With evolution of evidence-based medicine, risk prediction equations have been formulated and validated. Such risk engines and scoring systems are able to predict disease outcome and risks of possible complications with varying degrees of accuracy. From health policy makers point of view it helps in appropriate disbursement of available resources for greatest benefit of population at risk. Understandably, the accuracy of prediction of different risk engines and scoring systems are highly variable and has several limitations. Each risk engine or clinical scoring tool is derived from data obtained from a particular population and its results are not generalizable and hence its ability to predict risk/outcome in a different population with differences in ethnicity, ages, and differences in distribution of risk factors over time both within and between populations. These scoring systems and risk engines to begin with were available for manual calculations and references/use of formula and paper charts were essential. However, with evolution of information technology such calculations became easier to make with use of online web-based tools. In recent times with advancement of android technology, easy to download apps (applications) has helped further to have the benefits of these online risk engines and scoring systems at our finger tips.

Infectious diseases of the central nervous system (CNS) are increasingly being recognized as important causes of hypopituitarism. Although tuberculosis is the most common agent involved, non-mycobacterial agents like viruses, bacteria, fungus, and protozoa are important causes in our country. Involvement post infections could be due to a strategically located tuberculoma, or pituitary abscess, or meningoencephalitis. Although it might not be reasonable to screen all patients with CNS infections for hypopituitarism, awareness of the possibility and clinical follow-up for suggestive symptoms is required.

Glucocorticoids (GCs) are extensively used for various inflammatory and autoimmune disorders, but long term use of these agents is not without complications. Almost every GC formulations (e.g. oral, topical, inhaled, etc.) can cause systemic side effects. It can range from minor side effects (e.g. weight gain) to life-threatening effects (e.g. adrenal suppression, sepsis, etc.), which may require immediate intervention. Therefore, the decision to institute steroid therapy always requires careful consideration of the relative risk and benefit in each patient. The objectives of this study are to discuss monitoring of patients on GCs and management of the complications of GCs.

Calcium and Vitamin D are widely used therapies for Osteoporosis. Vitamin D is not a vitamin in true sense since it is produced in response to the action of sunlight on skin. Vitamin D has multiple roles in the body, not all of them well-understood. Vitamin D supplementation must be considered a form of hormone replacement therapy. Therefore it raises all the questions about efficacy, dose, and side effects. The Efficacy of use of Calcium and Vitamin D in all post menopausal women in terms of the prevention of fracture is uncertain. The Annual worldwide sales of these supplements have been several billion dollars. The variation of the results from various studies of Calcium and Vitamin D supplementation in elderly women suggest that benefit of calcium plus vitamin D on bone mineral density or the risk of fracture is small and may vary from group to group and baseline Vitamin D status. Women taking supplemental vitamin D and calcium have a statistically increased incidence of renal stones, according to evidence from the Women's Health Initiative. Studies have shown association between calcium use and increased risk for cardiovascular disease. In a recent review of evidence from 6 randomized trials evaluating the use of vitamin D and calcium to prevent fractures in postmenopausal women who are not living in a nursing home or other institution, the United States Preventive Task Force (USPTF) found no evidence of a benefit from supplementation with 400 IU or less of vitamin D3 and 1000 mg or less of calcium. Also in a report from institute of Medicine Committee, there was insufficient evidence, particularly from randomized trials, that vitamin D treatment affected the risk of non skeletal outcomes like risk of cancer, cardiovascular disease, diabetes, infections, autoimmune disease, and other extra skeletal outcomes.

Andropause or late-onset hypogonadism is a common disorder which increases in prevalence with advancing age. Diagnosis of late-onset of hypogonadism is based on presence of symptoms suggestive of testosterone deficiency - prominent among them are sexual symptoms like loss of libido, morning penile erection and erectile dysfunction; and demonstration of low testosterone levels. Adequate therapeutic modalities are currently available, but disparate results of clinical trial suggest further evaluation of complex interaction between androgen deficiency and ageing. Before initiating therapy benefits and risk should be discussed with patients and in case of poor response , alternative cause should be investigated.

Hyperglycemia is associated with adverse outcomes in hospitalized patients with and without previously known diabetes. Some therapies that are used in the in-patient setting, including glucocorticoids, enteral and parenteral nutrition are associated with new onset hyperglycemia even in previously normoglycemic patients. Current guidelines advise that fasting and premeal blood glucose (BG) be maintained at < 140 mg/dl, with maximal random BG < 180 mg/dl in non-critically ill-patients. In critically ill-patients, intravenous (IV) insulin infusion therapy with BG targets of 140-180 effectively maintains glycemic control with a low risk for hypoglycemia. Protocols targeting "tight" glycemic control, defined as BG 80-110 mg/dl, are no longer recommended due to the high frequency of severe hypoglycemia. Rational use of basal bolus insulin (BBI) regimens in non-critical care and IV insulin infusions in critical care settings has been demonstrated to effectively achieve and maintain recommended BG targets with low risk for hypoglycemia. The safety of BBI relies upon provider awareness of prescribing recommendations for initiating and adjusting insulin regimens according to changes in overall clinical and nutritional status, as well as careful review of daily BG measurements. Smooth transition of care to the out-patient setting is facilitated by providing oral and written instructions regarding the timing and dosing of insulin as well as education in basic skills for home management.

Diagnoses of subclinicaal hypothyroidism (SCH) is biochemically made, when serum thyroid stimulating hormone (TSH) levels is elevated while free thyroid hormone levels are within normal reference range. SCH is diagnosed after excluding all other causes of elevated TSH levels. Symptoms of SCH may vary from being asymptomatic to having mild nonspecific symptoms. The risk of progression to overt hypothyroidism is related to number of factors including initial serum TSH concentration, presence of auto antibodies, family history and presence goiter. Various screening recommendations for thyroid function assessment are in practice. There are still controversies surrounding SCH and associated risk of various cardiovascular diseases (CVDs), pregnancy outcomes, neuropsychiatric issues, metabolic syndrome, and dyslipidemia. Consensus will require more large randomized clinical studies involving various age groups and medical condition, especially in developing countries. All these efforts will definitely improve our understanding of disease and ultimately patient outcomes.

Blood glucose monitoring has evolved over the last century. The concept of adequate glycemic control and minimum glycemic variability requires an ideal, accurate and reliable glucose monitoring system. The search for an ideal blood glucose monitoring system still continues. This review explains the various blood glucose monitoring systems with special focus on the monitoring systems like self- monitored blood glucose (SMBG) and continuous glucose monitoring system (CGMS). It also focuses on the newer concepts of blood glucose monitoring and their incorporation in routine clinical management of diabetes mellitus.

The Look Action for Health in Diabetes AHEAD Study was designed as a long-term randomized controlled clinical trial and powered to detect differences in cardiovascular outcomes, the primary cause of early morbidity and mortality in type 2 diabetes, among subjects randomized to receive an intensive lifestyle intervention or a control group of diabetes support and education. The study was terminated early due to the absence of any difference in the primary outcome, defined as a composite of the first postrandomization occurrence of fatal and nonfatal myocardial infarction and stroke, or angina requiring hospitalization. However, important secondary favorable outcomes were observed in those receiving the intensive lifestyle intervention. This included more weight loss, greater fitness, less disability, less depression, reductions in sleep apnea and urinary incontinence, better glycemic control, and more subjects experiencing diabetes remission. These results underscore the importance of lifestyle interventions as a component of diabetes therapy. Long-term follow-up of Look AHEAD participants is planned, despite discontinuation of the intensive lifestyle program.

While thyroid dysfunction is a frequent complication of lithium treatment, myxedema crisis is a rare occurrence with a handful of cases described. Here, we describe a patient receiving lithium for about a decade for bipolar disorder, who presented with myxedema crisis and lithium toxicity. In this patient, myxedema crisis was likely precipitated by lithium toxicity and community acquired pneumonia. The effects of lithium on thyroid are briefly reviewed. Objective: To describe an elderly male who was diagnosed with myxedema crisis and lithium toxicity. Case Report: A 70-year-old male was admitted in our hospital with history of gradual onset progressive decrease in level of consciousness and altered behavior for last 1 month. Patient also had history of respiratory tract symptoms for 1 week. Patient was a known case of diabetes and bipolar affective disorder for which he had been receiving insulin and lithium for 10 years. One year earlier, patient was admitted in our ward for glycemic control and evaluation of complications and was found to be clinically and biochemically euthyroid; he never returned for follow up until the present admission. On examination patient had incoherent speech, hypothermia, and bradycardia. Thyroid function showed thyroid-stimulating hormone >150 IU/ml, Tetraiodothyronine (T4) <1 ΅g/dl, anti-thyroid peroxidase titer of 60 IU/ml. The serum lithium level was 2.9 nmol/L (therapeutic level 0.2-1.2 nmol/L). He was managed with levothyroxine, starting with a loading oral dose of 500 ΅g through ryles tube followed by 100 ΅g daily, IV antibiotics and fluids; lithium was stopped after consultation with a psychiatrist. From day 5, patient started showing progressive improvement and by day 10, he had a Glasgow Coma Scale of 15/15, normal electrolyte, serum creatinine of 1.8 mg/dl and serum lithium level of 0.5 nmol/L. Conclusion: Lithium-induced hypothyroidism may be life-threatening, thyroid function should be monitored before and during lithium therapy and drug should be discontinued and appropriate therapy instituted if hypothyroidism develops.

Thyroid associated orbitopathy, although seen most commonly with thyrotoxicosis, is also known to occur in primary hypothyroidism. Myasthenia gravis is an autoimmune condition with an established association with autoimmune thyroid disease. We report the case of a patient who presented with recent onset unilateral ptosis that was fatigable with a history of proptosis since a year. On examination, she had a goiter, bilateral proptosis, restriction of upward gaze and adduction both eyes and normal pupils. Investigations revealed primary hypothyroidism with anti-thyroid peroxidase positive and anti-acetylcholine receptor antibody positive. Computerized tomography orbit showed thickening of medial and inferior rectus characteristic of thyroid orbitopathy. A diagnosis of primary hypothyroidism with thyroid orbitopathy with ocular myasthenia gravis was made. Patient is on Levothyroxine and anticholinesterase medications and is on follow-up. We present this case to highlight that the presence of ptosis in a patient with thyroid orbitopathy should alert the clinician to the possible coexistence of myasthenia gravis.

We present a case of young female presenting with clinical features of cardiac tamponade. On initial investigation, the etiology of cardiac tamponade could not be made. The presence of bradycardia with cardiac tamponade prompted us to perform thyroid function test which lead to the diagnosis of hypothyroidism.

Hyperandrogenism is a common disorder among women in the reproductive age group. One of the rare causes for androgen excess is sex cord- stromal tumors of the ovary. These are usually unilateral. Here we report case of a 48 year old woman who presented with hyperandrogenism due to bilateral ovarian thecoma. Androgen levels normalized following resection of the tumor. This, to the best of our knowledge, is the first case of bilateral thecoma presenting as hirsutism in a premenopausal woman.

There are two types of vitamin D dependent rickets (VDDR) that cause rickets in children. VDDR type 1 (VDDR-I) is caused by an inborn error of vitamin D metabolism, which interferes with renal conversion of calcidiol (25OHD) to calcitriol (1,25(OH) ₂ D) by the enzyme 1-α-hydroxylase. Patients with VDDR-I have mutations of chromosome 12 that affect the gene for the enzyme 1-α-hydroxylase, resulting in decreased levels of 1,25(OH) vitamin D. Clinical features include growth failure, hypotonia, weakness, rachitic rosary, convulsions, tetany, open fontanels and pathologic fractures. We report a case of VDDR-I in 14-month-old male child. Establishing an early diagnosis of these genetic forms of rickets is challenging, especially in developing countries where nutritional rickets is the most common variety of the disease where genetic diagnosis is not always possible because of financial constraints. A prompt diagnosis is necessary to initiate adequate treatment, resolve biochemical features and prevent complications, such as severe deformities that may require surgical intervention.

A case of acute onset unilateral painful swelling of thigh is being presented where a high index of suspicion based on clinical presentation and characteristic MRI findings establish the diagnosis of DMI and avoided an inappropriate diagnosis and treatment.

Introduction: Vitamin D deficiency is expected to be higher in patients with diabetes and pulmonary tuberculosis (TB). Studies estimating prevalence in the subset of patients with both diabetes and pulmonary TB are scarce. Materials and Methods: A total of 155 subjects were recruited; 46 patients with type 2 diabetes, 39 non-diabetic healthy controls, 30 patients of pulmonary TB and 40 patients with both pulmonary TB and type 2 diabetes. Vitamin D level (25 OH vitamin D) levels were done for all the 4 groups. Results: Mean vitamin D levels were not different between groups with TB, diabetes mellitus or combination of both, but the prevalence of severe vitamin D deficiency was higher in the group with both diabetes and TB (45%) as compared with the group with only TB (26.66%) and diabetes (17.39%) and healthy controls (7.69%). Conclusion: The prevalence of patients with severe vitamin D deficiency is higher in patients with dual affection of TB and diabetes mellitus as compared with either disorder alone implying that patients with type 2 diabetes with the most severe vitamin D deficiency are the one of the most predisposed to pulmonary TB.

Objective: To investigate the efficacy and tolerability of the anti-diabetic agent acarbose (Glucobay^® ) as add-on or monotherapy in a range of patients with type-2 diabetes mellitus (T2DM), including those with cardiovascular morbidities in India. Materials and Methods: This was a part of a prospective, non-interventional, non-controlled, multicentre, multinational, observational study. The study included patients of either gender if they were aged at least 18 years and had untreated or pre-treated type-2 diabetes mellitus (T2DM) or impaired glucose tolerance and no acarbose treatment within the 3 months before study inclusion. Results: In total, 1996 Indian patients were included in the effectiveness and 2010 in the safety analysis. Patients received acarbose (25-150 mg/day). The mean age of the patients was 50.1 years and the mean BMI was 27.2 kg/m ² . Mean 2-h post-prandial plasma glucose (PPG) value and fasting blood glucose (FBG) decreased from 243.9 to 169.5 mg/dl and 158.3 to 120.4 mg/dl, respectively after the last follow-up of 12.4 weeks. The mean HbA1c value at initial visit was 8.4% and was 7.4% at the last follow-up visit. FBG, PPG and HbA1c deceased in 90.6%, 94.4% and 52.4% patients respectively, by the last follow-up visit. The mean decrease in weight and waist circumference was 1.4 kg and 1.6 cm, respectively by the last follow-up visit. Physicians assessed the efficacy of drug as positive response in "very good to good" in 91.08%, "sufficient" in 7.92% and "insufficient" in 0.90% of patients. Also, continuation of Acarbose was reported in 97.09% of patients. Adverse events were reported in 2.74% and drug-related adverse events were reported in 2.19% of patients. Majority of them were gastrointestinal adverse events but were not serious. Conclusion: Acarbose is effective and safe in Indian patients with T2DM. Further, it helps in weight reduction and has very good compliance in patients with T2DM.

Prader-Willi syndrome (PWS) is a rare cause of obesity. With the rising incidence of obesity, clinicians need to be aware of genetic causes of obesity and when to suspect them. A case of PWS, which was diagnosed in adulthood, has been discussed. This case is special because of lack of history of floppiness in infancy and predominance behavioral problems.

Introduction: Klinefelter syndrome usually presents in the puberty and adulthood with its characteristic features. We report a boy who had Klinefelter syndrome with hypospadias and hydrocele. Case Note: Six and half year old boy had complaints of genitourinary problem in the form of hypospadias, small phallus and hydrocele. Karyotyping showed 47,XXY. Conclusion: This case illustrates that Klinefelter syndrome was presented in the infancy with hypospadias and hydrocele which are very uncommon presentation of the disease

Disorders of sexual differentiation (DSD) are among the challenging problems in the field of endocrinology. When presenting late in an adult the therapeutic as well as diagnostic issues may be different and difficult. Bilateral anorchia is rare. The desire of future parenting is a real challenge when such patients ask for their own biological generations. This case depicts the late presentation of DSD in an anorchid adult and the management issues.

Background: Glucometers allow self-monitoring of blood glucose in a convenient manner. With the availability of various glucometers, there is a persistent attempt to improve the accuracy and the precision of these glucometer readings, so as to match the laboratory values of blood glucose. Objective: We compared the glucometers used in hospital and out-patient settings with the laboratory reference method. Materials and Methods: We analyzed a total of 105 blood samples collected from in-patient and out-patient from our tertiary care hospital. Venous blood samples were collected and checked on six glucometers and the same blood sample was sent to the laboratory for glucose estimation. The laboratory value was used as a reference for comparison. The accuracy was evaluated by the ISO criteria. The results were evaluated by Bland Altman graphs, correlation coefficients, scatter plots and Clarke's error grid analysis. Results: We observed good correlation between bed side glucometer and laboratory automated analyzer. Among the in-patient glucometers Breeze 2, Performa and SureStep, the correlation coefficient was 0.97, 0.96 and 0.88 respectively. Among the outpatient glucometers One touch ultra 2, Active and Contour, the correlation coefficient was 0.97, 0.97 and 0.95 respectively. Conclusions: There is a good correlation between different glucometers and laboratory values especially in the out-patient settings. Among all in-patient glucometers, SureStep by Johnson and Johnson had least correlation coefficient, whereas all three out-patient glucometers correlated well with the laboratory values.

Adrenal tuberculosis is a rare manifestation of active tuberculosis and is a difficult diagnosis to make if its presentation is sole manifestation of tuberculosis. We present an interesting case of a young male who presented only with symptoms of hyper pigmentation and was diagnosed as adrenal tuberculosis. Also, this report highlights the importance of drug interaction between antitubercular drug and steroid which lead to the deterioration in the early part of treatment and, later on was corrected by increasing the dose of steroids.

Sheehan's syndrome (SS) presents with hypopituitarism after parturition, usually preceded by postpartum hemorrhage. The first symptom of the disorder is lactation failure because of lactotroph cell necrosis. Recovery of lactotroph function after initial insult has not been reported in the literature. We describe the evaluation of a case of SS in whom lactotroph function recovered after the second pregnancy. A young woman delivered her first child at the age of 25 years; delivery was followed by severe postpartum hemorrhage and required blood transfusion. Sheehan's syndrome was diagnosed because of lactotroph, corticotroph, thyrotroph and somatotroph failure and empty sella on MRI. She conceived twice spontaneously and had normal lactation after the second delivery; investigations confirmed the normal basal and stimulable prolactin levels. We presume that recovery of lactotroph function after the second pregnancy in a patient with SS is possibly because of stimulatory effect of estrogen and progesterone on residual lactotroph cells.

A 27-year-old male was admitted with diabetic ketoacidosis and altered sensorium with slurring of speech and ataxia. He was managed with intravenous insulin and fluids and later shifted to basal bolus insulin regimen and during further evaluation was diagnosed to be suffering from primary hypothyroidism and adrenal insufficiency. He was started on thyroxin replacement and steroids only during stress. After three months of follow up he was clinically euthyroid. His glycemic control was adequate on oral anti-hyperglycemic drugs and adrenal insufficiency recovered. However, his thyrotropin levels were persistently elevated on adequate replacement doses of thyroxin. His repeat TSH was estimated after precipitating serum with polyethylene glycol which revealed normal TSH. Here we report reversible adrenal insufficiency with hypothyroidism with falsely raised TSH because of presence of heterophile antibodies in a case of poly glandular endocrinopathy syndrome.

Pituitary calcification occurs commonly in lactotroph or somatotroph adenoma but rare in chomophobe or gonadotroph adenoma. On imaging, it can mimic hemorrhage, hence may masquerade pituitary apoplexy if patient present with neurological manifestations. We present a case of pituitary calcification which mimicked pituitary apoplexy.