - Do it yourself-for the uninitiated busts expertise? Highly accessed article p. 179
Krishna G Seshadri
DOI:10.4103/ijem.IJEM_165_18  PMID:29911026
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ORIGINAL ARTICLES Top

Is a surgeon-performed ultrasound good enough in diagnosing thyroid malignancy? Highly accessed article p. 181
Gajarajan Mohanapriya, Maharajan Chandrasekaran
DOI:10.4103/ijem.IJEM_567_17  PMID:29911027
Background: The widespread availability of ultrasonography has facilitated the evaluation of thyroid nodules, to differentiate between malignant and benign nodules and between metastatic and reactive lymph nodes. From the radiologists' suite, ultrasound has moved into the surgeon's office. Aim: The aim of the present study was to evaluate the relevance of surgeon-performed ultrasound (SPUS) in the diagnosis of malignancy of the thyroid. Methods: SPUS for 389 consecutive patients attending the outpatient department of endocrine surgery in a tertiary care institute in Chennai. The SPUS data of 350 patients who underwent total thyroidectomy were compared with the report of radiologist-performed ultrasonogram, fine-needle aspiration cytology, and histopathology examination. Results: SPUS ranked the maximum with a Spearman's correlation of 0.886 (P < 0.0001). The sensitivity and specificity of positive-predictive value and negative-predictive value of SPUS were 98.53%, 95.72%, 96.81%, and 98%, respectively. Conclusion: SPUS is a very useful clinical adjunct in diagnosing malignancy of the thyroid and saves the patient time and resource in visiting another consultant. A surgeon who is more familiar with the anatomy and pathophysiology of thyroid disorders triages the nodule better.
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Characterization of metabolic parameters in responders and nonresponders treated with canagliflozin monotherapy in drug-naive subjects with Type 2 diabetes Highly accessed article p. 185
Eiji Kutoh, Asuka Wada, Teruma Murayama, Jyunka Hayashi
DOI:10.4103/ijem.IJEM_578_17  PMID:29911028
Objectives: The aim of this project is to compare the effect of canagliflozin monotherapy on metabolic parameters between responders and nonresponders with this drug. This study is a prospective, unblinded, observational study. Subjects and Methods: Drug-naïve patients with type 2 diabetes mellitus received only 50–100 mg/day canagliflozin for 3 months (n = 39). They were divided into two groups according to the novel “A1c index” to assess glycemic efficacies; responders (n = 24) and nonresponders (n = 15). Results: At baseline, glycated hemoglobin (HbA1c) and fasting blood glucose (FBG) were significantly higher and homeostatic model assessment (HOMA)-B and body mass index (BMI) were significantly lower in responders. In both groups, similar, significant reductions of BMI (−1.9% with responder and −1.8% with nonresponder) and HOMA-R (−35.8% for responder and –31.5% for nonresponder) were observed. However, differences were seen with other parameters as follows: 1) responders: significant reductions of HbA1c (10.95%–8.44%), FBG (−29.6%) or free fatty acid (FFA) (−16.2%), and significant increases of HOMA-B (79.7%) were observed. 2) Nonresponders: significant reductions of serum uric acid (UA) (−8.6%) levels were seen. Significant correlations were observed between the baseline levels of serum UA and those of HOMA-B (R = 0.7259). However, this link became uncorrelated with the treatment with canagliflozin. Conclusions: These results suggest that (1) responders with canagliflozin have lower BMI and beta-cell function. Reductions of body weight with canagliflozin were not associated with its glycemic efficacy, (2) reduced FFA levels and enhanced insulin sensitivity/beta-cell function could be a potential mechanism of good glycemic efficacy of canagliflozin, and (3) serum UA might be involved in modulating beta-cell function during canagliflozin treatment.
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Disorders of water balance following sellar and suprasellar surgeries: Patterns, determinants and utility of quantitative analysis p. 191
Sonu Kalappurakkal Simon, Praveen Valliyaparambil Pavithran, Aldyne Reena Asirvatham, R Ayyadurai, A Parasuram
DOI:10.4103/ijem.IJEM_647_17  PMID:29911029
Background and Objective: The primary objective of this study was to evaluate the application of principles of quantitative analysis to assess disorders of water balance following surgeries for sellar and suprasellar masses and also to investigate potential factors influencing the occurrence and course of these disorders. Materials and Methods: A total of 36 consecutive adult patients who underwent surgery for sellar and suprasellar masses between 2014 and 2015 were prospectively followed up in this observational study. Twenty-one patients had complete laboratory parameter records for quantitative analysis. Clinical parameters, daily fluid balance, and sodium balance were calculated based on the fluid chart and the estimation of sodium concentration of fluids and urine. Classical Edelman equation was used to predict the sodium values. Time course of these disorders and association with etiological and other clinical parameters were assessed. Standard institutional protocol was used in the management of patients studied. Results: Comparison between predicted values of quantitative analysis and observed values of sodium showed that 80-95% of the observed readings on various days showed concordance with calculated reading, with <5% error. 77.7% manifested at least one episode of dynatremia relating to water balance disorder during the postoperative period. Postoperative diabetes insipidus (DI) observed in 58% of patients, whereas syndrome of inappropriate antidiuretic hormone secretion observed in 47% of patients. Both DI and SIADH in different time points were noticed in 28%, and classical triple phase response was seen in 2.7%. Nearly 83% manifested one episode of dynatremia relating to water balance disorder during the post-operative period. Prolonged DI was noted in 11% and no case of cerebral salt wasting was observed in any of the patients studied. Conclusion: We observed high degree of correlation between the predicted and observed sodium values. Quantitative analysis in the management of patients with disorders of water balance in postsurgical settings in neurosurgery has the potential for improving clinical care.
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Association of androgenetic alopecia with metabolic syndrome: A case–control study on 100 patients in a tertiary care hospital in South India p. 196
KC Dharam Kumar, Yadalla Hari Kishan Kumar, Vivekananda Neladimmanahally
DOI:10.4103/ijem.IJEM_650_17  PMID:29911030
Background: Androgenetic alopecia (AGA) is the most common cause of hair loss. Although it is a medically benign condition, it can have a significant psychosocial impact on patients. “Metabolic syndrome” (MetS) is a collection of clinical signs that focus on cardiovascular and diabetes-related parameters. Despite the high burden of AGA and MetS in India, specific data on the participants are relatively sparse. Aim of the Study: The aim of is to study the association of AGA with MetS and its parameters. Materials and Methods: A case–control study was undertaken in a tertiary care hospital from December 2015 to November 2016 with 100 cases and controls in the age group of 20–50 years. Diagnosis of MetS was based on the National Cholesterol Education Program Adult Treatment Panel III. Independent t-test was used as a test of significance. Categorical data were assessed using Chi-square test of significance. P <0.05 was considered to be significant. Results: MetS was seen in 53% of cases and 17% of controls (P = 0.001). The mean serum triglyceride level (P = 0.015, P < 0.05), mean systolic blood pressure (P = 0.003, P < 0.05), high-density lipoprotein levels in males (P < 0.001), and waist circumference in males (P = 0.022, P < 0.05) were statistically significant in patients with androgenetic alopecia when compared to healthy controls. Conclusion: A higher prevalence of MetS was noted in androgenic alopecia. Early screening for MetS is beneficial in patients with androgenic alopecia.
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The deletion polymorphism in exon 8 of uncoupling protein 2 is associated with severe obesity in a Saudi Arabian case–control study p. 200
Yahia A Kaabi
DOI:10.4103/ijem.IJEM_655_17  PMID:29911031
Context: Obesity is a major health concern in Saudi Arabia. Uncoupling protein 2 (UCP2) seems to play a major role in the regulation of human metabolism; therefore, genetic polymorphisms in the UCP2 gene might contribute to obesity. Aim: This study aims to establish whether 45-blood pressure (BP) insertion (I)/deletion (D) polymorphisms in UCP2 are associated with moderate and/or severe obesity in a Saudi Arabian population. Settings and Design: Case–control study design. Materials and Methods: The study enrolled 151 male and female subjects originating from the eastern province of Saudi Arabia, and assigned each to a “nonobese,” “moderately obese,” or “severely obese” group. Genomic DNA was extracted from all subjects and screened for UCP2 I/D polymorphisms using a standard polymerase chain response protocol. Statistical Analysis Used: Analysis of variance, Chi-squared tests, and logistic regression analysis. Results: The frequencies of the UCP2 45-BP I/D genotypes D/D, I/D, and I/I within the analyzed population were 58.3%, 36.4%, and 5.3%, respectively. The D/D genotype was highly prevalent within the severely obese group (82.9%) compared to the nonobese (46.2%) and moderately obese (53.3%) groups. Using a dominance model, the conducted logistic regression analysis showed a strong association between the deletion allele and severe obesity (Odds ratio = 0.18, 95% confidence interval: 0.07–0.44, P = 0.0004). Conclusions: The present study reported that the frequency of UCP2 45-BP I/D polymorphisms in a population originating from eastern Saudi Arabia and identified a strong association between the D/D genotype and severe obesity.
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Assessment and evaluation of gustatory functions in patients with diabetes mellitus Type II: A study p. 204
Shriya Khera, Anjali Saigal
DOI:10.4103/ijem.IJEM_555_17  PMID:29911032
Introduction: The assessment of taste is critically important for an individual to enjoy life. This however, gets altered in various diseases. Diabetes Mellitus is one of the diseases in which person has dysgeusia. Objectives: This study was done to assess different taste sensations in patients suffering from Diabetes Mellitus Type II. Methods: A total of 120 subjects were taken in this study and were divided into 3 groups. One group consisted of patients who were uncontrolled diabetics (n = 40), the second group of controlled diabetics (n = 40) and 40 subjects who were normal healthy individuals (control group). To assess their gustatory functions, two tests were performed, whole mouth above threshold and localized taste test. Whole mouth above threshold test was performed by assessing their detection threshold for each taste. Results: It was seen that patients with Diabetes Mellitus showed a high threshold to sweet, salty and sour taste. Bitter was not affected in either of the groups. The other test performed was localized (spatial) test. In this test, various parts of the oral cavity are assessed by dabbing the highest concentration of the prepared solutions and their response is noted. The tongue was divided into Left posterior tongue (LPT), Right posterior tongue (RPT), Right Anterior tongue (RAT), Left Anterior tongue (LAT). Soft palate was divided into Right Soft Palate (RSP) and Left Soft Palate (LSP). The results showed a significant difference for the sweet taste in the localized regions (right anterior tongue [RAT], left anterior tongue [LAT], right posterior tongue [RPT], left posterior tongue [LPT], right soft palate [RSP], and left soft palate [LSP]) of the mouth between the three groups (P < 0.05). The results of the salty taste showed significant differences in the RAT, LAT, RSP, and LSP regions of the mouth between the groups (P < 0.05). However, the regions of LPT and RPT showed no differences between the study groups (P > 0.05).The results showed a significant difference in the sour taste in the localized regions of the mouth in all the study groups (P < 0.05). The results of the bitter taste showed significant differences in the regions of the mouth in all the three groups (P < 0.05). However, the region of LPT showed no differences between the study groups (P > 0.05). Conclusion: Within the limitation of this study, it was concluded that the diabetic patients had an increased satiation effect of sweet taste therefore they needed an increased quantity of sweet taste to be perceived. It was also significant for salty and sour taste, whereas bitter taste had no significance. Spatial taste test also showed differences in different regions of the tongue, soft palate. The left posterior tongue area showed no changes.
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Association between glycemic gap and adverse outcomes in Critically Ill patients with diabetes p. 208
Sandeep Donagaon, Mala Dharmalingam
DOI:10.4103/ijem.IJEM_580_17  PMID:29911033
Objectives: Glycemic excursions are commonly seen in patients admitted to the Intensive Care Unit (ICU) and are related to adverse outcomes. Glycemic gap is a marker of this excursion in patients with diabetes. It can be used to predict adverse outcomes in patients with diabetes admitted to the ICU. It is calculated by subtracting A1C-derived average glucose (ADAG) = ([28.7 × HbA1c]-46.7) from plasma glucose at admission. Objective of this study was to correlate glycemic gap and adverse outcomes in patients with type 2 diabetes mellitus (DM) admitted to the ICU. Materials and Methods: We conducted an ambispective study to include patients with type 2 DM admitted to the ICUs from July 2015 to June 2016. The following adverse outcomes were recorded: Multiorgan dysfunction syndrome (MODS), acute respiratory distress syndrome (ARDS), shock, upper gastrointestinal (UGI) bleed, acute kidney injury (AKI), and acute respiratory failure (ARF). Results: A total of 200 patients were enrolled, with a mean age ± standard deviation of 62 ± 11.24 years, and 64.5% were males. The median (interquartile range) duration of hospital stay and ICU stay were 8 (6–12) days and 4 (3–7) days, respectively. The most common primary diagnosis was cardiovascular (39.5%) followed by neurological (16.5%), infection at diagnosis (16.5%), respiratory (14%), gastrointestinal (7.5%), and others (6%). A higher glycemic gap was associated with occurrence of MODS (P < 0.01), ARDS (P = 0.026), shock (P = 0.043), UGI bleed (P = 0.013), AKI (P = 0.01), and ARF (P < 0.01). Glycemic gap cutoffs of 43.31, 45.26, and 39.12 were found to be discriminatory for predicting ICU mortality (area under the receiver operating characteristic [AUROC]=0.631, P = 0.05), MODS (AUROC = 0.725, P < 0.001), and ARF (AUROC = 0.714, P < 0.001). Conclusion: This study showed that higher glycemic gap levels were associated with an increased risk of MODS, ARDS, shock, UGI bleed, AKI, and ARF. Glycemic gap is a tool that can be used to determine prognosis in patients with diabetes admitted to the ICU.
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Fetal skeletal size and growth are relevant biometric markers in Vitamin D deficient mothers: A North East India prospective cohort study p. 212
Dipti Sarma, Uma K Saikia, Darvin V Das
DOI:10.4103/ijem.IJEM_652_17  PMID:29911034
Context: The neonatal skeletal outcomes due to maternal Vitamin D deficiency. Aims: The aim of this study is to assess the serum 25 hydroxy Vitamin D (25[OH]D) status in pregnant women and correlate with cord blood 25(OH)D levels, femur length at 34 weeks gestation, and neonatal anthropometry (birth weight, birth length, and head circumference). Settings and Design: This was prospective cohort study. Subjects and Methods: This study was carried out in 250 healthy primigravida between 18 and 40 years of age in the third trimester of gestation attending the Obstetrics and Gynaecology Department of Gauhati Medical College, Guwahati from December 2012 to December 2015. Dietary assessment of calcium and Vitamin D intake, sunlight exposure among the pregnant mothers and fetal femur length measurements were done. The neonates were followed up at birth for biometric assessment and the estimation of cord 25(OH)D. Statistical Analysis Used: Chi-square test and Pearson correlation were carried out to see the association and correlation between different variables. Statistical significance was set at the 0.05 level. Results: We found low Vitamin D levels (60%) in the majority of pregnant mothers and newborns (62.4%). The mean Vitamin D levels were 17.51 ± 2.24 ng/ml and 14.51 ± 1.8 ng/ml among the low Vitamin D maternal subjects and their new born, respectively. There was a significant association of maternal Vitamin D levels with sun exposure, dietary intake of Vitamin D, serum calcium, serum alkaline phosphatase levels, and serum parathyroid hormone in subjects with low Vitamin D. Fetal femur length and birth length were significantly shorter in mothers with low Vitamin D (P < 0.01). Conclusions: Maternal hypovitaminosis D was associated with adverse skeletal outcome in neonates.
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Subclinical hypothyroidism and cardiac risk: Lessons from a South Indian population study p. 217
Sashi Niranjan Nair, Harish Kumar, Manoj Raveendran, V Usha Menon
DOI:10.4103/ijem.IJEM_298_17  PMID:29911035
Introduction: The benefits of treating subclinical hypothyroidism are currently under debate, prevention of adverse cardiac events purporting to be one of the main benefits. The effect of subclinical hypothyroidism on the cardiovascular health of the Indian sub-population is largely unknown. This study was designed to examine these effects and to help guide treatment of this disorder. Methods: A cross-sectional adult population survey was carried out in urban coastal area of central Kerala. 986 volunteers underwent complete biochemical and physical examinations, 110 were found to have subclinical hypothyroidism (8.9%). The ten-year risk of an adverse cardiac event, was calculated using the Framingham score algorithm. Eligible subclinical hypothyroid subjects (N = 110) and a randomly selected, age and gender matched control group (N = 220) were compared. Results: This population was found to have high baseline levels of diabetes 19.5%, hypercholesterolemia 57.2% and systolic hypertension 24.6%. No association was found between subclinical hypothyroid status or rising TSH and Framingham 10-year risk. While no difference between groups was noted with respect to lipid profile, a rising TSH was found to be significantly correlated with mild worsening of the lipid profile. A significant positive correlation was found between skinfold thickness and TSH. Conclusions: Subclinical hypothyroidism is not a contributing factor to elevated Framingham risk in this population, and while a mild effect was observed on the lipid profile, its effect is unlikely to be clinically relevant. We hypothesize that in this population a genetic component may be responsible for the uniquely high rates of metabolic syndrome and other endocrine diseases.
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Assessment of cardiovascular risk in natural and surgical menopause p. 223
S Zafar Abbas, Vijayata Sangawan, Asim Das, Anil Kumar Pandey
DOI:10.4103/ijem.IJEM_620_17  PMID:29911036
Background: Menopause is associated with increased cardiovascular disease (CVD) risk. Arterial stiffness, a biomarker of vascular aging, increases the risk for CVD. Aims and Objectives: The study was aimed to determine whether menopause is associated with arterial stiffness amongst natural and surgical menopausal women. Materials and Methods: We conducted a cross-sectional study amongst natural postmenopausal women, with Surgical menopause and Premenopausal. Arterial stiffness was measured by Periscopy TM. Large artery stiffness may be an important mechanism by which hysterectomy increases the risk of cardiovascular disease in postmenopausal women. Results: Carotid femoral pulse wave velocity (cfPWV) and Brachial Ankle Pulse wave velocity (baPWV) were significantly higher in surgical and natural menopause compared to women with Premenopausal group.
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Prevalence pattern of key polymorphisms in the Vitamin D receptor gene among patients of Type 2 diabetes mellitus in Northeast India p. 229
Dipti Sarma, Vikram Singh Chauhan, Kandarpa Kumar Saikia, Partha Sarma, Sukanta Nath
DOI:10.4103/ijem.IJEM_213_17  PMID:29911037
Aims: To investigate the association between Vitamin D receptor gene polymorphisms (BsmI, TaqI and FokI) and type 2 diabetes mellitus in patients in north eastern India. Settings and Design: This was a case control study with 40 cases of type 2 diabetes and 20 controls. Materials and Methods: Genomic DNA was extracted from blood and genotyped for the single nucleotide polymorphism (SNPs) of BsmI [rs1544410], TaqI [rs731236] and FokI [rs2228570] by polymerase chain reaction and gene sequencing. Genotype distribution and allelic frequencies were compared between patients and controls. Data was expressed as mean ±standard deviation. Chi square test and t test were used to compare groups. Statistical analysis was done using SAS version 9.3 software. P value of <0.05 was considered significant. Results: Body weight and BMI were significantly associated with VDR polymorphisms BsmI and TaqI while BsmI was significantly associated with HbA1C. Vitamin D deficiency was significantly greater in cases than controls. The frequency of the heterozygous genotype of the BsmI polymorphism was significantly greater in type 2 diabetics than in controls. Conclusions: Vitamin D receptor polymorphisms are associated with type 2 diabetes in our population and require larger scale studies to be considered as possible risk factors or type 2 diabetes mellitus.
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Lean mass and disease activity are the best predictors of bone mineral loss in the premenopausal women with rheumatoid arthritis p. 236
Meha Sharma, Urmila Dhakad, Anupam Wakhlu, Danveer Bhadu, Deep Dutta, Siddharth K Das
DOI:10.4103/ijem.IJEM_665_17  PMID:29911038
Background and Objectives: Factors determining bone mineral (BM) loss in rheumatoid arthritis (RA) are not well known. This study aimed to determine the occurrence and predictors of BM loss in the young premenopausal women with RA. Methods: Ninety-six females with RA and 90 matched controls underwent clinical, biochemical, BM density (BMD), and body composition assessments. RA disease activity was assessed using disease activity score-28 (DAS-28) and hand X-ray. Results: In the young premenopausal females with RA having median symptom and treatment duration of 30 (18–60) and 4 (2–12) months, respectively, with moderate disease activity (DAS-28, 4.88 ± 1.17), occurrence of osteoporosis and osteopenia was 7.29% and 25% at spine, 6.25% and 32.29% at hip, and 17.7% and 56.25% at wrist, respectively (significantly higher than controls). RA patients had lower BMD at total femur, lumbar spine (LS), radius total, and radius ultra-distal. Total lean mass (LM) and BM content were significantly lower in RA (P = 0.022 and <0.001, respectively). In RA, BMD at majority of sites (LS, neck of femur, greater trochanter, radius total, and radius 33%) had the strongest positive correlation with LM followed by body fat percent. RA patients with most severe disease had lowest BMD at different sites and lowest LM. Stepwise linear regression revealed LM followed by DAS-28 to be best predictors of BMD. RA patients receiving glucocorticoids did not have significantly different BMDs from patients not taking glucocorticoids. Interpretation and Conclusion: BM loss is a significant problem in the young premenopausal women with recent-onset RA. LM and disease severity were the best predictors of BMD.
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Determinants of Vitamin D status in Indian school-children p. 244
Rubina Mandlik, Neha Kajale, Veena Ekbote, Vivek Patwardhan, Vaman Khadilkar, Shashi Chiplonkar, Anuradha Khadilkar
DOI:10.4103/ijem.IJEM_622_17  PMID:29911039
Introduction: Due to the high prevalence of Vitamin D deficiency in spite of abundant sunshine and scarcity of studies investigating Vitamin D status in Indian children from rural and semirural areas, the objectives of this cross-sectional study were to: (1) assess the Vitamin D status of school-children in a semi-rural setting and (2) identify the determinants of Vitamin D status in these children. Materials and Methods: Data collected included anthropometric measurements (height and weight), body composition, three-one-day dietary recall method, demographic data, and sunlight exposure. Serum 25-hydroxyVitamin D (25(OH)D) was estimated by enzyme-linked immunosorbent assay (ELISA) technique. SPSS software was used for statistical analysis. Results: Anthropometric characteristics of the children were similar and mean serum 25(OH)D concentration was 58.5 ± 10.3 nmol/L with no significant differences between genders. Around 80% children reported sunlight exposure of 2 h or more. A majority (71%) of children were Vitamin D insufficient with serum 25(OH)D concentrations between 50 and 74.9 nmol/L. Determinants of Vitamin D identified were duration of sunlight exposure and body fat percent. Significant (P < 0.05) positive association of duration of sunlight exposure was observed with serum 25(OH)D concentrations, while BF% showed a negative association with serum 25(OH)D (β = –0.307; standard error = 0.1388; P < 0.05). Discussion: We have reported a high prevalence of Vitamin D insufficiency in school-children aged 6–12 years, from a semirural setting, in spite of a majority (80%) reporting >2 h of sunlight exposure. We have also demonstrated that duration of sunlight exposure and body fat percentage are the two important determinants of serum 25(OH)D concentrations in these children.
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Duration of casual sunlight exposure necessary for adequate Vitamin D status in Indian Men p. 249
Vivek G Patwardhan, Zulf M Mughal, Shashi A Chiplonkar, Ann R Webb, Richard Kift, Vaman V Khadilkar, Raja Padidela, Anuradha V Khadilkar
DOI:10.4103/ijem.IJEM_473_17  PMID:29911040
Objectives: To investigate the duration of casual sunlight ultraviolet-B (UVB) exposure required to maintain optimal Vitamin D status (25-hydroxyvitamin-D [25(OH)D]) >50 nmol/L in urban Indian men, using polysulfone (PSU) dosimeters and a sunlight exposure questionnaire. Methods: In healthy men (aged 40–60 years) from Pune (18.52° N, 73.86° E), India, serum 25(OH)D was measured using enzyme-linked immunosorbent assay. Sunlight exposure was assessed using PSU dosimeter and by questionnaire. Results: Of 160 men (48.3 ± 5.6 years), 26.8% were deficient and 40.6% had insufficient Vitamin D concentrations. A hyperbolic function for the relationship between PSU measured sunlight exposure in standard erythema dose (SED) and serum 25(OH)D concentrations (r = 0.87, P < 0.01) revealed that daily exposure of 1 SED was sufficient to maintain serum 25(OH)D concentrations over 50 nmol/L. The curve plateaued around 5 SED (80 nmol/L) and extrapolation of the curve (>5 SED) did not increase 25(OH)D concentrations above 90 nmol/L. Receiver operating curve analysis confirmed that 1 SED-UV exposure was sufficient to maintain 25(OH)D concentrations over 50 nmol/L. Based on the questionnaire data, >1 h of midday casual sunlight exposure was required to maintain serum 25(OH)D concentrations above 50 nmol/L. Duration of sunlight exposure assessed by questionnaire and PSU dosimeter showed a significant correlation (r = 0.517, P < 0.01). Conclusion: In urban Indian men, >1 h of casual midday sunlight exposure daily was required to maintain serum 25(OH)D concentrations above 50 nmol/L, and >2 h of casual sunlight exposure was needed to maintain 25(OH)D concentrations above 75 nmol/L. Excess sunlight did not increase 25(OH)D linearly. The sunlight exposure questionnaire was validated for use in clinical studies and surveys.
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Height velocity in apparently healthy north Indian school children p. 256
Aashima Dabas, Rajesh Khadgawat, Monita Gahlot, Vineet Surana, Neena Mehan, Rekha Ramot, Aparna Pareek, V Sreenivas, Raman Kumar Marwaha
DOI:10.4103/ijem.IJEM_638_17  PMID:29911041
Objective: Linear growth is best estimated by serial anthropometric data or height velocity (HV). In the absence of recent data on growth velocity, we undertook to establish normative data in apparently healthy North Indian children. Materials and Methods: Prospective longitudinal study in a representative sample of 7710 apparently healthy children, aged 3–17 years from different regions of Delhi. Height was measured at baseline and at 12 months while pubertal examination was performed at baseline in a subset of children. Results: The data on HV and puberty were available in 5635 participants (73.08%; 2341 boys and 3294 girls) and 1553 participants (622 boys; and 931 girls), respectively. The mean peak height velocity (PHV) was 7.82 ± 2.60 cm in boys seen at 12–12.9 years and 6.63 ± 1.81 cm in girls at 10–10.9 years Although late maturing boys had a greater HV than early or normal maturers, it did not vary with the age of pubertal maturation in girls. HV correlated with parental height in prepubertal boys, girls, and pubertal boys (P < 0.01) while no correlation was seen in girls. Conclusions: The study presents normal height velocities in North Indian children. A secular trend was observed in achieving PHV in both boys and girls.
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Relation of bone mineral density with homocysteine and cathepsin K levels in postmenopausal women p. 261
Madhukar Mittal, Rajeev Verma, Arvind Mishra, Ajay Singh, Vivek Kumar, KK Sawlani, M Kaleem Ahmad, Pratishtha Mishra, Rishika Gaur
DOI:10.4103/ijem.IJEM_575_17  PMID:29911042
Background: Homocysteine (HCY) interferes with collagen cross-linking in bones and stimulates osteoclast activity. The activated osteoclasts secrete cathepsin K (CathK), a cysteine protease, in eminent quantity during bone resorption. Hyperhomocysteinemia may effect bone mineral density (BMD) through CathK. We, therefore, examined the relation between HCY and BMD along with CathK, 25-hydroxyvit-D (25[OH]D), intact parathyroid hormone (iPTH), and Vitamin B12. Materials and Methods: We recruited a total of 93 postmenopausal women between the age group of 45–60 years, attending the Endocrinology outpatient department at King George's Medical University, Lucknow. BMD was done by DXA scan using Hologic QDR1000 system. Based on the WHO criteria, patients were segregated into three groups as follows; normal bone mass, osteopenia, and osteoporosis. All women underwent routine biochemical laboratory parameters, HCY, Vitamin B12, and CathK levels. Results: Among 93 postmenopausal women, 56% (52) had osteoporosis. Nineteen percent (18) had normal BMD (mean age, 53.22 ± 8.5 years) and 23 (25%) had osteopenia (mean age 52.86 ± 6.67 years). The mean age in the osteoporetic group was 56.2 ± 6.9 years. The median (interquartile range) levels of HCY in the three groups were 14.5 μmol/L (12.2–24.7), 15.05 μmol/L (12.1–19.9) and 13.2 μmol/L (10.3–17.0), respectively. CathK levels were similar in three groups 7.6 ng/ml (7.0–80.5), 8.3 ng/ml (7.3–8.5), and 8.6 ng/ml (7.2–8.9). Both HCY and CathK were found positively associated with serum phosphorus (r = 0.584, P < 2.01 and r = 0.249, P < 0.05, respectively). Levels of HCY positively correlate with PTH (r = 0.303, P < 0.01) and inversely with Vitamin B12 (r = −0.248, P < 0.05). No significant association was seen between CathK level and 25(OH) D, iPTH, serum calcium. Conclusion: Low bone mass by DXA is a significant problem in postmenopausal females. HCY and CathK do not reliably correlate with bone loss in postmenopausal women although phosphorus metabolism may play a role.
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REVIEW ARTICLE Top

Polycystic ovary syndrome and periodontal disease: Underlying links- A review p. 267
Sri Chandana Tanguturi, Sreenivas Nagarakanti
DOI:10.4103/ijem.IJEM_577_17  PMID:29911043
Polycystic ovary syndrome (PCOS) is the most common endocrine disorder among women of reproductive age, which negatively affects various health systems. There is an extensive literature regarding the association of PCOS and other systemic conditions such as diabetes mellitus, cardiovascular disease, and psychological disorders. However, there is a lack of literature in associating PCOS and periodontal disease. Hence, PubMed search was done for various articles related to PCOS and its association with other comorbidities, including periodontal diseases. Analysis was done and data were synthesized and compiled in a sequential and presentable paradigm. This literature review of the pathophysiological mechanisms linking the two diseases suggests a positive relation between the two comorbidities. However, multicenter studies, with larger sample sizes, are to be conducted to establish a clearer and stronger association.
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BRIEF COMMUNICATIONS Top

Advanced diabetic nephropathy with “Clean” eyes: An extreme phenotype p. 274
Debmalya Sanyal, Sudip Chatterjee
DOI:10.4103/ijem.IJEM_590_17  PMID:29911044
Introduction: It is generally accepted that renal and eye changes in diabetes are concordant. There are however a fair number of patients with diabetes who have end-stage renal disease (ESRD) without any of the typical eye changes. The present study highlights the discordance between retinopathy and nephropathy and describes a series of patients of long-standing diabetes undergoing renal transplant who had little or no evidence of retinopathy. Methods: All patients with ESRD undergoing renal transplants underwent comprehensive fundus evaluation including dilated indirect ophthalmoscopy, slit lamp biomicroscopy, and fundus photography. The patients' age, gender, physical parameters (body mass index and blood pressure), duration of diabetes, glycosylated hemoglobin (HbA1c), albumin creatinine ratio, and presence of diabetic peripheral neuropathy (DPN) were determined. Renal histopathology was reviewed, if available. Results: Five patients with diabetic nephropathy (DN) underwent renal transplant and had no evidence of diabetic retinopathy (DR) or up to two microaneurysms per fundus. All the patients were between 50 and 65 (mean ± standard deviation – 58.6 ± 4.67) years of age. The mean duration of diabetes was 16 ± 2.91 years. All had poor glycemic control with a mean HbA1c of 9.2 ± 0.837%. All had hypertension, macroalbuminuria, and DPN. Conclusion: There is a well-recognized association between retinopathy and nephropathy, in which nephropathy without retinopathy is rare but retinopathy without nephropathy is common. We have identified a subset of patients with kidney disease of sufficient severity to warrant renal transplant but who are protected from retinopathy. It is possible that there is an extreme phenotype of DN patients with unaffected eyes who carry genes protecting against DR.
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Congenital hypothyroidism screening in term neonates using umbilical cord blood TSH values p. 277
Ravi Bhatia, Dinesh Rajwaniya
DOI:10.4103/ijem.IJEM_640_17  PMID:29911045
Congenital hypothyroidism remains one of the most common preventable causes of mental retardation among children. Screening for congenital hypothyroidism remains one of the most cost-effective tools to prevent mental retardation in the population. Umbilical cord blood thyroid-stimulating hormone (TSH) levels remain an attractive and a practical step for screening for congenital hypothyroidism. The aims of this study were as follows: (1) to find normative values of cord blood TSH for the study group and (2) to use cord blood TSH levels as a marker for screening of congenital hypothyroidism. Cord blood of 1824 neonates who were of term gestation, weighed >2.5 kg at birth, whose mothers were off thyroid medication were a part of the study group. Umbilical cord blood was collected at the time of delivery and TSH was estimated. All babies who had a cord blood TSH value of >20 mIU/L were called bay on day 7 of life for a full thyroid profile. Cord blood samples of 1824 neonates were tested for TSH. Male–female ratio was 979:845 = 1.15:1. The birth weights ranged between 2.5 and 4.5 kg with an average birth weight of 2.811 kg. Mean (standard deviation) TSH value was 7.725 (8.99). TSH values ranged between 1.2 and 100 mIU/ml. TSH values corresponding to the 3rd, 10th, 25th, 50th, 90th, 95th, and 97th percentile were 2.32, 4.05, 5.67, 7.5, 12, 20.63, and 30.88, respectively. Out of the 88 babies recalled for repeat testing, 80 babies only turned up; eventually one turned out to be hypothyroid on repeat testing. The incidence of congenital hypothyroidism in our study was 1 in 1824. To conclude, we can safely use a cutoff of cord blood TSH value of >20 mIU/L for the purpose of screening for congenital hypothyroidism. For logistic angles, a higher cutoff of >30 mIU/L can be used. Large population-based studies are required to establish normative values for cord blood TSH in our country.
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Vaccination status, knowledge, and acceptance of adult vaccinations against respiratory illness among patients with Type 2 diabetes mellitus p. 280
Christeena Geneev, Nisha Mathew, Jubbin Jagan Jacob
DOI:10.4103/ijem.IJEM_29_18  PMID:29911046
Patients with diabetes mellitus are more prone to develop infections with influenza virus and pneumococcus. Once they develop respiratory infections, they are twice more likely to die of complication related to the infection. Although there are no Indian guidelines, recent publications have recommended vaccination in patients with diabetes of all ages. Our study was undertaken to find the barriers to the uptake of adult vaccination against respiratory illness among patients with diabetes attending a diabetic clinic in a tertiary care institution. Of the 149 patients interviewed, only 2% and 0.7% had been previously vaccinated against influenza and pneumococcus, respectively. Although 52% of patients agreed that vaccination was safe and effective, only 17.4% got vaccinated during the period of observation after counseling. The primary reasons for refusal were financial (51.7%), while some were not completely convinced of its benefits (9.4%); the other reasons included fear of complications (7.4%) and needles (0.7%).
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ENDOCRINOLOGY AND THE ARTS Top

The goitrous Salting Madonnas: Iconography of goiter in religious portraits p. 283
Davide Lazzeri, Fabio Nicoli
DOI:10.4103/ijem.IJEM_13_18  PMID:29911047
Introduction: George Salting was an art collector, who bequeathed his collection of paintings to the National Gallery of London. The present investigation has revealed five portraits of five different artists belonging to this collection in which the Holy Mother holding the child has been portrayed with a variable grade of thyroid gland enlargement. The name Salting, applied to the Madonnas with child by Antonello da Messina, Robert Campin, Dirk Bouts, Cima da Conegliano, and Andrea del Verrocchio, denotes George Salting, the collector who donated the masterworks to the gallery in 1910. Materials and Methods: The five paintings were analyzed to determine the accuracy of the diagnosis of neck swelling and the underlying iconographical significance of this depiction, which is relatively uncommon in religious artworks. Results: The present investigation highlighted an abnormal profile of the neck of the Virgin Mary, which is suggestive of a presumptive medico-artistic diagnosis of goiter. The inclusion of thyroid swelling in a holy sitter is relatively uncommon and is related to specific meanings that the painter wanted to illustrate in the work, the reasons for which are herein discussed. Conclusions: It seems likely that the integration of the goiter in the paintings is a stylistic hallmark. Indeed, the depiction of a slight neck enlargement is most probably a rhetorical tendency of representing an idealized female beauty, especially in holy sitters, imbued by a balanced neck and graceful body. At the same time, it probably also reflects better anatomic accuracy and knowledge of Renaissance artists applied toward a more realistic and precise representation of subjects.
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CASE REPORT Top

Hypokalemic paralysis due to primary Sjogren syndrome p. 287
Anuj Sarma
DOI:10.4103/ijem.IJEM_666_17  PMID:29911048
Sjögren syndrome is an autoimmune disorder characterized by lymphocytic infiltration of exocrine gland. The most common symptom by virtue of its involvement includes dryness of eyes, mouth, and parotid gland enlargement. However, the disease may be associated with extraglandular manifestation affecting multiple organs. Such a presentation involves renal involvement with tubular dysfunction manifesting as severe hypokalemia.
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LETTERS TO THE EDITOR Top

Indeterminate thyroid nodule: Mystery continues despite recent advances p. 290
Ameya Joshi, Ritesh Agrawal
DOI:10.4103/ijem.IJEM_604_17  PMID:29911049
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Multiple lytic lesions on F-18 fluorodeoxyglucose positron emission tomography/computed tomography not always metastatic? p. 291
Averilicia Passah, Saurabh Arora, Nishikant Avinash Damle
DOI:10.4103/ijem.IJEM_32_18  PMID:29911050
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Reduced efficacy of insulin detemir in controlling hyperglycemia during pregnancy: An interesting case report p. 292
Arun Pande, Ajay Aggarwal, Roopak Wadhwa
DOI:10.4103/ijem.IJEM_41_18  PMID:29911051
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Is iodine excess associated with increased incidence of hypothyroidism? p. 295
Subramanian Kannan, Sudha Rathna Prabhu, Shriraam Mahadevan
DOI:10.4103/ijem.IJEM_605_17  PMID:29911052
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REVEAL study: Reveals the limitations of cholesteryl ester transfer protein inhibition p. 296
Anil Pareek, Indranil Purkait, Anu Grover, Ravi Tejraj Mehta
DOI:10.4103/ijem.IJEM_17_18  PMID:29911053
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