Background: Hypothyroidism is believed to be a common health issue in India, as it is worldwide. However, there is a paucity of data on the prevalence of hypothyroidism in adult population of India. Materials and Methods: A cross-sectional, multi-centre, epidemiological study was conducted in eight major cities (Bangalore, Chennai, Delhi, Goa, Mumbai, Hyderabad, Ahmedabad and Kolkata) of India to study the prevalence of hypothyroidism among adult population. Thyroid abnormalities were diagnosed on the basis of laboratory results (serum FT3, FT4 and Thyroid Stimulating Hormone [TSH]). Patients with history of hypothyroidism and receiving levothyroxine therapy or those with serum free T4 <0.89 ng/dl and TSH >5.50 μU/ml, were categorized as hypothyroid. The prevalence of self reported and undetected hypothyroidism, and anti-thyroid peroxidase (anti-TPO) antibody positivity was assessed. Results: A total of 5376 adult male or non-pregnant female participants ΃18 years of age were enrolled, of which 5360 (mean age: 46 ± 14.68 years; 53.70% females) were evaluated. The overall prevalence of hypothyroidism was 10.95% (n = 587, 95% CI, 10.11-11.78) of which 7.48% (n = 401) patients self reported the condition, whereas 3.47% (n = 186) were previously undetected. Inland cities showed a higher prevalence of hypothyroidism as compared to coastal cities. A significantly higher ( P < 0.05) proportion of females vs. males (15.86% vs 5.02%) and older vs. younger (13.11% vs 7.53%), adults were diagnosed with hypothyroidism. Additionally, 8.02% (n = 430) patients were diagnosed to have subclinical hypothyroidism (normal serum free T4 and TSH >5.50 μIU/ml). Anti - TPO antibodies suggesting autoimmunity were detected in 21.85% (n = 1171) patients. Conclusion: The prevalence of hypothyroidism was high, affecting approximately one in 10 adults in the study population. Female gender and older age were found to have significant association with hypothyroidism. Subclinical hypothyroidism and anti-TPO antibody positivity were the other common observations.

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Alcohol is one of the commonest illicit psychoactive substances consumed globally and is the world's third largest risk factor for disease and disability. It has been reported to have multiple effects on the hypothalamo-pituitary-thyroid axis and the functioning of the thyroid gland. It has been reported to cause direct suppression of thyroid function by cellular toxicity, and indirect suppression by blunting thyrotropin-releasing hormone response. It causes a decrease of peripheral thyroid hormones during chronic use and in withdrawal. Alcohol use may also confer some protective effect against thyroid nodularity, goiter, and thyroid cancer. This article presents a review of the clinically relevant effects of alcohol on the functioning of the thyroid gland and also discusses the effect of medication used in treatment of alcohol dependence on thyroid function.

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The kidneys play a major role in glucose homeostasis through its utilization, gluconeogenesis, and reabsorption via sodium glucose cotransporters (SGLTs). The defective renal glucose handling from upregulation of SGLTs, mainly the SGLT2, plays a fundamental role in the pathogenesis of type 2 diabetes mellitus. Genetic mutations in a SGLT2 isoform that results in benign renal glycosuria, as well as clinical studies with SGLT2 inhibitors in type 2 diabetes support the potential of this approach. These studies indicate that inducing glycosuria by suppressing SGLT2 can reduce plasma glucose and A1c levels, as well as decrease weight, resulting in improved β-cell function and enhanced insulin sensitivity in liver and muscle. Because the mechanism of SGLT2 inhibition is independent of insulin secretion and sensitivity, these agents can be combined with other antidiabetic agents, including exogenous insulin. This class represents a novel therapeutic approach with potential for the treatment of both type 2 and type 1 diabetes.

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Glycemic control and its benefits in preventing microvascular diabetic complications are convincingly proved by various prospective trials. Diabetes control and complications trial (DCCT) had reported variable glycated hemoglobin (HbA1C) as a cause of increased microvascular complications in conventional glycemic control group versus intensive one. However, in spite of several indirect evidences, its link with cardiovascular events or macrovascular complications is still not proved. Glycemic variability (GV) is one more tool to explain relation between hyperglycemia and increased cardiovascular risk in diabetic patients. In fact GV along with fasting blood sugar, postprandial blood sugar, HbA1C, and quality of life has been proposed to form glycemic pentad, which needs to be considered in diabetes management. Postprandial spikes in blood glucose as well as hypoglycemic events, both are blamed for increased cardiovascular events in Type 2 diabetics. GV includes both these events and hence minimizing GV can prevent future cardiovascular events. Modern diabetes management modalities including improved sulfonylureas, glucagon like peptide-1 (GLP-1)-based therapy, newer basal insulins, and modern insulin pumps address the issue of GV effectively. This article highlights mechanism, clinical implications, and measures to control GV in clinical practice.

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Diabetes is the ninth leading cause of death in women globally. In South Asians mortality in women with diabetes stands second highest. There is a marked gender discrimination which is faced by women across South Asia esp in access to services and support for diabetes, resulting in high rates of morbidity and mortality in women with diabetes. The most important risk factor identified for the diabetes epidemic is obesity along with genetic susceptibility. Lack of health care, social and cultural disparity, discrimination at work, disparity in marriage, restricted medical facilities are prevalent. Diabetes and depression are common in women. Increasing age, low level of education, low socioeconomic conditions, difficulties posed in finding partners, frequent divorce and family history of psychiatric illness are significant risk factors for diabetes and depression. Such patients usually have poor metabolic control, higher complication rates, increased healthcare costs, lost productivity, lower quality of life as well as increased risk of death.Preconception counseling should be incorporated in the routine diabetes clinic visit for all women of childbearing potential. Women with diabetes should have information and access to contraception. Proper family planning counseling and psychological support can help stop practices such as female foeticide and multiple pregnancies. Psychological support to patients and their families are needed to break the barrier.There is emerging evidence that women with diabetes are more prone to untoward outcomes as compared to men. Central obesity, metabolic syndrome and the polycystic ovary syndrome show ethnic specific differences in South Asian women. Optimal sexuality is an integral part of holistic health. Shortage of trained female health care professionals, lack of privacy in over-crowded health care facilities, a social taboo attached to such matters, and lack of confidence in patients contribute to the neglect of sexual issues in women attending diabetes clinics across South Asia. Guidelines for counselling in female sexual dysfunction, written in culturally appropriate manner for South Asia, are needed. Diabetes affects women more severely because of their unique biological, cultural and socioeconomic circumstances. Women have limited access to health care facilities because of illiteracy, ignorance and negative social customs. Transcending the gender hierarchy and inequality is a formidable challenge. Sensitising men, empowering women on self care and providing peer support maybe the answer to this challenge. It is essential for health care providers to use appropriate coping mechanism such as building psychological contact with the patient, including family and friends as part of social support and empower patient with complete process of managing diabetes. Increasing awareness through the media, seminars, posters, group discussions and education, regular monitoring and consulting the doctor, support group for women and facilities for aerobic exercises are recommended. The health care systems should consider custom-designed prevention and control programs tailored for women based on local and regional attitudes on health care, cultural beliefs, and available social support systems. Policies that empower adolescent girls and young women to take control of their metabolic management must be encouraged. Provision of gender specific diabetes education with a holistic life-cycle approach is recommended.

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Adult Treatment Panel (ATP), an expert panel to supervise cholesterol management was set up under the aegis of National Cholesterol Education Program (NCEP) in 1985. Since then NCEP-ATP has been revising and framing guidelines to enable clinician to deliver better treatment to cardiovascular patients and to educate general people. As a result, considerable reduction in cardiovascular related deaths has been observed in recent times. All three ATP guidelines viz. ATP-I, ATP-II and ATP-III have targeted low density lipoprotein as their primary goal. The ATP-III guideline was updated in the light of evidences from 5-major clinical trials and was released in 2004. It added therapeutic lifestyle changes, concept of risk equivalents, Framingham CHD-risk score non-high density lipoprotein cholesterol (non-HDL-C) as secondary target and gave strong emphasis on metabolic risk factors. The earlier treat-to-target paradigm faced fierce criticism from clinicians across the globe because of insufficient proof of safety and benefits of treating patients with respect to an individual's low density lipoprotein (LDL) level. Further, demonstration of non-HDL-C and total cholesterol/HDL-C ratio as strong predictors of overall cardiovascular risk foresees new guidelines. A tailored-treatment approach was suggested instead of LDL-C target based treatment approach which was soundly based on direct clinical trials evidences and proposes treatment based on individual's overall 5- to 10-year cardiovascular risk irrespective of LDL-C level, leading to lower number of people on high dose/s of statins. Recent report of the Cholesterol Treatment Trialist's Collaborators meta-analysis strongly supported primary prevention of LDL with statins in low risk individuals and showed that its benefits completely outweighed its known hazards. Markers other than LDL-C like apolipoprotein B, non-HDL-C and total cholesterol/HDL-C ratio would take precedence in the risk assessment and strong emphasis would be given on tailored-treatment approach in the upcoming ATP-IV guideline.

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Statins are an established class of drugs with proven efficacy in cardiovascular risk reduction. The concern over statin safety was first raised with the revelation of myopathy and rhabdomyolysis with the use of now withdrawn cerivastatin. Enhanced understanding of the mechanisms behind adverse effects of statins including an insight into the pharmacokinetic properties have minimised fear of statin use among clinicians. Studies reveal that occurrence of myopathy and rhabdomyolysis are rare 1/100000 patient-years. The risk of myopathy/rhabdomyolysis varies between statins due to varying pharmacokinetic profiles. This explains the differing abilities of statins to adverse effects and drug interaction potentials that precipitate adverse effects. Higher dose of rosuvastatin (80 mg/day) was associated with proteinuria and hematuria while lower doses were devoid of such effects. Awareness of drugs interacting with statins and knowledge of certain combinations such as statin and fibrates together with monitoring of altered creatine kinase activity may greatly minimise associated adverse effects. Statins also asymptomatically raise levels of hepatic transaminases but are not correlated with hepatotoxicity. Statins are safe and well tolerated including more recent potent statins such as, rosuvastatin. The benefits of intensive statin use in cardiovascular risk reduction greatly outweigh risks. The present review discusses underlying causes of statin-associated adverse effects including management in high risk groups.

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India, with one of the largest and most diverse populations of people living with diabetes, experiences significant barriers in successful diabetes care. Limitations in appropriate and timely use of insulin impede the achievement of good glycemic control. The current article aims to identify solutions to barriers in the effective use of insulin therapy viz. its efficacy and safety, impact on convenience and life-style and lack of awareness and education. Therapeutic modalities, which avoid placing an undue burden on patients' life-style, must be built. These should incorporate patient-centric paradigms of diabetes care, team-based approach for life-style modification and monitoring of patients' adherence to therapy. To address the issues in efficacy and safety, long-acting, flat profile basal insulin, which mimics physiological insulin and show fewer hypoglycemic events is needed. In addition, therapy must be linked to monitoring of blood glucose to enable effective use of insulin therapy. In conjunction, wide-ranging efforts must be made to remove negative perception of insulin therapy in the community. Patient- and physician - targeted programs to enhance awareness in various aspects of diabetes care must be initiated across all levels of health-care ensuring uniformity of information. To successfully address the challenges in facing diabetes care, partnerships between various stakeholders in the care process must be explored.

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Successful outcome of pregnancy depends upon genetic, cellular, and hormonal interactions, which lead to implantation, placentation, embryonic, and fetal development, parturition and fetal adaptation to extrauterine life. The fetal endocrine system commences development early in gestation and plays a modulating role on the various physiological organ systems and prepares the fetus for life after birth. Our current article provides an overview of the current knowledge of several aspects of this vast field of fetal endocrinology and the role of endocrine system on transition to extrauterine life. We also provide an insight into fetal endocrine adaptations pertinent to various clinically important situations like placental insufficiency and maternal malnutrition.

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Background: Gestational diabetes mellitus (GDM) is a metabolic disorder defined as glucose intolerance with the onset or first recognition during pregnancy. Women with GDM are at increased risk for adverse obstetric and perinatal outcome. Hence, it is imperative that an early detection and management of the disease is done to ensure better maternal and fetal outcomes. Aims: This study was done to evaluate the prevalence of gestational diabetes using diabetes in pregnancy Study Group India (DIPSI) criteria and further assess its feto-maternal outcome in western Rajasthan. Materials and Methods: This study was carried out in 500 patients between 24 and 28 weeks of gestation, attending the antenatal outdoor. These patients were given 75 g oral glucose irrespective of the meals and their plasma glucose was estimated at 2 h. Patients with plasma glucose values ΃140 mg/dl were labeled as GDM and the rest as the control or the non-GDM group. All GDM patients were followed up and treated with diet and/or insulin therapy till delivery to know maternal and fetal outcomes. Results: The prevalence of GDM in this study was 6.6%. Maternal and fetal complications in the GDM group were much higher than in the non-GDM group. Hypertension, vaginal candidiasis, and abruptio placentae were the common maternal complications, while macrosomia and stillbirths occurred in the fetuses. Conclusion: GDM as a disease entity adversely affects maternal and fetal outcomes. This also builds a strong case for following DIPSI guidelines in diagnosis and management of GDM.

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Background: Obesity is an important risk factor for non-alcoholic fatty liver disease (NAFLD); however, NAFLD does occur in lean subjects. This study was aimed to evaluate the magnitude, clinical, pathological, and metabolic profiles of NAFLD in normal body mass index (BMI) subjects (defined as lean NAFLD) in comparison to overweight or obese NAFLD and lean healthy control. Materials and Methods: 336 subjects (205 consecutive NAFLD, and 131 healthy controls) were studied. Results: Among 205 NAFLD patients, 27 (13.2%) were lean, while 141 (68.8%) and 37 (18%) patients were obese and overweight, respectively. The lean NAFLD compared to obese NAFLD had significantly lesser degree of fasting hyperinsulinemia ( P < 0.001), homeostasis model assessment insulin resistance (HOMA-IR, P < 0.001), and lower prevalence of diabetes mellitus ( P = 0.01) and metabolic syndrome ( P < 0.001). The profiles of serum lipids were similar between all 3 BMI categories, and 89% of lean NAFLD were dyslipidemic. Compared to obese subjects, patients with lean NAFLD had less hepatic necro-inflammation ( P = 0.05) and fibrosis ( P < 0.001). However, the proportion of steatohepatitis and advanced fibrosis were similar between all BMI categories. The profiles of overweight NAFLD were similar to those of lean NAFLD, except for higher HOMA-IR, uric acids and male gender in overweight group. Despite being lean, the mean BMI of lean NAFLD were still higher than unselected lean healthy controls ( P = 0.02). Conclusions: Lean NAFLD patients have less severe disease, minor, or no insulin resistance, but are frequently dyslipidemic and have BMI higher than lean healthy control.

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Gynecomastia is the most bothersome side effect in men taking antiandrogens. It is exceptionally severe and distressing physically and mentally as in the reported case. A man, aged 63, with a history of a well-treated macroprolactinoma, was referred in 2004 for gynecomastia that appeared after treatment by microsurgery, radiotherapy and flutamide for a lesion suspected to be prostate cancer. Clinical examination was normal except for huge enlargement of the breasts. Mammography and breasts MRI did not show any tumor. There was not any metastasis of the supposed prostate cancer and prostatic acid phosphates were within normal ranges. Hormonal exploration showed subclinical hypogonadism [testosterone: 7.4 ng/ml (n: 3-9), FSH: 14.9 mu/ml (n: 0.7-11) and LH: 9.7 mu/ml (n: 0.8-7.6)]. Testes ultrasounds were normal. Radiological and hormonal adrenal explorations were normal [Cortisol: 76 ng/ml (n: 50-250), DHEA-S: 59 μg/ml (n: 50-560), E2:40.2 pg/ml (n < 50)]. Body scan was normal too. The discussed etiologies were post radiation subclinical hypogonadism, and treatment with anti androgens. After flutamide withdraw, there was not any sign of prostate cancer recurrence, and gynecomastia decreased significantly, but did not disappear probably because of fibrosis.

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Phosphorus is a common anion. It plays an important role in energy generation. Renal phosphate handling is regulated by three organs parathyroid, kidney and bone through feedback loops. These counter regulatory loops also regulate intestinal absorption and thus maintain serum phosphorus concentration in physiologic range. The parathyroid hormone, vitamin D, Fibrogenic growth factor 23 (FGF23) and klotho coreceptor are the key regulators of phosphorus balance in body.

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Evans syndrome is a rare combination of autoimmune hemolytic anemia and immune thrombocytopenia. Their association with autoimmune thyroid diseases has been reported by few authors; however, a sequential development of the Evans syndrome in cases of Hashimoto's thyroiditis is extremely rare. The clustering of these autoimmune diseases might share a common pathogenic pathway. We present the fourth such case in world literature, of a 34-year-old female diagnosed with Hashimoto's thyroiditis in 2006, who has been taking synthetic thyroid hormone since then. Her condition is now clinically complicated with the development of the Evans syndrome.

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Objective: This study was undertaken to assess the efficacy and safetyof pioglitazone in combination with other oral antidiabetics (OADs) in Indian patients with type 2 diabetes mellitus (T2DM). Materials and Methods: This was an openlabel, prospective, no-randomized, single-center observational study conducted at a single center in India. A total of 958 adult patients with T2DM on OADs, with uncontrolled fasting (FBG) or postprandial blood glucose (PPG), were enrolled. Pioglitazone (7.5/15/30 mg) was added to existing therapy as a combination treatment with other OAD. Body weight (BW), body mass index (BMI), FBG and postprandial plasma glucose (PPPG) and glycosylated hemoglobin (HbA1c) were measured at the beginning (week 0) and at every follow-up treatment visit, i.e., 6 months (week 24), 1 year (week 48) and 2 years (week 96). Changes from baseline to each visit were analyzed using the Wilcoxon test. All patients also went through a urinalysis at baseline, and after 6 months, 1 year and 2 years of treatment, to assess for any abnormalities in the urine (pH, pus or protein), suggestive of bladder abnormalities. Results: The combined analysis was carried out on 958 completed patients in this study who were treated with pioglitazone 7.5 mg, 15 mg and 30 mg tablet and other OADs. The difference in mean value of FBG showed a highly significant decrease ( P < 0.0001) from baseline to end of treatment, i.e., from 167.0, (59.16) 172.6 (58.51) and 171.0 (39.47) to 140.2, (26.46) 143.8 (22.04) and 138.5 (27.82) mg/dL. Similarly, PPG showed a significant ( P < 0.0001, 0.002 and 0.008) decrease from baseline to end of the treatment, i.e., from 256.0, (61.79) 222.9 (67.88) and 223.6 (69.11) to 195.9, (46.92) 204.0 (48.03) and 187.6 (53.36) mg/dL, and there was a highly significant ( P < 0.0001) decrease in HbA1c levels, i.e., from 8.46, 8.34 and 8.42% to 7.781, 7.78 and 7.73%, respectively. However, gain in mean BW was also observed from baseline to end of the treatment, i.e., from 69.90, (9.44) 68.29 (8.62) and 67.64 (7.75) kg to 71.69, (8.35) 70.08 (7.96) and 69.70 (7.99) kg, respectively, and BMI increased from 26.74 (14.18-53.04) kg/m ² at baseline to 27.45 (12.87-53.73) kg/m ² at the end of the treatment, respectively ( P < 0.0001). No significant changes were found in urine in patients even after 2 years of treatment with pioglitazone. There was little variation in pH or presence of pus and proteins in the urine, indicating no increased risk of bladder-related abnormalities across all treated age groups even after 2 years of treatment with pioglitazone. Conclusion: Pioglitazone in combination with other OADs in Indian patients was an effective treatment protocol in glycemic control, reduction in FBG, PPPG and HbA1c and also helps in controlling weight gain in patients with T2DM. In this patient population, there was no increased risk of bladder-related abnormalities. Pioglitazone was therefore found to be a safe and efficacious addition to treatment in patients with poorly controlled diabetes.

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Context: Diabetes mellitus (DM) is the most common of the endocrine disorders. Mucocutaneous manifestations of diabetes mellitus are many and vary from trivial to life-threatening. Sometimes, mucocutaneous disorders may herald the onset of diabetes. Aims: To study the pattern of mucocutaneous manifestations in diabetics and role of it in diagnosing diabetes mellitus and its complications. Settings and Design: It was a longitudinal observational study of patients having diabetes with skin complaints attending skin outdoor department or admitted in wards for any reason in a tertiary care hospital. Materials and Methods: Total 300 patients were included in the study. Detailed history, clinical examination, and relevant investigations were done to diagnose the mucocutaneous disorders, diabetes, and diabetic complications. Statistical Analysis Used: The data was analyzed by using Epi info software. Results: Demographic profile shown majority of cases (78.66%) in more than 40 years of age with almost equal male and female preponderance. Mucocutaneous manifestations as presenting feature of diabetes were observed in 21.67% cases. Infections were most common in 119 (39.66%) cases, followed by acanthosis nigricans in 46 (15.33%) cases. Various associated complications like hypertension, retinopathy, hyperlipidemia, coronary artery disease, neuropathy, nephropathy, and diabetic ketoacidosis were observed in 160 (53.3%). Conclusions: Skin is the mirror, which reflects internal diseases; this aptly applies to skin and diabetes mellitus. Through awareness about cutaneous manifestations of DM, dermatologist can not only take credit for detecting DM but also facilitate early diagnosis of systemic complications of DM. This is immensely beneficial to patients in long run.

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Introduction: The Clinical and radiological manifestations of newborns with severe VDD have not been studied well. Materials and Methods: We studied the clinical, biochemical, and radiological manifestations of 10 full-term (FT) newborns (6: M, 4: F) infant presented to with symptomatic hypocalcemia (seizure) secondary to vitamin D deficiency (VDD) during the first 10 days of life are described. All were exclusively breastfed since birth. All their mothers have low 25 hydroxy vitamin D (25OHD) level <10 ng/mL and were not taking vitamin supplements during pregnancy. Results: FT newborns with hypocalcemia secondary to VDD presented with generalized convulsions (10/10) and craniotabes (8/10), but none had rachitic chest rosaries or joint broadening. Cranial ultrasonographic evaluation was normal. Serum 25OHD concentrations were low in these newborns (13.2 ± 3.8 ng/mL) and their mothers (8.1 ± 1.5 ng/mL). A total of 60% of them had increased parathormone (PTH) concentrations (>60 ng/mL) and 60% had decreased magnesium (Mg) concentrations (<0.7 mmol/L). Their alkaline phosphatase (ALP) concentrations were significantly higher than normal newborns. All other laboratory results (liver function tests, urea and electrolytes, C reactive protein, lumbar puncture, blood culture, and lactate) were normal. In all patients, seizures ceased within 2 days of starting treatment with alphacalcidol and calcium. Radiological manifestations included metaphyseal band of relative lucency (osteopenia), just under the line of provisional calcification, within distal radius (7/10), femur (4/10), and tibia (3/10), mild cupping and haziness of distal radius (2/10). Discussion: Newborns with VDD had significantly lower serum calcium, ALP and PTH and higher phosphate concentrations, compared to older infants with VDD rickets. In newborns with VDD, serum calcium levels were correlated significantly with 25OHD (r = 0.597, P < 0.001), Mg concentrations (r = 0.436, P < 0.001) and negatively with ALP concentrations (r = −0.451, P < 0.001). Serum PTH concentrations were correlated significantly with serum Mg (r = 0.78, P < 0.0001) but not with serum calcium (r = −0.103, P = 0.3) or 25OHD (r = −0.03, P = 0.7) concentrations. Conclusion: The clinical, biochemical, and radiological manifestations of VDD in newborns indicate that they are less adapted to VDD compared to older infants. VD supplementation for mothers and newborns should be considered to avoid short-term complications of VDD in the neonatal period and on the growing infants especially in countries with high prevalence of VDD.

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Background: Diabetes mellitus is associated with high cardiovascular risk. Carotid intima media thickness (CIMT) is used commonly as a noninvasive test for the assessment of degree of atherosclerosis. The objective of this study was to find out the cut-off point for CIMT for ischemic stroke in patients with type 2 diabetes mellitus (T2DM) and to correlate CIMT with various parameters like smoking, hypertension, lipid profile and duration of T2DM. Materials and Methods: A total of 80 subjects in the age group of 30-75 years (M:F = 57:23) were selected and divided into three groups, i.e. diabetes with ischemic stroke, diabetes and healthy subjects. All the participants were subjected to B-mode ultrasonography of both common carotid arteries to determine CIMT, along with history taking, physical examination and routine laboratory investigations including included fasting and 2-hour postprandial blood sugar, blood urea, serum creatinine, lipid profile, glycated hemoglobin, and microalbuminuria. Results: Patients with T2DM with or without ischemic stroke were found to have significantly higher prevalence of increased CIMT and a value greater than 0.8 mm was found to be associated with the occurrence of stroke. The mean carotid IMT of the group as a whole was 0.840 ± 0.2 mm. The mean carotid IMT was not significantly different between T2DM patients with or without ischemic stroke (1.06 ± 0.2 vs. 0.97 ± 0.26 mm, P = 0.08). However, the mean CIMT was significantly higher in diabetic subjects compared to healthy subjects (1.01 ± 0.28 mm vs. 0.73 ± 0.08, P = 0.006). Other parameters like higher age, smoking, hypertension, hyperlipidemia, low HDL cholesterol, the glycemic parameters and the duration of diabetes were independently and significantly related to CIMT. Conclusion: A high CIMT is a surrogate and reliable marker of higher risk of ischemic stroke amongst type 2 diabetic patients. Our study demonstrates the utility of carotid IMT as a simple non-invasive screening test for the assessment of atherosclerosis risk/prognosis in type 2 diabetics.

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The actions of vitamin D are not confined to bone. Vitamin D receptors are present in nearly all the nuclei and its actions are manifold. Populations deficient in vitamin D are at higher risk of developing autoimmune diseases, diabetes, cancer, infections, allergies and other chronic illnesses.

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Objective: Polycystic ovary syndrome (PCOS) is the most common endocrine disorder among women of reproductive age.PCOS is considered to be not only a reproductive endocrinopathy, but also a metabolic disorder.The objective of the present study was to characterize the anthropometric and dietary profile of women with PCOS and to compare it with that of healthy age-matched women. Design: In this case-control study, 65 women with PCOS served as cases. The control group consisted of 65 age-matched healthy women. For each participant, demographic, anthropometric and dietary intake data were gathered and compared between the two groups. Results: There was no significant difference between the mean of the body mass index of the two groups, but the mean of waist circumference was significantly higher in the PCOS group, than the control group ( P = 0.016). Compared to the normal weight PCOS patients, a significantly higher percentage of overweight patients had hirsutism ( P = 0.009). In dietary analysis, women with PCOS consumed more calories and more fat than healthy women ( P = 0.001 and P = 0.019, respectively). Conclusion: It is concluded that in PCOS patients, android obesity is a common feature and this abdominal adiposity may be related to the syndrome's complications. PCOS symptoms were more severe in overweight patients than the normal weight. Regarding the dietary pattern, it was indicated that patients with PCOS consume more calories and more fat in their diets and this might have been correlated to their disease.

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Objective: The study assessed the risk of developing type 2 diabetes Mellitus in Ogun State, Nigeria. Materials and Methods: Finnish Medical Association diabetes risk score was administered across 25 communities facilitated by non-communicable disease clinics established under a World Diabetes Foundation project. Subjects in the high risk group had blood glucose estimated. Results: 58,567 respondents included 34,990 (59.6%) females and 23,667 (40.3%) males. Majority (61.2%) were between 25 years and 54 years. Considering waist circumference, 34,990 (38.1%) females and 23,667 (5.3%) males had values above 88 cm and 102 cm respectively. Overall, 11,266 (19.2%) were obese and 28.9% overweight using body mass index (BMI). More females had elevated BMI than males. Mean systolic blood pressure (SBP) and diastolic blood pressure (DBP) of all subjects were 129.54 mm Hg ± 23.5 mm Hg and 76.21 mm Hg ± 15.5 mm Hg respectively. Prevalence of hypertension (Joint National Committee VII classification) was 27.7%. More subjects had normal DBP than SBP (68.2% vs. 42.5% P < 0.05). Mean fasting blood glucose (FBG) of all subjects was 5.5 mmol/L ± 0.67 mmol/L. Using a casual blood glucose >11.1 mmol/L and/or FBG >7 mmol/L, the total yield of subjects adjudged as having diabetes was 2,956 (5.05%). Mean total risk score was 5.60 ± 3.90; this was significantly higher in females (6.34 ± 4.16 vs. 4.24 ± 3.71, P < 0.05). A total of 2,956 (5.05%) had high risk of developing DM within 10 years. Conclusion: The risk of developing DM is high in the community studied with females having a higher risk score. There is urgent need to implement diabetes prevention strategies.

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A 25 year old lady presented with pain and swelling of left thigh. On examination she was found to have tenderness of left femur with a separate soft tissue swelling within the thigh muscle. Further evaluation revealed expansile bony lesion on X-ray of left tibia and multiple hot spots on bone scan suggestive of fibrous dysplasia. The soft tissue swelling on excision and histopathological examination was found to be intramuscular myxoma. The combination of the above two, called Mazabraud syndrome is being reported.

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Background: A low-glycemic index diet is effective in blood glucose control of diabetic subjects, reduces insulin requirement in women with gestation diabetes mellitus (GDM) and improves pregnancy outcomes when used from beginning of the second trimester. However there are limited reports to examine the effect of low glycemic load (LGL) diet and fiber on blood glucose control and insulin requirement of women with GDM. Therefore, the aim of this study was to examine the effect of low glycemic load diet with and without fiber on reducing the number of women with GDM requiring insulin. Materials and Methods: All GDM women (n = 31) were randomly allocated to consume either a LGL diet with Fiber or LGL diet. Results: We found that 7 (38.9%) of 18 women with GDM in Fiber group and 10 (76.9%) in "Without Fiber" group required insulin treatment. Conclusion: The LGL diet with added fiber for women with GDM dramatically reduced the number needing for insulin treatment.

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Background: Depression is found to be common among patients with diabetes and it is associated with poor outcomes in disease control. This study was carried out to find out the proportion and determinants associated with depression among patients with established type 2 diabetes mellitus (T2DM) in various tertiary care hospitals in Mangalore city of south India. Materials and Methods: This study was conducted in one government and three private tertiary care hospitals in Mangalore in December 2010. All consenting patients with confirmed diagnosis of T2DM were interviewed and screened for depression by administering the 9-item PRIME-MD Patient Health Questionnaire (PHQ-9). Results: Of the 230 T2DM patients, 119 (51.7%) were males. The mean age of all participants was 53.61 ± 10.7 years. The median duration of T2DM was found to be 12.1 ± 7.35 years. Among the participants, 71 (30.9%) met the criteria for moderate depression, 33 (14.3%) for severe depression, and the remaining 126 (54.8%) had no clinically significant depression. Only 26 (11.3%) patients were already aware that they were depressed, of whom just 3 had taken medical consultation. Among the risk factors, depression was found to be significantly associated with older age, female gender, low socioeconomic status, unskilled and retired employment status, having complications due to T2DM or comorbidities like hypertension and coronary artery disease, being overweight and being on insulin syringe injections. Conclusion: This study found a high proportion of depression among patients with T2DM. Therefore the care of individuals with diabetes mellitus (DM) should include the screening and possible treatment of depression in order to achieve and sustain treatment goals.

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Acromegaly is characterized by chronic, excess secretion of growth hormone (GH) from a pituitary adenoma, and elevated hepatic insulin-like growth factor 1 (IGF-1) levels. Significant progress has been made in the development of medical therapies to achieve biochemical and symptomatic control in acromegaly. In this review we discuss the three currently available medical therapies, which include somatostatin analogs, dopamine agonists and pegvisomant. We describe a step-wise approach in which a somatostatin analog is followed by the addition of a dopamine agonist, and then if required the addition of or replacement by pegvisomant. New somatostatin agonists such as pasireotide, and the introduction of new orally-acting somatostatin agonists, should increase the therapeutic choices available in the near future.

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Catecholamine induced cardiomyopathy in the setting of pheochromocytoma is an unusual clinical entity. Earlier studies have reported left ventricular dysfunction in around 10% of subjects with pheochromocytoma. ^[1] Catecholamine induced vasoconstriction, direct toxic effect of byproducts of catecholamine degradation and direct receptor-mediated mechanisms are thought to contribute to cardiomyopathy in subjects with pheochromocytoma. The presentation remains a diagnostic challenge as patients may already have hypertensive heart disease and acute coronary syndrome on account of uncontrolled secondary hypertension. We report a case of a 42-year-old male, who presented with features of pheochromocytoma induced cardiomyopathy.

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Over a period of time, anthropometric parameters have evolved into reliable indicators for predicting the incidence of diabetes mellitus. A number of studies have shown correlations between anthropometry and lipid profiles in healthy volunteers. This study examined correlations between anthropometry and lipid profile in type 2 diabetics. The limited observations made in this study reveal that anthropometric parameters are not ideal for predicting lipid profile abnormalities in type 2 diabetics.

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The aim of this study was to describe a young man with probably the largest pheochromocytoma associated with MEN 2A, described till date. The patient, a non-vegetarian, fifth of eight siblings, married, having five children, presented with episodes of difficult-to-control hypertension requiring over five antihypertensives. He was referred to us with an abdominal CT scan that revealed a 16 cm left-sided adrenal mass. Biochemical testing confirmed a catecholamine secreting pathology. Histopathology confirmed the mass as a pheochromocytoma weighing 1.8 kg. Further evaluation suggested a parathormone-dependent hypercalcemia and a left-sided thyroid mass. Histopathology confirmed parathyroid hyperplasia and medullary carcinoma of the thyroid mixed with papillary carcinoma of thyroid. Putting all the findings together showed that the patient was suffering from multiple endocrine neoplasia 2. Multiple endocrine neoplasia 2A is a rare syndrome. The case is unique in the way it presented, with all the three tumors at the same time. The management was bold and addressed all the three lesions in the same hospital admission. We are also reporting the largest described case of pheochromocytoma from India.

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To study the prevalence of metabolic syndrome (MS) among newly diagnosed hypertensive patients in a tertiary care hospital in the northern hilly state of Himachal Pradesh, India, located in western Himalayas at a moderate altitude of 2200 m above mean sea level. One hundred and eighteen newly diagnosed hypertensive patients above the age of 20 years were studied in a hospital-based cross-sectional study. MS prevalence was estimated by International Diabetes Federation (IDF) criteria and modified National Cholesterol Education Program-Adult Treatment Panel III (NCEP-ATP III) criteria. Student's t-test was used to compare the mean of the continuous variables. Chi-square test was used to compare discrete variables. The prevalence of MS in hypertensive patients was 68.6% (modified NCEP-ATP III) and 63.6% (IDF criteria). The most common phenotype of MS with the component of hypertension was the coexistence of waist circumference (90.1%), low high-density lipoprotein (HDL; 70.4%), and high triglycerides (67.9%) as per the modified NCEP-ATP III criteria, and low HDL (76.2%) and high triglycerides (66.4%) as per the IDF criteria. Fasting blood glucose (33.2% as per the modified NCEP-ATP III criteria and 32.6% as per the IDF criteria) was the least significant factor having an association with MS. The prevalence of MS among hypertensive patients was high and indicates the need for metabolic screening in all hypertensive patients at the first diagnosis.

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Background: The 1μg cosyntropin test has some advantages over the 250μg test as a test of adrenal function. One of the concerns regarding the 1 μg test includes stability of the cosyntropin when reconstituted and stored. Classically the 5 ^th percentile responses to cosyntropin in normal individuals have been used to define a normal response. Recent studies have shown that these normative values should be determined for individual assays. Materials and Methods: We performed a 1μg cosyntropin test using reconstituted and refrigerated (4-8^° C) cosyntropin in saline solution in 49 non pregnant adults who were apparently healthy and had no exposure to exogenous glucocorticoids. The cosyntropin solution was stored for up to 60 days following reconstitution. We analysed the data for any association between duration of cosyntropin solution storage and the cortisol responses to cosyntropin administration. Results: The mean ± SD cortisol level at baseline, 30 and 60 min were-12.19 ± 3 μg/dl, 20.72 ± 2.63 μg/dl, 16.86 ± 3.33 μg/dl. The 5 ^th percentile cortisol response at 30 min was 16.5 μg/dl (16.33 μg/dl rounded off). The correlation coefficients between number of days of cosyntropin solution storage and the cortisol responses at 30 and 60 min were (Spear mans rho = 0.06,-0.24 respectively) (P = 0.69 and 0.41). There were no differences in cortisol values whether the storage was for less than 30 days or more than 30 days (mean difference 0.25 μg/dl P = 0.44). Conclusion: The 5 ^th percentile normative values determined for our assay is lower than what is currently being used clinically and in research publications. Prolonged refrigerated storage of cosyntropin solution does not affect the validity of the 1 μg cosyntropin test.

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A 19-year-old girl presented with classical features of Cushing's syndrome. Endocrinal evaluation was consistent with pituitary source of ACTH; but imaging showed normal pituitary. Bilateral inferior petrosal sinus sampling confirmed the diagnosis. A successful remission was achieved after adenomectomy by transphenoidal route. Histopathological examination was consistent with pituitary oncocytoma and immunohistochemistry was positive for synaptophysin, chromogranin, neuron specific enolase, S-100, ACTH, prolactin, and GH.

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Thymic neuroendocrine (NE) tumors are a rare manifestation of multiple endocrine neoplasia syndrome type 1 (MEN-1). They are malignant and aggressive tumors and form a major cause of mortality in MEN-1. Transcervical thymectomy (TCT) at the time of parathyroid surgery for primary hyperparathyroidism (PHPT) in MEN-1 usually prevents thymic NE tumors. We report a 56-year-old nonsmoker male with sporadic MEN-1 who presented with thymic NE carcinoma developing rapidly within a span of 8 months after subtotal parathyroidectomy and TCT for PHPT. We present a brief review of literature on this rare NE malignancy, focusing on its occurrence despite TCT. This case highlights the fact that thymic NE carcinoma may develop even after TCT in MEN-1. Regular surveillance for these aggressive thymic NE tumors is mandatory even after TCT in MEN-1 setting.

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Acromegaly a common pituitary disorder has significant adverse effects on well-being and survival. The slight increase in the prevalence of hypertension in acromegaly is well known and is proposed to be the direct effects of growth hormone. The hypertension for calculating the prevalence in most series was defined as diastolic more than 100 mmHg, but hypertensive emergency is rarely ever described in the literature. Growth hormone excess has been associated with renal manifestations such as hypercalciuria and nephrolithiasis, but never with renal failure. We present a case referred to a tertiary care nephrology center with malignant hypertension. This is the first case of a patient of acromegaly presenting with hypertensive emergency progressing to malignant nephrosclerosis and renal failure.

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Background: There is a World Diabetes Foundation funded research on detection of diabetes mellitus (DM) in tuberculosis (TB) which is currently being carried out in 56 TB centers in Lagos State Nigeria and against this background, we decided to evaluate the knowledge of DM and (TB) amongst the health workers from these facilities. Materials and Methods: We employed the use of self-administered questionnaires comprising questions to determine participant's knowledge on risk factors, clinical presentation and complications of DM, diagnosis, management of DM, and presentation and management of TB. We documented and also compared responses that differed in a statistically significant manner amongst the various cadres of health worker and the three tiers of healthcare facilities. Results: A total of 263 health care workers responded, out of which medical doctors constituted 72 (27.4%) while nurses and other categories of health care workers constituted 191 (72.6%). All the respondents knew that TB is a communicable disease and a large majority- 86% knew that DM is a chronic disorder that as of now has no cure. One hundred and eighty one (71%) respondents gave a correct response of a fasting plasma glucose level of 9mmol/L, which is in the range for diagnosis of DM. About a third-90-of the health workers, however, stated that DM may be diagnosed solely on clinical symptoms of DM. However, 104 (46%) of the Study participants stated that urine may be employed for objectively diagnosing DM. All respondents had hitherto not had patients with TB who had been routinely screened for DM. There was insufficient knowledge on the non-pharmacological management with over half of the respondents, irrespective ofstatus, maintained that all persons diagnosed with DM should be made to lose weight and carbohydrate should make up less than 30% of the component of their meals. Conclusion: There remains largely inadequate knowledge on diagnosing and non-pharmacological management of DM among the health workers in our TB facilities.

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Developmental abnormalities of the thyroid gland are very rare. The most common abnormalities include ectopic thyroid tissues that are commonly seen in lingual or sublingual location, agenesis, and hemiagenesis of the thyroid gland. These developmental defects may or may not be associated with thyroid dysfunction. Our case is an 18-year-old male who presented with swelling in the neck of 4-year duration. Clinical examination revealed an oval-shape swelling in the left side of the thyroid gland. The ultrasound and the nuclear scan report revealed the presence of thyroid hemiagenesis of the right lobe with isthmus along with double ectopic thyroid tissue at suprahyoid and infrahyoid region. His thyroid function test showed elevated thyroid-stimulating hormone (TSH) and normal free T4. We report a very rare case of thyroid hemiagenesis with double ectopic thyroid tissue; and to the best of our knowledge, this is the first report in the world literature.

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