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   2018| May-June  | Volume 22 | Issue 3  
    Online since July 16, 2018

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Study of visceral and subcutaneous abdominal fat thickness and its correlation with cardiometabolic risk factors and hormonal parameters in polycystic ovary syndrome
Debarchan Jena, Arun Kumar Choudhury, Swayamsidha Mangaraj, Mamata Singh, Binoy Kumar Mohanty, Anoj Kumar Baliarsinha
May-June 2018, 22(3):321-327
DOI:10.4103/ijem.IJEM_646_17  PMID:30090722
Aim of the Study: This study aimed to compare the different adiposity parameters, namely visceral adipose tissue (VAT) and subcutaneous adipose tissue (SAT) between patients with polycystic ovary syndrome (PCOS) and controls. In addition, it aimed to correlate these adiposity indices with hormonal parameters as well as cardiovascular (CV) risk factors in patients with PCOS. Materials and Methods: Newly diagnosed PCOS patients of reproductive age group according to Rotterdam criteria were included. Age- and body mass index (BMI)-matched healthy females with normal menstrual cycles were taken as controls. All the study participants underwent detailed clinical, biochemical, and hormonal evaluation. Transabdominal ultrasound (US) was performed for detailed ovary imaging and assessment of adiposity (SAT and VAT) parameters. Results: A total of 58 PCOS patients and 40 age- and BMI-matched controls were included. PCOS patients had significantly higher levels of androgens (P < 0.001), elevated highly sensitive C-reactive protein (P = 0.007), and higher degree of insulin resistance (P < 0.001) than controls. PCOS patients had a mean SAT of 2.37 ± 0.7 cm and mean VAT of 8.65 ± 1.78 cm. These parameters were significantly higher than controls who had a mean SAT of 2.01 ± 0.7 cm (P = 0.014) and mean VAT of 7.4 ± 1.89 cm (P = 0.003), despite both groups having similar BMI. Among PCOS cohort, VAT correlated positively with total testosterone (r = 0.295, P = 0.025) and negatively with dehydroepiandrosterone sulfate (r = −0.210, P = 0.114). However, no significant correlation was observed between SAT and androgens in PCOS group. Conclusion: PCOS patients, whether obese or nonobese, had elevated visceral adiposity than controls. VAT correlated positively with adverse CV risk factors and testosterone in PCOS patients. Hence, a simple and inexpensive ultrasonography screening of visceral fat may identify women who have adverse metabolic profile and enhanced CV risk.
  5 2,356 208
Nonalcoholic fatty liver disease and Type 2 diabetes mellitus
Mala Dharmalingam, P Ganavi Yamasandhi
May-June 2018, 22(3):421-428
DOI:10.4103/ijem.IJEM_585_17  PMID:30090738
Type 2 diabetes mellitus (T2DM) and nonalcoholic fatty liver disease (NAFLD) commonly exist together. It has been regarded as a manifestation of the metabolic syndrome. The presentations of NAFLD range from simple steatosis (NAFL), nonalcoholic steatohepatitis (NASH), and cirrhosis. NAFLD has a prevalence of 70% among T2DM patients. Overweight/obesity and insulin resistance (IR) have been strongly linked with NAFLD. Noninvasive assessment and staging of disease are based on clinical parameters such as age, sex, liver function test, platelet count, lipid profile, BMI, and imaging modalities such as USG, transient elastography (TE), and magnetic resonance imaging mass spectroscopy. Such clinical scoring systems and TE are useful in the early detection of NAFLD and predicting fibrosis. The principle behind the management of NAFLD with T2DM involves an indirect effect through improvement in IR and glycemia and thus is used for the treatment of T2DM as well.
  5 4,337 763
Temporal change in profile of association between diabetes, obesity, and age of onset in Urban India: A brief report and review of literature
Rajiv Singla, Arpan Garg, Sweta Singla, Yashdeep Gupta
May-June 2018, 22(3):429-432
DOI:10.4103/ijem.IJEM_601_17  PMID:30090739
Context: Indian population is known to develop diabetes at lower body mass index (BMI) and younger age than their western counterparts. However, data on the prevalence of overweight/obesity in people with diabetes have not been well documented in the Indian literature. The current study also establishes time trends for the age of onset of diabetes mellitus type 2 in Urban India. Aims: The aim of this study was to analyze the current trend in the presentation of people with diabetes in a metropolitan city (Urban residents) in context to age, sex, and BMI. Settings and Design: Retrospective cross-sectional study. Subjects and Methods: Data captured in clinic electronic medical records from May 2015 to March 2017 are analyzed. The profile of newly diagnosed diabetes is also presented. Statistical Analysis Used: Data were analyzed descriptively and for statistical analysis, SPSS software was used. Results: A total of 1473 patients with age 52.6 ± 12.7 (mean ± standard deviation) and BMI of 27.86 ± 4.83 kg/m2 were analyzed. About 17.6% were overweight; 71.5% were obese. The significant higher proportion of females was overweight/obese (91.2% vs. 82% of males; P < 0.0001). Females had significantly higher mean BMI than males (29.19 ± 4.99 vs. 26.93 ± 4.83; P ≤ 0.001). Overall, mean HbA1c of patients was 7.84% ±1.61% with no significant difference between genders. However, there was no difference in mean HbA1c based on either gender or BMI category. Among people with new-onset diabetes, there was even higher proportion of people with BMI ≥23 kg/m2 (overall 89.1%, males 87.6%, and females 91.6%). About 43.8% of people presented at <40 years age. Totally, 49.5% of males presented at age <40 years as compared to 33.9% of females. Conclusions: The prevalence of obesity among people with diabetes in Indian setting is now as high as in western studies. Indians are now presenting with diabetes at even earlier age with higher BMI.
  3 2,898 117
Preoperative preparation of hyperthyroidism for thyroidectomy – Role of supersaturated iodine and lithium carbonate
Gopalakrishnan C Nair, Misha J C. Babu, Riju Menon, Pradeep Jacob
May-June 2018, 22(3):392-396
DOI:10.4103/ijem.IJEM_3_18  PMID:30090733
Introduction: Thyroidectomy is effective and safe procedure for permanent cure of hyperthyroidism (HT). Iodine preparations are widely used before operation to prevent excess blood loss. Ideal regimen for refractory HT is debated. This retrospective case–control study is designed to study the efficacy of various regimens of preoperative preparations. Materials and Methods: Case records, anesthesia charts, and follow-up details of hyperthyroid patients undergoing thyroidectomy were reviewed and compared with an age- and sex-matched euthyroid patients operated during the same period. Iodine preparations were not used for preoperative preparation. Study group was subdivided based on preoperative regimens of anti-thyroid medications. Results: Of the 168 patients in the study group, procedure time, duration of hospital stay, and overall complication rate were high compared to euthyroid group. Operative blood loss was not high in the study group. There was no difference in rate of complications in the subgroups of the study cohort. Conclusion: Iodine preparations are not mandatory in preoperative preparation of HT. Lithium carbonate is effective in preoperative preparation of refractory HT. Rate of postthyroidectomy complications is not different in patients receiving thionamides alone or in combination with β-blocker.
  3 6,489 297
Correlation of thyroid hormone profile with biochemical markers of renal function in patients with undialyzed chronic kidney disease
Swati Srivastava, Jitendra Rajput, Mayank Shrivastava, Ramesh Chandra, Mayank Gupta, Raman Sharma
May-June 2018, 22(3):316-320
DOI:10.4103/ijem.IJEM_475_17  PMID:30090721
Objective: The present study was conducted to evaluate the correlation of renal functions with thyroid hormone levels in patients with undialyzed chronic kidney disease (CKD). Literature shows significant alteration in thyroid hormone function tests in CKD patients who are receiving long-standing dialysis treatment. However, not much is described in those receiving conservative management without dialysis. Although CKD is associated with an increased prevalence of primary hypothyroidism, various studies on thyroid hormone status in uremic patients have reported conflicting results. Methodology: Thyroid hormone levels and biochemical markers of renal function were estimated in 30 undialyzed CKD patients and similar number of age- and sex-matched healthy controls, followed by statistical analysis and correlation. Results: Free triiodothyronine (FT3) and free thyroxine (FT4) were found to be significantly reduced (P < 0.001 for each) in undialyzed CKD patients whereas thyroid-stimulating hormone (TSH) levels showed statistically insignificant alteration in both groups. We also observed that urea and creatinine were negatively correlated whereas creatinine clearance was positively correlated with both FT3 and FT4 having high statistical (two tailed) significance with P < 0.001. Nonsignificant correlation was seen between blood urea and TSH (r = 0.236, P = 0.069), creatinine clearance, and TSH (r = 0.206, P = 0.114 Pearson's correlation coefficient). There is just significant positive correlation between the serum creatinine values and TSH (r = 0.248, P = 0.049). Conclusions: Thyroid hormones were significantly decreased in undialyzed CKD patients as compared to healthy controls.
  2 2,874 314
Paget's disease of bone: An entity still exists in India
Kripa Elizabeth Cherian, Nitin Kapoor, Sahana Shetty, Felix K Jebasingh, Hesarghatta Shyamasunder Asha, Julie Hephzibah, Anne Jennifer Prabhu, Simon Rajaratnam, Nihal Thomas, Thomas Vizhalil Paul
May-June 2018, 22(3):368-372
DOI:10.4103/ijem.IJEM_19_18  PMID:30090729
Background: Paget's disease of bone (PDB) is uncommonly reported from India. We attempted to study the clinical and imaging features and management of participants who presented with PDB. Materials and Methods: In this retrospective study, clinical and imaging profile, biochemistry, and treatment outcomes of participants with PDB (n = 48) were obtained. Results: The mean age was 60 ± 11.3 years and 35% were women. Twenty percent were asymptomatic. Many (87%) had polyostotic involvement. Sixty percent (n = 29) underwent treatment with zoledronic acid and rest with oral bisphosphonates, and all achieved remission. Conclusion: Most of the pagetic participants had polyostotic disease and one-fifth were asymptomatic. All participants had disease remission following treatment.
  2 2,554 179
Prevalence of pediatric metabolic syndrome and associated risk factors among school-age children of 10–16 Years living in District Shimla, Himachal Pradesh, India
Anmol Gupta, Amit Sachdeva, Narender Mahajan, Aakriti Gupta, Neha Sareen, Ravindra Mohan Pandey, Lakshmy Ramakrishnan, Hem Chandra Sati, Brij Sharma, Neetu Sharma, Umesh Kapil
May-June 2018, 22(3):373-378
DOI:10.4103/ijem.IJEM_251_17  PMID:30090730
Introduction: Recently, an increasing trend in the prevalence of pediatric metabolic syndrome (PMS) among school-age children has been documented in different parts of India. There is lack of data on the prevalence of PMS and its associated risk factors among school-age children living in district Shimla, Himachal Pradesh. Hence, to fill in the gap in the existing knowledge, the present study was conducted. Methodology: A cross-sectional study was conducted during 2015–2016. Thirty clusters (schools) were identified from a list of all schools using population proportionate to size sampling methodology. From each school, 70 children in the age group of 10–16 years were selected. Data was collected on the sociodemographic characteristics, anthropometry, waist circumference, blood pressure, and physical activity. Fasting venous blood samples were collected for estimation of blood glucose, triglycerides, and high-density lipoprotein levels. Results: The prevalence of PMS using International Diabetes Federation classification was 3.3% and using modified-adult treatment panel classification criteria was 3.5%. Risk factors identified to be associated with PMS among school-age children were (i) male gender, (ii) high family monthly income, (iii) sedentary lifestyle, (iv) consumption of evening snack, (v) television/computer viewing, and (vi) motorized transportation for commuting to school. Conclusion: The PMS prevalence was 3.3% in school-age children residing in District Shimla. There is a need to formulate interventions to prevent and correct metabolic syndrome among them for reducing early onset of cardiovascular disease during adulthood.
  2 2,571 198
Flummoxed by diamox
Karthik Balachandran, Adlyne Reena Asirvatham, Shriraam Mahadevan
May-June 2018, 22(3):433-434
DOI:10.4103/2230-8210.236799  PMID:30090740
  1 2,161 100
Pontine myelinolysis as the presenting complication of Type 2 diabetes mellitus
Kiran Kumar Ramineni, Krishna Mohan Reddy, B Saroj Kumar Prusthi, Ravi Kanth Jakkani
May-June 2018, 22(3):434-435
DOI:10.4103/ijem.IJEM_110_18  PMID:30090741
  1 2,029 96
A Comparison of clinicopathological characteristics and short-term outcome of papillary thyroid carcinoma with tall cell histology and classic papillary thyroid carcinoma: A single-institution experience
Geethalakshmi Sampathkumar, Vasantha Nair, Usha V Menon, NV Smitha, Shanmuga Sundaram, Harish Kumar, Praveen V Pavithran, Nisha Bhavani, Arun S Menon, Nithya Abraham, Annie Pullikkal
May-June 2018, 22(3):405-409
DOI:10.4103/ijem.IJEM_65_18  PMID:30090735
Context: Papillary thyroid carcinoma with tall cell histology (PTC-TCH) is an aggressive subtype in terms of clinicopathological features and outcome. Even 10% of tall cells can show aggressive features. Aims: The aim of this study is to investigate the behavior of PTC-TCH, to compare with classic PTC (cPTC), and evaluate the short-term outcome. Settings and Design: This is a retrospective analysis of patients with cPTC and those with TCH (PTC-TCH) seen from January 2010 to May 2017 seen in our Thyroid Cancer Clinic. Materials and Methods: A total of 40 patients with TCH were compared with 352 cPTC and evaluated for age, gender, tumor size, presence of multifocality, capsular, vascular invasion, extrathyroid extension, and appearance of metastases. Short-term response to therapy was assessed using the 2015 American Thyroid Association guidelines. Statistical Analysis: P < 0.05 was considered statistically significant. All analyses were performed with SPSS software (Version 21.0, Chicago, IL, USA). Results: PTC with TCH presented at a younger age, had larger tumors, and more extrathyroid extension. Seven out of 40 cases developed lung metastases, (17.5% vs. 4.5% in cPTC), within a year of diagnosis. Conclusion: PTC-TCH irrespective of percentage of tall cells showed aggressive features and early metastases. They should be recognized early as an aggressive subtype and treated intensively. Close follow-up must be instituted to look for metastases, especially to the lungs.
  1 2,085 131
The impact of uniform capsular dissection technique of total thyroidectomy on postoperative complications: An experience of more than 1000 total thyroidectomies from an endocrine surgery training centre in North India
Gyan Chand, Sudhi Agarwal, Anjali Mishra, Gaurav Agarwal, AK Verma, Saroj Kumar Mishra, Amit Agarwal, Ashok Kumar
May-June 2018, 22(3):362-367
DOI:10.4103/ijem.IJEM_598_17  PMID:30090728
Background: Total thyroidectomy (TT) with a uniform technique of capsular dissection (CD) is the preferred technique worldwide. The aim of study is to analyze the impact of uniform technique of CD for done as primary surgery at an endocrine surgery training centre. Patients and Methods: Retrospective review from 1995 to 2009. Data collected from hospital records and follow-up . Results: One thousand and thirty-eight cases were included, with mean age 42.91 ± 13.48 years; male:female – 1:2.2; mean duration of goiter – 99.83 ± 105.1 months; 67.8% were euthyroid and 30.7% – hyperthyroid at initial presentation; 35.5% were malignant. Surgery includes TT alone – 77.7% and TT with lymph nodes dissection – 22.3%; sternotomy required in 1.2% and thoracotomy in 0.1%; tracheomalacia present in 3.9%; however, tracheostomy required in 4.5% and parathyroid autotransplantation in 21%; Peroperative mean gross gland weight was 124.34 ± 129.85 g. Complications include hypocalcemia (temporary – 35.9%; permanent – 1.3%); recurrent laryngeal nerve palsy (temporary – 2.7%; permanent – 91%); hemorrhage – 1.3%; and various others. Conclusion: TT with uniform technique of CD is a safe procedure. Certain risk factors may predispose to complications, which can be avoided and managed adequately if anticipated beforehand.
  1 2,351 116
The changing face of primary hyperparathyroidism
Girish Parmar, Manoj Chadha
May-June 2018, 22(3):299-300
DOI:10.4103/2230-8210.236781  PMID:30090717
  - 2,119 184
Lean metabolic syndrome: An emerging concept
Debmalya Sanyal
May-June 2018, 22(3):301-302
DOI:10.4103/2230-8210.236782  PMID:30090718
  - 2,120 201
Unmasking of neuropsychiatric manifestations after total thyroidectomy for graves' disease
Roma Pradhan, Shobha Pakhriya, Manish Gutch, Sushil K Gupta, Amit Agarwal
May-June 2018, 22(3):436-437
DOI:10.4103/2230-8210.236777  PMID:30090742
  - 1,781 92
Menses without uterus
Karthik Balachandran, Adlyne Reena Asirvatham, Sathishkumar Balasubramanian, Shriraam Mahadevan
May-June 2018, 22(3):437-438
DOI:10.4103/ijem.IJEM_614_17  PMID:30090743
  - 2,466 124
Intraoperative parathyroid hormone monitoring in guiding adequate parathyroidectomy
Aabid Hassan Naik, Munir Ahmad Wani, Khursheed Alam Wani, Bashir Ahmad Laway, Ajaz Ahmad Malik, Zafar Amin Shah
May-June 2018, 22(3):410-416
DOI:10.4103/ijem.IJEM_678_17  PMID:30090736
Background: Parathyroidectomy has been traditionally performed through bilateral neck exploration (BNE). However, with the use of intraoperative parathyroid hormone (IOPTH) assay along with preoperative localization studies, focused parathyroidectomy can be performed with good surgical success rate, multiglandular disease can be predicted, and hence recurrence and surgical failure can be prevented. Furthermore, it predicts eucalcemia in the postoperative period. The aim of this study was to evaluate the usefulness of IOPTH assay in guiding adequate parathyroidectomy in patients of primary hyperparathyroidism. Materials and Methods: Between year 2015 and 2017, 45 patients of primary hyperparathyroidism underwent parathyroidectomy with IOPTH assay employed as an intraoperative tool to guide the surgical procedure. Blood samples were collected: (1) at preincision time, (2) preexcision of gland, (3) 5-min postexcision of gland, and (4) 10-min postexcision of gland. On the basis of the Irvin criterion, an intraoperative PTH drop >50% from the highest either preincision or preexcision level after parathyroid excision was considered a surgical success. Otherwise, BNE was performed and search for other parathyroid glands done. Results: Ten-min postexcision PTH levels dropped >50% in 34 (75.6%) patients. True positive among them were 31 (68.8%), true negative 8 (17.7%), false positive 3 (6.6%), and false negative 3 (6.6%). We performed focused exploration at the outset in 40 (88.9%) patients and bilateral exploration for five patients as guided by preoperative localizing studies. Hence, IOPTH was helpful in guiding further exploration in 8 (17.7%) patients and prevented further exploration in 32 (71.1%) patients and also was able to predict eucalcemia in 97.7% patients at 6 months. Thus, IOPTH was able to obviate or to ask for additional procedure in 88.8% of patients. However, in three (6.6%) patients, IOPTH would guide unnecessary exploration and in equally, that is, three (6.6%) patients may require reoperation for unidentified parathyroids. Conclusion: IOPTH in adjunct with other localizing studies is very helpful for carrying out successful parathyroidectomy in uniglandular disease and predicting postoperative eucalcemia. However, more importantly, its role is valuable in equivocal imaging, in such cases, it prevents unnecessary exploration or helps in adequate parathyroidectomy.
  - 2,774 172
Incidence of congenital hypothyroidism in Western Rajasthan using cord blood thyroid-stimulating hormone levels as a screening tool: A cross-sectional hospital-based study
Monika Chaudhary, Jai Prakash Soni, Vishnu Kumar Goyal, Pramod Sharma, Mohan Makwana, Sawai Singh Lora
May-June 2018, 22(3):417-420
DOI:10.4103/ijem.IJEM_354_16  PMID:30090737
Background: Congenital hypothyroidism (CH) is considered the most common preventable cause of intellectual impairment, with a worldwide annual incidence of 1:4000 live births. In the absence of screening program actual incidence in India is not exactly known, but in previous studies it varies from 1:500 to 1:3400. We wished to find out the incidence of CH in Western Rajasthan using cord blood TSH as a screening tool and venous TSH within 14 days of life as a confirmatory test. Methods: This cross sectional descriptive study was conducted over a period of six months in teaching hospitals attached to Medical College. Cord blood TSH value of 20 mIU/L or >20 mIU/L was taken as cut off for screening and all screen positive neonates were re-tested for serum TSH by taking venous samples within 14 days of life. Repeat TSH levels of 20mIU/L or more tested by Enzyme Linked Fluorescent Assay were considered confirmatory. Results: Total 9558 cord blood samples were analyzed for TSH levels, out of which 533 came out to be screen positive (recall rate 5.57%). Out of these 58 could not be confirmed, so were excluded from the further analysis. Effective sample size and screen positive cases dropped to 9500 and 475 respectively, and out of these 13 were confirmed as CH (incidence - 1.37 per thousand live births). Conclusions: Considering the previous studies, incidence of CH is much higher in Western Rajasthan than the anticipated. Overall in India CH seems to be more prevalent than the other parts of the world, necessitating the need of national screening program.
  - 2,090 114
Lean metabolic syndrome: A concept or a reality?
Pradip Mukhopadhyay, Sujoy Ghosh, Kingshuk Bhattacharjee, Kaushik Pandit, Partha Sarathi Mukherjee, Subhankar Chowdhury
May-June 2018, 22(3):303-307
DOI:10.4103/ijem.IJEM_639_17  PMID:30090719
Aims and Objectives: Metabolic syndrome (MetS) is fairly common in India. International Diabetes Federation (IDF) has defined it as the presence of central obesity with region/ethnicity-specific waist circumference as a mandatory defining criterion along with the presence of two other features from dysglycemia, systolic and/or diastolic hypertension, hypertriglyceridemia, and low high-density lipoprotein. Although obesity is not prevalent in rural parts of India, especially among the underprivileged population, other individual components of the syndrome are not infrequent among these lean/nonobese persons. In this study, we evaluated the prevalence of MetS in rural West Bengal. We also examined that if those persons above the recommended cutoff for waist are excluded, and thus only lean/nonobese persons are included, and the same definition of MetS (herein termed as lean MetS) is applied (three out of four criteria), what will be the prevalence of MetS and will it be lower in the nontribal population compared to the tribal population? Materials and Methods: A population-based study was done in the rural area of West Bengal comprising 200 peoples from scheduled tribe (ST) population and 205 people from the neighborhood community from non-ST population to compare the metabolic health with respect to anthropologic and biochemical parameters. Results: The prevalence of MetS from rural areas of West Bengal was found to be 21.48% as per IDF criterion, but applying NCEP ATP III criteria, the overall prevalence of MetS rose to 31.1%. The prevalence of normal waist/lean MetS was 12.8%, and there was no significant difference between nontribals versus tribal cohort (14.6% of the nontribes versus 11.6% of the tribal cohort, P = 0.436). Conclusion: A significant number of persons with nonobese/lean MetS exist in the rural area. We suggest that if region-specific waist criteria are not satisfied, the diagnosis should still be sorted by NCEP ATP III criteria.
  - 2,351 253
Neuroendocrine neoplasms in rare locations: Clinicopathological features and review of the literature
Cristina Díaz del Arco, Javier Sastre, Paloma Peinado, Ángel Díaz, Luis Ortega Medina, Ma Jesús Fernández Aceñero
May-June 2018, 22(3):308-315
DOI:10.4103/ijem.IJEM_446_17  PMID:30090720
Introduction: Neuroendocrine tumors (NETs) occur more often in lungs, gastrointestinal tract, or pancreas. Data about terminology and grading of NETs in rare locations are scarce and variable, and they have been reported mainly as case reports. Materials and Methods: We here describe our experience with NETs in unusual locations. We have reviewed all NETs diagnosed in our institution and summarized their clinicopathological features. We have also reviewed the literature and discussed the main characteristics of NETs in each site. Results: Two hundred and forty-three primary NETs were diagnosed. About 55.2% of patients were men and the mean age was 62 years. About 90.7% of NETs were located in lungs, gastrointestinal tract, or pancreas, and 50.8% of them were low-grade tumors. We identified 13 NETs in rare locations: breast, ovary, endometrium, vulva, uterine cervix, extrahepatic biliary tract, kidney, sinonasal tract, and thymus. Three additional tumors were diagnosed by the senior author in other institution. Patients were asymptomatic or presented with nonspecific symptoms. All NETs were treated with surgery and 31% of patients received adjuvant therapy. There were 10 Grade 3 (62.5%), 2 Grade 2 (12.5%), and 4 Grade 1 (25%) tumors. Mean follow-up was 72 months. About 60% of G3 tumors recurred or progressed. G2 tumors were located in breast, and both patients are stable. About 50% of G1 tumors recurred or progressed (both renal NETs). Conclusions: NETs in rare locations are heterogeneous, and their behavior does not seem to correlate absolutely with tumor grade. More studies are needed to clarify the role of proliferation rate in these tumors.
  - 2,498 257
Sex hormone profile in human immunodeficiency virus-infected men and it's correlation with CD4 cell counts
Jyoti Aggarwal, Rajesh Satyapal Taneja, Pulin Kumar Gupta, Mohsin Wali, Anubhuti Chitkara, Afroz Jamal
May-June 2018, 22(3):328-334
DOI:10.4103/ijem.IJEM_694_17  PMID:30090723
Background: In human immunodeficiency virus (HIV)-infected men, hypogonadism is the most common endocrinological disorder, and most cases of hypogonadism are secondary. The aim of this study was to find out the hormonal abnormalities in HIV-infected males and it's correlation with CD4 cell counts. Materials and Methods: One hundred HIV-infected male patients were evaluated in the Department of Medicine, Postgraduate Institute of Medical Education and Research and Dr. Ram Manohar Lohia Hospital, New Delhi, India, over a period of 12 months from September 2014 to August 2015 using history, physical examination, routine baseline investigations, and CD4 counts. Free testosterone, dehydroepiandrosterone sulfate (DHEAS), luteinizing hormone (LH), follicle-stimulating hormone (FSH), and prolactin were measured using an overnight fasting sample. Patients were divided into three groups on the basis of CD4 counts (Group A: CD4 counts ≥350/mm3, Group B: CD4 counts between 200 and 349/mm3, and Group C: CD4 counts <200/mm3). Data were analyzed using Student's t-test, ANOVA test, Chi-square test, and Pearson's test and P ≤ 0.05 was considered statistically significant. Results: In 100 HIV-infected males, overall prevalence of hypogonadism was found to be 66%, and 30%–35% patients had symptoms of hypoandrogenemia. Hypogonadotropic hypogonadism was found in 42% of patients. A significant association (P = 0.027) was found between prevalence of hypogonadism and the level of immunodeficiency with an increase in the prevalence of hypogonadism as CD4 counts decreased. Lower levels of free testosterone and DHEAS were found in cases of severe immunosuppression with a statistically significant correlation with CD4 counts. Correlation of other sex hormones (LH, FSH, and prolactin) with CD4 counts not statistically significant. Mean free testosterone and FSH were found to be significantly higher in patients on antiretroviral therapy (ART) than in those not on ART (P = 0.028 and P = 0.045, respectively), but no specific ART drug or their drug combination was found to have a significant correlation with levels of any sex hormone. Conclusion: Hypogonadism (hypogonadotropic hypogonadism) was found to be a common endocrinological disorder in HIV-infected male population, seen more commonly in association with low CD4 counts.
  - 2,391 137
Impairment of health-related quality of life among Indian patients with hypothyroidism
C Shivaprasad, Boppana Rakesh, Kolly Anish, Pullikal Annie, Goel Amit, CS Dwarakanath
May-June 2018, 22(3):335-338
DOI:10.4103/ijem.IJEM_702_17  PMID:30090724
Context: Health-related quality of life (HRQL) is an important outcome measure for various diseases, although there are sparse data regarding HRQL among Indian patients with hypothyroidism. Aims: This study aimed to assess HRQL among Indian patients with hypothyroidism using the SF-36 questionnaire. Methods: This cross-sectional study evaluated 244 consecutive patients with hypothyroidism who were treated at the Vydehi Institute of Medical Sciences and Research Centre in Bengaluru. All patients were >18 years old and visited the outpatient department for endocrine treatment. Perceived health status was evaluated using the SF-36 questionnaire. The patients' data were compared to data from 250 age-matched and sex-matched healthy controls. Results: Compared to the healthy controls, the patients with hypothyroidism had significantly lower scores for six of the eight SF-36 scales. No significant intergroup differences were observed in the “role emotional” and “social functioning” dimensions. Interpretation and Conclusions: Hypothyroidism was associated with reduced HRQL among Indian patients. These patients generally experienced greater reductions in physical dimensions, compared to social and emotional dimensions.
  - 2,866 164
Molecular profiling of follicular variant of papillary thyroid cancer reveals low-risk noninvasive follicular thyroid neoplasm with papillary-like nuclear features: A paradigm shift to reduce aggressive treatment of indolent tumors
Nelson George, Amit Agarwal, Niraj Kumari, Sarita Agarwal, Narendra Krisnani, Sushil Kumar Gupta
May-June 2018, 22(3):339-346
DOI:10.4103/ijem.IJEM_86_18  PMID:30090725
Introduction: Encapsulated follicular variant of papillary thyroid carcinoma (EFVPTC) has been reclassified into noninvasive follicular thyroid neoplasm with papillary-like nuclear features (NIFTP) and invasive EFVPTC. NIFTP is considered a low-risk neoplasm. Therefore, follicular variant of papillary thyroid cancer (FVPTC) presently has two distinct histopathological subtypes – invasive EFVPTC and infiltrative/diffuse FVPTC. Molecular characteristics of these groups remain unclear. Methodology: Thirty FVPTCs (10 NIFTPs, 12 invasive EFVPTCs, and 8 infiltrative/diffuse variants) were reviewed and screened for BRAF and RAS mutations by restriction fragment length morphism-polymerase chain reaction (PCR) and Sanger sequencing. The mRNA expression levels of iodine-metabolizing genes were analyzed using real-time PCR. The mutations status and mRNA expression levels were correlated with clinicopathological features. Results: All 10 NIFTPs had predominant follicular pattern. One case showed NRAS mutation, whereas none showed BRAF mutation. All invasive EFVPTC had capsular and/or lymphovascular invasion and 4/12 showed lymph node metastasis. BRAF and NRAS were seen in three cases each of invasive FVPTC. All eight infiltrating/diffuse FVPTCs showed infiltration into adjacent thyroid parenchyma and lymph node metastasis. Conclusion: BRAF mutation was observed in 62.5% of cases; however, no NRAS mutation was found. Sodium iodide symporter (NIS) expressions in NIFTP were similar to that of normal thyroid tissue, whereas it was downregulated in invasive and infiltrative/diffuse FVPTC. Our study supports the argument that NIFTP can be considered as low-risk follicular thyroid neoplasm. Those tumors that harbor BRAF mutations may be offered a complete thyroidectomy because they show decreased expression of NIS gene which confers a tendency to lose radioactive iodine avidity and further recurrence of the tumor.
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Neck circumference to height ratio is a reliable predictor of liver stiffness and nonalcoholic fatty liver disease in prediabetes
Samim Ali Mondal, Deep Dutta, Manoj Kumar, Pankaj Singh, Madhurima Basu, Chitra Selvan, Satinath Mukhopadhyay
May-June 2018, 22(3):347-354
DOI:10.4103/ijem.IJEM_31_18  PMID:30090726
Background and Objectives: Nonalcoholic fatty liver disease (NAFLD) and dysglycemia are public health challenges. There is urgent need for anthropometric surrogates for NAFLD screening. This study evaluated role of neck circumference (NC) and neck-height ratio (NHtR) as predictors of liver stiffness measure (LSM) in individuals with prediabetes (IPD). Methods: In a cross-sectional study, 188 IPD from 1130 screened individuals underwent anthropometry, ultrasonography, Fibroscan® for LSM, dyslipidemia, insulin resistance (IR), and fetuin-A assessment. Results: Hypertension, hypertriglyceridemia, low high-density lipoprotein cholesterol (HDL-C), metabolic syndrome (MetS), NAFLD, and significant liver stiffness (SLS) (LSM >8.5kPa) were observed in 53.7%, 31.4%, 71.3%, 73.9%, 24.5%, and 11.2% prediabetes individuals, respectively. Prediabetes with NAFLD had significantly higher body mass index (BMI), NC, NHtR, glycated hemoglobin, triglycerides, fatty liver index (FLI), and LSM. Prediabetes in highest NHtR quartile had significantly higher BMI, hypertension, MetS, fasting glucose, glycated hemoglobin, homeostatic model assessment-IR, NAFLD, LSM, SLS, and lower HDL-C. Stepwise forward linear regression revealed that NHtR, FLI, and LDL-C were best predictors of LSM, at baseline (Model-1), after adjusting for age and sex (Model-2), and adjusting model-2 plus systolic and diastolic blood pressure (Model-3). NHtR and NC (in females) and NHtR and BMI (in males) had largest area under the curves for predicting LSM, NAFLD, and MetS. NHtR ≥21.54 cm/m (sensitivity: 90%; specificity: 52.5%; females) and ≥21.62 cm/m (sensitivity: 80%; specificity: 49.4%; males) was best predictor of SLS. Interpretation and Conclusion: NHtR is a reliable tool for community screening of NAFLD and liver stiffness in prediabetes.
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Five-year retrospective study on primary hyperparathyroidism in South India: Emerging roles of minimally invasive parathyroidectomy and preoperative localization with methionine positron emission tomography-computed tomography scan
VJ Mallikarjuna, Vivek Mathew, Vageesh Ayyar, Ganapathy Bantwal, V Ganesh, Belinda George, GN Hemanth, P Vinotha
May-June 2018, 22(3):355-361
DOI:10.4103/ijem.IJEM_445_16  PMID:30090727
Background: Primary hyperparathyroidism (PHPT) is a common endocrine disease with a variable clinical presentation. PHPT is usually symptomatic at presentation in majority of the patients, especially in developing countries. As the accessibility to investigations, advanced imaging methods and surgical procedures are improving, the clinical profile of the patients with PHPT has undergone a palpable change compared to the earlier description. Hence we decided to look for a change in clinical, imaging and surgical outcomes of PHPT patients from South India. Methods: We collected the data on clinical presentation, biochemistry, radiological features and operative findings of patients with PHPT treated in our hospital from 2011-2015. Cases of PHPT were identified from the laboratory values using the biochemical criteria, after the exclusion of secondary and tertiary hyperparathyroidism cases. Results: Our study identified 54 patients (19 males and 35 females) with age ranging from 16 to 71 years. A Significant proportion(38.9%) of the patients were asymptomatic. Musculoskeletal symptoms (40.7%), renal manifestations (27.7%) and gastrointestinal system involvement (27.7%) constituted the other common modes of presentation. CNS involvement was seen in 3 patients. A palpable nodule in the neck was detected in 4 patients. Interestingly 4 patients were managed for parathyroid crisis at presentation. Biochemical features included hypercalcaemia (100%) and hypophosphatemia (59%) with a mean intact PTH level of 602.0±721.3 pg/ml. Sensitivity of Ultrasonography and Tc99M Sestamibi was 72% and 70.6% respectively for detecting a parathyroid adenoma. Sensitivity of C11 methionine PET-CT was 71.4% in those patients who were negative for other imaging modalities. Forty three patients (79.6%) underwent minimally invasive parathyroidectomy. Conclusion: In South India we have a notable change in the clinical presentation of PHPT from a symptomatic to an asymptomatic state. C11 Methionine PET - CT is an emerging modality for preoperative localisation especially when other imaging modalities are negative and when a minimally invasive parathyroidectomy is desired.
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Etiological search and epidemiological profile in patients presenting with hypokalemic paresis: An observational study
Shinjan Patra, Partha Pratim Chakraborty, Sugata Narayan Biswas, Himanshu Barman
May-June 2018, 22(3):397-404
DOI:10.4103/ijem.IJEM_633_17  PMID:30090734
Introduction: Hypokalemia is associated with increased morbidity and at times mortality. “Hypokalemic paralysis”, particularly if recurrent, has often been considered synonymous with “hypokalemic periodic paralysis (HPP)”; however, diseases such as Gitelman syndrome (GS), Bartter syndrome (BS), and renal tubular acidosis (RTA) can have identical presentation. We have tried to explore the etiological spectrum along with epidemiological and certain clinical, biochemical, and electrophysiological features in patients with hypokalemic paralysis. Materials and Methods: In this observational study, 200 appropriate patients with hypokalemic paralysis (serum K+ <3.5 mmol/L) were evaluated for transcellular shift, extra-renal or renal loss of K+ as the underlying etiology of hypokalemia. We took urinary potassium >25 mmol/day as the cutoff for inappropriate renal loss of potassium in presence of hypokalemia. Serum and urinary osmolality along with arterial blood gas analysis were performed in all patients with renal loss of potassium. Serum and urinary sodium, potassium, calcium, magnesium, chloride, and creatinine were measured in normotensive patients with metabolic alkalosis. Hypertensive patients were evaluated with plasma aldosterone and renin activity. Results: Probable GS topped the list involving 28% individuals of the entire cohort while probable BS, distal RTA, and HPP were diagnosed in 20%, 22%, and 19% cases, respectively. Rural tribal population (61%) and age group of 30–40 years suffered the most (48%) with concentration of cases in hot and humid summer months. Conclusions: We suggest that patients with hypokalemic paresis should be evaluated thoroughly to unmask the underlying etiology that may have a different therapeutic and prognostic connotations and not to use the term “periodic” in cases of recurrent hypokalemic paralysis.
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The incidence of hypoglycemia among insulin-treated patients with Type 1 or Type 2 diabetes: Bangladeshi cohort of international operations-hypoglycemia assessment tool study
Md. Faruque Pathan, M Fariduddin, Khwaja Nazimuddin, Abdus Saleque Mollah, Md. Nazrul Islam Siddiqui, Kazi Ali Hassan, HS Ferdous, Muhammad Hafizur Rahman, SM Ashrafuzzaman, Md. Javed Sobhan, Md. Reza E-Tanvir Haider, Mohammod Feroz Amin
May-June 2018, 22(3):379-386
DOI:10.4103/ijem.IJEM_545_17  PMID:30090731
Objectives: The objective of this study was to assess the incidence of hypoglycemia in patients with type 1 diabetes mellitus (T1DM) or type 2 diabetes mellitus (T2DM) in Bangladeshi cohort of the International Operations-Hypoglycemia Assessment Tool study. Materials and Methods: Patients diagnosed with either T1DM or T2DM, aged ≥18 years, treated with insulin (any regimen) for >12 months, and completed self-assessment questionnaires (SAQs) to record demography, treatment information, and hypoglycemia during the 6-month retrospective and 4-week prospective periods (a total of 7 months) were enrolled in the study. Results: A total of 1179 patients were enrolled and completed the SAQ1 (T1DM, n = 25; T2DM, n = 1154). Almost all patients (T1DM: 100.0% [95% confidence interval (CI): 86.3%, 100.0%] and T2DM: 97.0% [95% CI: 95.9%, 97.9%]) experienced at least 1 hypoglycemic event prospectively. The estimated rates of any and severe hypoglycemia were 26.6 (95% CI: 19.8, 35.0) and 14.1 (95% CI: 9.3, 20.4) events per patient-per year (PPY), respectively, for patients with T1DM and 18.3 (95% CI: 17.4, 19.2) and 12.1 (95% CI: 11.4, 12.9) events PPY, respectively, for patients with T2DM during the prospective period. At baseline, mean glycated hemoglobin (HbA1c) (±standard deviation) was 8.1 (±1.8%) for T1DM and 8.8 (±1.8%) for T2DM. Hypoglycemic rate was independent of HbA1c levels and types of insulin. Conclusions: This is the first patient dataset of self-reported hypoglycemia in Bangladesh; results confirm that hypoglycemia is underreported.
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Prognostic value of thyroid profile in critical care condition
Manish Gutch, Sukriti Kumar, Keshav Kumar Gupta
May-June 2018, 22(3):387-391
DOI:10.4103/ijem.IJEM_20_18  PMID:30090732
Background: Patients suffering from critical illness admitted to the Intensive Care Unit (ICU) exhibit alterations in their thyroid hormone levels, collectively termed as euthyroid sick syndrome or nonthyroidal illness syndrome. Our study was conducted to determine the correlation between these changes in thyroid hormone levels and the prognosis of ICU-admitted patients. Methods: A total of 270 ICU-admitted patients without previous history of thyroid disorder were included in the study. We recorded their baseline characteristics, acute physiology and chronic health evaluation (APACHE-II) score, thyroid hormone levels, lactate, and other parameters on admission. ICU mortality was the primary outcome. We analyzed the ability of each parameter to predict mortality in the participants. Further, we also evaluated whether the combination of thyroid hormone levels with APACHE-II score could improve the mortality prediction. Results: The mean age of the study population was 38.99 ± 18.32 years. A total of 81 patients (30%) expired during their ICU treatment. Both fT3 and fT4 levels were lower in nonsurvivors compared to survivors. Among the thyroid hormones, fT3 had the highest predictive value for ICU mortality, as seen by the largest area under the curve (AUC) value (0.990 ± 0.007) which was even greater than AUC of APACHE-II score (0.824 ± 0.051) and fT4 (0.917 ± 0.049). Univariate logistic regression analysis showed that fT3 (β = 140.560) had the highest predictive potential for ICU mortality compared with APACHE-II score (β = 0.776), fT4 (β = 17.62) and other parameters. Multivariate logistic regression analysis revealed that the combination of fT3 and APACHE-II (R2 = 0.652) was superior in predicting mortality than APACHE-II alone (R2 = 0.286). Conclusion: We observed that fT3 was the strongest predictor of ICU mortality compared to all other parameters included in our study. Further, the combination of fT3 levels and APACHE-II scores provided for a higher probability for predicting mortality in ICU patients.
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