Objective : To determine the proportion of polycystic ovarian syndrome (PCOS) patients who have normal body mass index (BMI) and to compare the clinical, hormonal, and metabolic profile between lean and overweight patients of PCOS. Materials and Methods: One hundred consecutive infertile women with PCOS were studied and divided into lean (BMI between 18.5 and 23) and overweight (BMI ≥ 23). Metabolic and hormonal profile (serum FSH, LH, testosterone, prolactin, TSH on days 2-3 of menstrual cycle; serum progesterone premenstrually; serum insulin-fasting and 2 hours postglucose, glucose tolerance test, and fasting serum lipid profile) was performed along with pelvic sonogropahy; and clinical features, viz. waist hip ratio, hirsutism, acne, acanthosis nigricans, and clitoromegaly were recorded. Results: 42% of the PCOS subjects had normal BMI. Average age, hirsutism (80.9% vs. 89.7%), irregular cycles (92.8% vs. 96.6%), acne (9.5% vs. 15.5%), clitoromegaly (2.3% vs. 3.4%), endometrial thickness >4 mm (9.5% vs. 15.5%), and hormonal profile were similar in the lean and overweight PCOS groups. Family history of diabetes (9.5% vs. 24.1%), abnormal glucose tolerance test (GTT) (4.7% vs. 10.3%), deranged lipid profile (14.2% vs. 31%), and 2-hour postprandial insulin levels were higher in the overweight PCOS (P < 0.05). Insulin resistance was observed in 83.3% of lean PCOS but was still lower than 93.1% seen in overweight PCOS (P < 0.05). Conclusion: 42% of the PCOS had normal BMI, but clinical and hormonal profile was similar to PCOS patients with elevated BMI (overweight/obese). However, insulin resistance is observed in 83.3% of lean PCOS. Family history of diabetes, impaired GTT, deranged lipid profile, and insulin resistance were more prevalent in overweight PCOS.

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Aim: To evaluate the clinical profile and management of 46 XX Congenital Adrenal Hyperplasia (CAH) patients presenting with severe virilization and assigned a male gender. Materials and Methods: Of 173 children diagnosed with CAH at the Pediatric Intersex Clinic since 1980, seven children with CAH presented late with severe virilization and were reared as males. All of them were assigned the male sex with removal of the female adnexa. Six were treated with male genitoplasty. Appropriate hormonal supplementation was offered after puberty. Results: The mean age at presentation was 14.2 years (7 - 21). Six patients had presented after puberty, only one at seven years of age. Staged male genitoplasty comprising of chordee correction, male urethroplasty, and bilateral testicular prosthesis was performed. The female adnexa (uterus, ovaries, most of the upper vagina, and the fallopian tubes) were removed. The mental makeup was masculine in six and bigender in one. Bilateral mastectomy was performed at puberty in all. Hormonal treatment comprised of glucocorticoids and testosterone. Six patients were comfortable with the outcome of the masculinizing genitoplasty. One had a short-sized phallus. One had repeated attacks of urinary tract infection arising from the retained lower vaginal pouch. Social adjustments were good in all, except in one who had a bigender mental makeup. Conclusion: CAH patients with severe virilization presenting late and reared as males are extremely rare. However, the assigned gender can be retained adequately as males, meeting the socioeconomic compulsions of the society. The results are satisfactory following appropriate surgical procedures and hormonal supplementation.

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Diabetes Mellitus is a metabolic cum vascular syndrome with resultant abnormalities in both micro- and macrovasculature. The adverse long-term effects of diabetes mellitus have been described to involve many organ systems. Apart from hyperglycemia, abnormalities of angiogenesis may cause or contribute toward many of the clinical manifestations of diabetes. These are implicated in the pathogenesis of vascular abnormalities of the retina, kidneys, and fetus, impaired wound healing, increased risk of rejection of transplanted organs, and impaired formation of coronary collaterals. A perplexing feature of the aberrant angiogenesis is that excessive and insufficient angiogenesis can occur in different organs in the same individual. The current article hereby reviews the molecular mechanisms including abnormalities in growth factors, cytokines, and metabolic derangements, clinical implications, and therapeutic options of dealing with abnormal angiogenesis in diabetes.

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Advances in the treatment of diabetes have led to an increase in the number of injectable therapies, such as human insulin, insulin analogues, and glucagon-like peptide-1 analogues. The efficacy of injection therapy in diabetes depends on correct injection technique, among many other factors. Good injection technique is vital in achieving glycemic control and thus preventing complications of diabetes. From the patients' and health-care providers' perspective, it is essential to have guidelines to understand injections and injection techniques. The abridged version of the First Indian Insulin Injection technique guidelines developed by the Forum for Injection Technique (FIT) India presented here acknowledge good insulin injection techniques and provide evidence-based recommendations to assist diabetes care providers in improving their clinical practice.

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Lipodystrophy is a clinical disorder characterized by maldistribution of body fat. Hyperinsulinemia, insulin resistance, and abnormalities of glucose homeostasis are commonly described among these patients. Hyperinsulinemia is also involved in the pathogenesis of polycystic ovarian syndrome, a condition, described rarely in patients with lipodystrophy. Here, we describe 2 females of partial lipodystrophy who presented with features of polycystic ovarian disease. Both had severe hyperinsulinemia and irregular periods, one had hyperandrogenism and hirsuitism while the other was non-hirsuite.

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Contraception is an accepted route for the control of population explosion in the world. Traditionally hormonal contraceptive methods have focused on women. Male contraception by means of hormonal and non hormonal methods is an attractive alternative. Hormonal methods of contraception using testosterone have shown good results. Non hormonal reversible methods of male contraception like reversible inhibition of sperm under guidanceare very promising. In this article we have reviewed the current available options for male contraception.

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Diabetes has emerged as a disease of major public health importance in India affecting the rich and the poor alike. Conventionally, comprehensive diabetes management is aimed at preventing micro and macro vascular complications. However, morbidity and mortality due to infections are also significant. In developing countries like India, the concept of adult immunization is far from reality. Recently the H1N1 pandemic has triggered the necessity for considering immunization in all age groups for the prevention of vaccine-preventable fatal infectious diseases. Considering the economics of immunization in a developing country, providing free vaccines to all adults may not be a practical solution, although the free universal immunization program for children is in existence for several decades. There is no consensus on the use of vaccines in diabetes subjects in India. However, there are some clinics offering routine pneumococcal, influenza and other vaccinations. Patients with diabetes have a deranged immune system making them more prone for infections. Hospitalization and death due to pneumococcal disease and influenza are higher in diabetes patients. They, like other healthy individuals, have a normal humoral response to vaccination with clinically significant benefits. The American Diabetes Association, Advisory Committee on Immunization Practices, Centers for Disease Control and Prevention, World Health Organization, United Kingdom Guidelines and a number of other scientific organizations have well defined guidelines for vaccination in diabetes. In this article we make some suggestions for clinicians in India, regarding use of vaccines in subjects with diabetes.

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Primary hyperparathyroidism is a disease characterized by excessive secretion of parathormone. During the course of this disease, bone loss occurs, particularly depending on resorption of the skeletal system. One of the complications of primary hyperparathyroidism is fibrotic, cystic bony changes which is called Brown tumor. Skeletal manifestations in the form of Brown tumors are rare and according to literature occur in less than 2% of patients suffering from any form of hyperparathyroidism. Such rare and multiple benign lesions may simulate a malignant neoplasm and pose a real challenge for the clinician in its differential diagnosis. We present a case of a 23-year-old Indian woman who was evaluated for multiple lytic expansile lesions with a strong suspicion of malignancy and fibrous dysplasia but turned out to be a case of primary hyperparathyroidism.

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Introduction: Hypomagnesemia is reported in type 2 diabetes; magnesium deficiency may play a role in the development of endothelial dysfunction and altered insulin function. Objective: To assess the incidence of hypomagnesemia among noncritically ill patients of Type 2 diabetes mellitus and to evaluate the relation of hypomagnesemia to glycemic control and various long-term complications of diabetes mellitus. Materials and Methods: One hundred and fifty, noncritically ill (APACHE score < 10) type 2 diabetes mellitus patients, who were admitted in the Departments of Medicine and Endocrinology, GMCH for uncontrolled hyperglycemia and/or various diabetic complications were studied. Serum magnesium was assessed at admission and rechecked in those found to be deficient. Results: Hypomagnesemia (Se magnesium < 1.6 mg/dl) was documented in 17 (11.33%) patients with a female:male ratio of 9:8. Mean HbA1c was 11.9% in the hypomagnesemic patients compared with 9.8% in controls (P =0.0016). Retinopathy, microalbuminuria, macroalbuminuria, foot ulceration, and neuropathy was present in 64%, 47%, 17.64%, 58.8%, and 82.35%, respectively, of the patients with hypomagnesemia as compared with 45.8% (P =0.118), 38.34% (P =0.704),15.03% (P =0.566), 22.55% (P =0.011) and 82.7% (P =0.976) without hypomagnesemia. Coronary artery disease was less common in the hypomagnesemia group (17.6% vs 39%), but comparable in the subgroup < 50 years (27% vs 25%) (P =0.796). Conclusion: Hypomagnesemia in diabetes was associated with poorer glycemic control, retinopathy, nephropathy, and foot ulcers.

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The epidemic of type 2 diabetes and the recognition that achieving specific glycemic goals can substantially reduce morbidity have made the effective treatment of hyperglycemia a top priority. Despite compelling evidence that tight glycemic control is crucial for delaying disease progression, increased risk of hypoglycemia associated with such control underscore the complexity of diabetes management. In most cases, hypoglycemia results from an excess of insulin, either absolute or relative to the available glucose substrate and the factors perhaps exacerbating the risk are pharmacokinetic imperfections, behavioral, co-morbidities etc. Additionally, many patients remain undiagnosed, and many diagnosed patients are not treated appropriately. In this article, the challenges of hypoglycemia, confronting health care providers and their patients with diabetes, are discussed for making treatment decisions that will help minimize risk of hypoglycemia and eventually overcome formidable barriers to optimal diabetes management. Strategies to treat and minimize the frequency and severity of hypoglycemia without compromising on glycemic goals are also presented.

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Introduction: Polycystic ovary syndrome (PCOS) is a common endocrinopathy of women of child-bearing age. Although some studies have suggested an association between PCOS and autoimmune thyroiditis, to our knowledge, only a few cases indicating association between PCOS and Graves' disease are reported. Objective: We aim to describe this first case series of six women presenting with PCOS and Graves' disease together. Materials and Methods: Women attending the endocrinology clinic at a tertiary care centre in north India and fulfilling the AE-PCOS criteria for diagnosis of PCOS were studied using a predefined proforma for any clinical, biochemical and imaging features of Graves' disease. Results: The series consisted of six women with a mean age of 27.5 years and menarche as 12.6 years. All women were lean with mean BMI of 22.73 kg / m ² and three out of six had waist circumference <80 cm. The mean FG score of subjects was 16.66 and average total testosterone was 77.02 ng / dl (25.0-119.64). All the patients had suppressed TSH, the average being 0.052 μIU/ml (0.01-0.15). Thyroid gland was enlarged in all clinically and on ultrasonography and imaging with ^99m Tc and/or RAIU revealed diffuse increased uptake. Conclusions: The association of a rare disorder like Graves' disease with a relatively common disorder like PCOS is unlikely to be because of a chance alone and may point to a common aetiopathogenic linkage leaving a scope for molecular characterization.

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Background: Pheochromocytoma/paragangliomas have been described to be associated with rare vascular abnormalities like renal artery stenosis. Coexistence of physiologically significant renal artery lesions is a compounding factor that alters management and prognosis of pheochromocytoma patients. Apart from individual case reports, data on such association in Indian population is not available. The aim of this study is to find the nature and prevalence of associated vascular abnormalities. Materials and Methods: From 1990 to 2010, a total of 50 patients were diagnosed with pheochromocytoma/paragangliomas. Hospital charts of these patients were reviewed retrospectively to identify those with unusual vascular abnormalities. Available literature was also reviewed. Results: Of the 50 patients with pheochromocytoma, 7 (14%) had coexisting vascular lesions including renal artery stenosis in 4, aortoarteritis in 1, aortic aneurysm in 1 and inferior vena cava thrombosis in 1. Pheochromocytoma was adrenal in 42 and extra adrenal in 8. Laparoscopic adrenalectomy was done in the patients. One patient with renal artery stenosis due to intimal fibrosis was subjected to percutaneous balloon angioplasty; the other three improved after adrenalectomy and lysis of fibrous adhesive bands. The patient with aortoarteritos was treated with oral steroids. Inferior vena cava thrombosis was reversed with anticoagulants. The patient with abdominal aortic aneurysm was advised for annual follow-up on account of its size of 4.5 cm and asymptomatic presentation. Conclusion: There are multiple mechanisms that can lead to renal artery stenosis and other vascular abnormalities in a case of pheochromocytoma. A high index of suspicion is necessary to enable both entities to be diagnosed preoperatively and allow proper planning of surgical therapy. Incomplete diagnosis may lead to persistent hypertension postoperatively in a case of associated renal artery stenosis.

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The essence of writing for publication in the medical field is distilled into a dozen precepts to guide the anxious author. These precepts focus on the attitude of the writer, rather than the mechanics of writing. A medical author must strive to be the following: Original, honest, innovative, organized, careful, clear, modest, fair-minded, frank, persistent, rigorous, and realistic. These attributes are essential because there is a new climate of skepticism among the lay public as to the validity of scientific and medical claims. This climate has encouraged journal editors to be demanding of authors and to be especially vigilant about plagiarism; originality of all contributions is therefore essential.

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An increased incidence of Type 1 diabetes mellitus (T1DM) is expected worldwide. Eventually, T1DM is fatal unless treated with insulin. The expansion of interventions to prevent diabetes and the use of alternative treatments to insulin is a dream to be fulfilled. The pathophysiology in T1DM is basically a destruction of beta cells in the pancreas, regardless of which risk factors or causative entities have been present. Individual risk factors can have separate patho-physiological processes to, in turn, cause this beta cell destruction. Currently, autoimmunity is considered the major factor in the pathophysiology of T1DM. In a genetically susceptible individual, viral infection may stimulate the production of antibodies against a viral protein that trigger an autoimmune response against antigenically similar beta cell molecules. Many components of the immune system have been implicated in autoimmunity leading to β-cell destruction, including cytotoxic and helper T-cells, B-cells, macrophages, and dendritic cells. The inflammatory process in early diabetes is thought to be initiated and propagated by the effect of Th1-secreted cytokines (e.g. g interferon) and suppressed by Th2-secreted antiinflammatory cytokines (interleukins). Structure and function of β-cell may be modulated by using Th1/Th2-secreted cytokines. Several experimental and clinical trials of applying GAD65, Hsp60, peptide-MHC, pepetide-277 immunization, anti-CD3 infusion, and interleukins to modulate immune response in T1DM were done. Applying such trials in patients with prediabetes, will most likely be the future key in preventing Type 1 autoimmune diabetes.

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Background: C-reactive protein (CRP), which is a marker of inflammation, has not been widely studied in inflammatory thyroid disorders particularly in sub-acute thyroiditis (SAT). Aim: This study was aimed to find the significance of CRP level rise in patients with SAT and compare that to the rise in erythrocyte sedimentation rate (ESR), a gold standard laboratory parameter in establishing the diagnosis of SAT. Materials and Methods: Serum CRP levels were measured at initial presentation in 28 subjects with SAT(12 male, 16 female, age (Mean +SD) 37.96 ±8.5 years),and 19 patients with Graves' disease (2 male, 17 female, age [Mean +SD] 36.8 ±16.5 years) as controls. Erythrocyte sedimentation rate (ESR) was measured in all 28 patients with SAT by Westergrens' method. Either Tc ⁹⁹ nucleotide thyroid scan or high resolution ultrasonography (HR-USG) was performed to differentiate SAT from Graves' disease.Fine needle aspiration cytology (FNAC) of thyroid was performed selected patients. Results: Serum CRP level was high in 61% of SAT patients but in none of the Graves'patients. Mean (SEM) (90%CI) serum CRP level (mg/L) was also significantly higher (P <0.0004) in the SAT group [27.55 (5.76) (15.72-39.38)], than in the Graves' group [4.09 (0.12) (3.81-4.36)]. The sensitivity of serum CRP was 73.33%, specificity 53.85%, positive predictive value (PPV) 64.71%, and negative predictive value (NPV) 63.64% as compared to the sensitivity (53.57%), specificity (15.38%), PPV (57.69 %), and NPV (13.33%) of ESR. Conclusion: There is significantly higher rise in serum CRP level in patients with SAT is compared to patients with Graves' disease. It correlates well with the rise in ESR. Such findings of this pilot study highlight the scope of using serum CRP as a diagnostic marker of SAT specially in situations when it may be confused with Graves' disease, another common cause of thyrotoxicosis. It is logical to carry out studies to find a particular cut-off for serum CRP which can serve as an objective parameter for grading the inflammation in patients with SAT.

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Background: One dietary strategy aimed at improving both diabetes control and control of cardiovascular risk factors is the use of low glycemic index diets. These diets have been reported to be beneficial in controlling diabetes, and also increase high density lipoprotein cholesterol (HDL-C), lower serum triglyceride, and reduce glycated protein. Aim: Therefore, we aimed to investigate the effect of a low glycemic index-low glycemic load (GL = 67-77) diet on lipids and blood glucose of poorly controlled diabetic patients. Materials and Methods: In an intervention study, 100 poorly controlled diabetic patients (age 52.8 ± 4.5 years) who were taking insulin or on oral medication underwent administration of low GL diet (GL = 67-77; energy = 1800-2200 kcal, total fat = 36%, fat derived from olive oil and nuts 15%, carbohydrate = 41%, protein = 22%) for 10 weeks. Patients were recommended to follow their regular lifestyle. Total cholesterol, low density lipoprotein (LDL), HDL, triglyceride, glycated hemoglobin (HbA1c), weight, and body mass index (BMI) were measured before and 10 weeks after the intervention. Results: Before intervention, initial blood cholesterol and triglyceride concentrations were 205.9 ± 21.6 and 181.5 ± 22.2, respectively, and were reduced to 182.6 ± 18.2 and 161.6 ± 16.7, respectively, after 10 weeks intervention (P < 0.001). LDL reduced and HDL increased significantly. The HbA1c percentage reduced by 12% (from 8.85 ± 0.22% to 7.81 ± 0.27%) (P < 0.001), and also their weight significantly reduced from 74.0 ± 5 kg to 70.7 ± 4.6 kg (P < 0.001). Conclusion: This study demonstrated that low GL diet having lower carbohydrate amount and higher fat content is an appropriate strategy in blood lipid and glucose response control of poorly controlled diabetic patients.

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Kocher-Debre-Semelaigne (KDS) syndrome is a rare form of hypothyroid myopathy, with associated hypertrophy of muscles. Although cardiac manifestations of hypothyroidism are well known, reports of cardiac involvement in KDS have only described the occurrence of pericardial effusion as an association. This report describes an adolescent male presenting with typical features of this rare syndrome along with arrhythmogenic right ventricular cardiomyopathy/dysplasia (ARVC/D), an association not yet described in the literature.

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Objective: We evaluated the thyroid function tests in individuals with metabolic syndrome to explore the possibility of thyroid receptor resistance. Materials and Methods: The study was a cross-sectional study. It included 40 patients (group I) and 20 healthy individuals served as controls (group II). Patients in group I fulfilled the three or more of the NCEP ATP III (National Cholesterol Education Programme - Adult Treatment Panel III) criterion to define the metabolic syndrome. Blood sugar and serum insulin levels were measured in both the groups. All the patients (group I) had insulin resistance as per the HOMA IR (the homeostasis model for insulin resistance) model. The HOMA IR value obtained in group II individuals served as a reference mark to define insulin resistance. T ₃ , T ₄ , TSH levels were measured as indicators of thyroid functions. There was an increase in TSH levels with normal T ₃ and T ₄ in group I indicating that increased TSH probably due to thyroid receptor resistance may be a part of metabolic syndrome rather than a state of hypothyroidism. Results: T ₃ and T ₄ levels were comparable in patients and controls. There was a significant increase in TSH levels in patients as compared to the controls. Conclusion: Raised TSH in patients with metabolic syndrome independent of lowered T ₃ and T ₄ suggest it to be a part and parcel of this syndrome.

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Background: Though cardiac involvement is common in acromegaly, overt congestive heart failure is uncommon. Materials and Methods: This is retrospective analysis of hospital record between 1996 and 2007. We analyzed records of 150 consecutive patients with acromegaly. We included the patients with acromegaly those who had overt congestive heart failure either at presentation or during the course of illness for the present analysis. The diagnosis of acromegaly and congestive cardiac failure were based on standard criteria. Results:Out of 150 patients with acromegaly, 6 patients had overt CHF (4.0%), of which 4 presented with the features of CHF and 2 developed during the course of illness. Three patients had hypertension and 1 had diabetes. Baseline echocardiography showed severe biventricular dysfunction and global hypokinesia in all. Angiography showed dilated hypokinetic left ventricle with normal coronaries in 3, it was confirmed at autopsy in 1. Three underwent trans-sphenoidal surgery, 1 received somatostatin analogue as primary treatment modality. Normalization of growth hormone and IGF-1 led to improvement in cardiac function in 1, 1 patient lost to follow up, and 4 died during the course of illness. In 1 patient, autopsy was performed and cardiac specimen revealed normal coronaries, concentric ventricular hypertrophy, and dilatation with myofibrolysis and interfascicular fibrosis. Conclusion:Prevalence of overt CHF is 4% in present series. Overt CHF carries poor prognosis and hence, this complication should be recognized at earliest, and medical management to normalized cardiac function should be given utmost priority.

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Polycystic Ovary Syndrome (PCOS) is a leading cause of infertility. We studied the rheological properties of cervical-vaginal secretions in five PCOS patients during variable treatment intervals with metformin. Five ovulatory normal women for a total of thirteen cycles served as control patients. All subjects collected daily cervical-vaginal fluid(CVF) samples with an aspirator, and CVF samples were characterized by a flow metric, die swell ratio (B), which measured CVF elasticity. Ovulatory cycles were indexed to the day of positive urine or serum LH (luteinizing hormone). CVF B levels from ovulatory normal women had a characteristic concave parabolic pattern of a minimum near the day of ovulation with higher values outside the periovulatory phase. In contrast, the five PCOS patients with or without metformin treatment had no periodicity of CVF B, and their CVF B levels were typically less compared to those in the early preovulatory and luteal phases of normal patients.

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Background: The details about the research productivity in the specialty of endocrinology from India is lacking. We plan to assess the publishing trends and the research productivity of Endocrinology related research articles published in the Journal of the Association of Physicians of India (JAPI). Materials and Methods: We carried the bibliometric analysis of endocrinology related articles from JAPI. The data were obtained from the JAPI website for the publications between 2000 and 2011. The articles were analyzed for the type (original article, case reports, correspondence, and pictorial image), subspecialty (diabetes, thyroid, etc.), and place of the research. Data were presented with descriptive statistics in numbers and percentages. Results: Out of a total 2977 articles published by JAPI, 312 articles belong to endocrine subspecialty. Endocrinology related articles constitute about 11.2%-23.2% of the published articles per year in JAPI and the percentage is increasing every year. Original articles (52%) and case reports (27%) constituite the majority, while the rest were letters to editor (9%) and pictorial images (12%). Diabetes (57%) and metabolic bone disorders (16%) lead the subspecialty articles, followed by thyroid (9%), adrenal and gonad (8%), and pituitary (8%). Chennai (20%), Mumbai (14%), and Delhi (9%) are the top 3 places contributing to the articles followed by Chandigarh and Varanasi. Conclusion: Majority of endocrinology related research productivity is seen in form of original articles and case reports. Diabetes is the leading disease with maximum research articles from Chennai and other glands are equally represented in the research productivity.

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Objective: Women with polycystic ovary syndrome (PCOS) may represent a large underappreciated segment of female population who is at increased cardiovascular risk because of the presence of cluster of metabolic abnormalities. The aim of our study was to assess atherosclerotic risk factors in women with PCOS. Materials and Methods: In a cross-sectional study, 50 women with PCOS and 50 age and weight-matched healthy controls were enrolled. Endothelial dysfunction by flow-mediated dilatation (FMD) of brachial artery, highly sensitive C-reactive protein (hs CRP), and carotid intima media thickness (CIMT) were measured in both cases and control groups. Results: The mean age of women with PCOS was 26.82 ± 3.26 years and Body-mass index (BMI) of 26.2 ± 4.8 kg/ m ² . Thirty-six (72%) patients were overweight or obese,54% had central obesity and 12% had impaired glucose tolerance. Among the markers of atherosclerosis, hsCRP levels were nonsignificantly higher in patients with PCOS than in controls. The FMD was 12.18 ± 2.3% vs 8.3 ± 2.23% in patients with PCOS and controls respectively (P=0.01). CIMT was significantly different in two study groups (0.68 ± 0.11 in PCOS vs 0.52 ± 0.02 in normal subjects, (P=0.01). FMD had significant negative correlation with homeostasis model assessment (HOMA) index (r = −0.32, P=0.02) and hs CRP (r = −0.37, P=0.04) while hs CRP was correlated with BMI (r = 0.54, P=0.005), HOMA (r = 0.38, P=0.02) and FMD (r = -0.33, P=0.01). CIMT was significantly different in women with PCOS and control subjects, and it had significant correlation with age (r = 0.42, P=0.03), BMI (r = 0.36, P=0.01), waist circumference (r = 0.52, P=0.001) and HOMA (r = 0.31, P=0.04). Conclusion: Women with PCOS definitely have increased risk for future cardiovascular events. Clinicians should consider early cardiovascular screening and interventions to control all modifiable cardiovascular risk factors.

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Background: In congenital adrenal hyperplasia (CAH), long-term glucocorticoid treatment coupled with increased androgens may lead to undesirable metabolic effects. The aim of our report was to determine the prevalence of metabolic abnormalities and cardiovascular risk factors in a population of adult patients with CAH due to 21 hydroxylase deficiency. Materials and Methods: Twenty-six patients (11 males and 15 females, mean age ± SD=27.4±8.2 years) were recruited. Anthropometry, body composition, metabolic parameters and cardiovascular risk factors were studied. Results: Obesity (overweight included) was noted in 16 patients (61.5%), with android distribution in all cases. Bioelectrical impedance showed increased body fat mass in 12 patients (46.1%). Lipid profile alterations and carbohydrate metabolism disorders were detected in seven (26.9%) and five (19.2%) patients respectively. Moderate hepatic cytolysis, associated with hepatic steatosis, was found in one patient. Seven patients (27%) had insulin resistance. Ambulatory blood pressure monitoring showed abnormalities in six patients (23%). Increased carotid intima media thickness was found in 14 patients (53.8%). Conclusion: Adult CAH patients tend to have altered metabolic parameters and a higher prevalence of cardiovascular risk factors. Lifelong follow-up, lifestyle modifications, and attempts to adjust and reduce the glucocorticoid doses seem important.

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Introduction: Non-alcoholic fatty liver disease (NAFLD) is associated with Type 2 diabetes (T2DM) and the metabolic syndrome, and can progress to chronic liver disease. We examined the incidence of elevated (>35 iu/l) alanine transaminase (ALT), as a surrogate marker for NAFLD, in patients with newly diagnosed T2DM. Materials and Methods: Retrospective analysis of ALT with metabolic parameters, in 606 consecutive patients presenting to district wide education sessions for newly diagnosed T2DM. Results: ALT was elevated in 155 patients (25.6% (95% CI 22.1, 29.2)), who tended to be older (mean difference 7.3 years (5.2, 9.5), P < 0.001), heavier (body mass index (BMI) mean difference 2.0 kg/m ^{2 (} 1.0, 3.0), P < 0.001), and more likely to be male (M:F raised ALT 104:51, normal ALT 219:232, P < 0.001), with higher triglycerides (median difference 0.2 mmol/l, P = 0.001) and lower HDL cholesterol (mean difference 0.09 mmol/l (0.02, 0.15), P = 0.001). There were no statistically significant differences in HBA1C or total cholesterol. Conclusions: In a well-defined population of newly diagnosed people with T2DM, there is a high incidence of abnormal ALT levels, which is associated with features of the metabolic syndrome (obesity and lipid abnormalities), but not glycemic control.

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Context: Effect of parenteral testosterone esters administration on bone-mineral density (BMD) and bone turnover in young age onset male hypogonadism is not studied in Indian subjects. Aims: To prospectively study the effect of short-term (6 months) replacement therapy with parenteral testosterone enanthate-propionate combination on BMD and bone turnover markers in hypogonadal adult patients. Settings and Design: Prospective, tertiary care academic center. Materials and Methods: Thirteen young, otherwise healthy hypogonadal males (age 25.5 ± 4.9 yrs, serum testosterone 2.56 ± 4.29 nmol/l) were subjected to BMD measurements (DXA) and estimation of urinary Crosslaps™ and serum osteocalcin at baseline. Twelve healthy age and BMI-matched males served as controls for BMD measurements. The hypogonadal patients were administered parenteral testosterone esters (as mixed enanthate and propionate) 250 mg i.m. every 2-3 weeks, and prospectively followed for 6 months. BMD and bone markers were studied at the end of 6 months. Statistical Analysis Used: Mann-Whitney nonparametric test, paired t-test and Pearson's test of two-tail significance. Results: At baseline, BMD was significantly lower in hypogonadal males as compared to that in controls. With testosterone replacement, there was significant improvement in BMD, both at trabecular and cortical sites, There was a decline in bone turnover with treatment (Ur Crosslaps™:creatinine ratio: pretreatment 72.8 ± 40.4, post-treatment 35.5 ± 23.8 μg/mmol, P = 0.098; serum osteocalcin: pre-treatment 41.0 ± 16.8, post-treatment 31.7 ± 2.1 ng/ml, P = 0.393). Conclusions: Short-term parenteral testosterone replacement significantly improves BMD at the hip, lumbar spine and forearm in hypogonadal young males.

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Metformin is one of the most commonly prescribed drugs for management of Type 2 diabetes mellitus. It has been in use for almost five decades. Now, pharmacological properties of this agent are being exapted for use in a number of other indications. New facets of its personality are coming up, generating more interest of the scientific community in this "middle-aged" molecule. This article explores the role of metformin in cardioprotection and its hepatoprotective properties. Nephroprotective, protection against excess body fat and gonadoprotective actions, properties have also been discussed. Additionally, this manuscript briefly reviews the thyroid stimulating hormone (TSH)-lowering properties in diabetic and non-diabetic patients, besides reviewing its actions on different types of cancers. Some of these actions may become approved indications for use of metformin following generation of new evidence. Metformin still has many unexplored dimensions that deserve further exploration.

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Pituitary thyrotroph hyperplasia with hyperprolactinemia has been described as a rare presentation of primary hypothyroidism. Premenopausal females with this disorder can present with features of hypothyroidism, menstrual disturbances, galactorrhea, and visual field defects because of enlarged pituitary. Here we describe a 32-year-old female presenting to her gynecologist primarily with galactorrhea and secondary amenorrhea. She was found to have raised serum prolactin, and MRI brain showed enlarged pituitary. She was referred for pituitary surgery when she came to us. Clinical examination and biochemistry were suggestive of primary hypothyroidism. She was prescribed levothyroxine replacement. At 6 weeks follow-up, serum prolactin came down to normal, galactorrhea subsided, and spontaneous menstrual cycles resumed. In 12 weeks, pituitary enlargement completely regressed and in another month after that, she conceived. Hence, primary hypothyroidism can present with thyrotroph hyperplasia, where correct diagnosis and levothyroxine therapy can prevent unnecessary pituitary surgery. Hyperprolactinemia in this setting is of no clinical significance.

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Background: Regulatory T cells have an important role in the control of immune reactivity against self antigens and probably play a role in pathogenesis of type 1 diabetes (T1D). We aimed to determine the frequency of regulatory T cells in recently diagnosed children with/T1D. Materials and Methods: 20 children with/T1D and 20 healthy children of matched age and sex as controls were enrolled in this study. All cases were subjected to a thorough history taking, full clinical examinations and investigations which include; insulin C peptide levels and flow cytometric detection of B-, T-lymphocytes and regulatory T cells. Results: Insulin C peptide level was significantly lower in children with/ T1D compared with controls. The percentages of B and T-lymphocytes were not significantly different between patients and controls. The percentages of CD4+CD25+High and CD4+CD25+High Foxp3+ cells both in total lymphocytes and in CD4+ lymphocytes were significantly decreased in patients than controls, while the percentages of total CD4+CD25+ and CD4+CD25+Intermediate both in total lymphocytes and in CD4+ lymphocytes were not significantly different between patients and controls. The geometric mean of fluorescence intensity (MFI) of Foxp3+ expression in CD4+CD25+High cells was significantly decreased in patients than controls. Positive correlations were observed between both age and insulin C peptide and frequency of CD4+CD25+High Foxp3. Conclusion: The percentage of regulatory T cells; CD4+CD25+High Foxp3 was decreased in children with recent T1D and may have a role in its pathogenesis. Their role as a prognostic signifi cance and their relation to various complications should be explored.

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Pregnancy in a patient with acromegaly is a rare occurrence. Here in, we report a patient with acromegaly who presented to us in the 2 ^nd trimester of pregnancy with visual loss in the right eye. Her vision improved after surgery. She went on to have an uneventful pregnancy and delivered a term baby, by caesarian section. One year following her delivery, she received stereotactic radiotherapy. Subsequent follow-up revealed that her tumor had regressed and her IGF-1 levels had normalized.

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An 82-year-old male, a known case of severe osteoporosis with vertebral fracture and prostatic carcinoma, was treated with gonadotropin releasing hormone analogue, calcium carbonate, cholecalciferol sachet and injection teriparatide. His diet consisted of milk and curd. He developed altered behavior and generalized weakness, and on investigation, hypercalcemia, hypokalemia, and metabolic alkalosis with low parathyroid hormone levels were detected. Injection teriparatide was stopped and he was managed with forced saline diuresis and injection zoledronic acid. He was diagnosed as a case of milk alkali syndrome in whom teriparatide and prolonged immobilization played a permissive role in the development of hypercalcemic encephalopathy.

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We report of an 18-year-old male who presented with an epileptiform disorder, features of hypocalcemia, and an extrapyramidal symptom in the form of choreoathetosis. On evaluation he had idiopathic hypoparathyroidism with extensive calcifications in the extrapyramidal system of the brain; basal ganglion, as well as in the cerebral cortex and cerebellum, which is a rare entity. We report the rare presentation of a common disorder, which requires to be considered in evaluating hypoparathyroidism.

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Aim of Study: To assess the utility of internal jugular vein (IJV) / peripheral adrenocorticotropic hormone (ACTH) gradient in determining the etiology of ACTH- dependent Cushing's syndrome. Materials and Methods: Patients with ACTH-dependent Cushing's syndrome, (except children less than 12 years), had IJV blood collection under ultrasound guidance using a linear 7 MHZ probe. Blood was collected with a 21 G needle at the level of mandible with the patient in supine position. Six ml of blood was collected sequentially from right and left internal jugular veins for ACTH and prolactin estimation. Peripheral blood for ACTH and prolactin was taken from a previously placed IV cannula in the antecubital vein. Results: Thirty patients (20 F, 10 M, age 14 to 50 yrs) were enrolled for this study. Source of ACTH excess was pituitary in 22, ectopic ACTH in 4, and unknown in 4 cases. Using an IJV: Peripheral ACTH ratio of ≥ 1.6, 15 out of 22 Cushing's disease patients were correctly identified. However, 1 out of 4 ectopic Cushing also had IJV: Peripheral ratio ≥ 1.6. Overall, it had sensitivity of 68% with specificity of 75% while MRI pituitary and HDDST had sensitivity of 86% and 59%, respectively, with specificity of 100% each. Conclusion: IJV: Peripheral ACTH gradient was observed in 68% of patients with Cushing's disease. Simultaneous IJV and peripheral sample collection with CRH stimulation may improve sensitivity and specificity of this test.

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A patient with microprolactinoma, who had two successful pregnancies, is described for management issues. First pregnancy was uneventful. During the second pregnancy, the tumor enlarged to macroprolactinoma with headache and blurring of vision which was managed successfully with bromocriptine. Post delivery, complete disappearance of the tumor was documented.

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Renal artery stenosis (RAS) often coexists with pheochromocytoma (Pheo)/paraganglioma (PGL) and often alters the management of patients with Pheo/PGL. We have studied the prevalence of RAS in our Pheo/PGL patients. The study included 70 consecutive, histopathologically proven Pheo/PGL patients from a tertiary health care center. In 60 patients, tumors were limited to adrenal glands (54 unilateral and 6 bilateral) while other 10 patients had extra-adrenal abdominal tumors. Five patients had RAS with an overall prevalence of 14%. Only two out of 60 patients with Pheo had RAS with a low prevalence of 3.3% while three out of 10 patients with extra-adrenal abdominal PGL had RAS with a prevalence of 30%. To conclude, RAS commonly coexists with Pheo/PGL, more often with extra-adrenal PGL.

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