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   2018| July-August  | Volume 22 | Issue 4  
    Online since July 31, 2018

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Coping with illness: Insight from the Bhagavad Gita
Bharti Kalra, Ameya Joshi, Sanjay Kalra, Vivekanand G Shanbhag, Jyoti Kunwar, Yatan Pal Singh Balhara, Sandeep Chaudhary, Deepak Khandelwal, Sameer Aggarwal, Gagan Priya, Komal Verma, Manash P Baruah, Rakesh Sahay, Sarita Bajaj, Navneet Agrawal, Sivatharshiya Pathmanathan, Inderjit Prasad, Ashim Chakraborty, Nanik Ram
July-August 2018, 22(4):560-564
DOI:10.4103/ijem.IJEM_228_17  PMID:30148107
The Shrimad Bhagavad Gita enlightens everyone on how to cope up with various situations in life. It uses the conversation between Lord Krishna and Arjuna to highlight initial negative coping mechanisms exhibited by the latter. It goes on to showcase positive coping skills suggested by Lord Krishna and implemented by Arjuna. The Bhagavad Gita, through this “case-based methodology,” teaches us how to cope with a demanding situation. Diabetes is a lifestyle disease, which warrants a thorough change in one's lifestyle, including changes in basic activities such as diet and exercise. This brief communication utilizes the teachings of Bhagavad Gita to help in coping with illness, especially chronic illness such as diabetes. The article cites verses from the Bhagavad Gita to show how one may cope with the stress of illness such as diabetes.
  6,418 632 -
Hepatogenous diabetes: An underestimated problem of liver cirrhosis
Ramesh Kumar
July-August 2018, 22(4):552-559
DOI:10.4103/ijem.IJEM_79_18  PMID:30148106
The prevalence of diabetes mellitus in cirrhotic patients is much higher than that in the general population. Two types of diabetes are usually seen in patients with cirrhosis: type 2 diabetes mellitus and hepatogenous diabetes (HD). The HD is an acquired condition which is believed to be caused by impaired insulin clearance and pancreatic β-cell dysfunction in cirrhotic patients. Increased levels of advanced glycation end products and hypoxia-inducible factors have been implicated in the pathogenesis of HD. Patients with HD typically present with normal fasting glucose, but abnormal response to an oral glucose tolerance test, which is required for the diagnosis. Because the level of glycated hemoglobin is often falsely low in patients with cirrhosis, it does not help in the early diagnosis of HD. HD is associated with an increased rate of complications of cirrhosis, decreased 5-year survival rate, and increased risk of hepatocellular carcinoma. The major complications of cirrhosis associated with HD include hepatic encephalopathy (HE), spontaneous bacterial peritonitis, sepsis, variceal hemorrhage, and renal dysfunction. Treatment of HD may be difficult as many antihyperglycemic therapies are associated with increased risk of complications in cirrhosis, particularly hypoglycemia. Biguanides, alpha-glucosidase inhibitors, and new medications such as dipeptidyl peptidase-4 inhibitors and sodium-glucose co-transporter 2 inhibitors appear to be safe in patients with cirrhosis. Though insulin therapy is currently advocated, requirement of insulin is variable and is difficult to predict. The liver transplantation usually results in reversal of HD. This review article provides an overview of magnitude, patients' characteristics, clinical implications, pathophysiological mechanisms, diagnosis, and management of HD.
  4,622 775 3
Tanner's target height formula underestimates final height in Asian Indians – A cross-sectional observational study
Sridevi Atluri, Kavya Bharathidasan, Vijaya Sarathi
July-August 2018, 22(4):441-444
DOI:10.4103/ijem.IJEM_92_18  PMID:30148085
Introduction: Target height (TH) calculation by Tanner's formula has been shown to be inaccurate in many countries However, there is no published data on the accuracy of TH calculation by Tanner's formula in Indians. Hence, this study was conducted to assess whether Tanner's TH formula is an accurate tool to predict final height in Asian Indian population and to identify new TH formulae or models to better fit Indian population. Material and Methods: This is a cross-sectional, questionnaire-based study conducted in a tertiary care hospital from South India. A total of 396 questionnaires were randomly distributed to undergraduate medical students who were instructed beforehand to get their heights and heights of their parents and siblings between the age of 18 to 24 years of age measured by a nearby pediatrician. From 396 questionnaires, data of 481 young adults and their parents were obtained. Target height was calculated by Tanner's formula and compared with attained height. Results: The study comprised of 197 males and 284 females. Sons and daughters were 2.34 ± 7.19 cm and 1.58 ± 5.68 cm taller than TH. Son's height had best correlation with TH (r = 0.408), whereas daughter's height had best correlation with maternal height (r = 0.560). Both males (0.263 vs 0.365) and females (0.319 vs 0.560) had relatively weaker correlation with paternal heights than maternal heights. Target height explained 29.7% and 16.7% of variance in daughter's and son's height, respectively. Using the parental heights as variables, multiple regression yielded 50.03 + 0.172 (father's height) +0.510 (mother's height) and 74.09 + 0.236 (father's height) +0.377 (mother's height) as the best models to predict daughter's and son's height, respectively. Conclusion: Our study suggests that Tanner's TH formula underestimates final attainable height in Asian Indians.
  3,559 300 -
Etiological profile of galactorrhoea
Sridevi Atluri, Vijaya Sarathi, Amit Goel, Rakesh Boppana, C Shivaprasad
July-August 2018, 22(4):489-493
DOI:10.4103/ijem.IJEM_89_18  PMID:30148095
Background: Recent increase in the non-specific use of prokinetics in clinical practice may alter the etiological profile of hyperprolactinemia and galactorrhea. Hence, we have studied the etiological profile of patients presenting with galactorrhea and characteristics of drug-induced galactorrhea. Materials and Methods: This retrospective study was conducted at a tertiary health care center from South India. Patients who presented with or referred for galactorrhea and/or hyperprolactinemia to the Department of Endocrinology between January 2017 and December 2017 were included in the study. Results: Forty women presented with or referred for galactorrhea to the Department of Endocrinology during the study period. Thirty-two patients had received drugs that are associated with hyperprolactinemia (levosulpiride in 15, domperidone in 13, ranitidine in 2, oral contraceptive pill in 1, and amisulpiride in 1) of whom etiology was proved in 27 patients, whereas in four patients the cause was inconclusive due to lack of follow-up. The patient on amisulpiride was found to have concomitant pituitary microadenoma. Idiopathic galactorrhea (n = 2), idiopathic hyperprolactinemia (n = 2), and prolactinoma (n = 4) accounted for the remaining cases. Six patients with prokinetic-induced galactorrhea had received cabergoline inspite of which hyperprolactinemia and/or galactorrhea persisted and six patients had also undergone pituitary magnetic resonance imaging (MRI) for evaluation of galactorrhea. Conclusions: Prokinetic use is the most common cause of galactorrhea in our study and often was investigated with costly tests and treated with D2 agonists unnecessarily. Hence, there is a need to ensure measures to reduce the non-specific use of prokinetics and increase awareness regarding the occurrence of galactorrhea with prokinetics use, to reduce unnecessary investigations and treatment.
  2,083 255 1
The twin white herrings: Salt and sugar
Lovely Gupta, Deepak Khandelwal, Deep Dutta, Sanjay Kalra, Priti R Lal, Yashdeep Gupta
July-August 2018, 22(4):542-551
DOI:10.4103/ijem.IJEM_117_18  PMID:30148105
India has the dubious distinction of being a hotspot for both diabetes and hypertension. Increased salt and sugar consumption is believed to fuel these two epidemics. This review is an in-depth analysis of current medical literature on salt and sugar being the two white troublemakers of modern society. The PubMed, Medline, and Embase search for articles published in January 2018, using the terms “salt” [MeSH Terms] OR “sodium chloride” [All Fields] OR “sugar” [All Fields]. India is world's highest consumer of sugar with one of the highest salt consumption per day. Increased salt intake is associated with increased risk of hypertension, left ventricular hypertrophy and fi brosis, cardiovascular events, renal stones, proteinuria, and renal failure. Increased sugar intake is directly linked to increased risk of obesity, fatty liver disease, and metabolic syndrome. Also, increased sugar intake may be indirectly related to the increased risk of type 2 diabetes. Both salt and sugar intake is directly linked to increased systemic and hypothalamic infl ammation, endothelial dysfunction, microangiopathy, cardiovascular remodelling, cancers, and death. High fructose corn is especially damaging. There is no safe limit of sugar consumption, as the human body can produce its own glucose. Being nature's gift to mankind, there is no harm in moderate consumption of salt and sugar, however, modest reduction in the consumption of both can substantially reduce the burden of non-communicable diseases. Public health interventions to facilitate this behavioural change must be instituted and encouraged.
  1,873 242 1
Fluorocholine PET imaging of parathyroid disease
Meghana Prabhu, Nishikant A Damle
July-August 2018, 22(4):535-541
DOI:10.4103/ijem.IJEM_707_17  PMID:30148104
To give an overview of the potential clinical utility of 18F-fluorocholine PET/CT (FCH PET/CT) in imaging of parathyroid adenoma. Available studies have provided preliminary results of 18F-FCH PET/CT in primary and secondary hyperparathyroidism. Results of various studies have shown that 18F-FCH is a promising upcoming tracer for the detection of parathyroid adenomas, especially when multiple, or having low size. FCH PET/CT has the potential to be a standard investigation in the detection of parathyroid lesions.
  1,346 257 3
Efficacy and safety of biosimilar growth hormone in Indian children
Vaman Khadilkar, Veena Ekbote, Anuradha Khadilkar, Ankita Maheshwari
July-August 2018, 22(4):525-529
DOI:10.4103/ijem.IJEM_118_18  PMID:30148102
Objective: To study efficacy and safety of use of biosimilar growth hormone (GH) in Indian children with growth disorders. Materials and Methods: We studied 322 children (May 2012–2017) with growth disorders including growth hormone deficiency (GHD), multiple pituitary hormone deficiency (MPHD, idiopathic short stature (ISS), small for gestational age (SGA), and Turner syndrome (TS). Children were treated either with innovator molecule (Norditropin) or biosimilar GH (Headon) with standard dosage protocol for 1 year. Height and weight was measured using standard protocol. Height and BMI for age Z-scores (HAZ, BMIZ), height velocity (HV), and HV Z-score (HVZ) were computed from available data. Results: Mean age of the studied children (n = 322) was 9.6 ± 4.1 years, 32% children had GHD, 39% had ISS, 11% had MPHD, 12% had SGA, and 6% children had TS. There were no serious adverse events; three patients recorded eight instances of headaches, two had rash at injection site, and one each had hives and facial edema. Reactions were mild and were treated symptomatically. At the end of the 1 year of GH therapy, change in HAZ was similar in children from both the innovator and biosimilar GH groups. Similarly, the HV and HVZ were also similar in children from both groups and all the studied growth disorders. Conclusion: Biosimilar GH was effective and safe for treatment in children with growth disorders where GH use is indicated. However, in the view of scarcity of such data a longitudinal study with large sample size is warranted.
  1,322 213 -
A study on psychiatric disorders, body image disturbances, and self-esteem in patients of Cushing's disease
Akanksha Sharma, Neena Sawant, Nalini Shah
July-August 2018, 22(4):445-450
DOI:10.4103/ijem.IJEM_94_18  PMID:30148086
Background: Cushing's disease (CD) is a rare endocrine disorder associated with increased serum levels of cortisol secreted due to an underlying tumour in pituitary. Psychiatric disturbances like depression, psychosis, mania along with body image disturbances are seen in patients of CD. Hence, we undertook this research to find the prevalence and type of psychiatric disorders, body image disturbances, and self-esteem in patients of CD. Materials and Methods: Thirty-five patients diagnosed as CD as per the standard criteria by the endocrinologist were recruited after informed consent and ethics approval. Proforma with demographic details, Structured Clinical Interview for DSM-IV, Beck Depression Inventory (BDI), Rosenberg Self-Esteem Scale, and Body Image Concern Inventory were used for assessment of the aims. Results: 65% patients had psychopathology with 21% patients having major depressive disorder, 62% patients had mild, and 28% had moderate depression on BDI. 50% patients had body image disturbances and 60% had low self-esteem. Depression was found to have a negative correlation with self-esteem and positive correlation with body image disturbances. Conclusion: A high prevalence of psychopathology is seen in patients of CD which may often go undetected. Liaison with the endocrinologist would also work towards improving the issues of body image disturbances and self-esteem for better prognosis for the patient.
  1,287 240 2
Growth hormone stimulation: An achilles heel in the evaluation of short stature
MK Garg, K VS Harikumar
July-August 2018, 22(4):439-440
DOI:10.4103/ijem.IJEM_255_18  PMID:30148084
  1,213 293 -
Assessment of glomerular and tubular function in the evaluation of diabetic nephropathy: A cross-sectional study
Sandeep Kumar Agarwal, Uma Kaimal Saikia, Dipti Sarma, Runi Devi
July-August 2018, 22(4):451-456
DOI:10.4103/ijem.IJEM_303_17  PMID:30148087
Background: Diabetic nephropathy (DN) occurs in 20%–40% of patients with diabetes, and it is characterized by proteinuria and progressive loss of renal functions ultimately leading to end-stage renal disease. Classically, albuminuria is regarded as a consequence of diabetes-induced glomerular damage. It is now being appreciated that the renal tubulointerstitium also plays a role in the development of DN.[1] Urinary cystatin C (UCC) is an emerging marker of DN. It is totally catabolized by proximal tubular cells and is not normally present in the urine. However, in the presence of tubulopathy, it is excreted in urine, and serum levels also are elevated due to lack of catabolism. Materials and Methods: The present study was conducted to evaluate the presence of glomerulopathy and tubulopathy in patients with type 2 diabetes mellitus (T2DM) and to correlate them with established risk factors for nephropathy. We aimed at evaluating the level of UCC as a marker of tubulointerstitial damage in patients with T2DM in relation to the level of albuminuria and other parameters. Seventy-two patients with T2DM (mean age, 47.44 ± 10.40 years) and 45 healthy age- and sex-matched subjects were evaluated for UCC, serum creatinine, and urinary albumin-creatinine ratio (UACR) along with other parameters. Results: Of the 72 patients included in the study, microalbuminuria was found in 26% and macroalbuminuria in 10% of cases. UCC was significantly higher in micro- and macro-albuminuric groups in comparison with normoalbuminuric patients and correlated positively with UACR. Among the 46 patients with normoalbuminuria, 11 had elevated UCC levels indicating early tubular dysfunction. Conclusions: This finding may support the hypothesis of a “tubular phase” of diabetic kidney disease preceding overt DN, and hence, the use of UCC measurement for early evaluation of renal involvement.
  1,150 305 1
Clonidine stimulation test: Is single best time point, convenient yet efficacious?
Darshana S Thakur, Nikhil M Bhagwat, Milind M Bhide, Chaitanya G Yerawar, Gayatri A Ghanekar, Ashutosh B Sonawane, Manoj D Chadha, Premlata K Varthakavi
July-August 2018, 22(4):511-514
DOI:10.4103/ijem.IJEM_101_18  PMID:30148099
Context: To find a single time point during clonidine stimulation test (CST), with highest diagnostic value to rule out growth hormone deficiency (GHD). Settings and Design: This is a retrospective study of 79 CSTs carried out in a tertiary care center in India. Materials and Methods: A cohort of 79 children with unexplained short stature was divided into two groups: GHD and non-GHD. Any one stimulated growth hormone (GH) level >10 ng/mL was used to rule out GHD. Diagnostic accuracy of not only single time points but also time points in pairs was calculated. Statistical Analysis: The data were analyzed using SPSS statistical software 22.0. Descriptive statistics were used for analyzing demographic data. Mode for time to peak GH was calculated in each group. The specificity and false positive rates at each time point as well as combined time points were determined. Results: Assaying a single sample at 60 min after clonidine resulted in 20.5% false positive tests with specificity of 79.5%. Addition of the 90 min sample increased specificity to 92.3%. Conclusion: The 60 min sample after clonidine stimulation was the best single sample to rule out GH deficiency. Combined sampling at 60 min + 90 min is economical and less cumbersome, with minimal compromise on the specificity.
  1,073 192 1
Correlation between basal insulin glargine dose required in achieving target fasting blood glucose and various clinical and laboratory parameters in hospitalized noncritical patients
Om J Lakhani, Surender Kumar, Sudhir Tripathi, Mitali A Desai, Chandani Seth
July-August 2018, 22(4):469-472
DOI:10.4103/ijem.IJEM_297_17  PMID:30148091
Aims: The primary objective was to study the interrelationship between the basal insulin glargine dose and baseline clinical and laboratory parameters in noncritically ill hospitalized patients who have achieved the stable fasting blood glucose in the target range of 100–140 mg/dl. Patients and Methods: This was retrospective, cross-sectional, observational study. Consenting, nonpregnant, adult patients on basal-bolus insulin who had fasting capillary blood glucose in the range of 100–140 mg/dl as measured by glucometer for 3 consecutive days were included in this study. Patient receiving any basal insulin other than insulin glargine were excluded from this study. The data collected for these patients included age, sex, glycated hemoglobin (HBA1c) at the time of admission, timing of basal insulin, basal insulin dose (BID), BID/kg, weight, and serum creatinine. BID/kg was correlated with other parameters using regression analysis (Pearson's). Comparison of BID/kg in various subgroups was analyzed using Student's t- test. Parametric data of more than three groups were compared using ANOVA. The P < 0.05 was considered as statistically significant. Results: A total of 180 patients were included in the study. On correlating the BID/kg with various parameters, we found statistically significant correlation between BID/kg and glycated hemoglobin (HbA1c) at the time of admission (P = 0.044). Patients with HbA1c ≥8.0% had higher BID/kg compared to those with HbA1c <8.0% (P = 0.004). The mean BID in patients with renal failure was significantly higher compared to those without renal failure. Conclusion: HbA1c at the time of admission is the most important parameter for determining the appropriate BID in hospitalized patients. Patients with renal failure may require a higher dose of basal insulin than those not having renal failure.
  1,041 145 -
Reduced diabetes mellitus-related comorbidities by regular self-monitoring of blood glucose: Economic and quality of life implications
Viswanathan Mohan, Jayashree A Mapari, Pratibha D Karnad, Jasdeep S Mann, Vikalp K Maheshwari
July-August 2018, 22(4):461-465
DOI:10.4103/ijem.IJEM_216_17  PMID:30148089
Objectives: The objective of the study was to understand the role of self-monitoring of blood glucose (SMBG) for better management of glycemic fluctuations, reducing the risk of complications, and the associated cost benefits for diabetes patients in India. Materials and Methods: An Excel-based Cost Impact Model was developed to analyze the impact of SMBG by calculating the savings over a 10-year time period. A literature review was undertaken to model the impact of SMBG on the risk of complications and cardiovascular morbidities. The model was developed based on inputs from previous studies. Results: In the base case, SMBG cohort was associated with a 10-year discounted cost of INR 718,340, resulting in an estimated saving of INR 120,173 compared to no SMBG cohort. Implementation of a once-daily SMBG protocol, for a decade, can reduce the complication-related costs. More frequent SMBG and tri-monthly hemoglobin A1c tests along with lifestyle changes can significantly reduce the financial burden on the patient over the lifespan. Conclusion: Our study has shown that proactive management of diabetes with SMBG can improve treatment outcomes and reduce morbidity and mortality associated with this disease. Near-normal blood glucose levels can bring in cost savings in the form of reduced long-term complications and avoidance of repeated hospitalization for the management of such complications, along with an improved quality of life.
  955 213 5
The risk of developing obesity, insulin resistance, and metabolic syndrome in former power-sports athletes - Does sports career termination increase the risk
Mohammadreza Emami, Amir Behforouz, Lida Jarahi, Ahmadreza Zarifian, Amir Rashidlamir, Masoud Mahdavi Rashed, Homa Khaleghzade, Zahra Ghaneifar, Mohammad Safarian, Mohsen Azimi-Nezhad, Hossein Nikroo, Mohsen Nematy
July-August 2018, 22(4):515-519
DOI:10.4103/ijem.IJEM_83_18  PMID:30148100
Introduction: Obesity is associated with several complications like metabolic syndrome. Many professional athletes adopt a sedentary lifestyle after retirement. This study was aimed at assessing the risk of developing obesity, insulin resistance (IR), and metabolic syndrome among former power-sports athletes, compared with age-matched active athletes and nonathletes. Materials and Methods: The study was conducted in Mashhad during 2012–2014. The individuals were recruited through announcements and were divided into three groups of active athletes (n = 34), ex-athletes (n = 30), and nonathletes (n = 30). Demographic and anthropometric data were collected and biochemical factors including low-density lipoprotein cholesterol (LDL-C), high-density lipoprotein cholesterol (HDL-C), total cholesterol, triglycerides (TG), fasting plasma glucose, insulin, and high-sensitive C-reactive protein were measured. Results: Ex-athletes had significantly higher mean values of weight, body mass index, diastolic blood pressure, LDL-C, insulin, homeostatic model assessment (HOMA) IR, and HOMA β-cell function (HOMA-%β-cell) compared with active athletes and nonathletes (P < 0.001, P < 0.001, P < 0.001, P = 0.03, P = 0.01, P = 0.02, and P = 0.01, respectively). However, mean values of HDL-C was significantly lower in ex-athletes compared with nonathletes (P < 0.001). The prevalence of metabolic syndrome showed no significant difference among three groups, although its mean was higher among ex-athletes. Conclusions: The results showed that abandoning regular athletic exercise and weight cycling in power sports athletes leads to adverse outcomes such as obesity and IR. Although higher IR might not necessarily result in metabolic syndrome in short term, it could cause metabolic syndrome in the long run.
  977 175 2
Study on coagulation factor VIII and fibrinogen levels in patients with thyroid disorders
Muhammed Thoyyib, Sandeep Garg, Naresh Gupta, Sunita Aggarwal, Sanjay Pandit
July-August 2018, 22(4):479-484
DOI:10.4103/ijem.IJEM_583_17  PMID:30148093
Introduction: A kaleidoscope of coagulation disorders has been reported in patients with thyroid dysfunctions. Globally, these disorders involve both primary and secondary hemostasis and range from subclinical laboratory abnormalities to, more rarely, life-threatening hemorrhages or thrombotic events. While overt hypothyroidism appears to be associated with a bleeding tendency, hyperthyroidism emerged to have an increased risk of thrombotic events. As a controversy, subclinical hypothyroidism and mild hypothyroidism have been reported as prothrombotic state. The mechanisms involved in these observations are also not conformed. Objective: To study the levels of prothrombotic coagulation factor VIII and fibrinogen in patients with thyroid disorder at baseline and to correlate the change in these factors after attaining euthyroid state by treatment. Study Design: This was a longitudinal interventional study. Subjects and Methods: Forty patients were recruited based on the inclusion and exclusion criteria, and their coagulation profile (prothrombin time, aPTT, Factor VIII, and fibrinogen levels), routine hematological, and biochemical profile was done at baseline and 6 weeks after attaining euthyroid state. Results and Conclusion: Hyperthyroidism and mild hypothyroidism were found to be hypercoagulable states and moderate-to-severe hypothyroidism as hypocoagulable states. Nevertheless, further observational and intervention studies are needed to provide more definitive information on the clinical relevance of this association, along with the potential implication for prevention and treatment of coagulation/fibrinolytic abnormalities in patients with thyroid dysfunction.
  924 192 -
PTPN22 1858 C/T exon polymorphism is not associated with Graves' disease in Kashmiri population
Faheem Shehjar, Dil-Afroze , Riaz A Misgar, Sajad A Malik, Bashir A Laway
July-August 2018, 22(4):457-460
DOI:10.4103/ijem.IJEM_105_18  PMID:30148088
Background: Graves' disease (GD) is a multifactorial autoimmune disease with contribution from both genetic and epigenetic factors in its causation. Association of genetic factors and GD has been extensively studied. Gene “protein tyrosine phosphatase nonreceptor 22” (PTPN22) is an important immunoregulatory gene preventing hyper responsiveness of T cells by negatively regulating their signal transduction. Association of single-nucleotide polymorphism (SNP) 1858 C/T within PTPN22 with some autoimmune diseases has been described. Methods: We aimed to analyze whether 1858 C/T SNP of PTPN22 gene has any association with GD in Kashmiri population. Polymerase chain reaction-restriction fragment length polymorphism was performed for genotyping 1858 C/T SNP in 135 patients with GD and 150 age- and gender-matched healthy controls. Results: Among the patients with GD, the frequencies of PTPN22 1858 CC, CT, and TT genotypes were 97.7, 2.2, and 0%, respectively, whereas in healthy controls the frequencies of CC, CT genotypes were 100 and 0%, respectively. No significant association was found between PTPN22 1858 C/T SNP and patients with GD. Conclusion: GD is not associated with PTPN22 1858 C/T SNP in Kashmiri population. Furthermore, 1858 C/T SNP in PTPN22 gene could be a part of variation in different ethnic populations across the globe.
  953 156 -
Mutational profile of papillary thyroid carcinoma in an endemic goiter region of North India
Nelson George, Amit Agarwal, Niraj Kumari, Sarita Agarwal, Narendra Krisnani, Sushil Kumar Gupta
July-August 2018, 22(4):505-510
DOI:10.4103/ijem.IJEM_441_17  PMID:30148098
Introduction: Mitogen activated protein kinase (MAPK) pathway is regularly altered in papillary thyroid carcinomas (PTCs). Serine/threonine-protein kinase B-Raf (BRAF) V600E mutations were observed very frequently in PTC along with less frequent rat sarcoma (RAS) and rearranged during transfection (RET) gene, also known as RET/PTC translocation. The present study aimed to analyze the mutational profile of PTCs from an endemic Goiter area of North India. Methodology: Tissues from 109 PTC patients were used to isolate DNA and RNA. BRAF V600E was detected by restriction fragment length polymorphism-polymerase chain reaction (PCR). RAS mutations were screened by using Sanger's sequencing method. RET/PTC rearrangements were analyzed by real-time PCR. Results: BRAF V600E mutation was detected in 51.38% (56/109) of PTCs, whereas RAS mutations were less frequent. No RET/PTC rearrangements were observed. BRAF V600E was found to be associated with the aggressive clinicopathological features such as lymph node metastasis, distant metastasis, higher tumor-node-metastasis stages, and high-risk groups. Conclusion: The prevalence of BRAF V600E is high in patients from Indian Subcontinent and found to be associated with aggressive features of PTC. Concomitant mutations of BRAF V600E and RAS mutations impart more aggressiveness to PTCs.
  793 150 3
Models that explain the cause of obesity
SS Prakash
July-August 2018, 22(4):569-570
DOI:10.4103/ijem.IJEM_67_18  PMID:30148109
  707 133 -
Cinacalcet: A viable therapeutic option for primary hyperparathyroidism in the elderly
Hussam Abusahmin, Ashutosh Surya, Andrew Aldridge, Onyebuchi Okosieme, Gautam Das
July-August 2018, 22(4):485-488
DOI:10.4103/ijem.IJEM_684_17  PMID:30148094
Objective: Parathyroidectomy is usually curative in primary hyperparathyroidism (PHPT), but its utility would be limited if patients are elderly who may either refuse surgery or may have advanced frailty and multimorbidity. We evaluated the effectiveness of cinacalcet, an allosteric modulator of calcium-sensing receptor in PHPT in an elderly cohort of patients. Methods: A prospective analysis of 29 patients who had PHPT and despite fulfilling criteria for surgery were unable to undergo parathyroidectomy either due to self-refusal (n = 12) or due to advanced multimorbidity (n = 17). All patients completed treatment with cinacalcet for at least for 6 months. Analysis were performed as per age (<75 and ≥75 years) and Charlson comorbidity index (CCI) score (≤5 and >5). Results: Our patients were the elderly (77 ± 12.7 years). In the whole group, complete normocalcemia was observed in 72.4% of patients (mean reduction: −0.55 mmol/l [confidence interval (CI) 0.4–−0.7; P < 0.0001]) and parathormone (PTH) normalized (≤6.9 pmol/l) in 33.4% of patients [mean reduction: −5.5 pmol/l (CI −11.6–0.6; P = 0.0015)]. In subgroup analysis, the severity of hypercalcemia was found to be higher patients with age <75 years and also in patients with CCI score >5. Cinacalcet lowered adjusted calcium in both age groups (P < 0.0001) with a greater reduction (20.5% vs. 16.2%; P < 0.0001 for both) in patients with CCI score >5. PTH fell in both age groups but significantly (−6.7 pmol/l [CI −14.9–1.5]; P = 0.008) in ≥ 75 years category and likewise, the drop was greater in patients with higher CCI scores (−7.1 pmol/l [CI −15.8–1.6); P = 0.009] vs. [−4.5 pmol/l [CI −3.9–−5.10]; P = 0.001). Patients with age <75 years and with CCI score ≤5 needed higher doses of cinacalcet to achieve biochemical targets. Conclusion: Cinacalcet is a viable and valuable treatment strategy for elderly patients with multiple comorbidities who suffer from PHPT but either cannot or refuse to undergo parathyroidectomy.
  670 166 -
The burden of severe hypoglycemia on quality of life among diabetes mellitus patients in a tertiary level hospital of Bangladesh
Afsar Ahammed, Faruque Pathan, Faria Afsana, Imran Ahammed, Ahmed Salam Mir, Abdullah Yusuf
July-August 2018, 22(4):499-504
DOI:10.4103/ijem.IJEM_338_17  PMID:30148097
Objective: This study aimed to determine the impact of hypoglycemia on health-related quality of life from a patient perspective. Materials and Methods: A cross-sectional study was conducted in 164 type 2 diabetes patients admitted due to severe hypoglycemia from August 2015 to October 2016 at Bangladesh Institute of Research and Rehabilitation in Diabetes, Endocrine and Metabolic Disorders, in Dhaka. Impact of severe hypoglycemia on health-related quality of life in diabetic patients was evaluated using the disease-specific questionnaire audit of diabetes-dependent quality of life-19 (ADDQOL-19). Results: The median ADDQOL score was calculated at −3.31. Totally, 88 (53.7%) patients reported an ADDQOL score of − 3.31 or more, and 76 (46.3%) patients had an ADDQOL score of less than −3.31 (lower quality of life [QoL]). After considering weighting, “Freedom to eat” (mean Weighted Impact Score-6.32 ± 1.94) was the most and “Holidays” (mean Weighted Impact Score-0.96 ± 0.19) was the least affected QoL domains, respectively. In multivariate logistic regression analysis, severe hypoglycemia impact on ADDQOL was related with age (odds ratio [OR] 0.932, 95% confidence intervals [CIs] 0.897–0.969, P < 0.001), sex (OR 0.088, 95% CIs 0.023–0.338, P < 0.001), glycated hemoglobin (%) (OR 0.613, 95% CIs 0.422–0.890, P = 0.010), and marital status (OR 9.264, 95% CIs 2.467–34.790, P = 0.001). Conclusions: The results of this analysis suggest hypoglycemia impacts heavily on the well-being and quality of life of people with diabetes, and every effort should be made to minimize hypoglycemia while aiming for good glycemic control.
  673 155 -
Which criteria to use to identify metabolic syndrome among patients with addictive disorders?: Observations among patients with alcohol and opioid dependence syndrome
Yatan Pal Singh Balhara, Raka Jain, Pooja Patnaik Kuppili, Anukriti Shukla, Nishtha Chawla, Rishi Gupta
July-August 2018, 22(4):565-568
DOI:10.4103/ijem.IJEM_617_17  PMID:30148108
In spite of various psychoactive substances (including tobacco, alcohol, and opioids) being closely associated with development of metabolic syndrome (MS), little research exists on the prevalence of MS among persons with addictive disorders. The criteria used to diagnose MS varied across these studies, and part of the variation in the prevalence rate (5.1%–30.6%) could be attributable to this fact. The current study aimed to assess the prevalence of MS in patients with alcohol dependence syndrome (ADS) and opioid dependence syndrome (ODS) using revised National Cholesterol Education Programme Adult Treatment Panel (NCEP ATP-III) criteria and International Diabetes Federation (IDF) criteria. We tried to assess the impact of the choice of the diagnostic criteria on the prevalence rate of MS in the persons with ADS and ODS. This was a cross-sectional observational study. Semi-structured pro forma was used to collect information on the sociodemographic profile and clinical profile. Anthropometric measurements included waist circumference, height, weight, and body mass index (BMI). The systolic and diastolic blood pressure, fasting blood sugar (FBS), serum triglycerides, and serum high-density lipoprotein were measured. Patients were diagnosed as having MS by using revised NCEP ATP-III and IDF criteria. Statistical analysis was done by Chi-square (Fischer's exact test), independent sample Student's t-test, and Cohen's kappa. Among the individuals with ADS, the prevalence of MS was found to be 20.8% and 9.9% according to revised NCEP ATP III criteria and IDF criteria, respectively. Among individuals with ODS, the prevalence of MS was found to be 20.3% and 5.1% according to revised NCEP ATP III criteria IDF criteria, respectively. While there was a good degree of concordance between IDF and modified NCEP-ATP III criteria for MS for ADS (n = 256) (κ = 0.649, P < 0.001), the concordance was only fair for ODS (κ = 0.333, P < 0.001). The findings of our study thereby support the recommendation that revised NCEP ATP-III criteria is better choice than IDF criteria for identification of MS in individuals having addictive disorders, especially opioid dependence.
  674 120 1
Base rate, Occam's razor, and hypoglycemia
Karthik Balachandran, Adlyne Reena Asirvatham, Shriraam Mahadevan
July-August 2018, 22(4):572-573
DOI:10.4103/ijem.IJEM_119_18  PMID:30148112
  702 86 -
OLR1 gene polymorphism and oxidized LDL levels in metabolic syndrome in Indian population
Elvia Jamatia, Pramod Lali, BC Koner, DK Dhanwal, Mirza Masroor, Kritika Krishnamurthy, Aditi Singh
July-August 2018, 22(4):530-534
DOI:10.4103/ijem.IJEM_112_18  PMID:30148103
Objective: Metabolic syndrome (MetS) is associated with abnormal lipid profile and high cardiovascular risk. There is an increased prevalence of coronary artery disease and Type 2 Diabetes Mellitus in India. Oxidized Low Density Lipoprotein Receptor 1(OLR1), a cell surface endocytosis receptor recognize, internalize and degrade oxidized LDL (oxLDL) in vascular endothelium and plays a role in the pathogenesis of atherosclerosis. The aim was to explore the association of OLR1 gene polymorphism and measure the serum levels of ox-LDL in patients with MetS in Indian population. Materials and Methods: Forty cases fulfilling the IDF diagnostic criteria for MetS and 40 healthy controls having similar age and sex ratio were genotyped for OLR1 gene (SNP: IVS4–73C>T , rs3736234) by RFLP-PCR. Serum ox-LDL was estimated by ELISA.Their BP, BMI and waist circumference were measured. Fasting Plasma glucose, Serum Triglyceride and HDL-C were measured. Results: Serum oxLDL was significantly higher in MetS cases as compared to controls (p < 0.0001). Odds ratio of T allele of above OLR1 SNP among subjects with MetS was 14.79 (95%CI: 1.80-121.2, p < 0.05). But no association was found between the SNP and serum ox-LDL levels. People having TT allele had higher BMI compared to those having CC allele. Conclusion: Ox LDL, being more atherogenic might contribute in the pathogenesis of MetS. The intronic SNP: IVS4-73 C>T of OLR1 gene increases the risk of developing MetS by a yet unknown mechanism that is independent of rise in ox-LDL. This OLR1 SNP probably influences BMI.
  669 112 1
Discrepancy between the recommended and functional cut offs of Vitamin D among under-five children: Experiences from a pilot study
Suchitra Surve, Shahina Begum, Sanjay Chauhan, Ikram Khatkhatay, Beena Joshi
July-August 2018, 22(4):473-478
DOI:10.4103/ijem.IJEM_574_17  PMID:30148092
Background and Objectives: Vitamin D is a key determinant of bone health and calcium homeostasis in children. Vitamin D deficiency (VDD) in early years may have an effect on total bone mass and risk of osteoporosis. Despite widespread prevalence of VDD among children, there is limited information in under-five age group. The objectives of the current study were to estimate the community-based prevalence of VDD and to identify the factors associated with children aged 1–5 years. Materials and Methods: A community-based cross-sectional study was conducted among 201 apparently healthy children (aged 1–5 years) in an urban slum of the selected geographical area in Mumbai. VDD was defined as serum 25-hydroxy Vitamin D (25[OH]D) levels <20 ng/ml as per the US Endocrine society classification. Results: The prevalence of VDD was found to be 74.6% (95% of confidence interval [68.6–80.6]). It was significantly higher (P = 0.04) among children staying indoors (44.8%). 25(OH)D was negatively correlated with parathyroid hormone (PTH) ([r = −0.199, P = 0.005]) and Alkaline phosphatase ([r = −0.140, P = 0.05]). However, the increase in PTH was observed when 25(OH)D levels were <10 ng/ml unlike anticipated increase at <20 ng/ml. Conclusion: The study revealed a high prevalence of VDD in 1–5 years age group. It was observed that the outdoor activities and sun exposure have a significant association with Vitamin D status. Majority of children had normal PTH levels despite VDD. The study endorses the importance of sun exposure and throws light on that fact that functional cutoffs for VDD may be lower in under-five children and also highlights the need of redefining cutoffs of Vitamin D among the Indian children.
  634 111 1
Serum lipid and leptin concentrations in patients with Sheehan syndrome
Shahnaz A Mir, Tabinda Shah, Hardeep Singh, Iram Shabir, Bashir A Laway
July-August 2018, 22(4):466-468
DOI:10.4103/ijem.IJEM_23_18  PMID:30148090
Background: Sheehan syndrome (SS) refers to the occurrence of hypopituitarism after parturition. Hypopituitary adults with growth hormone (GH) deficiency have abnormal body composition with increased fat mass. As leptin is secreted almost exclusively by fat cells and the circulating leptin level is proportional to total fat mass, it is expected that abnormal elevations of leptin concentrations are found in GH deficient hypopituitary patients. The present study was undertaken to evaluate the anthropometric, lipid and leptin levels in patients with SS. Materials and Methods: Thirty patients with SS and 30 age and body mass index (BMI) matched controls were part in this study. All patients were stable on conventional replacement therapy for at least 6 months before the study. The subjects underwent detail clinical, biochemical, and hormone analysis. Results: Patients with SS on conventional replacement therapy showed significantly higher mean triglyceride, total cholesterol, low density lipoprotein cholesterol and lower high density cholesterol concentrations. The leptin levels were significantly raised in the patients with SS on standard replacement therapy compared with controls. The difference was more marked in obese cases versus obese controls than in lean cases and controls (P = 0.001). Conclusion: SS, a cause of GH deficiency. Our study demonstrated that patients with SS have an abnormal lipid profile, and raised leptin levels as compared to age and BMI matched controls.
  607 132 -
The impact of thyroiditis on morbidity and safety in patients undergoing total thyroidectomy
Krishnan Ravikumar, Sankaran Muthukumar, Dhalapathy Sadacharan, Umadevi Suresh, Thalavai Sundarram, Selladurai Periyasamy
July-August 2018, 22(4):494-498
DOI:10.4103/ijem.IJEM_209_17  PMID:30148096
Background: The indications for surgery in thyroiditis vary from compressive symptoms to cosmesis. We analyzed the complications in patients who underwent total thyroidectomy (TT) in goiters associated with thyroiditis. Materials and Methods: This retrospective study was done in an endocrine surgical center over 4 years. A total of 724 patients, who underwent TT for benign thyroid disorders, were included in the study. Patients were divided into two groups based on histopathology into Group A (nonthyroiditis cases) and Group B (thyroiditis cases); Group B is subdivided into Group B1 (nodular goiter with associated thyroiditis) and Group B2 (Hashimoto's thyroiditis). The preoperative parameters analyzed were serum calcium, serum Vitamin D, serum parathyroid hormone (PTH), and vocal cord status. The intraoperative parameters observed were operating time, parathyroid preservation, and autotransplantation and course of recurrent laryngeal nerve (RLN). Postoperative parameters monitored were serum calcium, serum PTH, serum magnesium, signs and symptoms of hypocalcemia, and vocal cord status. Follow-up was done at 6 months with serum calcium, serum PTH, and video laryngoscopy. Results: Both groups were age and sex matched. All preoperative and intraoperative parameters were comparable among groups. Both transient complications (<6 months) were higher in Group B than A. Transient hypocalcemia was higher in Group B (39.70%) than Group A (24.77%) (P = 0.001). Transient hypocalcemia was higher in Group B1 (36.58%) than Group B2 (44.44%) (P = 0.014). Transient RLN palsy was higher in Group B (9.55%) than Group A (7.52%) (P = 0.040). Transient RLN palsy was higher in Group B1 (8.53%) than Group B2 (11.11%) (P = 0.039). Permanent hypoparathyroidism and permanent RLN palsy were comparable between the Groups A and B and between Groups B1 and B2. Conclusion: The incidences of transient complications are higher in patients with thyroiditis. Careful analysis of surgical indications will avoid unnecessary surgery in thyroiditis cases.
  609 104 1
Comparison of the efficacy of three different methods of explaining the surgical procedure of hemithyroidectomy
Sabaretnam Mayilvaganan, Channabasappa Shivaprasad
July-August 2018, 22(4):520-524
DOI:10.4103/ijem.IJEM_609_17  PMID:30148101
Background: For patients indicated for surgical treatment, adequate information about the procedure and its complications is a prerequisite for consent, reassures the patient, and allows them to make a well-informed decision. This prospective randomized study aimed to compare the outcomes of three different methods of explaining the procedure of hemithyroidectomy to patients' satisfaction. Material and Methods: The three different methods for explaining the surgical procedure included a conventional diagram, three-dimensional (3D) thyroid model, and 2-minute animated video. A modified Patient Satisfaction Questionnaire was used to evaluate the efficacy of the methods and assess overall patient experience; 20 patients were randomized to each group. An endocrine surgeon performed the operative procedure using a sutureless technique. The procedure was explained to the patient a week before surgery in the outpatient department. Results: Majority of the patients were female. The most common indication for surgery was a solitary thyroid nodule. Patients who watched the animated video demonstrated significantly higher satisfaction levels and significantly lower anxiety levels than those in the other groups (P < 0.01). Patients who watched the video or who received instructions using the 3D model also reported that their information needs were met. Overall experience with the procedure and hospital stay was not significantly different between the groups. Conclusion: Overall patient satisfaction for the surgical procedure was similar across the three groups. However, the animated video appeared to be a better model to explain the procedure to the patient, resulting in enhanced knowledge acquisition, reduced anxiety, and improved patient satisfaction.
  591 106 -
Acute intermittent porphyria presented with acute intestinal pseudo-obstruction
Hans Raj Pahadiya, Manoj Lakhotia, Ronak Gandhi
July-August 2018, 22(4):573-574
DOI:10.4103/ijem.IJEM_677_17  PMID:30148113
  565 108 -
Strain, diet, and gender influence the role of miR155 in diabetes mellitus
V Padmanaban, SS Prakash
July-August 2018, 22(4):570-572
DOI:10.4103/ijem.IJEM_125_18  PMID:30148111
  575 87 -
First trimester thyroid function tests: Normative data from Western India
Vimal M Nambiar, Anurag R Lila, Tushar R Bandgar, Nalini S Shah
July-August 2018, 22(4):574-575
DOI:10.4103/ijem.IJEM_178_18  PMID:30148114
  472 117 -
Importance of variables in nonalcoholic fatty liver disease patients
Vivek Kumar Garg, Neelam Goel
July-August 2018, 22(4):570-570
DOI:10.4103/ijem.IJEM_120_18  PMID:30148110
  375 79 -