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   2016| Nov-Dec  | Volume 20 | Issue 6  
    Online since October 24, 2016

 
 
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REVIEW ARTICLES
Bone turnover markers: Emerging tool in the management of osteoporosis
Sahana Shetty, Nitin Kapoor, Joseph Dian Bondu, Nihal Thomas, Thomas Vizhalil Paul
Nov-Dec 2016, 20(6):846-852
DOI:10.4103/2230-8210.192914  PMID:27867890
Bone is a dynamic tissue which undergoes constant remodeling throughout the life span. Bone turnover is balanced with coupling of bone formation and resorption at various rates leading to continuous remodeling of bone. A study of bone turnover markers (BTMs) provides an insight of the dynamics of bone turnover in many metabolic bone disorders. An increase in bone turnover seen with aging and pathological states such as osteoporosis leads to deterioration of bone microarchitecture and thus contributes to an increase in the risk of fracture independent of low bone mineral density (BMD). These microarchitectural alterations affecting the bone quality can be assessed by BTMs and thus may serve as a complementary tool to BMD in the assessment of fracture risk. A systematic search of literature regarding BTMs was carried out using the PubMed database for the purpose of this review. Various reliable, rapid, and cost-effective automated assays of BTMs with good sensitivity are available for the management of osteoporosis. However, BTMs are subjected to various preanalytical and analytical variations necessitating strict sample collection and assays methods along with utilizing ethnicity-based reference standards for different populations. Estimation of fracture risk and monitoring the adherence and response to therapy, which is a challenge in a chronic, asymptomatic disease such as osteoporosis, are the most important applications of measuring BTMs. This review describes the physiology of bone remodeling, various conventional and novel BTMs, and BTM assays and their role in the assessment of fracture risk and monitoring response to treatment with antiresorptive or anabolic agents.
  3,316 1,274 22
ORIGINAL ARTICLES
Trimester-specific reference interval for thyroid hormones during pregnancy at a Tertiary Care Hospital in Haryana, India
Rajesh Rajput, Bhagat Singh, Vasudha Goel, Amit Verma, Shashi Seth, Smiti Nanda
Nov-Dec 2016, 20(6):810-815
DOI:10.4103/2230-8210.192903  PMID:27867885
Background: Reference intervals for thyroid hormone during pregnancy need to be gestational age, method , and population specific and there is need to establish trimester-specific thyroid levels for the different population across the world. The aim of this study was to establish trimester-specific reference range for thyroid hormone during pregnancy in a tertiary care center in Haryana. Materials and Methods: A total of 1430 pregnant women were recruited for the study. Participants having any history of chronic illness, goiter on physical examination, thyroid illness in the past or present, consuming thyroid medications, family history of thyroid illness, presence of anti-thyroid peroxidase antibody, poor obstetrics history were excluded from the study and reference population was identified to calculate serum free triiodothyronine (FT3), free thyroxine (FT4) and thyrotropin (TSH) for each trimester of pregnancy. Results: The 2.5–97.5th percentiles for FT3, FT4, and TSH obtained in this study were 2.53–4.54 pg/ml, 0.88–1.78 ng/ml and 0.37–3.69 μIU/ml in the first trimester, 2.0–4.73 pg/ml, 0.91–1.78 ng/ml and 0.54–4.47 μIU/ml in the second trimester, 2.01–4.01 pg/ml, 0.83–1.73 ng/ml, and 0.70–4.64 μIU/ml in the third trimester of pregnancy. Mean TSH increased and mean FT3 decreased significantly with the progression of gestational period. FT4 decreased from trimester 1–3rd, but the decrease was nonsignificant from 2nd to 3rd trimester. Conclusions: Existing results for trimester-specific reference intervals for thyroid hormones are inconsistent and cannot be extrapolated due to differences in ethnicity, maternal iodine status, laboratory assay method, and rigor for selection of reference population. Thus, establishment of reference intervals in each region is of great importance.
  3,666 360 2
Neck height ratio is an important predictor of metabolic syndrome among Asian Indians
Chitra Selvan, Deep Dutta, Anubhav Thukral, Titli Nargis, Manoj Kumar, Satinath Mukhopadhyay, Subhankar Chowdhury
Nov-Dec 2016, 20(6):831-837
DOI:10.4103/2230-8210.192927  PMID:27867888
Background and Aims: The predictive potential of neck circumference (NC) based indices (a measure of upper body fat distribution) for predicting metabolic syndrome (MetS) and its components among Indians is not known. This study aimed to evaluate the role of NC and neck height ratio (NHtR) as independent predictors of MetS and its components as compared to traditional anthropometric indices. Materials and Methods: A total of 451 individuals from 867 screened individuals, 30–80 years age, without any co-morbid state who gave informed written consent underwent clinical, anthropometric, and biochemical assessment. Results: Patients with MetS in both the sexes had significantly higher NC, NHtR, glycated hemoglobin, fasting glucose, and dyslipidemia (higher triglycerides, total cholesterol/high-density lipoprotein cholesterol (HDL-C) ratio, low-density lipoprotein cholesterol/HDL-C ratio, and lower HDL-C). In both sexes, individuals in the highest tertile of NC had significantly greater central and generalized obesity, lower HDL-C, and significantly higher MetS. Receiver operating characteristic analysis revealed waist circumference (WC) to have the largest area under the curve for predicting MetS in both sexes, followed by NHtR, NC, and body mass index. NC and NHtR of >34.9 cm (sensitivity 78.6%; specificity 59.3%) and >21.17 cm/m (sensitivity 80.7% and specificity 64.6%) respectively for men and >31.25 cm (sensitivity 72.3%; specificity 64.4%) and >20.48 cm/m (sensitivity 80.4% and specificity 60%) respectively for women were the best values for identifying MetS. Increased NC and NHtR had odds ratio of 1.52 (95% confidence interval [CI]: 1.37–1.68; P< 0.001) and 1.96 (95% CI: 1.67–2.29; P< 0.001) respectively in identifying MetS. Conclusion: NC and NHtR are good predictors of MetS and cardiovascular risk factors in Asian Indians. NHtR is reliable and perhaps an even better index than NC with regards to cardiovascular risk prediction.
  3,569 355 6
Prevalence and predictors of depression and anxiety in patients of diabetes mellitus in a tertiary care center
Rajesh Rajput, Pratibha Gehlawat, Deepak Gehlan, Rajiv Gupta, Meena Rajput
Nov-Dec 2016, 20(6):746-751
DOI:10.4103/2230-8210.192924  PMID:27867873
Background: Diabetes is one of the most common chronic diseases and affects virtually every organ of the human system. Depression and anxiety is common among patients with diabetes and associated with worse diabetes outcomes. Aims and Objective: To study the prevalence and predictors of depression and anxiety in patients of Type 2 diabetes mellitus (T2DM) in Pt. B.D. Sharma, PGIMS, Rohtak, Haryana, India, a tertiary care center in Northern India. Materials and Methods: Four hundred ten consecutive patients having T2DM and 410 healthy controls matched for age and sex attending the endocrine out-patient department of a tertiary care center of Northern India were included in the study. Sociodemographic and relevant clinical variables were collected. They were evaluated for depression and anxiety using Hamilton Depression Rating Scale and Hamilton Anxiety Rating Scale respectively. Results: It was found that a significantly larger proportion of diabetic patients had depression (26.3% vs. 11.2%, P = 0.001), anxiety (27.6% vs. 12.7%, P = 0.001) and comorbid depression and anxiety (21.0% vs. 7.3%, P = 0.001) as compared to healthy controls. Diabetic women had higher depression (17.1% vs. 9.3%) and anxiety (17.6% vs. 10.0%) than men. The major predictors for a severe form of depression and anxiety among T2DM cases were age, female sex, insulin therapy, retinopathy, nephropathy, and ischemic heart disease. Conclusion: The present findings reveal that diabetic cases had significantly higher depression and anxiety as compared to healthy controls. The risk factors for depression and anxiety were age, female sex, insulin therapy, and diabetic complications.
  2,427 540 12
LETTERS TO THE EDITOR
Hypocalcemia and Fahr syndrome in a patient with Graves'disease: Difficult etiological diagnosis
Ibtissem Oueslati, Karima Khiari, Najla Bchir, Néjib Ben Abdallah
Nov-Dec 2016, 20(6):885-887
DOI:10.4103/2230-8210.192907  PMID:27867902
  2,142 157 -
REVIEW ARTICLES
Fasting practices in Tamil Nadu and their importance for patients with diabetes
Subramanian Kannan, Shriraam Mahadevan, Krishna Seshadri, Dhalapathy Sadacharan, Kumaravel Velayutham
Nov-Dec 2016, 20(6):858-862
DOI:10.4103/2230-8210.192921  PMID:27867892
Religious practices and cultural customs related to eating habits have a significant impact on lifestyle and health of the community. The Ramadan fasting in Muslims and its influence on various metabolic parameters such as diabetes have been reasonably studied. However, literature related to Hindu religious customs related to fasting and food patterns during various festivals and its effect on diabetes are scarce. This article is an attempt to describe the Hindu religious customs related to fasting and food practices from the State of Tamil Nadu (South India) and to raise the awareness among physicians about its relationship with diabetes which may help in managing their diabetic patients in a better way.
  1,994 211 2
ORIGINAL ARTICLES
Comparison clinical and metabolic effects of metformin and pioglitazone in polycystic ovary syndrome
Karoon Shahebrahimi, Nasrin Jalilian, Nasrin Bazgir, Mansour Rezaei
Nov-Dec 2016, 20(6):805-809
DOI:10.4103/2230-8210.192925  PMID:27867884
Introduction: Polycystic ovary syndrome (PCOS) is one of the most common endocrine disorders in women. PCOS comprises a broad spectrum of anomalies, including hyperandrogenism, chronic anovulation, obesity, and infertility. Insulin resistance and its compensatory hyperinsulinemia play a key role in the pathogenicity of PCOS. This study compares the effects of 2 types of insulin sensitizer drugs, metformin and pioglitazone, on clinical, metabolic, and endocrine characteristics of women with PCOS. Methods: In this randomized clinical trial, 56 women with PCOS (ages 20–49 years) were treated orally with either metformin (500 mg 3 times daily) or pioglitazone (30 mg daily) for 3 months. Clinical (body weight, blood pressure [BP], and body mass index) and laboratory indices (fasting blood sugar [FBS], serum triglyceride [TG], cholesterol, low-density lipoprotein, high-density lipoprotein, insulin, testosterone, and dehydroepiandrosterone [DHEA]) were measured before and after therapy. Data were analyzed by Chi-square and McNemar's tests. Results: Significant decreases were seen after treatment with metformin in extent of hair loss (P = 0.008), wrist circle (P = 0.011), weight (P = 0.047), diastolic BP (P = 0.023), and DHEA (P = 0.035). A significant decrease in TG was seen with pioglitazone treatment (P = 0.047). In both groups, significant decreases in acne, menstrual disturbance, FBS, and serum insulin were seen. Conclusion: There is a significant amelioration of endocrine and metabolic indices with pioglitazone in PCOS patients. Although we were not able to recommend one treatment regime over the other, pioglitazone offers a useful, alternate treatment in women with PCOS who are not able to tolerate metformin.
  1,395 446 7
Coronary artery calcium scoring is a better predictor of cardiac risk in subclinical hypothyroidism patients with low-risk Framingham score
Rajesh Verma, Ashish Verma, Piyush Gupta, NK Agrawal
Nov-Dec 2016, 20(6):756-762
DOI:10.4103/2230-8210.192901  PMID:27867875
Context: Overt hypothyroidism accelerates the cardiovascular disease. Subclinical hypothyroidism (SCH), being considered as a preclinical state, impacts on cardiovascular status is not clear. Aims: This study was aimed at assessing cardiac risk stratification by Framingham risk scoring (FRS) and coronary coronary artery calcium score (CACS) by noncontrast cardiac computed tomography in SCH. Study Design: Observational study. Subjects and Methods: We enrolled thirty treatment-naive SCH patients (aged 30–60 years with no serious concurrent medical conditions), thirty euthyroid (age, sex, and body mass index-matched) controls, and ten healthy controls. All cases were evaluated for coronary artery calcium scoring and Framingham risk score. Statistical Analysis: Qualitative data were analyzed using the Chi-square test. In addition, demographics and CACS are summarized graphically or in a table. Results: SCH cases had higher thyroglobulin, while there was a trend toward an increase in total cholesterol, low-density lipoprotein (LDL), very LDL, and decrease in HDL levels. All participants had low-risk FRS (10-year FRS < 10%). The mean CACS in SCH was significantly higher than simple obese and healthy controls (47.17 vs. 2.67 vs. 0.00). Conclusion: This study suggests that SCH is an independent risk factor for coronary artery disease in apparently healthy controls. The risk of occult coronary artery disease is increased in SCH cases.
  1,360 297 -
ENDOCRINOLOGY AND GENDER
Gender of rearing and psychosocial aspect in 46 XX congenital adrenal hyperplasia
Arushi Gangaher, Viveka P Jyotsna, Vasundhera Chauhan, Jomimol John, Manju Mehta
Nov-Dec 2016, 20(6):870-877
DOI:10.4103/2230-8210.192922  PMID:27867895
Background: In congenital adrenal hyperplasia (CAH) with ambiguous genitalia, assigning gender of rearing can be complex, especially If genitalia is highly virilized. Apart from karyotype, prenatal androgen exposure, patient's gender orientation, sociocultural, and parental influences play a role. The aim of this study was to assess gender dysphoria and psychosocial issues in patients of CAH raised as males and females. Materials and Methods: This is a cross-sectional study that includes patients (old and new) with CAH who were treated by us in the last 6 months. A semi-structured interview proforma was used to elicit history and psychosocial background of the patients. The clinical and biochemical details were noted. For psychological analysis, patients were screened for gender dysphoria using Parent Report Gender Identity Questionnaire for children <12 years and Gender Identity/Gender Dysphoria Questionnaire for Adolescents and Adults. Results: We analyzed 22 46 XX CAH patients among which, 3 were reared as males and 19 as females. Among the 19 patients reared as females, 17 patients showed no gender dysphoria. Two patients revealed gender dysphoria as indicated by their marginally low scores on the gender dysphoria assessment. However, in view of current literature and the age groups of the patients, behavior of the 6-year-old patient can be best understood as being tomboyish. Gender dysphoria in the 22-year-old can be explained by the dominance of psychosocial factors and not hormones alone. Among the three patients reared as males, two prepubertal were satisfied with their male gender identity. The third patient, aged 32 years, had gender dysphoria when reared as a male that resolved when gender was reassigned as female and feminizing surgery was done. Conclusion: Gender assignment in 46 XX CAH is guided by factors such as degree of virilization of genitalia, gender orientation, patient involvement, sociocultural, and parental influences.
  1,420 230 3
ORIGINAL ARTICLES
Serum adiponectin levels in gestational diabetes mellitus
Abhijit Bhograj, KM Suryanarayana, Ashwini Nayak, NS Murthy, Mala Dharmalingam, Pramila Kalra
Nov-Dec 2016, 20(6):752-755
DOI:10.4103/2230-8210.192909  PMID:27867874
Introduction: Gestational diabetes mellitus (GDM) is defined as any degree of glucose intolerance with onset or first recognition during pregnancy.[1] Pregnancy is a unique situation in which there is a physiological temporary increase in insulin resistance (IR). The mechanisms responsible for the gestational-induced IR are not completely understood. The current study was undertaken to compare adiponectin levels during 24–28 weeks period of gestation in drug-naive newly diagnosed GDM women with a cohort of normoglycemic pregnant women. Subjects and Methods: A total of 47 pregnant women in the age group of 18–40 years were included in this cross-sectional study, of which 13 were GDM cases and 34 were normoglycemic controls. Serum adiponectin level was analyzed by enzyme-linked immunosorbent assay. Results: The mean adiponectin level was 16.92 ng/ml (standard deviation [SD] = 2.78) and 19.38 ng/ml (SD = 2.71) in case and control groups, respectively, and the difference was found to be statistically significant (P = 0.008). Conclusion: Our study demonstrated decreased serum adiponectin levels in women with GDM when compared with age- and body mass index-matched euglycemic pregnant women.
  1,200 329 2
REVIEW ARTICLES
Bangladesh national guidelines on the management of tuberculosis and diabetes mellitus co-morbidity (summary)
Mohammad Delwar Hossain, Jamal Uddin Ahmed, Muhammad Abdur Rahim, A. K. M. Musa, Zafar Ahmed Latif
Nov-Dec 2016, 20(6):853-857
DOI:10.4103/2230-8210.192898  PMID:27867891
Tuberculosis (TB) and diabetes mellitus (DM) have synergetic relationship. People with diabetes are 2–3 times at higher risk of getting active TB disease. On the other hand, TB or anti-TB treatment may cause glucose intolerance. The dual disease of DM and TB is more likely to be associated with atypical disease presentation, higher probability of treatment failure and complications. In most of the health-care delivery systems of the world, DM and TB are managed separately by two vertical health-care delivery programs in spite of clear interaction between the two diseases. Thus, there should be a uniform management service for TB-DM co-morbidity. Realizing this situation, Bangladesh Diabetic Samity (BADAS), a nonprofit, nongovernment organization for the management of diabetes in Bangladesh, with the patronization of TB CARE II Project funded by U.S. Agency for International Development (USAID), launched a project in 2013 titled BADAS-USAID TB Care II, Bangladesh with the goal of “Integrated approach to increase access to TB services for diabetic patients.” One of the project objective and activity was to develop a national guideline for the management of TB-DM comorbidity. Thus, under the guidance of National Tuberculosis Control Program, of the Directorate General of Health Services, Government of the People's Republic of Bangladesh and World Health Organization (WHO), this guideline was developed in 2014. It is based on the existing “National Guidelines and Operational Manual for TB Control” (5th edition) and guidelines for management of DM as per WHO and International Diabetes Federations. Along with that, expert opinions from public health experts and clinicians and “Medline”-searched literature were used to develop the guidelines. These guidelines illustrate the atypical presentation of the TB-DM co-morbidity, recommendations for screening, treatment, and follow-up of these patients and also recommendations in case of management of TB in patients with kidney and liver diseases. Thus, these guidelines will be a comprehensive tool for physicians to manage TB in diabetic patients.
  1,199 322 1
ORIGINAL ARTICLES
Liraglutide effect and action in diabetes-In (LEAD-In): A prospective observational study assessing safety and effectiveness of liraglutide in patients with type 2 diabetes mellitus treated under routine clinical practice conditions in India
Subhash Kumar Wangnoo, Surender Kumar, Arpandev Bhattacharyya, Sudhir Tripathi, Shahid Akhtar, Raman Shetty, Samit Ghosal
Nov-Dec 2016, 20(6):838-845
DOI:10.4103/2230-8210.189232  PMID:27867889
Background: This 26-week, open-label observational study assessed the incidence and type of adverse events (AEs) associated with liraglutide use according to the standard clinical practice settings and the local label in India. Materials and Methods: A total of 1416 adults with type 2 diabetes (T2D) treated with liraglutide in 125 sites across India were included in the study. Participants were newly diagnosed or already receiving antidiabetic medications. Safety and efficacy data were collected at baseline and at approximately weeks 13 and 26. The primary outcome was incidence and type of AEs while using liraglutide, with events classified by Medical Dictionary for Regulatory Activities system organ class and preferred term. The secondary objective was to assess other clinical parameters related to effective T2D management. Results: Twenty AEs, predominately gastrointestinal, were reported in 1.3% of the study population in scheduled visits up to week 26. No serious AEs, including death, were reported. Hypoglycemic episodes were reported in 7.3% of participants at baseline and 0.7% at week 26. No major hypoglycemic events were reported up to week 26 (baseline: 0.4%). Glycated hemoglobin was reduced from baseline (8.8 ± 1.3%) to week 26 by 1.6 ± 1.1% (P < 0.0001); significant improvements in fasting blood glucose, and 2-h postprandial blood glucose (post-breakfast, -lunch, and -dinner) were also observed. Mean body weight decreased by 8.1 ± 6.5 kg from baseline (92.5 ± 14.6 kg; P< 0.0001). Conclusions: From the number of AEs reported, it is suggested that liraglutide was well tolerated in subjects with T2D treated under standard clinical practice conditions in India. Liraglutide was effective, and no new safety concerns were identified.
  1,158 272 1
Feasibility and acceptability of ambulatory glucose profile in children with Type 1 diabetes mellitus: A pilot study
Sushma Rai, Anjana Hulse, Prasanna Kumar
Nov-Dec 2016, 20(6):790-794
DOI:10.4103/2230-8210.192894  PMID:27867881
Background: Insulin administration and self-monitoring of blood glucose (SMBG) are pillars in the management of diabetes in children. Introduction of continuous glucose monitoring (CGM) has made it possible to understand the glycemic profiles which are not picked up by SMBG. Recent advent of flash glucose monitoring with inbuilt software to obtain ambulatory glucose profile (AGP) has emerged as a novel method to study glycemic patterns in adults with Type I diabetes. However, the use of AGP in children is yet to be explored. Methods: AGP was used in 46 children with Type 1 diabetes mellitus. Feasibility was measured regarding data and sensor failure. Acceptability was measured using a questionnaire. Results: Forty-six children (22 girls and 24 boys) with a mean age of 10.07 years and mean diabetes duration of 3.4 years were included in the study. In this cohort, for 30 (65.21%) subjects, the sensor remained in situ for a complete duration of 14 days. Except for minor discomfort, AGP was well accepted by most of the children and their parents. Conclusion: AGP is a feasible option for monitoring glycemic status in children with diabetes with a high rate of acceptance.
  1,030 306 6
Genotype-phenotype correlations of dyshormonogenetic goiter in children and adolescents from South India
Bangaraiah Gari Ramesh, Panchangam Ramakanth Bhargav, Bangaraiah Gari Rajesh, Nangedda Vimala Devi, Rajagopalan Vijayaraghavan, Bhongir Aparna Varma
Nov-Dec 2016, 20(6):816-824
DOI:10.4103/2230-8210.192923  PMID:27867886
Background: Dyshormonogenetic goiter is one of the most common causes of hypothyroidism in children and adolescents in iodine nonendemic areas. The exact genotype-phenotypic correlations (GPCs) and risk categorization of hypothyroid phenotypes of dyshormonogenetic mutations are largely speculative. The genetic studies in pediatric dyshormonogenesis are very sparse from Indian sub-continent. In this context, we analyzed the implications of TPO, NIS, and DUOX2 gene mutations in hypothyroid children with dyshormonogenetic hypothyroidism (DH) from South India. Materials and Methods: This is interdisciplinary prospective study, we employed eight sets of primers and screened for 142 known single nucleotide polymorphisms in TPO, NIS, and DUOX2 genes. The subjects were children and adolescents with hypothyroidism due to dyshormonogenetic goiter. Congenital hypothyroidism, iodine deficiency, and Hashimoto's thyroiditis cases were excluded. Results: We detected nine mutations in 8/22 (36%) children. All the mutations were observed in the intronic regions of NIS gene and none in TPO or DUOX2 genes. Except for bi-allelic, synonymous polymorphism of TPO gene in child number 14, all other mutations were heterozygous in nature. GPCs show that our mutations significantly expressed the phenotypic traits such as overt hypothyroidism, goiter, and existence of family history. Other phenotypic characters such as sex predilection, the age of onset and transitory nature of hypothyroidism were not significantly affected by these mutations. Conclusion: NIS gene mutations alone appears to be most prevalent mutations in DH among South Indian children and these mutations significantly influenced phenotypic expressions such as severity of hypothyroidism, goiter rates, and familial clustering.
  974 191 1
EDITORIALS
Does being born low birth weight affect the ability to exercise?
Nihal Thomas, IB Bygbjerg
Nov-Dec 2016, 20(6):741-743
DOI:10.4103/2230-8210.192920  PMID:27867871
  845 314 -
ORIGINAL ARTICLES
Prevalence of hypothyroidism in diabetic kidney disease and effect of thyroid hormone replacement on estimate glomerular filtration rate
Sarita Bajaj, Naincy Purwar, Arvind Gupta, Poonam Gupta, Anubha Srivastava
Nov-Dec 2016, 20(6):795-798
DOI:10.4103/2230-8210.192893  PMID:27867882
Aims: To determine the prevalence of subclinical and overt hypothyroidism in diabetic kidney disease (DKD) and effect of thyroid hormone replacement on progression of DKD. Materials and Methods: A prospective cohort study on 41 adult DKD patients who were screened for hypothyroidism. Hypothyroid DKD patients were started on levothyroxine replacement and were reviewed after 3 and 6 months. Results: Of the total population, 14 (34.1%) cases were hypothyroid, among whom 12 (29.3%) cases were subclinical, and 2 (4.8%) were overt hypothyroidism. Prevalence of hypothyroidism and mean thyroid stimulating hormone levels increased with increasing severity of DKD. There were 2 (14.3%) hypothyroid cases in stage 3b, 4 (28.5%) cases in stage 4, and 8 (57.2%) in stage 5 DKD. The mean estimate glomerular filtration rate (ml/min/1.73 m2) at baseline was 13.6 ± 13.3 which increased to 16.4 ± 14.5 and 21.2 ± 15.3 after 3 and 6 months of thyroid hormone replacement therapy (THRT), respectively (P < 0.001). Conclusions: Hypothyroidism is commonly associated with DKD. Prevalence of hypothyroidism increased with declining renal function. THRT significantly improved renal function in DKD patients with hypothyroidism after 3 and 6 months of therapy.
  854 279 1
BRIEF COMMUNICATIONS
Hyperthyroidism and Graves' disease: Is an ultrasound examination needed?
Lakshminarayanan Varadhan, George Iype Varughese, Sailesh Sankaranarayanan
Nov-Dec 2016, 20(6):866-869
DOI:10.4103/2230-8210.192899  PMID:27867894
Aim: The aim of our study was to assess the limitation of clinical examination in determining the morphology of thyroid gland in patients with hyperthyroidism and its implications. Methods: A retrospective analysis of consecutive patients with hyperthyroidism seen in a tertiary endocrine clinic were analyzed. Sub-analysis was performed on patients with proven Graves' disease. Results: Of the 133 patients included in this study with hyperthyroidism, 60 (45%) patients had significant nodularity on ultrasound (US). However, only 67% of these were identified on clinical examination. In patients with confirmed Graves' disease (n = 73), the discordance between US and clinical examination was very similar (18 of 30 patients, 60%). Conclusion: US should form an essential part of the evaluation of hyperthyroidism as the morphology of thyroid gland could be variable and nodules in these glands would also need to be appropriately investigated. This would also significantly influence decision-making and appropriate immediate and follow-up management plan.
  921 204 -
ORIGINAL ARTICLES
Prevalence of hypothalamo pituitary dysfunction in patients of traumatic brain injury
K. V. S. Hari Kumar, MN Swamy, MA Khan
Nov-Dec 2016, 20(6):772-778
DOI:10.4103/2230-8210.192917  PMID:27867878
Background: Traumatic brain injury (TBI) is common in young soldiers of armed forces leading to significant morbidity and mortality. We studied the prevalence of hypopituitarism following TBI and its association with trauma severity. Materials and Methods: We conducted a 12-month prospective study of 56 TBI patients for the presence of hormonal dysfunction. Hormonal parameters were estimated during the early phase (0–10 days posttraumatically) and after 6 and 12 months. Dynamic testing was done when required, and the results were analyzed by appropriate statistical methods. Results: Hormonal dysfunction was seen in 39 of the 56 (70%) patients at initial assessment. Persisting pituitary deficiencies are seen in 7 and 8 patients at the end of 6 months and 12 months, respectively. Hypogonadotropic hypogonadism, hypothyroidism, and growth hormone deficiency are the most common diagnoses. Initial severe TBI and plurihormonal involvement predicted the long-term hypopituitarism. Conclusion: Early hypopituitarism was common in severe TBI, but recovers in majority. Evaluation for the occult pituitary dysfunction is required during the rehabilitation of TBI patients.
  881 239 7
Demographic details, clinical features, and nutritional characteristics of young adults with Type 1 diabetes mellitus - A South Indian tertiary center experience
Mini Joseph, Asha H Shyamasunder, Riddhi D Gupta, Vijayalakshmi Anand, Nihal Thomas
Nov-Dec 2016, 20(6):799-804
DOI:10.4103/2230-8210.192895  PMID:27867883
Context: Type 1 diabetes mellitus (T1DM) accounts for 5–10% of all diagnosed diabetes and the highest incidence is found in India. Aims: The main objectives were to study the demographic, clinical, and nutritional characteristics of young adults with T1DM and its effect glycosylated hemoglobin levels. Subjects and Methods: This cross-sectional study was conducted among young adults with T1DM (18–45 years of age) in a tertiary hospital in South India. Data were obtained from updated medical records. The dietary data were assessed from food diaries and 24 h recall method. Anthropometry was determined. Results: The analysis revealed that socio-economic variables did not affect the glycosylated hemoglobin levels. The mean glycosylated hemoglobin value was 8.81 ± 2.38%. Nearly, half the patients were malnourished. The overall dietary intake was inadequate. The multivariate regression model, adjusted for confounding factors such as gender, age, and body mass index, revealed that only duration of diabetes and protein intake were significant predictors of glycosylated hemoglobin status (P < 0.005). Conclusion: Integrated care provided at subsidized cost has been pivotal in effective diabetes management. However, there is an urgent need to educate our patients on nutrition therapy. T1DM patients need specialized advice to ensure appropriately balanced nutrition that has a significant impact on their long-term glycemic control.
  889 187 1
Prevalence and pattern of growth abnormalities in children with extrahepatic portal vein obstruction: Response to shunt surgery
Toufeeq Ahmad Mir, Raiz Ahmad Misgar, Bashir Ahmad Laway, Omar Javed Shah, Zafar Amin Shah, Showkat Ali Zargar
Nov-Dec 2016, 20(6):763-766
DOI:10.4103/2230-8210.192912  PMID:27867876
Objective: Growth retardation is common in children with extrahepatic portal vein obstruction (EHPVO) and growth hormone (GH) resistance may play a dominant role. The aim of this study was to ascertain growth parameters and growth-related hormones in children with EHPVO, comparing with controls and to study the response of shunt surgery on growth parameters. Materials and Methods: The auxological and growth-related hormone profile (GH; insulin-like growth factor binding protein-3 [IGFBP-3] and IGF-1) of thirty children with EHPVO were compared with controls. The effect of shunt surgery on growth parameters in 12 children was also studied. Results: The mean height standard deviation score (HSDS) of cases (−1.797 ± 1.146) was significantly lower than that of controls (−0.036 ± 0.796); the mean weight SDS of cases (−1.258 ± 0.743) was also lower than that of controls (−0.004 ± 0.533). The mean GH level of cases (5.00 ± 6.46 ng/ml) was significantly higher than that of controls (1.78 ± 2.04 ng/ml). The mean IGF-1 level of cases (100.25 ± 35.93 ng/ml) was significantly lower as compared to controls (233.53 ± 115.06 ng/ml) as was the mean IGFBP-3 level (2976.53 ± 1212.82 ng/ml in cases and 5183.28 ± 1531.28 ng/ml in controls). In 12 patients who underwent shunt surgery, growth parameters significantly improved. Conclusions: Marked decrease in weight and height SDSs associated with GH resistance is seen in children with EHPVO, which improves with shunt surgery.
  872 172 1
Relationship of lean mass and obesity in Indian urban children and adolescents
MK Garg, Raman K Marwaha, Namita Mahalle, Nikhil Tandon
Nov-Dec 2016, 20(6):779-783
DOI:10.4103/2230-8210.192908  PMID:27867879
Background: The association of obesity and lean mass (LM) has not been examined well in children and adolescents, and it remains controversial. Objective: The objective of this study was to evaluate the relationship of body mass index (BMI) categories and regional obesity with total and regional LM in children and adolescents. Methods: A total of 1408 children and adolescents (boys 58.9%; girls 41.1%) divided according to BMI (normal weight 79.5%, overweight 16.0%, and obese 4.5%) were included in this cross-sectional study. Total and regional LM and fat mass were measured by DXA. Leg and arm fat-to-total fat ratio (LATR) indicative of subcutaneous fat and trunk fat-to-total fat ratio (TTR), an indicator of visceral fat, were calculated. Results: Mean age of the study population was 13.2 ± 2.7 years (boys - 13.0 ± 2.7; girls - 13.4 ± 2.8 years). Total LM (TLM) and its regional distribution were higher in overweight and obese groups when compared with those with normal BMI in both genders. TLM was comparable between overweight and obese in both genders. TLM per unit of fat progressively decreased from normal to obese categories. The difference in LM per unit fat between BMI categories persisted after adjustment for age, height, and sexual maturity score. TLM increased across the quartiles of TTR, but decreased with an increment in subcutaneous fat (quartiles of LATR). Conclusions: Obese children and adolescents apparently have higher LM than normal BMI children, but have lower LM per unit of fat. Subcutaneous fat had a negative impact and visceral fat had a positive impact on TLM.
  873 163 1
EDITORIALS
The rule of two-thirds in thyroid epidemiology
Sanjay Kalra, AG Unnikrishnan, Vipin Talwar
Nov-Dec 2016, 20(6):744-745
DOI:10.4103/2230-8210.192919  PMID:27867872
  735 267 -
ORIGINAL ARTICLES
Cross-sectional study of nutritional markers in pregnancy
Subhadra Sharma, Jai Bhagwan Sharma, Manisha Yadav, BR Usha, Sunesh Kumar, AK Mukhopadhyay
Nov-Dec 2016, 20(6):825-830
DOI:10.4103/2230-8210.192926  PMID:27867887
Objectives: To note the value of serum Vitamin B12, folic acid, and ferritin in normal and high-risk pregnancies (HRPs) in patients attending antenatal clinic at All India Institute of Medical Sciences (AIIMS). Materials and Methods: This is a cross-sectional study where a total of 282 patients attending Gynaecology Outpatient Department at AIIMS, New Delhi, India were recruited. Among the 282 subjects, 251 were pregnant, and 31 were controls. The serum was tested for serum Vitamin B12, serum folic acid, and serum ferritin levels using Beckman Coulter Access 2 immunoassay. Results: The median value of serum folic acid level in pregnant women was 12 pg/ml with range being 2–20 pg/ml in contrast to 8 pg/ml with range being 3–20 pg/ml in nonpregnant female. This difference was statistically significant. (P = 0.05). There was no significant difference in the median level of serum Vitamin B12 and serum ferritin in pregnant and nonpregnant group. Serum Vitamin B12 level was lower in the third trimester (127 pg/ml) than in first trimester (171 pg/ml) and the difference is statistically significant (P = 0.03). Serum ferritin levels were also significantly lower in the second trimester (16.4 pg/ml) than third trimester (24.55 pg/ml). Although the median serum folic acid level was lower in the first trimester (9.84 pg/ml) than in second trimester (10.8 pg/ml) and in the third trimester (13.18 pg/ml) but the difference was not statistically significant. There was no significant difference in Vitamin B12 level in HRPs (median value 134 pg/ml) as compared to low-risk pregnancies (149.5 pg/ml). Conclusion: Serum folic acid levels are significantly higher during pregnancy as compared to nonpregnant state. However, there was no significant difference in the median level of serum Vitamin B12 and serum ferritin in pregnant and nonpregnant group. Serum folic acid level and ferritin level were significantly higher in HRPs compared to low-risk pregnancies.
  851 151 -
Effect of curative parathyroidectomy on insulin resistance
Rachel Putnam, Deba Prasad Dhibar, Shweta Varshney, Arunanshu Behera, BR Mittal, Anil Bhansali, Sudhaker D Rao, Sanjay Kumar Bhadada
Nov-Dec 2016, 20(6):784-789
DOI:10.4103/2230-8210.192916  PMID:27867880
Background: Primary hyperparathyroidism (PHPT) is characterized by inappropriately elevated serum parathyroid hormone (PTH) level despite elevated serum calcium. Insulin resistant is the basic pathophysiology, behind the higher prevalence of diabetes mellitus in patients with PHPT. However, the improvement in insulin resistance (IR) after curative parathyroidectomy (CPTX) has not been established yet, as the study results are conflicting. Materials and Methods: In this prospective interventional study, ten patients with mild PHPT (Group 1) and another ten patients with moderate to severe PHPT (Group 2) were undergone CPTX. The IR was assessed by homeostasis model assessment-IR (HOMA-IR), quantitative insulin sensitivity check index (QUICKI), fasting plasma glucose (FPG), and fasting serum insulin (FSI), before and 3 months after CPTX. Results: There was no significant change of FPG and FSI, before and after CPTX in Group 1 (P = 0.179 and P = 0.104) and Group 2 (P = 0.376 and P = 0.488). Before surgery, HOMA-IR was higher, and QUICKI was significantly lower, in both Group 1 (P = 0.058 and P = 0.009) and Group 2 (P = 0.023 and P = 0.005) as compared to published normal reference mean, with no significant difference between the groups. Three months after surgery HOMA-IR increased further and QUICKI remained unchanged as compared to baseline, in both Group 1 (P = 0.072 and 0.082) and Group 2 (P = 0.54 and 0.56), but statistically insignificant. Conclusion: IR remained unchanged after CPTX in mild as well as moderate to severe PHPT. Asymptomatic PHPT with abnormal IR should not be used as criteria for parathyroidectomy.
  821 174 5
LETTERS TO THE EDITOR
Current practice in treating adult female thalassemia major patients with hypogonadism: An International Network of Clinicians for Endocrinopathies in Thalassemia and Adolescence Medicine survey from Italy
Vincenzo De Sanctis, Ashraf T Soliman, Heba Elsedfy, Salvatore Di Maio
Nov-Dec 2016, 20(6):880-881
DOI:10.4103/2230-8210.192905  PMID:27867897
  724 225 -
ERRATUM
Erratum: Study of Vitamin B12 deficiency and peripheral neuropathy in metformin-treated early Type 2 diabetes mellitus

Nov-Dec 2016, 20(6):895-895
DOI:10.4103/2230-8210.192929  PMID:27867908
  698 224 -
ORIGINAL ARTICLES
Does one-to-one demonstration with insulin pads by health-care providers improves the insulin administration techniques among diabetic patients of a Tertiary Care Teaching Hospital in South India?
Urvasi Kapoor, Gomathi Ramasamy, Kalaiselvi Selvaraj, Jaya Prakash Sahoo, Sitanshu Sekhar Kar
Nov-Dec 2016, 20(6):767-771
DOI:10.4103/2230-8210.192904  PMID:27867877
Objectives: The study was aimed to capture the effect of using injection pads as a tool in educating the diabetic patients who were on insulin. The attitude and practice of the patients in storage of insulin vials and disposal of insulin syringes were also assessed. Materials and Methods: A facility based Quasi-experimental study was carried out among the diabetic patients on insulin, attending diabetic clinic in endocrinology OPD in a tertiary care hospital, Puducherry. One to one intervention was given to the study participants or their attendants (who were involved in injecting insulin), by a trained investigator regarding all the steps of insulin administration. The insulin administration practices before and immediately after the intervention was assessed using a checklist. Results: In total 91 patients were included for the study with mean (SD) age of 53.9 (10.6) years and of them 76% were females. The attitude and practices of the study participants, such as hand washing before handling insulin, checking the expiry date, storage of insulin, inspection of injection site, rolling and cleaning the vial, withdrawal of the syringe up to the required dose, pushing the plunger after inserting the syringe into the vial, checking and removal of air bubbles, cleaning the injection site and allow to dry and injection technique improved significantly after the intervention (P < 0.05). Conclusion: This study findings shows that using injection pads for educating patients helps them to practise better insulin administration. The findings from the study can be applied in routine care and has to be explored further in diabetic patient management.
  750 167 -
LETTERS TO THE EDITOR
How prevalent are depression and anxiety symptoms in hypothyroidism?
Samir Kumar Praharaj
Nov-Dec 2016, 20(6):882-883
DOI:10.4103/2230-8210.192906  PMID:27867899
  664 188 -
Reply to “How prevalent are depression and anxiety symptoms in hypothyroidism?”
Manish Bathla, Manpreet Singh
Nov-Dec 2016, 20(6):883-884
DOI:10.4103/2230-8210.192913  PMID:27867900
  650 133 -
Incremental role of 18F-fluorocholine PET/CT over technetium-99m-labeled MIBI scan in hyperparathyroidism
Abhishek Behera, Nishikant Avinash Damle
Nov-Dec 2016, 20(6):888-890
DOI:10.4103/2230-8210.192897  PMID:27867904
  640 133 1
Synchronous parathyroid adenoma and papillary thyroid cancer detected on 99mTc-sestamibi scintigraphy
Sameer Kamalakar Taywade, Nishikant A Damle, Madhavi Tripathi, Shipra Agarwal, Sameer Aggarwal
Nov-Dec 2016, 20(6):878-879
DOI:10.4103/2230-8210.192915  PMID:27867896
  617 152 -
Hypercalcemia and electrocardiogram changes
Jayant Vishwanath Kelwade, KD Modi, Nirmal Kumar, Harsh Parekh
Nov-Dec 2016, 20(6):892-893
DOI:10.4103/2230-8210.192900  PMID:27867906
  630 134 1
BRIEF COMMUNICATIONS
Forum for Injection Technique 2.0 Addendum 1: Insulin use in indoor settings
Sanjay Kalra, Hemraj B Chandalia, Manoj Chawla, Nita Munshi, Aruna Poojary, Ami Varaiya, Prajakta Hindlekar, Mugdha Lad, Valsa Thomas, Neha Karle, AG Unnikrishnan
Nov-Dec 2016, 20(6):863-865
DOI:10.4103/2230-8210.192918  PMID:27867893
Insulin is a frequently used drug in the indoor setting. Comprehensive recommendations for best practice in insulin injection technique have been published by the forum for injection technique (FIT), India. This addendum focuses on insulin use in indoor settings, and complements the FIT 2.0 recommendations. It discusses insulin use and disposal in critical care and noncritical care settings. It also highlights the need to ensure continuing nursing and medical education, and frame insulin policies for such use.
  618 140 1
LETTERS TO THE EDITOR
Comments on: Microvascular and macrovascular complications in diabetes mellitus: Distinct or continuum?
Anubhav Chauhan, Shashi Datt Sharma
Nov-Dec 2016, 20(6):881-882
DOI:10.4103/2230-8210.192910  PMID:27867898
  505 182 -
Sheehan's syndrome in two generations
Bashir Ahmad Laway, Mahroosa Ramzan, Shahnaz Ahmad Mir
Nov-Dec 2016, 20(6):884-885
DOI:10.4103/2230-8210.192911  PMID:27867901
  495 100 -
Incretin Learning and Excellence Academy for Diabetes (iLEAD)
Sarita Bajaj, Subhankar Chowdhury, Ashok Kumar Das, Sanjay Kalra, Rakesh Kumar Sahay
Nov-Dec 2016, 20(6):887-888
DOI:10.4103/2230-8210.192902  PMID:27867903
  472 115 -
ERRATUM
Erratum: Sodium-glucose cotransporter 2 inhibitors with insulin in type 2 diabetes: Clinical perspectives

Nov-Dec 2016, 20(6):894-894
DOI:10.4103/2230-8210.192928  PMID:27867907
  464 95 -
LETTERS TO THE EDITOR
Multiple retroperitoneal paragangliomas
Ibtissem Oueslati, Karima Khiari, Néjib Ben Abdallah
Nov-Dec 2016, 20(6):890-891
DOI:10.4103/2230-8210.192896  PMID:27867905
  391 79 -
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