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   2012| December  | Volume 16 | Issue 8  
    Online since January 4, 2013

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Continuous subcutaneous insulin infusion: practical issues
Banshi D Saboo, Praful A Talaviya
December 2012, 16(8):259-262
The growing number of individuals with diabetes mellitus has prompted new way of treating these patients, continuous subcutaneous insulin infusion (CSII) or insulin pump therapy is an increasingly form of intensive insulin therapy. An increasing number of individuals with diabetes mellitus individuals of all ages have started using insulin pump therapy. Not everyone is a good candidate for insulin pump therapy, and the clinician needs to be able to determine which patients are able to master the techniques required and to watch for the adverse reactions that may develop. Insulin pump increases quality of life of patient with diabetes mellitus with increasing satisfaction with treatment and decrease impact of diabetes mellitus. Manual errors by insulin pump users may lead to hypo or hyperglycemia, resulting into diabetic ketoacidosis (DKA) sometimes. Some of practical aspect is associated with insulin pump therapy such as selection of candidates, handling of pump and selection of site, and pump setting, henceforth this review is prepared to explore and solve the practical problems or issues associated with pump therapy.
  26,990 6,772 -
Variability of capillary blood glucose monitoring measured on home glucose monitoring devices
Narendra Kotwal, Aditi Pandit
December 2012, 16(8):248-251
Self monitoring of blood glucose helps achieve glycemic goals. Glucometers must be accurate. Many variables affect blood glucose levels. Factors are analytical variables (intrinsic to glucometer and glucose strips) and pre analytical related to patients. Analytical variables depend on factors like shelf life, amount of blood and enzymatic reactions. Preanalytical variables include pH of blood, hypoxia, hypotension, hematocrit etc.CGMS has the potential to revolutionise diabetes care but accuracy needs to be proven beyond doubt before replacing current glucometer devices.
  28,314 1,203 -
Etiology of anemia in primary hypothyroid subjects in a tertiary care center in Eastern India
Chanchal Das, Pranab K Sahana, Nilanjan Sengupta, Debasis Giri, Mukut Roy, Prasanta Mukhopadhyay
December 2012, 16(8):361-363
Introduction: The association of anemia with primary hypothyroidism has been common knowledge for many years. However; its pathogenesis is far from clear in many cases. Often the causes of anemia are manifold. Aims and objectives: In this study, we evaluated the causes of anemia in patients with primary hypothyroidism. Materials and Methods : Sixty adult nonpregnant untreated primary hypothyroid patients with anemia without any obvious cause were included. All patients were subjected to full medical history, clinical examination, biochemical and imaging studies. Serum iron profile, vitamin B12, folic acid, anti parietal cell antibody, anti TPO antibody, bone marrow study, and stool for occult blood, Coomb's test, HPLC for hemoglobinopathies and complete hemogram with reticulocyte count were done and analyzed. Results: Normocytic, normochromic anemia was present in 31 patients (51.6%) followed by microcytic anemia in 26 patients (43.3%). Six patients (10%) had megaloblastic anemia with vitamin B12 deficiency including 3 cases of pernicious anemia. Two patients had combined deficiency of iron and vitamin B12. Conclusion: Normocytic normochromic anemia with normal bone marrow was commonest type of anemia in this study, followed by iron deficiency anemia.
  12,827 745 -
A case of simultaneous occurrence of Graves' disease and Hashimoto's thyroiditis
Anirban Majumder, Debmalya Sanyal
December 2012, 16(8):338-339
Introduction: Simultaneous occurrence of Hashimoto's thyroiditis (HT), and Graves' disease (GD) is rare. Aims and Objectives: We report a case of simultaneous occurrence of GD and HD, at presentation. Case Report: A 60-year-old lady presented with tremulousness of hands, palpitation, and excessive sweating. She had a history of weight loss and neck-swelling. Her weight was 46 kg, BMI 17, afebrile, regular pulse rate of 110/min with fine tremor in hands. Thyroid gland was symmetrically enlarged, firm, without any bruit, but mildly tender with lobular surface. There were no occular manifestations. Initial thyroid function tests (TFT) revealed: T3: 3.80 ng/ml (0.80-2.10), T4: 12.40 ug/dl (5.10-12), thyroid stimulating hormone (TSH): 0.20 μU/L (0.70-5). Her anti thyroperoxidase (TPO) antibody: 374 IU/ml (normal [nl.] <35) and TSH receptor antibody: 15 U/L (nl. <1) were both strongly positive. Ultrasonogram of thyroid revealed a hypoechoic enlarged gland. 99mTc pertechnetate scan showed an enlarged gland with increased uptake of radiocontrast: 17% (nl. 0.4-4%) with some patchy defects in both lower poles. Thyroid fine needle aspiration cytology (FNAC) showed sheets of Hurthle cells with abdunce of lymphocytes indicating HT. She was observed on beta blockers. Repeat TFT, 3 months later showed: T3: 4.20 ng/ml, T4: 14.40 ug/dl, TSH: 0.001 μU/L, with increased uptake on repeat scan. Conclusion: HT rarely occurs following GD. Our case of an elderly lady with no eye signs, lobular, firm tender goiter with patchy uptake in both lower poles on Tc99m scan were odd points in diagnosing isolated GD. FNAC confirmed simultaneous HD with GD.
  7,721 324 -
Prevalence of polycystic ovary syndrome in young women from North India: A Community-based study
Harmandeep Gill, Pallavi Tiwari, Preeti Dabadghao
December 2012, 16(8):389-392
Background: Polycystic ovary syndrome (PCOS) is one of the most common endocrine disorders in women of reproductive age. Due to the logistics of diagnosis and lack of consensus on the diagnostic criteria, there are very few prevalence studies in the community. This study was aimed to assess the prevalence of PCOS in women 18-25 years of age, conducted in college girls from Lucknow, North India. Materials and Methods: Sample size for the study was calculated as 1052. Girls from 3 different colleges were approached (n = 2150), 1520 (70.7%) agreed to participate. They were asked to fill up a questionnaire asking details of menstrual cycle and features of hyperandrogenism. Hirsutism was self-reported. Responses were verified by a trained research assistant. A probable case was defined as a girl with menstrual irregularity (MI) or hirsutism (H) or both. All the probable cases were invited for detailed examination, hormone estimation, and ovarian ultrasonography. Results: Of the 1520 girls, 200 (13.1%) were labeled as probable cases; 175 (87.5%) had MI and 25 (12.5%) had both MI and H. Of the 200 cases, 75 (37.5%) had hormonal evaluation while 11 agreed for ultrasonography. 27 girls had confirmed PCOS. Therefore, if all the 200 girls would have had hormonal evaluation, 56 girls were likely to be confirmed as PCOS, giving a calculated prevalence of 3.7% (95% CI, 2.6-4.4) in this population. The mean age of these PCOS cases was 18.96 ± 1.73 yrs, body mass index was 21.72 ± 5.48 Kg/m 2 , and waist hip ratio was 0.81 ± 0.08. Only 12% girls had a body mass index ≥ 27.5 Kg/m 2 , but 44% had waist hip ratio > 0.81, again highlighting that despite low BMI, Indians have more abdominal obesity. Conclusion: Calculated prevalence of PCOS in women between the ages of 18-25 years from Lucknow, north India, is 3.7%. Majority of these girls were lean but have abdominal obesity.
  5,704 728 -
Childhood obesity: Determinants, evaluation, and prevention
Moutusi Raychaudhuri, Debmalya Sanyal
December 2012, 16(8):192-194
Childhood obesity is a grave issue, which needs to be addressed urgently because it leads to several medical and psychosocial problems in children. High prevalence is being increasingly reported in children from developing countries as well. The combination of our genetic propensity to store fat, the ready availability of calorie dense foods, and sedentary lifestyle promotes overweight. The child's food environment at home and parental obesity are strong determinants. Urban poor in developed countries and urban rich in developing countries are both at risk. In developing countries, a number of beliefs passed down over generations are other important determinants. Evaluation includes assessing the child's lifestyle, excluding weight-promoting medication history; poor linear growth needs endocrine evaluation; genetic syndromes should be considered if there are clinical pointers. Overweight children should be evaluated for hypertension, dyslipidemia, T2DM, and NAFLD. Therapeutic lifestyle changes targeting food habits and physical activity through parental participation and social support are the cornerstones of preventing childhood obesity. Active travel and play by making the built environment more accessible, ban on 'junk' food advertising, and effective health education through active participation of clinicians, school systems, and the media will go a long way in reversing anticipated trends in childhood obesity.
  5,413 945 -
Prolactin and cancer: Has the orphan finally found a home?
Bipin Kumar Sethi, GV Chanukya, V Sri Nagesh
December 2012, 16(8):195-198
Prolactin has, for long, been associated with galactorrhea and infertility in women while its role in men is largely unknown. Recently, expression of prolactin in various other tissues like the breast, prostate, decidua, and the brain has been recognized. This has led to evaluation of paracrine and autocrine actions of prolactin at these tissues and a possible role in development of various cancers. Increased expression of PRL receptors has also been implicated in carcinogenesis. Breast cancer has the strongest association with increased prolactin and prolactin receptor levels. Prostate cancer also has reported significant association, while the role of prolactin in colorectal, gynecological, laryngeal, and hepatocellular cancers is more tenuous. Prolactin/prolactin receptor pathway has also been implicated in development of resistance to chemotherapy. Thus, the effects of this pathway in carcinogenesis seem widespread. At the same time, they also offer an exciting new approach to hormonal manipulation of cancers, especially the treatment-resistant cancers.
  5,515 434 -
CHARGE Association
Semanti Chakraborty, Jayanta Chakraborty
December 2012, 16(8):501-503
We present here a case of 17-year-old boy from Kolkata presenting with obesity, bilateral gynecomastia, mental retardation, and hypogonadotrophic hypogonadism. The patient weighed 70 kg and was of 153 cm height. Facial asymmetry (unilateral facial palsy), gynecomastia, decreased pubic and axillary hair, small penis, decreased right testicular volume, non-palpable left testis, and right-sided congenital inguinal hernia was present. The patient also had disc coloboma, convergent squint, microcornea, microphthalmia, pseudohypertelorism, low set ears, short neck, and choanalatresia. He had h/o VSD repaired with patch. Laboratory examination revealed haemoglobin 9.9 mg/dl, urea 24 mg/dl, creatinine 0.68 mg/dl. IGF1 77.80 ng/ml (decreased for age), GH <0.05 ng/ml, testosterone 0.25 ng/ml, FSH-0.95 ΅IU/ml, LH 0.60 ΅IU/ml. ACTH, 8:00 A.M cortisol, FT3, FT4, TSH, estradiol, DHEA-S, lipid profile, and LFT was within normal limits. Prolactin was elevated at 38.50 ng/ml. The patient's karyotype was 46XY. Echocardiography revealed ventricularseptal defect closed with patch, grade 1 aortic regurgitation, and ejection fraction 67%. Ultrasound testis showed small right testis within scrotal sac and undescended left testis within left inguinal canal. CT scan paranasal sinuses revealed choanalatresia and deviation of nasal septum to the right. Sonomammography revealed bilateral proliferation of fibroglandular elements predominantly in subareoalar region of breasts. MRI of brain and pituitary region revealed markedly atrophic pituitary gland parenchyma with preserved infundibulum and hypothalamus and widened suprasellar cistern. The CHARGE association is an increasingly recognized non-random pattern of congenital anomalies comprising of coloboma, heart defect, choanal atresia, retarded growth and development, genital hypoplasia, ear abnormalities, and/or deafness. [1] These anomalies have a higher probability of occurring together. In this report, we have described a boy with CHARGE association.
  4,933 178 -
Thyroid dysfunction in type 2 diabetes mellitus: A retrospective study
Laloo Demitrost, Salam Ranabir
December 2012, 16(8):334-335
Introduction: Type 2 diabetes mellitus (DM) is a growing problem in our country and we have observed that many patients are associated with thyroid dysfunction later in their life. However, the prevalence of thyroid dysfunction in these patients has not been investigated. Aims and Objectives: To find the prevalence of thyroid dysfunction in type 2 DM in Manipur, India. Materials and Methods: In this retrospective study, data of 202 Type 2 DM patients who attended the diabetic clinic of the Regional Institute of Medical Sciences, Imphal from January 2011 to July 2012, and whose thyroid stimulating hormone (TSH) level was investigated were included. The inclusion criteria are known cases of type 2 DM. Exclusion criteria are patients with previous history of hypothyroidism and those on drugs affecting the thyroid profile. Results: Out the 202 type 2 DM patients for the study of which 61 are males and 141 are females, 139 (68.8%) are euthyroid, 33 (16.3%) have subclinical hypothyroidism (10 males and 23 females), 23 (11.4%) have hypothyroidism (6 males and 17 females), 4 (2%) have subclinical hyperthyroidism and 3 (1.5%) are hyperthyroidism cases. Maximum cases were of hypothyroidism (subclinical and clinical) seen in the age group of 45-64 years. Patients with BMI > 25 were at increased risk of having hypothyroidism (P < 0.016). Conclusion: Prevalence of hypothyroidism is quite high in type 2 DM patients above 45 years and more so if their BMI is over 25.
  4,068 1,016 -
Thyroid disorders in pregnancy
Menaka Ramprasad, Shaila Shamanur Bhattacharyya, Arpandev Bhattacharyya
December 2012, 16(8):167-170
Thyroid disorders are common in pregnancy and the most common disorder is subclinical hypothyroidism. Due to the complex hormonal changes during pregnancy, it is important to remember that thyroxine requirements are higher in pregnancy. According to recent American Thyroid Association (ATA) guidelines, the recommended reference ranges for TSH are 0.1 to 2.5 mIU/L in the first trimester, 0.2 to 3.0 mIU/L in the second trimester, and 0.3 to 3.0 mIU/L in the third trimester. Maternal hypothyroidism is an easily treatable condition that has been associated with increased risk of low birth weight, fetal distress, and impaired neuropsychological development. Hyperthyroidism in pregnancy is less common as conception is a problem. Majority of them are due to Graves' disease, though gestational hyperthyroidism is to be excluded. Preferred drug is propylthiouracil (PTU) with the target to maintain free T4 in upper normal range. Doses can be reduced in third trimester due to the immune-suppressant effects of pregnancy. Early and effective treatment of thyroid disorder ensures a safe pregnancy with minimal maternal and neonatal complications.
  4,342 653 -
Antioxidants and diabetes
Sarita Bajaj, Afreen Khan
December 2012, 16(8):267-271
Hyperglycemia promotes auto-oxidation of glucose to form free radicals. The generation of free radicals beyond the scavenging abilities of endogenous antioxidant defenses results in macro- and microvascular dysfunction. Antioxidants such as N-acetylcysteine, vitamin C and α-lipoic acid are effective in reducing diabetic complications, indicating that it may be beneficial either by ingestion of natural antioxidants or through dietary supplementation. However, while antioxidants are proving essential tools in the investigation of oxidant stress-related diabetic pathologies and despite the obvious potential merit of a replacement style therapy, the safety and efficacy of antioxidant supplementation in any future treatment, remains to be established
  3,842 841 -
FRAX: Facts and Fantasy
Yashpal Gogate, Sanjay Kumar Bhadada
December 2012, 16(8):224-226
FRAX is an important web based tool to assess fragility fracture risk in osteoporosis. It has many important limitations too. Good clinical judgement is needed to interpret the results of FRAX. With increasing use we can improvise this tool further.
  4,204 470 -
Vitamin D toxicity presenting as hypercalcemia and complete heart block: An interesting case report
G Garg, R Khadgwat, D Khandelwal, N Gupta
December 2012, 16(8):423-425
Vitamin D deficiency is widely prevalent across the globe. This has lead to widespread use of vitamin D supplements in populations. We present our experience of vitamin D toxicity in a subject resulting in hypercalcemia and CHB (Complete Heart Block). A 70-year-old female, known hypertensive for thirty five years and diabetic for seven years underwent total knee replacement (TKR) for osteoarthritis left knee in December 2010. For perioperative glycemic control, multiple subcutaneous injections of insulin were advised. Patient later presented with poor glycemic control, decreased appetite and constipation for last 1 month with history of episodes of transient loss of consciousness for 15 days and recurrent vomiting. Biochemical work-up showed hypercalcemia (Serum calcium 12.4 mg/dL). Sr. albumin, ALP, Sr. phosphorus and PTH levels were normal, thus suggesting PTH independent hypercalcemia. Strong suspicion led us to check vitamin D levels in dilution which were 2016 ng/mL, thus confirming vitamin D toxicity. Retrospective analysis of treatment history revealed patient receiving 4 injections of Architol (6 Lac units im) prior to presentation. Work-up for malignancy was negative, brain imaging and EEG were normal. Holter was suggestive of intermittent CHB. Patient was given hydration, injection calcitonin 100 I.U. subcutaneously, injection pamidronate 60 mg infusion, with serum calcium levels normalizing, with relief in constipation, vomiting and behavioral improvement. However, persistence of rhythm disturbances led to permanent pacemaker placement. The present case highlights the dangers of indiscriminate vitamin D usage, exposing patients to potentially life threatening complications.
  4,258 262 -
Refractory rickets due to Fanconi's Syndrome secondary to Wilson's disease
Chitra Selvan, Anubhav Thukral, Partha P Chakraborthy, Rana Bhattacharya, Ajitesh Roy, Soumik Goswani, Dayanidhi Meher, Sujoy Ghosh, Satinath Mukhopadhyay, Subhankar Chowdhury
December 2012, 16(8):399-401
Renal tubular disorders are an important cause of refractory rickets. Wilson's disease, an inherited disorder of copper metabolism has varied presentations. We present a case of refractory rickets due to Fanconi's syndrome attributable to Wilson's disease. An adolescent girl presented with pain in the hip and knee joints and a knock-knee deformity since six years. She had received multiple doses of cholecalciferol with little improvement. There was no history of seizures, polyuria, jaundice, intake of drugs, or similar complaints in the family. Examination revealed a severely short stature with widening of the wrist joint and genu valgum. Examination of the central nervous system (CNS) was normal. Skeletal radiographs showed features suggestive of rickets at the hip and knee joints. Routine biochemistry was normal, 25-hydroxyvitamin D [25(OH)D] was adequate (57.1 ng/dL), with normal corrected calcium (9.24 mg/dL), low phosphate (2.76 mg/dL), elevated bone-specific alkaline phosphatase, and normal renal functions. Twenty-four-hour urine revealed phosphaturia, kaliuresis, and glucosuria with normal blood sugars and aminoaciduria. Blood gas analysis revealed normal anion gap metabolic acidosis with a urine pH of 7. Ammonium chloride (NH 4 CL) challenge test revealed proximal tubular acidosis. A search for causes revealed Kayser-Fleischer rings. The diagnosis of Wilson's disease was confirmed by low serum ceruloplasmin levels (6.5 mg/dL; normal: 18-35 mg/dL) with high 24-hour urine copper levels (433 mcg; normal: 20-50 mcg). She was started on a replacement of alkali, phosphate, calcium, and vitamin D, with zinc acetate for Wilson's disease. Rickets as a presenting feature of Wilson's disease has been reported rarely. Recognition of this entity is important, as treatment of the primary condition may improve tubular function as well.
  3,999 258 -
A simple way to identify insulin resistance in non-diabetic acute coronary syndrome patients with impaired fasting glucose
Sayantan Ray, Ashit Kumar Bairagi, Santanu Guha, Satyabrata Ganguly, Debes Ray, Ashis Kumar Basu, Anirban Sinha
December 2012, 16(8):460-464
Background and Objective: The incidence of coronary artery disease (CAD) is increasing in India. Recent data suggesting insulin resistance can predict cardiovascular disease independently of the other risk factors, such as hypertension, visceral obesity, or dyslipidemia, so a focus on the relation between acute coronary syndrome (ACS) and insulin resistance is relevant. Several studies addressing serum lipoprotein ratios as surrogates for insulin resistance have found promising results. We analyzed the association of lipoprotein ratios with the homeostatic model assessment of insulin resistance (HOMA-IR). Methods: One hundred non-diabetic patients with impaired fasting glucose admitted with a diagnosis of ACS were included in the study. Admission fasting glucose and insulin concentrations were measured. The HOMA-IR was used to calculate insulin resistance. The fasting serum total cholesterol (TC), triglycerides (TG), and high-density lipoprotein (HDL-C) levels are used to calculate following lipid ratios: TC/HDL-C and TG/HDL-C. The areas under the curves (AUC) of the receiver operating characteristic curves (ROC) were used to compare the power of these serum lipoprotein ratio markers. Results: Lipoprotein ratios were significantly higher in patients with HOMA Index >2 as compared to patients with Index <2. TG/HDL-C ratio and TC/HDL-C ratio were significantly correlated with HOMA-IR (P < 0.05) as obtained by Pearson's correlation analysis (r = 0.4459, P = 0.0012; r = 0.4815, P = 0.0004; r = 0.3993; P = 0.0041, respectively). The area under the ROC curve of the TG/HDL-C and TC/HDL-C ratios for predicting insulin resistance was 0.80 (95% CI, 0.67-0.93), 0.78 (95% CI, 0.65-0.91), respectively. Conclusion: A plasma TG/HDL-C ratio and TC/HDL-C ratio provide a simple means of identifying insulin resistant and can be used as the markers of insulin resistance and cardiovascular diseases risk in adult non-diabetic patients.
  3,511 465 -

December 2012, 16(8):514-524
  3,568 327 -
Oral use of "Low and Slow" Rosuvastatin with Co-Enzyme Q 10 in patients with Statin-Induced Myalgia: Retrospective case review
Madhurima Vidyarthi, Peter Jacob, Tahseen A Chowdhury
December 2012, 16(8):498-500
Background: Statins have proven efficacy in reducing vascular disease, but statin-induced myalgia is relatively common in clinical practice, and can sometimes leave patients who are high risk for vascular disease unable to take these important preventative treatments. Low or intermittent dose rosuvastatin has been shown to be useful in lowering cholesterol with fewer side-effects. Supplementation with co-enzyme Q 10 is suggested to reduce statin-induced myalgia. Materials and Methods: A retrospective review of patients attending a tertiary referral lipid clinic with statin-induced myalgia was carried out. Patients were counseled on commencing low-dose rosuvastatin, titrated at monthly intervals, and supplemented by co-enzyme Q 10 100 mg daily. Results: Forty Three patients were reviewed. Six were unable to tolerate the regime at all. The remaining 37 patients tolerated rosuvastatin between 5 mg weekly and 20 mg daily. Total and LDL-cholesterol levels fell by a mean of 29.1% and 27.5%, respectively. 62.2% of patients achieved total cholesterol under 5.0 mmol/L. Conclusions: In this retrospective review of clinical practice, "low and slow" rosuvastatin supplemented by co-enzyme Q 10 led to clinically meaningful reductions in total and LDL-cholesterol in patients with statin-induced myalgia.
  3,537 204 -
Subclinical hypothyroidism in children
Krishna G Seshadri
December 2012, 16(8):156-158
The prevalence of SH in the pediatric population is < 2%, the caveat being the limited number of studies addressing SCH in the pediatric population. congenital deveolopental anamolies. Mutations in the several proteins are important causes of this condition. Despite the limited data available, SCH in children and adolescents appears to be a benign and remitting disease with a low risk of evolution to OH. It appears that thyroid hormones appear to be functioning well despite elevated TSH. Predictors of progression include, goiter, celiac disease, and positive anti TPO.
  3,106 558 -
Precocious puberty in girls
Sachin Chittwar, Shivprakash , AC Ammini
December 2012, 16(8):188-191
Precocious puberty in girls can be due to number of factors of which idiopathic central precocious puberty is the most common etiology. Here, we describe 3 cases of precocious puberty where the first case had premature thelarche in the background history of mother with Type 2 Diabetes Mellitus, cases 2 and 3 had ovarian tumours with heterogeneity in presentation.
  3,090 482 -
Acromegaly presenting as hirsuitism: Uncommon sinister aetiology of a common clinical sign
Rajesh Jain, Deep Dutta, KS Shivaprasad, Indira Maisnam, Sujoy Ghosh, Satinath Mukhopadhyay, Subhankar Chowdhury
December 2012, 16(8):297-299
Hirsuitism though not uncommon (24%), is not considered to be a prominent feature of acromegaly because of its lack of specificity and occurrence. Hirsuitism is very common in women of reproductive age (5-7%) and has been classically associated with polycystic ovarian syndrome (PCOS). Twenty-eight year lady with 3 year duration of hirsuitism (Modified Ferriman Gallwey score-24/36 ), features of insulin resistance (acanthosis), subtle features of acromegaloidism (woody nose and bulbous lips) was diagnosed to have acromegaly in view of elevated IGF-1 (1344 ng/ml; normal: 116-358 ng/ml), basal (45.1 ng/ml) and post glucose growth hormone (39.94 ng/ml) and MRI brain showing pituitary macroadenoma. Very high serum androstenedione (>10 ng/ml; normal 0.5-3.5 ng/ml), elevated testosterone (0.91 ng/ml, normal <0.8) and normal dehydroepiandrosterone sulphate (DHEAS) (284 mcg/dl, normal 35-430 mcg/dl) along with polycystic ovaries on ultrasonography lead to diagnosis of associated PCOS. She was also diagnosed to have diabetes. This case presentation intends to highlight that hirsuitism may rarely be the only prominent feature of acromegaly. A lookout for subtle features of acromegaly in all patients with hirsuitism and going for biochemical evaluation (even at the risk of investigating many patients of insulin resistance and acromegloidism) may help us pick up more patients of acromegaly at an earlier stage thus help in reducing disease morbidity.
  3,139 223 -
Correlation of acanthosis nigricans with insulin resistance, anthropometric, and other metabolic parameters in diabetic Indians
PP Patidar, P Ramachandra, R Philip, S Saran, P Agarwal, M Gutch, KK Gupta
December 2012, 16(8):436-437
Introduction: Acanthosis nigricans is a non-specific reaction pattern that may accompany obesity, diabetes, excess corticosteroids, pineal tumors, malignancies, and other endocrine disorders. It is considered a cutaneous marker of tissue insulin resistance. Aims and Objectives: To determine the prevalence of acanthosis nigricans in type 2 diabetes mellitus (DM) and its correlation with various anthropometric measurements and insulin resistance by HOMA-IR and other metabolic parameters. Materials and Methods: One hundred and fifty consecutive subjects with newly diagnosed type 2 DM, attending the endocrinology OPD of LLRM Medical College, Meerut were studied. Acanthosis was graded based on standard scale of 0-4 as described by Burke et al. Anthropometric data were obtained and insulin resistance calculated as HOMA-IR from fasting insulin and fasting blood sugar values. Results: The average age of the study population was 45.2 years, with male to female ratio of 1:5. The prevalence of acanthosis in males was 56.67% and in females was 86.92%. The acanthosis neck severity grading had a statistically significant correlation with fasting glucose levels, fasting insulin levels, and insulin resistance values: HOMA-IR, HOMA-S, and HOMA-B (P < 0.05). Other acanthosis parameters such as axillary grading, acanthosis at knuckles, and skin tags, did not have a statistically significant correlation with insulin resistance. Conclusion: Acanthosis nigricans neck severity grading correlates well with insulin resistance and can be used as a clinical surrogate for assessment of severity of insulin resistance.
  2,804 428 -
Post-prandial hyperglycemia
Santosh Kumar Singh
December 2012, 16(8):245-247
Isolated post prandial hyperglycaemia (PPHG) has been shown to double the risk for cardiovascular mortality. It also makes a significant contribution to overall glycaemia reflected in the HbA1c level. The harmful effects of PPHG are increased cardiovascular mortality, association with mic rovascular complications, cognitive decline and cancers. A variety of both pharmacologic and non-pharmacologic trherapies are available to target PPHG.
  2,660 567 -
Dyslipidemia in subclinical hypothyroidism and the effect of thyroxine on lipid profile
Ajay Asranna, RS Taneja, Bindu Kulshreshta
December 2012, 16(8):347-349
Introduction: Subclinical hypothyroidism (SH) has a prevalence between 4% and 10.5% in various studies. The burden of SH in India is expected to increase with increasing iodine sufficiency. Studies have shown conflicting results concerning not only the degree of lipid changes in SH but also the effect of thyroxine substitution therapy. Indian studies on dyslipidemia in SH and the effect of thyroxine on lipid profile are currently lacking. Aims and Objectives: (1) To assess the association of SH and lipid profile. (2) To quantify the effect of thyroxine treatment on lipid profile. Materials and Methods: About 54 patients who were detected to have SH were compared with 56 healthy controls. Thyroid stimulating hormone (TSH), free T3, free T4, anti thyroperoxidase (TPO) antibodies, total cholesterol, high density lipoprotein (HDL) cholesterol, low density lipoprotein (LDL) cholesterol, Very low density lipoprotein (VLDL) cholesterol, serum triglycerides were measured in all the patients after an overnight fast. Selected patients were started on thyroxine replacement. Twenty-one patients were followed up after 3 months with a repeat lipid profile. Results: Mean total cholesterol and mean LDL levels were significantly higher in SH compared to controls, but there was no statistically significant difference in the mean HDL, VLDL, and triglyceride levels. There was a significant reduction in mean T. cholesterol, mean LDL, mean VLDL, and mean triglyceride levels after treatment with thyroxine, while there was no significant difference among the mean HDL levels. Conclusion: Dyslipidemia is more common in SH compared to controls. There is a TSH dependent increase in cholesterol, LDL, VLDL, and triglyceride levels. Achieving euthyroid status with thyroxine has a favourable effect on lipid profile.
  2,612 528 -
A clinical study to compare the efficacy and safety of pregabalin sustained release formulation with pregabalin immediate release formulation in patients of diabetic peripheral neuropathic pain
A Srivastava, S Shah, A Maseeh, B Vyasa, M Balaji, S Bhatter, P Buch, D Dantara, J Karnani, V Kumar, S Lodha, D Maji, A Moses, S Phatak, S Polarappu, S Shah, B Upadhayay
December 2012, 16(8):477-479
Objective: To compare the efficacy and safety of sustained release (SR) formulation of pregabalin with immediate release (IR) formulation in patient with diabetic peripheral neuropathic pain. Materials and Methods: In this open label, randomized, comparative, multicentric study, the primary efficacy measure was reduction in visual analogue scale (VAS) of short form McGill pain questionnaire (SF-MPQ) score from baseline to last visit. The secondary evaluation measures included reduction in SF-MPQ descriptive score and present pain intensity score and change in clinical global impression - improvement of illness (CGI-I) and clinical global impression - severity of illness (CGI-S) from baseline to last visit. Total duration of the study was 12 weeks. Safety evaluation was done by recording treatment emergent adverse events and laboratory investigations at baseline and end of treatment. Results: Of 265 randomized patients, 133 received pregabalin SR tablets and 132 pregabalin IR. Patients randomized to both treatments responded to respective treatments. The least square means of VAS score in both the groups were reduced significantly (P <0.01). Reduction in both groups was similar (P = ns). At the end of the trial in both the groups, there was a significant reduction in the SF-MPQ descriptive score (P <0.01), severity of illness as well as clinically significant improvement in the symptoms. Difference between the groups for CGI-I (P = 0.37) and CGI-S (P = 0.41) score was not statistically significant. Treatment in both the groups was found safe and well tolerated. Conclusion: The study shows that the pregabalin SR is safe and effective in patients of diabetic peripheral neuropathic pain. The results of the study demonstrated that pregabalin SR has comparable efficacy and safety as pregabalin IR.
  2,591 375 -
Endocrinology @ the nobels
Sanjay Kalra, Ambika G Unnikrishnan, Jubbin Jacob
December 2012, 16(8):138-139
  2,622 251 -
Mild acute pancreatitis with vildagliptin use
Ravikant Saraogi, Ritwika Mallik, Sujoy Ghosh
December 2012, 16(8):480-482
Vildagliptin has not been associated with the development of acute pancreatitis in postmarketing reports except one case report from Sydney, Australia. We present the case report of 42 year old male, diabetic, with no historyof alcohol use, on vildagliptin 50 mg and metformin 500 mg daily since 6 months, who presented with severe abdominal pain radiating to back, nausea and fever. On evaluation, serum pancreatic enzymes were elevated, triglycerides were not raised and ultrasound showed swollen and echogenic pancreas, loss of peripancreatic fat plane and pancreatic duct was not dilated. Vildagliptin was stopped and the pancreatits resolved. On Follow up, no secondary cause was not identified. This appears to be the first reported case of acute pancreatitis from India probably attributable to use of vildagliptin, thus raising the possibility that this rare reaction may be a class effect of the DPP-4 inhibitors.
  2,637 209 -
Diabetes in young: Beyond type 1
Anju Virmani, Abhishek Kulkarni
December 2012, 16(8):256-258
Although majority of diabetes in children is type1 diabetes, childhood type2 diabetes prevalence is rapidly increasing due to changing lifestyle. Most patients can be definitely grouped into either of the two but some present diagnostic difficulty due to overlapping and non specific clinical features and laboratory findings. MODY and several other diseases affecting the pancreas also result in childhood diabetes. Treatment of diabetes in children presents unique challenges and primary prevention is of prime importance.
  2,433 379 -
Pituitary Gigantism: A Case Report
Rana Bhattacharjee, Ajitesh Roy, Soumik Goswami, Chitra Selvan, Partha P Chakraborty, Sujoy Ghosh, Dibakar Biswas, Ranen Dasgupta, Satinath Mukhopadhyay, Subhankar Chowdhury
December 2012, 16(8):285-287
Objective: To present a rare case of gigantism. Case Report: A 25-year-old lady presented with increased statural growth and enlarged body parts noticed since the age of 14 years, primary amenorrhea, and frontal headache for the last 2 years.She has also been suffering from non-inflammatory low back pain with progressive kyphosis and pain in the knees, ankles, and elbows for the last 5 years. There was no history of visual disturbance, vomiting, galactorrhoea, cold intolerance. She had no siblings. Family history was non-contributory.Blood pressure was normal. Height 221 cm, weight 138 kg,body mass index (BMI)28. There was coarsening of facial features along with frontal bossing and prognathism, large hands and feet, and small goitre. Patient had severe kyphosis and osteoarthritis of knees. Confrontation perimetry suggested bitemporal hemianopia. Breast and pubic hair were of Tanner stage 1. Serum insulin like growth factor-1 (IGF1) was 703 ng/ml with all glucose suppressedgrowth hormone (GH)values of >40 ng/ml. Prolactin was 174 ng/ml. Basal serum Lutenising Hormone (LH), follicle stimulating Hormone (FSH) was low. Oral glucose tolerance test (OGTT), liver and renal function tests, basal cortisol and thyroid profile, Calcium, phosphorus and Intact Parathyroid hormone (iPTH) were normal.Computed tomographyscan of brain showed large pituitary macroadenoma. Automated perimetry confirmed bitemporal hemianopia. A diagnosis of gigantism due to GH secreting pituitary macroadenoma with hypogonadotrophichypogonadism was made. Debulking pituitary surgery followed by somatostatin analogue therapy with gonadal steroid replacement had been planned, but the patient refused further treatment.
  2,408 343 -
Tetany due to hypoparathyroidism as the initial manifestation of autoimmune polyendocrine syndrome type-2: A case report
Deep Dutta, Indira Maisnam, Sujoy Ghosh, Ranen Dasgupta, Satinath Mukhopadhyay, Subhankar Chowdhury
December 2012, 16(8):495-497
Hypoparathyroidism is most commonly isolated and idiopathic. Hypoparathyroidism in autoimmune polyendocrine syndrome type-2 (APS-2) is extremely rare with few isolated reports and usually presents late. We present perhaps for the first time, hypoparathyroidism being the initial manifestation of APS-2 which was diagnosed in a 32 year lady with tingling of the extremities along with hypocalcemic tetany for 15 years. She also had generalized acral and mucosal hyperpigmentation of 2 years duration. Investigations were significant for low calcium (7.1mg/dl), elevated phosphorus (4.8mg/dl), vitamin-D insufficiency (27.4ng/ml), low intact parathyroid hormone (2.3pg/ml), low basal (4.7mcg/dl) and stimulated serum cortisol (9.2mcg/dl at half hour, 11.4mcg/dl at 1 hour post synacthen), elevated triiodothyronine (2.1ng/ml) and free tetraiodothyronine (2.4ng/dl) along with suppressed TSH (<0.005 U/L). Imaging relevaled mild cerebellar calcification, normal adrenals with diffuse uptake of Tc 99 - pertechnate. A diagnosis of hypoparathyroidism with Addison's and Graves' disease as a part of APS-2 was made. This report intends to highlight the clinical heterogeneity and varied presentation of APS-2. Routine screening of other hormonal function (especially adrenal function, thyroid function and blood glucose) in a patient with diagnosed hypoparathyroidism is advisable to decrease the chances of missing APS-2.
  2,380 202 -
De morseir syndrome presenting as ambiguous genitalia
Anubhav Thukral, S Chitra, Partho P Chakraborty, Ajitesh Roy, Soumik Goswami, Rana Bhattacharjee, Deep Dutta, Indira Maisnam, Sujoy Ghosh, Satinath Mukherjee, Subhankar Chowdhury
December 2012, 16(8):509-511
Background: A 10-year-old boy presented with genital ambiguity, poor linear growth, and delayed milestones. The aim and to highlight that although rare but congenital, hypogonadotropic hypogonadism may rarely present as ambiguity. Materials and Methods: The patient was found to have bilateral cryptorchidism with proximal penile hypospadias, microphallus with a proportionate dwarfism with mildly delayed bone age, and karyotype 46XY. Euthyroid with normal steroid axis, growth hormone insufficient as suggested by auxology, low IGF1, and poor response to clonidine stimulation. MRI brain shows hypoplastic corpus callosum, hypoplastic anterior pituitary, and ectopic posterior pituitary bright spot. Results: The patient underwent laparoscopic removal of right intrabdominal testis and orchidoplexy was performed on the left one. Testicular biopsy revealed no malignancy and growth hormone replacement was initiated. The patient awaits definitive repair of hypospadias. Conclusion: As a provisional diagnosis of combined growth hormone and gonadotropin deficiency, most probable diagnosis is septo-optic dysplasia or de moseir syndrome leading to genital ambiguity.
  2,337 215 -
Congenital hypothyroidism: Screening dilemma
Meena P Desai
December 2012, 16(8):153-155
Primary sporadic congenital hypothyroidism (CH) is the most common cause of hypothyroidism infancy early childhood in iodine sufficient region. Screening for neonatal CH began in 1970s. The rationale and reason for neonatal screening for CH (NSCH) are well established. It is mandatory in most developed countries along with the screen for metabolic disorder. The possibility of measuring TSH and thyroid hormones in cord blood paved the way for newborn screening (NS) for CH. Worldwide it is estimated that 25% of the live born population of 130 million babies undergo NSCH. Klein et al., by 1972 had shown improved CNS prognosis in CH treated by age 3 months. NSCH has largely eradicated the severe irreversible neurodevelopmental damage and reversed the chances of growth failure in infancy and early childhood.
  2,037 511 -
Study of Primary Hyperparathyroidism
Parmar Girish, M Lala, M Chadha, NF Shah, PH Chauhan
December 2012, 16(8):418-420
Introduction: The clinical spectrum of primary hyperparathyroidism (PHPT) has undergone a striking change with asymptomatic form predominant in developed countries, whereas symptomatic form predominant in developing countries. In this study, we have analyzed clinical presentation, investigations, management, operative findings in patients with PHPT at our center. Materials and Method: A retrospective, review of medical records of all patients with PHPT between 2000 and July 2012 at our institute was undertaken. A total of 96 patients were included in this study. Results: The mean age of patients was 50.8 years. Of the 96 patients, 63 were females (65.6%) and 33 were males (34.4%). Among them, 17.7% were asymptomatic and 82.3% were symptomatic. Bone pain was the most common complaint (52%) followed by renal stones (27%). Nearly 10.4% were part of familial PHPT, whereas others were sporadic adenomas. All patients had hypercalcemia (range 10.5-19.4 mg/dl) with elevated parathyroid (PTH) levels (range 32-3820 pg/ml). 25(OH) VitD levels were available in 86 patients (89.6%). There was no correlation between VitaminD levels and symptomatology. Sestamibi scan was true positive in 95.6%, false negative 2.2%, and inconclusive in 2.2%. Ultrasonography (USG) results were true positive in 84.2%, false positive in 6.3%, and false negative in 9.5%. Intraoperative PTH levels were measured in 83.3% patients. Postoperative complications were reported in 20.8% patients. Conclusions: Clinical spectrum of PHPT varies but bones and stones are still the predominant manifestations even in affluent society. Asymptomatic form also exists and can be detected by routine measurement of serum calcium. There was no correlation seen between the 25 VitD levels and clinical symptoms.
  2,328 187 -
Atypical presentations of Wolframs syndrome
S Saran, R Philip, PP Patidar, M Gutch, P Agroiya, P Agarwal, KK Gupta
December 2012, 16(8):504-505
Background: Wolfram syndrome is a rare hereditary or sporadic neurodegenerative disorder also known as DIDMOAD. The classically described presentation is of insulin-dependent diabetes, followed by optic atrophy, central diabetes insipidus, and sensory neural deafness. Also included are less well-described presentations of Wolframs syndrome. We here present three cases of atypical presentation of this syndrome. Case 1: A 15-year-old boy with insulin-dependent diabetes was presented for evaluation of depressive symptoms associated with suicidal tendency. Neuropsychiatric manifestations are described with Wolframs syndrome, and wolframin gene, in recessive inheritance, is associated with psychiatric illnesses without other manifestations of Wolframs syndrome. Case 2: A 17-year-old diabetic boy on insulin with good control of blood sugar presented for evaluation of delayed puberty. Central hypogonadism and other anterior pituitary hormone dysfunctions are the less publicized hormone dysfunctions in Wolframs syndrome. Case 3: A 23-year-old female who was on insulin for diabetes for the past 14 years, got admitted for evaluation of sudden loss of vision. This patient had developed a vitreous hemorrhage and, on evaluation, was found to have optic atrophy, sensory neural hearing loss, and diabetes insipidus, and presented differently from the gradual loss of vision described in Wolframs syndrome. Conclusion: Wolframs syndrome being a multisystem degenerative disorder can have myriad other manifestations than the classically described features. Neuropsychiatric manifestations, depression with suicidal risk, central hypogonadism, and secondary adrenal insufficiency are among the less well-described manifestations of this syndrome.
  2,336 178 -
Spot urine cortisol-creatinine ratio - A useful screening test in the diagnosis of Cushing's syndrome
Nitin Kapoor, Victoria Job, L Jayaseelan, Simon Rajaratnam
December 2012, 16(8):376-377
Introduction : Although,there are several tests available, not one of them fulfils the criteria of being an ideal screening test. Continuing the search for an ideal screening test, we explored the use of urine spot cortisol-creatinine ratio as a novel method of evaluating patients with Cushing's syndrome. Method: A total of 35 subjects were studied and divided into 3 groups - 15 having cushings syndrome, 15 patients with obesity and 5 normal weight subjects. All patients with cushings syndrome were positive for the other screening tests. Results : The mean (standard deviation) of cortisol:creatinine ratio among the 3 groups (cushings, obese and control subjects) was 36.00(24.74), 7.01(2.73) and 3.49(2.68) respectively. Using the cutoff of 12.27 nano mol/ micro mol(based on data of normal subjects) for the urine cortisol creatinine ratio we get a sensitivity of 93.75% and a specificity of 100%. Also the positive and negative predictive value as calculated with this cutoff is 100% and 93.3% respectively. Conclusion: In this study we found that UCCR is similar in both Obese and Non Obese subjects who did not have cushings syndrome. UCCR is significantly elevated in individuals with Cushing's syndrome as compared to those who do not have cushings syndrome. Also when a cut off of 12.27 nano mol/ micro mol was used this test had a higher sensitivity, however this test had a higher specificity at a cut off of 15.35.
  2,221 263 -
Prevalence of pre-diabetes, diabetes, pre-hypertension, and hypertension in children weighing more than normal
Priti Phatale, Hemant Phatale
December 2012, 16(8):483-485
Aim: Prevalence of pre-diabetes, diabetes, pre-hypertension (pre-HT), and hypertension (HT) in children weighing more than normal. Materials and Methods: Three- to eighteen-year old children weighing more than normal were included. Pathological short children were excluded. According to Centre for Disease Control (CDC), children are grouped into overweight (OW) and obese (OB). Indian B.P. reference tables are used for defining HT and pre-HT. [2] HbA1c by HPLC (BIO RAD) method was used to define pre-diabetes and diabetes. [3] Children with HbA1c ≥6.5 were subjected for Glucose Tolerance Test (GTT). C-peptide assay was done to rule out (r/o) IDDM. Observations: When we compare this with our earlier presentation at PEDICON 2011, we found that hypertension (HTN) (22.9% vs. 23.07%) is not significantly different but pre-HTN (28.09% vs. 33.9%), pre-diabetes mellitus (pre-DM) (3.7% vs. 64.3%), and diabetes mellitus (DM) (0.35% vs. 3.8%) are significantly high in this study. Conclusion: (1) Prevalence of HT (22.90% vs. 23.07%) is similar in both groups but pre-HT (33.9% vs. 28.09%) is high in this study. (2) Significant rise in prevalence of diabetes (3.84% vs. 0.35%) and pre-diabetes (64.33% vs. 3.7%) is seen in this study. (3) This change is because of using HbA1c as screening tool in children weighing more than normal.
  2,061 302 -
Pediatric Cushing's disease: Management Issues
Martin O Savage, Helen L Storr
December 2012, 16(8):171-175
Cushing's disease (CD), caused by an ACTH-secreting pituitary corticotroph adenoma, is the commonest cause of Cushing syndrome in children over 5 years of age. It is rare in the pediatric age range and presents difficult diagnostic and therapeutic challenges. Key presenting features include weight gain, growth failure and change in facial appearance. Most pediatric endocrinologists have limited experience managing children or adolescents with CD and thus benefit from close consultation with adult colleagues. We describe a diagnostic protocol which broadly follows the model for adult patients. Treatment strategies are examined and appraised. The management of pediatric CD patients after cure is also discussed.
  1,869 412 -
Vascular calcification in diabetic foot and its association with calcium homeostasis
Jayshree Swain, Shalbha Tiwari, DD Pratyush, Awanindra Dwivedi, Balram Gupta, RC Shukla, SK Singh
December 2012, 16(8):450-452
Introduction: Vascular calcification (VC), long thought to result from passive degeneration, involves a complex process of biomineralization resembling osteogenesis, frequently observed in diabetes and is an indicator of diabetic peripheral vascular disease with variable implications. Aim and Objective : To study the association between vascular calcification and calcium homeostasis in diabetic patients with foot ulcers without stage 4, 5 chronic kidney disease. Materials and Methods : A total of 74 patients with diabetic foot ulcer were enrolled, and VC was detected by X-ray and Doppler methods. Serum calcium, phosphate, alkaline phosphatase (ALKP), fasting and post-prandial glucose levels, and glycosylated hemoglobin (HbA1C) were recorded. Serum iPTH and 25 (OH) vitamin D were estimated by immune radiometric assay and radioimmunoassay, respectively. Data was analyzed by SPSS 16.0. Results: Vascular calcification was present in 42% of patients. Significant difference in the mean (±SD) of vitamin D, HbA1C, and eGFR was observed in VC +ve compared to VC -ve. There was no significant association of age, duration, BMI, PTH, Ca, PO4, ALKP with that of VC incidence. Severe vitamin D deficiency was more common in VC +ve (51.6%) compared to in VC -ve (18.6%). Sub-group analysis showed that the risk of VC was significantly higher (RR = 2.4, P < 0.05, 95% C.I. = 0.058-2.88) in patients with vitamin D < 10 ng/ml compared to others. Conclusion: Vitamin D deficiency could be a risk for vascular calcification, which possibly act through receptors on vascular smooth muscle cells or modulates osteoprotegerin/RANKL system like other factors responsible for VC in diabetic foot patients.
  2,014 260 -
The variability of responses to growth hormone therapy in children with short stature
Martin O Savage, Peter Bang
December 2012, 16(8):178-184
Growth hormone (GH) is widely prescribed for children with short stature across a range of growth disorders. We describe the variability of responses seen in conditions approved for GH therapy. Although responses in different growth disorders are satisfactory, evidence is increasing for an unacceptably high rate of poor or unsatisfactory response (i.e., not leading to significant catch-up growth) in terms of change in height standard deviation score and height velocity. Consequently, there is a need to define a poor response and to prevent or correct it by optimizing treatment regimens. This review discusses the optimal investigation of the child who is a candidate for GH therapy so that a diagnosis-based guide to therapy and dosage can be made. The relevant parameters in the evaluation of growth response are described together with the definitions of a poor response.
  1,796 396 -
Enlarged hands and feet - Not always acromegaly
Vikrant Ghatnatti, Dipti Sarma, Uma Saikia
December 2012, 16(8):318-320
Pachydermoperiostosis maybe mistaken for acromegaly as it can present with progressive enlargement of hands and feet. We describe a 32 year old male with enlargement of hands and feet and extensive keloid formation. Family history was positive for similar complaints. X ray imaging showed normal heel pad thickness with acroosteolysis and subperiosteal new bone formation in hands and feet.IGF-1 was normal and glucose suppressed GH values were normal.
  1,914 266 -
Failed Parathyroidectomy: The road ahead
Amit Agarwal, Roma Pradhan
December 2012, 16(8):221-223
Persistent hyperparathyroidism due to failed parathyroidectomy is an uncommon but challenging problem as re-operation carries higher complication and failure rates. Re-operations can often be performed via a minimally invasive approach by experienced surgeons after localisation using requisite imaging techniques, the preferred sequence of which is still under evolution. A carefully planned operation with additional adjuncts is of utmost importance as parathyroidectomy remains the only curative treatment option.
  1,988 186 -
Familial glucocorticoid deficiency presenting with generalized hyperpigmentation in adolescence. Report of three siblings
KS Shivaprasad, Deep Dutta, Rajesh Jain, Sujoy Ghosh, Satinath Mukhopadhyay, Subhankar Chowdhury
December 2012, 16(8):382-384
Background: Familial glucocorticoid deficiency (FGD) is a rare autosomal recessive disorder characterized by glucocorticoid deficiency, high ACTH levels and normal mineralocorticoid levels. FGD is caused due to defects in adrenocorticotropic hormone (ACTH) signaling. The defect can be caused by mutations in genes encoding the ACTH receptor (melanocortin 2 receptor) or its accessory protein. Patients: Here we report three siblings with FGD. The second in order of siblings presented at an age of 15 years with history of diffuse hyperpigmentation since childhood. Their parents were non consanguineous. The patients were hyperpigmented and taller compared with their parents. None of the siblings had ambiguous genitalia or neurological abnormalities. There was no history of tuberculosis in the family. Biochemical investigations revealed low serum cortisol (<1 μg/dl) and elevated plasma ACTH (>1250 pg/ml). Serum electrolytes, aldosterone, and plasma renin activity was normal. Based on the above mentioned data, a provisional diagnosis of FGD was made after ruling out the common causes of glucocorticoid deficiency. Conclusion: FGD is a rare autosomal recessive disorder which causes isolated glucocorticoid deficiency. Unawareness about the condition may lead to delayed diagnosis and treatment, which are associated with high rates of morbidity and mortality. Once a diagnosis is made it is easily treatable.
  1,907 245 -
Assessing bone health in children and adolescents
Michael A Levine
December 2012, 16(8):205-212
During normal childhood and adolescence, the skeleton undergoes tremendous change. Utilizing the processes of modeling and remodeling, the skeleton acquires its adult configuration and ultimately achieves peak bone mass. Optimization of peak bone mass requires the proper interaction of environmental, dietary, hormonal, and genetic influences. A variety of acute and chronic conditions, as well as genetic polymorphisms, are associated with reduced bone density, which can lead to an increased risk of fracture both in childhood and later during adulthood. Bone densitometry has an established role in the evaluation of adults with bone disorders, and the development of suitable reference ranges for children now permits the application of this technology to younger individuals. We present a brief overview of the factors that determine bone density and the emerging role of bone densitometry in the assessment of bone mass in growing children and adolescents.
  1,822 316 -
Endocrine manifestations of celiac disease
R Philip, PP Patidar, S Saran, P Agarwal, TVS Arya, KK Gupta
December 2012, 16(8):506-508
Background: Celiac disease can have extra gastrointestinal tract (GIT) presentations, most of which are endocrine. The aim of this study was to present patients diagnosed to have celiac disease from an endocrine department and to study the prevalence of endocrinopathies in celiac disease. Materials and Methods: A total of 36 patients from the endocrinology department (LLRM Medical College, Meerut) between January 2011 and July 2012 and who were diagnosed to have celiac disease were included in the study. Results: Short stature was the commonest presentation (25%), other presentations included short stature and delayed puberty (20%), delayed puberty (11%), screening for celiac disease in type-1 DM patients (17%), rickets (6%), anemia not responding to oral therapy (6%), type-1 DM with recurrent hypoglycaemia (6%), and osteomalacia (3%). The endocrine manifestations include (after complete evaluation) short stature (58%), delayed puberty (31%), elevated alkaline phospahatase (67%), low calcium (22%), X-rays suggestive of osteomalacia or rickets (8%), capopedal spasm (6%), and night blindness (6%). Anti-TPO antibody positivity was found in 53%, hypothyroidism in 28%, subclinical hypothyroidism in 17%, and type-1 DM in 25% of the patients. A total of 14% patients had no GI symptoms. Conclusion: Celiac disease is an endocrine disrupter as well as the great masquerader having varied presentations including short stature, delayed puberty, and rickets. Some patients who have celiac disease may not have any GI symptoms, making the diagnosis all the more difficult. Also, there is significant incidence of celiac disease with hypothyroidism and type-1 DM, making screening for it important in these diseases.
  1,822 308 -
Calcium-sensing receptor: Role in health and disease
RV Thakker
December 2012, 16(8):213-216
The calcium-sensing receptor (CaSR) is a 1,078 amino acid G protein-coupled receptor (GPCR), which is predominantly expressed in the parathyroids and kidney. The CaSR allows regulation of parathyroid hormone (PTH) secretion and renal tubular calcium re-absorption in response to alterations in extracellular calcium concentrations. Loss-of-function CaSR mutations have been reported in the hypercalcemic disorders of familial benign (hypocalciuric) hypercalcemia (FBH or FHH), neonatal severe primary hyperparathyroidism (NSHPT), and adult primary hyperparathyroidism. However, some individuals with loss-of-function CaSR mutations remain normocalcemic. Gain-of-function CaSR mutations have been shown to result in autosomal-dominant hypocalcemia with hypercalciuria (ADHH) and Bartter's syndrome type V. CaSR auto-antibodies have been found in FHH patients who did not have loss-of-function CaSR mutations and in patients with an acquired form (i.e. autoimmune) of hypoparathyroidism. Thus, abnormalities of the CaSR are associated with 4 hypercalcemic and 3 hypocalcemic disorders.
  1,697 402 -
Ileal Interposition with Diverted sleeve gastrectomy for treatment of Type 2 diabetes
Sunil Kumar Kota, Surendra Ugale, Neeraj Gupta, S.V.S. Krishna, KD Modi
December 2012, 16(8):458-459
Objective: The objective of the present study was to prospectively evaluate the results of laparoscopic ileal interposition (II) with diverted sleeve gastrectomy (DSG) for control of type 2 diabetes mellitus (T2DM) and related metabolic abnormalities. Materials and Methods: All patients underwent II +DSG. They had T2DM ≥5 years with poor glycemic control despite adequate dosage of oral hypoglycemic agents (OHAs) and/or insulin. The primary outcome was remission of diabetes (HbA1C <6.5% without OHAs/insulin), and secondary outcomes were reduction in antidiabetic agent requirement and components of metabolic syndrome. Results: We report the preliminary postoperative follow-up data of 13.1 ± 5.3 months (range: 3-26 months). There were 32 patients (Male: female = 21:11) with mean age of 48.7 ± 7.8 (range, 34-66 years), duration of diabetes of 13.1 ± 5.8 years (range, 5-30 years), and preoperative body mass index of 29.1 ± 6.9 kg/m 2 (range: 22.4-39.5 kg/m 2 ). Sixteen patients (50%) had hypertension, while dyslipidemia and microalbuminuria were present in 12 patients (39%) each. Twenty two patients (70.5%) had diabetes remission. Fifteen/sixteen (93%) patients had remission in hypertension. All participants had weight loss ranging between 15% and 25%. Postoperatively, statistically significant decline was observed in the glycemic and lipid parameters, microalbuminuria at all intervals (P<0.05). Patients with duration of follow up more than 6 months demonstrated to havebetter improvement in terms of reduction in glycemic, lipid parameters, and microalbuminuria. Three patients had vitamin B12 deficiency 1 year after surgery. Conclusion: Ileal interposition combined with DSG addresses both foregut and hindgut theories and brings about remissions in T2DM patients with reasonable safety. Our preliminary observations demonstrated the feasibility and efficacy of this novel surgical procedure as a promising option in T2DM.
  1,898 183 -
Two cases of fetal goiter
Ashish Saini, Murli Manohar Reddy, Roopal Panchani, Tarun Varma, Nitinranjan Gupta, Sudhir Tripathi
December 2012, 16(8):358-360
Introduction: Anterior fetal neck masses are rarely encountered. Careful routine ultrasound screening can reveal intrauterine fetal goiters (FGs). The incidence of goitrous hypothyroidism is 1 in 30,000-50,000 live births. The consequences of both FG and impaired thyroid function are serious. Aims and Objectives: To emphasize role of ultrasound in both invasive and non-invasive management of FG. Materials and Methods: Two pregnant patients, during second trimester, underwent routine antenatal ultrasound revealing FG, were investigated and managed. Results: Case 1: Revealed FG with fetal hypothyroidism. Intra-amniotic injection l-thyroxine given. Follow-up ultrasound confirmed the reduction of the goiter size. At birth, thyroid dyshormogenesis was suspected and neonate discharged on 50 mcg levothyroxine/day with normal growth and development so far. Case 2: Hypothyroid mother with twin pregnancy revealed FG, in twin 1, confirmed on magnetic resonance imaging (1.5 × 1.63 cm). The other twin had no thyroid swelling. Cordocentesis confirmed hypothyroidism in twin 1. Maternal thyroxine dose increased as per biochemical parameters leading to reduction in FG size. Mother delivered preterm and none of the twins had thyroid swelling. Fetal euthyroidism was confirmed on biochemical screening. Conclusion: FG during pregnancy should be thoroughly evaluated, diagnosed and immediately treated; although in utero options for fetal hypothyroidism management are available, emphasis should be laid on non-invasive procedures. Newer and better resolution techniques in ultrasonography are more specific and at the same time are less harmful.
  1,818 220 -
Glycemic control and fetal abdominal circumference
S Gopinath, G Varalakshmi, K Manoj, Rubiya
December 2012, 16(8):445-446
Aim: To study about the correlation between the glycemic status and increase in fetal abdominal circumference in gestational diabetes patients and its relationship with fetal birth weight. Materials and Methods: Seventy-five gestational diabetes mellitus (GDM) patients were taken up for study with duly informed consent and suggested for anthropometry profile and glycemic profile with HbA1C. Fetal abdominal circumference was measured during routine scans. The patients were followed up till delivery and the fetal birth was noted. Inclusion Criteria: Seventy-five gestational diabetic mothers who have attended a secondary level diabetic clinic and on regular follow-up were included in the study. Exclusion Criteria: Pre-GDM mothers, patients with co-morbid disease were excluded from the study. Expected Results: Fetal abdominal circumference correlated well with fluctuating glycemic control and fetal birth weight.
  1,797 209 -
Congenital adrenal hyperplasia - experience from a tertiary centre in South India
George Belinda, D Vinay, J Moolechery, V Mathew, R Anantharaman, V Ayyar, G Bantwal
December 2012, 16(8):385-386
Congenital adrenal hyperplasia is a group of autosomal recessive disorders caused by enzyme deficiency which leads to defects in biosynthesis of steroid precursors. Most common is 21 hydroxylase deficiency. Clinical spectrum varies from non-classical CAH to classic CAH, and it may be simple virilising form or salt-wastinfg type. 29 patients were included in our study from January 2012 to October 2012. 76% were females. Male babies typically presented with adrenal crisis between 3 rd to 6 th week of life. Around 20% of females were identified and appropriately treated only after late adolescence. Short stature was seen in 1/3 rd of patients. 1/3 rd of patients had suppressed 17 OHP levels suggestive of over-replacement therapy which may contribute to final reduction in adult height.
  1,779 217 -
Growth charts from controversy to consensus
Vaman Khadilkar, Supriya Phanse
December 2012, 16(8):185-187
Growth follows a specific set of patterns inspite of variability in children. This led to the development of growth charts . As growth provides an interplay of many factors, growth chart helps monitor growth and diagnose disease. They are also used for epidemiological purpose. There are many growth charts available. Training of health care workers to use and interpret growth chart in the children is needed for national health.
  1,577 365 -
Graves' orbitopathy: Management of difficult cases
Wilmar M Wiersinga
December 2012, 16(8):150-152
Management of Graves' ophthalmopathy (GO) is based on three pillars: to stop smoking, to restore and maintain euthyroidism, and to treat the eye changes according to severity and activity of GO. Difficulties are frequently encountered in each of these three management issues. The advice to discontinue smoking is straightforward, but just a small minority of smokers is able to quit smoking. Detailed information on how smoking adversely affects the outcome of Graves' disease may convince patients they have to stop smoking right away. Controversy exists on the most appropriate treatment of Graves' hyperthyroidism in the presence of GO. 131I therapy is associated with a risk of about 15% for worsening of GO; a preventive course of steroids is indicated in the presence of risk factors (smoking, biochemically severe hyperthyroidism, high level of TSH receptor antibodies, active GO). Alternatives are thyroidectomy or long-term treatment with antithyroid drugs, which apparently are rather neutral with respect to the course of GO. Mild GO is not always perceived as being mild by the patients themselves. Selenium improves mild GO. Moderate-to-severe GO is preferably treated with intravenous methylprednisolone pulses, but serious side effects and relapsing GO do occur. After steroid failure combination therapy with low-dose oral prednisone with either cyclosporine or retrobulbar irradiation can be effective. Dysthyroid optic neuropathy is best treated with IV pulses, followed by orbital decompression if visual functions do not improve. In resistant cases, rituximab might be considered, although failures of this drug are also described.
  1,523 397 -
What the future holds for gliptins
Radhika Jindal, Ayesha Ahmad, Mohammad A Siddiqui, Subhash K Wangnoo
December 2012, 16(8):242-244
Gliptins have revolutionised the treatment of Type 2 Diabetes Mellitus, addressing the hyperglycemia through its effects on the alpha and beta cells of the pancreas. In this article,we review the extra-glycemic effects of gliptins on central nervous system, cardiovascular biology and the bone health and concerns regarding pancreatitis and pancreatic cancer.
  1,511 376 -
Adrenal incidentalomas: A collection of six interesting cases and brief review of literature
Roopal Panchani, Ashutosh Goyal, Tarun Varma, Nitinranjan Gupta, Sudhir Tripathi, Surender Kumar
December 2012, 16(8):378-381
Introduction: Adrenal incidentalomas (AI) are detected in approximately 4-7% of patients in imaging studies. Majority are benign, but careful evaluation is warranted to rule out carcinoma and functional adenomas. Aim: The purpose of presenting these cases is to highlight the approach to management of AI in terms of diagnosis, follow-up, and treatment. Materials and Methods: Seven patients presenting in the endocrine clinic with AI were evaluated for their presenting clinical features and investigated. Results: Case 1 was a 49-year-old female, with adrenal androgen secreting adrenocortical carcinoma with amenorrhoea which was mistaken as menopause. She had minimal hirsutism, which was mistaken as postmenopausal hirsutism. Case 2 was a 39-year-old male, presenting with hyperglycemia found to have Conns' syndrome with aldosterone producing adenoma on routine ultrasound. Case 3 was a 32-year-old male, presenting with gastritis and bloating, where ultrasound showed bilateral large adrenal masses revealed as diffuse large B cell lymphoma on biopsy. Case 4 was a 21-year-old boy, who had pheochromocytoma misdiagnosed as benign intracranial hypertension (HTN). Case 5 was a 59-year-old hypertensive male, presenting with fever had pheochromocytoma with catecholamine excess, producing fever. Case 6 was isolated adrenal tuberculosis who presented with chronic diarrhea. Conclusion: AI are common, though prevalence varies depending on the reason for scanning, the characteristics of the population studied, and the radiological techniques used. Most are non-secreting cortical adenomas. AI should be evaluated both biochemically and radiologically. When a hormonal disorder is suspected clinically, targeted, diagnostic testing for autonomous cortisol secretion, pheochromocytoma, and hyperaldosteronism is indicated.
  1,630 225 -
Thyrotoxicosis and radioiodine therapy: Does the dose matter?
Andrew Collier
December 2012, 16(8):147-149
There are 3 treatment options for thyrotoxicosis: Antithyroid drugs, Surgery and radioiodine. The choice of treatment varies geographically. Radioiodine therapy is preferred in the United States. The aim of radioiodine is to destroy sufficient thyroid tissue to cure the hyperthyroidism. There is a lack of consensus towards what dose of radioiodine should be used. Several methods are used to determine the dose. In our practice we administer 400 MBq to patients with Graves and in patients with large multinodular goiter, we would administer 800 MBq.
  1,583 262 -
Serum lipids and diabetic retinopathy: A cross-sectional study
Jyothi Idiculla, Suneetha Nithyanandam, Mary Joseph, VK Ajoy Mohan, Usha Vasu, Mohammed Sadiq
December 2012, 16(8):492-494
Aim: To evaluate the association of elevated serum lipids with retinal hard exudates formation, the occurrence clinically significant macular edema (CSME), occurrence and severity of diabetic retinopathy (DR) and loss of vision in type 2 diabetics. Materials and Methods: Type 2 diabetic patients seeking ocular evaluation for diabetic retinopathy were included in this cross-sectional study. They were assessed for presence and severity of diabetic retinopathy (DR), presence of hard exudates, clinically significant macular oedema (CSME) and best corrected visual acuity (BCVA). Retinal findings were correlated to serum lipids levels using univariate and multivariate analysis. Results: Totally 330 patients were included, of which 141/330 had diabetic retinopathy of any grade. Retinal hard exudate formation, was found to have statistically significant correlation with the presence of dyslipidemia (p=0.02), increased total cholesterol (p=0.002) and LDL levels (p=0.001). On multivariate analysis, after correcting for duration, glycemic control and albuminuria, increased cholesterol remained significantly associated with increased hard exudate formation (p=0.02). Elevated cholesterol also showed independent association with visual loss (p=0.04). The occurrence CSME showed a statistically significant correlation with dyslipidemia (p=0.04) and increased LDL levels (0.04), which did not persist on multivariate analysis. However the there was no correlation with the occurrence and severity of diabetic retinopathy Conclusion: Elevated serum lipids showed a significant association with retinal hard exudate formation, CSME and loss of vision in type 2 diabetics. Lipid lowering agents may help in reducing the occurrence of these retinal findings and loss of vision in diabetic patients.
  1,332 508 -
Continuous glucose monitoring
Kaushik Pandit
December 2012, 16(8):263-266
Continuous glucose monitoring (CGM) technology with its recent development in the real-time feedback has got the potential to revolutionize diabetes care in the near future in the arena of the rapeutic interventions and flexibility in variations in lifestyle or dietary intake. CGM has made the attainment of near-normal blood glucose concentrations, a practical goal for most patients with diabetes.
  1,527 279 -
Diabetes mellitus in the young: Gliptins or sulfonylurea after metformin?
J Muthukrishnan, S Dawra, V Marwaha, JS Bishnoi, CS Narayanan
December 2012, 16(8):474-476
Introduction: Diagnosis and initial management of diabetes mellitus (DM) in the young are clinical dilemma. Gliptins may be a safer and more effective option than sulfonylureas. Few Indian studies have addressed this issue of clinical relevance. Aim: To compare the use of sitagliptin and glimepiride as early add-on drugs along with metformin in young patients with DM to achieve optimum glycemic targets. Methods: This was a prospective, open-label, cohort study set in a tertiary care hospital in North India. Newly diagnosed patients of DM ≤35 year of age were initially treated to pre-defined glycemic goals (Fasting plasma glucose (FPG) 70-130, post prandial glucose (PPG) < 180 mg/dl) with insulin and metformin 1 g for 8 weeks. Insulin was discontinued and metformin increased to 2 g daily for next 4 weeks. Thereafter, glimepiride 1 mg or sitagliptin 100 mg was randomly added to those who were not maintaining the set glucose targets. Dose of glimepiride was uptitrated every 4 weeks upto a maximum of 4 mg. Three groups (Gp A: Metfromin 2 g/d, Gp B: Metformin 2 g + Glimepiride 1-4 mg/d, and Gp C: Metformin 2 g + sitagliptin 100 mg/d) were followed up over next 24 weeks. They were compared for glycemic control and weight change. Those failing therapy on these drugs (FPG > 180, PPG > 250 mg/dl with/without catabolic symptoms/ketosis) were withdrawn. Results: Sitagliptin with metfromin and metfromin alone group fared better than the glimepiride group for glycemic control, lesser treatment failures, and less weight gain. Conclusion : In this limited study, we found that sitagliptin is a safer and more effective option in young, newly diagnosed patients with DM. Findings of this study are relevant for clinical practice in Indian setting.
  1,439 348 -
Pancreatic carcinoma in fibrocalcific pancreatic diabetes: An eastern India perspective
Partha Pratim Chakraborty, Deep Dutta, Kaushik Biswas, Triranjan Sanyal, Sujoy Ghosh, Satinath Mukhopadhyay, Subhankar Chowdhury
December 2012, 16(8):486-488
Fibrocalcific pancreatic diabetes (FCPD) is a rare cause of diabetes (<1%) of uncertain etiology associated with >100-fold increased risk of pancreatic cancer. We present 3 patients of FCPD with pancreatic cancer who had long duration of diabetes (19 years, 25 years, and 28 years, respectively), all of whom presented with anorexia, weight loss, and worsened glycemic control. Patient-1 in addition presented with deep venous thrombosis. All the 3 patients had evidence of metastasis at the time of diagnosis. Computerized tomography (CT) abdomen revealed atrophic pancreas, dilated pancreatic ducts, and multiple calculi in the head, body, and tail of pancreas in all of them. Patient-1 had 38 mm × 38 mm × 32 mm mass in the tail of pancreas with multiple target lesions were seen in the right lobe of liver. Patient-2 had a mass in the tail of pancreas (46 × 34 × 31 mm) encasing the celiac plexus and superior mesenteric artery infiltrating the splenic hilum and splenic flexure of colon. Patient-3 also had a mass in the tail of pancreas (33 × 31 × 22 mm), with multiple target lesions in the liver, suggestive of metastasis. All patients had elevated serum CA19-9 (828.8, 179.65, and 232 U/L, respectively; normal <40 U/L). Patients of FCPD with anorexia, weight loss, worsening of glycemic control should be evaluated to rule out pancreatic cancer. Studies are warranted to evaluate CA19-9 as a screening tool for diagnosing pancreatic cancer at an earlier stage in FCPD.
  1,567 218 -
Promise and pitfalls of molecular markers of thyroid nodules
S Jadhav, Anurag Lila, Tushar Bandgar, Nalini Shah
December 2012, 16(8):162-166
Thyroid nodules are common in the general population with a prevalence of 5-7% The initial evaluation of thyroid nodules commonly involves thyroid function tests, an ultrasound (USG) and fine needle aspiration biopsy (FNAB). The optimal management of patients with thyroid nodules with indeterminate cytology is plagued by the lack of highly sensitive and specific diagnostic modalities In this article we attempt to review the available literature on the molecular markers which are increasingly being studied for their diagnostic utility in assessing thyroid nodules. The various molecular markers consist of gene mutations, gene re arrangements, RNA based assays and immunohistochemical markers. The molecular markers definitely would help to optimise the management of such patients.
  1,441 335 -
A challenging case of an ectopic parathyroid adenoma
Roopal Panchani, Tarun Varma, Ashutosh Goyal, Nitinranjan Gupta, Ashish Saini, Sudhir Tripathi
December 2012, 16(8):408-410
The occurrence of ectopic parathyroid adenomas is not uncommon (3-4% of all parathyroid adenomas). A 42-year-old female diagnosed as having GH secreting pituitary adenoma presented with an ectopic mediastinal parathyroid adenoma located between left (Lt) pulmonary artery and Lt main bronchus. The aim of presenting this case is not to appreciate the rarity of the condition but to rather discuss some of the vital practical problems faced during its management. Patient presenting in endocrine OPD with nausea, vomiting, drowsiness and chronic constipation was investigated biochemically and with various imaging modalities and accordingly managed. Patient was also investigated from the perspective of MEN 1 syndrome.Results: Baseline routine investigations revealed hypercalcemia (corrected S. Ca- 16.9 mg/dl) due to primary hyperparathyroidism (PHP, PTH-1190 ng/L) with adenoma located between Lt main bronchus and Lt pulmonary artery. Patient was medically managed and after proper preoperative preparation, surgical excision by open thoracotomy was planned but two days before surgery she developed pulmonary embolism and was shifted to ICU where she died after 20 days. An accurate preoperative localization by various imaging procedures plays a decisive role in case of ectopic adenomas in the chest. Ectopic parathyroid adenomas are frequent cause of failed initial surgery. The best surgical approach to these ectopic adenomas is still controversial. Equally effective newer medical treatment modalities are also required in patients who are awaiting or are unfit for surgery. Lastly combination of MEN 1 with ectopic parathyroid adenoma is rare.
  1,576 198 -
Stem cell therapy for diabetes
KO Lee, SU Gan, RY Calne
December 2012, 16(8):227-229
Stem cell therapy holds immense promise for the treatment of patients with diabetes mellitus. Research on the ability of human embryonic stem cells to differentiate into islet cells has defined the developmental stages and transcription factors involved in this process. However, the clinical applications of human embryonic stem cells are limited by ethical concerns, as well as the potential for teratoma formation. As a consequence, alternative forms of stem cell therapies, such as induced pluripotent stem cells, umbilical cord stem cells and bone marrow-derived mesenchymal stem cells, have become an area of intense study. Recent advances in stem cell therapy may turn this into a realistic treatment for diabetes in the near future.
  1,471 283 -
Esicon 2012,Kolkata: The best of Indian Endocrinology
Debmalya Sanyal, Sujoy Ghosh
December 2012, 16(8):136-137
  1,505 236 -
Evaluation of diabetic polyneuropathy in Type 2 diabetes mellitus by nerve conduction study and association of severity of neuropathy with serum sFasL level
Avijit Mondal, Sangita Sen, Debarati Chanda, Sunanda kundu, Mitali Chatterjee, Satinath Mukherjee
December 2012, 16(8):465-467
Introduction: Diabetes mellitus (DM), a growing health problem globally, has reached epidemic proportions in India. Recently, Fas-mediated apoptosis has been proposed as a causative factor responsible for neuronal degeneration in diabetic polyneuropathy (DPN), but there are very few studies to show association of serum soluble Fas ligand (sFasL) level with severity of neuropathy. Aim and Objective: The aim of this study was to investigate whether serum sFasL, a transmembrane glycoprotein involved in apoptosis, has any association with severity of peripheral neuropathy in Type 2 DM. Materials and Methods: The study was conducted in Department of Physiology in collaboration with Department of Endocrinology, IPGME&R. sFasL levels in serum were assessed using ELISA method in healthy individuals (n = 16), newly diagnosed diabetic controls (n = 16) without any complications, and in DPN cases (n = 33) with predominant neuropathy only. All subjects underwent both electrodiagnostic procedures and vibration perception threshold (VPT) for quantitative assessment of the severity of neuropathy. Using nerve conduction studies, amplitudes, velocities, and latencies of both sensory and motor nerves were recorded. Results: In DPN patients, concentration of sFasL levels (87.53 ± 3.49) was significantly decreased (P < 0.0001) not only when compared with normal controls (225.30 ± 2.97) but also when compared with diabetic patients without any complication (161 ± 3.63). Moreover, the concentration of sFasL is significantly (P < 0.0001) associated with the severity of neuropathy both by VPT and nerve conduction velocity (NCV). Conclusion: Fas-mediated apoptosis is involved in Type 2 DM and might be associated with the severity of polyneuropathy.
  1,474 256 -
Lymphocytic hypophysitis masquerading as pituitary adenoma
Rajneesh Mittal, Pramila Kalra, Mala Dharmalingam, Ravi Gopal Verma, Sanjay Kulkarni, Pushparaja Shetty
December 2012, 16(8):304-306
Introduction: Pituitary hypophysitis (PH) is characterized by pituitary infiltration of lymphocytes, macrophages, and plasma cells that could lead to loss of pituitary function. Hypophysitis may be autoimmune or secondary to systemic diseases or infections. Based on the histopathological findings PH is classified into lymphocytic, granulomatous, xanthomatous, mixed forms (lymphogranulomatous, xanthogranulomatous), necrotizing and Immunoglobulin- G4 (IgG4) plasmacytic types. Objective: To report a case of lymphocytic hypophysitis (LH). Case Report: A 15-year-old girl presented with history of headache, amenorrhea, and history of polyuria for past 4 months. Initial evaluation had suppressed follicular stimulating hormone (<0.01 mIU/ml), high prolactin levels (110.85 ng/ml) and diabetes insipidus (DI). Magnetic resonance imaging of sella was suggestive of pituitary macroadenoma with partial compression over optic chiasma. Patient underwent surgical decompression. Yellowish firm tissue was evacuated and xanthochromic fluid was aspirated. Histopathology was suggestive of LH. She resumed her cycles postoperatively after 4 months, prolactin levels normalized, however, she continues to have DI and is on desmopressin spray. This case has been presented here for its rare presentation in an adolescent girl because it is mostly seen in young females and postpartum period and its unique presentation as an expanding pituitary mass with optic chiasma compression. Conclusion: Definitive diagnosis of LH is based on histopathological evaluation. Therapeutic approach should be based on the grade of suspicion and clinical manifestations of LH.
  1,495 220 -
Thyromimetics - What does the future hold?
AG Unnikrishnan, Manash Baruah, Sanjay Kalra
December 2012, 16(8):159-161
Thyromimetic agents that can treat dyslipidemia without adverse effects like cardiac arrhythmias and osteoporosis are attractive options. Initial experience with desssicated thyroid hormone extract and DT4 were disappointing. Thyroid hormone has nuclear action with four receptor isoforms- TR α1, TRα2, TRβ1, TRβ2. TR α1 has predominant effects on CVS, TRβ2 acts mainly on the pituitary and TRβ1 has hepatoselective action and decrease cholesterol levels. Eprotirome and Sobetirome are 2 thyromimetics that have selective TRβ1 activity. They act in dyslipidemia by multiple mechanisms. They are presumably safe on the pituitary- thyroid axis.
  1,359 328 -
A rare case of Silver-Russell syndrome associated with growth hormone deficiency and urogenital abnormalities
Namburi Rajendra Prasad, Ponnala Amaresh Reddy, TS Karthik, Mithun Chakravarthy, Faizal Ahmed
December 2012, 16(8):307-309
Introduction: Silver-Russell syndrome (SRS) is a very rare genetic disorder. This is usually characterized by asymmetry in the size of the two halves or other parts of the body. Background: We are presenting a case of SRS with growth hormone (GH) deficiency and urogenital abnormalities. Case Report: A 15-year-old boy a product of non-consanguineous marriage brought with a history of short stature and poor development of secondary sexual characters. There were no adverse perinatal events, but weighed 1500 g (<3 rd centile) at birth. He had delayed developmental milestones. He has had a poor appetite and feeding difficulties since childhood. On physical examination, he had a broad forehead, triangular facies, and low-set prominent ears. Asymmetry of the face, upper and lower extremities was noted, with hemihypertrophy on the right side. His height was 119 cm (<3 rd centile) and weight was 18 kg which were low (<3 rd centile) as per his age. He was biochemically euthyroid and GH stimulation testing with clonidine (0.15 mg/m 2 ) showed low GH levels at 30×, 60×, and 90× were 1.7, 1.6, and 1.1ng/ml, respectively. On micturatingcystourethrogram, grade V complex was noted on the right side. Dimercaptosuccinic acid (DMSA) showed normal functioning kidneys. He was started on recombinant GH with a height velocity of 10 cm/ year. Conclusion : Urogenital abnormalities are rare but well described anomalies associated with SRS, and all cases have to be screened for them. GH deficiency is not uncommon in SRS, and GH treatment proves to be beneficial.
  1,478 203 -
Beyond the Barker hypothesis and the thrifty genotype - The womb, ethnicity, genes and the environment - Recent perspectives on the evolution of diabetes and the metabolic syndrome in India
Nihal Thomas
December 2012, 16(8):142-146
  1,362 312 -
Subacute thyroiditis: An uncommon cause of fever of unknown origin
Sambit Das
December 2012, 16(8):340-341
Subacute thyroiditis (SAT) is a self-limited, possibly viral, inflammatory thyroid disorder usually associated with thyroid pain and systemic disorder. SAT is not uncommon and can present with pyrexia of unknown origin. High index of suspicion is required and cases are managed symptomatically.
  1,448 220 -
A case of normotensive pheochromocytoma with management dilemma
Mukut Roy, Nilanjan Sengupta, Pranab Kumar Sahana, Debasis Giri, Chanchal Das
December 2012, 16(8):371-372
Introduction: We report an unusual case of normotensive pheochromocytoma detected incidentally, presenting a pre-operative management problem. Case Note: A 40-year-old lady with vague abdominal symptoms was initially discovered with a left adrenal incidentaloma by ultrasound abdomen, which was also revealed in computed tomography (CT). After exclusion of all the causes with possible necessary investigations, pheochromocytoma was confirmed with elevated 24 hour urinary metanephrine and normetanephrine. Her blood pressure was in low to normotensive range all throughout. She was attempted to be prepared with combined alpha and beta blockade but could not tolerate this regimen due to symptomatic hypotension. Subsequently, surgical preparation was planned cautiously with alpha-adenergic blockade only. With intensive monitoring, she underwent uneventful left adrenalectomy, and surgical pathology was consistent with pheochromocytoma. Conclusion: This case illustrates an unusual presentation of normotensive pheochromocytoma as adrenal incidentaloma. Pre-operative preparation in these patients can be achieved with alpha-adrenergic blockade, adequate hydration, and liberal salt intake.
  1,419 215 -
Sub-clinical Addison's disease
Manash P Baruah
December 2012, 16(8):176-177
As autoimmune adrenalitis is fast replacing tuberculosis as the most common etiology cause of adrenal insufficiency, subtler forms of the same are being recognised as subclinical addison's disease. In this article, we review what is known about this entity till date.
  1,269 361 -
Recurrent pregnancy loss in patients with thyroid dysfunction
Debanjali Sarkar
December 2012, 16(8):350-351
Purpose of the Review: Thyroid disturbances are common in women during their reproductive years. Thyroid dysfunction interferes with human reproductive physiology, reduces the likelihood of pregnancy and adversely affects pregnancy outcome, thus becoming relevant in the algorithm of reproductive dysfunction. This review highlights the "gap" in knowledge regarding the contribution of thyroid dysfunction in reproduction. Literature Reviewed: Following implantation, the maintenance of the pregnancy is dependent on a multitude of endocrinological events that will eventually aid in the successful growth and development of the fetus. It is estimated that approximately 8-12% of all pregnancy losses are the result of endocrine factors. Autoimmune thyroid disease is present in around 4% of young females and up to 15% are at risk because they are thyroid antibody-positive. There is a strong relationship between thyroid immunity on one hand and infertility, miscarriage, and thyroid disturbances in pregnancy and postpartum, on the other hand. Even minimal hypothyroidism can increase rates of miscarriage and fetal death and may also have adverse effects on later cognitive development of the offspring. Hyperthyroidism during pregnancy may also have adverse consequences. Summary: Pregnant women with subclinical hypothyroidism or thyroid antibodies have an increased risk of complications, especially pre-eclampsia, perinatal mortality, and miscarriage. Universal screening for thyroid hormone abnormalities is not routinely recommended at present, but thyroid function must be examined in female with fetal loss or menstrual disturbances. Practitioners providing health care for women should be alert to thyroid disorders as an underlying etiology for recurrent pregnancy loss.
  1,257 339 -
Precipitation of new onset diabetes by H1N1 infection
S. V. S. Krishna, K Sunil, R Devi Prasad, KD Modi
December 2012, 16(8):438-440
Infectious diseases in type 2 diabetes can complicate diabetic ketoacidosis, derange hyperglycemia, or precipitate new onset diabetes. Pulmonary tuberculosis being the most common. High index of clinical suspicion is required for co-existing H1N1 virus, which if present has high mortality if not treated. A 63-year-old female, with no known chronic illness, was hospitalized in month of Aug 2010 with influenza-like symptoms and diabetes. Quick evaluation revealed tachycardia, tachypnea, p02 90% at room air, and normotensive. Clinical chest examination was normal. Further evaluation revealed NHO in both lung fields on chest X-ray, hyperglycemia 325 mg/dl, detected for first time. Her signs and symptoms were out of proportion to clinical findings and chest X-ray findings. Patient was managed with insulin infusion and empirical broad-spectrum antibiotic coverage in ICU. As her condition worsened over next 12 hrs, infection with H1N1 was suspected and empirically started on oseltamavir after taking throat swab for H1N1 test and later, the sample was tested positive for H1N1 influenza by RT-PCR. Clinical course in the hospital was complicated by oxygen dependence requiring 10-12 ltr/hr by nasal mask. She made an uneventful recovery. In a known diabetic, infection with H1N1 quadruples ICU hospitalization, and only few cases of new onset diabetes with H1N1 were reported. Two reported from Iran had fatal outcome. This case emphasis on clinical acumen in recognition, and prompt institution of therapy will reduce associated mortality.
  1,423 137 -
Adrenocortical carcinoma: An extremely uncommon entity and the role of Immunohistochemistry in its diagnosis
G Gogoi, Manash P Baruah, P Borah, M Borgohain
December 2012, 16(8):373-375
Adrenocortcal carcinoma is an extremely uncommon entity with an incidence of two in one millionth population. Here we present a 60 year gentleman with pain in abdomen, nausea, and backache, and weight loss. Contrast enhanced computed tomography (CECT) abdomen revealed a heterogenous well defined mass measuring (15 × 10.3 × 13) cm 3 on the left suprarenal region with central necrosis which extended medially up to the midline. Locally, the growth infiltrated the upper pole of left kidney. Initially, the differential diagnosis included that of renal cell carcinoma arising from upper pole of left kidney involving adrenal gland. The patient underwent left radical nephrectomy and left adrenalectomy. Histological evaluation could not differentiate it from of malignant pheochromocytoma, but immunohistochemistry confirmed it as adrenocortical carcinoma. This case highlights the crucial role of immunohistochemistry in establishing the diagnosis like tumors.
  1,354 199 -
Incidence of primary hypothyroidism in patients exposed to therapeutic external beam radiation, where radiation portals include a part or whole of the thyroid gland
BA Laway, Kuchay M Shafi, Sabiya Majid, M Maqbool Lone, F Afroz, Showkat Khan, R Roohi
December 2012, 16(8):329-331
Introduction: Hypothyroidism is a known consequence of external-beam radiotherapy to the neck encompassing a part or whole of the thyroid gland. In this non-randomized prospective study, we have tried to evaluate the response of the thyroid gland to radiation by assessing thyroid function before irradiation and at regular intervals after irradiation. Aims and Objectives: The aim of this study were to assess in the cancer patients, who were exposed to the therapeutic external beam radiation, where radiation portals include a part or whole of the thyroid gland: the incidence of primary hypothyroidism, the time required to become hypothyroid, any relation between the total dose for the development of hypothyroidism, and whether there are any patient or treatment-related factors that are predictive for the development of hypothyroidism, including the use of concurrent chemotherapy. Materials and Methods: This non-randomized, prospective study was conducted for a period of 2 years in which thyroid function was assessed in 59 patients (cases) of head and neck cancer, breast cancer, lymphoma patients and other malignancies, who had received radiotherapy to the neck region. 59 euthyroid healthy patients (controls) were also taken, who had not received the neck irradiation. These patients/controls were assessed periodically for 2 years. Results: The incidence of hypothyroidism after external beam radiation therapy (EBRT) to neck where radiation portals include part or whole of the thyroid gland was 16.94%, seven cases had subclinical hypothyroidism (11.86%) and three cases had clinical hypothyroidism (5.08%). Mean time for development of hypothyroidism was 4.5 months. There was no effect of age, gender, primary tumor site, radiation dose and chemotherapy, whether neoadjuvant or concurrent with the development of hypothyroidism. Conclusion: In summary, we found that thyroid dysfunction is a prevalent, yet easily treatable source of morbidity in patients undergoing radiation therapy to neck where radiation portals include a part or whole of the thyroid gland.
  1,287 238 -
Sertoli cell only syndrome: Status of sertoli cell maturation and function
Manish Jain, Ashutosh Halder
December 2012, 16(8):512-513
Background of the study: Mature and functional Sertoli cells are essential for the survival of germ cells in testes. In Sertoli cell only syndrome (SCOS), there is no germ cells. Then, question arises whether absence of germ cells in SCOS secondary to Sertoli cells immaturity or mal function. Sertoli cells maturational and functional status is unclear in SCOS. This study investigated status of maturation and function of Sertoli cells in patients with SCOS. Materials and Methods: The present study was comprised of 37 cases of SCOS and 50 normal control males. Detailed clinical examination and investigation were carried out as per pre-determined proforma. Semen analysis, hormonal analysis (FSH, LH, testosterone, etc.), and fine needle aspiration cytology (FNAC) of testes (bilateral) were performed. Fluorescence in situ hybridization (FISH) with XY probes was carried out in addition to conventional chromosome analysis to find out chromosomal abnormalities, in particular sex chromosome aneuploidy, including mosaicism. Yq microdeletion status was also investigated. The anti-mullerian hormone (AMH), inhibin B, and seminal lactate were estimated by ELISA methods. Results: The study did not find any case of high AMH. About 78% cases had low inhibin B, and 60% had low AMH. FSH was high in about 78% cases. Low level of lactate was found in 49% cases. There was one case of high level of inhibin B. There were 6 (16.2%) cases of chromosomal abnormality (2 mosaic Klinefelter and 4 Klinefelter syndrome) and 4 (10.8%) cases of Yq microdeletion. Conclusion: We conclude that Sertoli cell immaturity does not play any role in SCOS (no case of high AMH). It seems, in majority cases, Sertoli cells are functionally- and/or numerically-deficient (low inhibin B, AMH and lactate). However, in about 22% cases, Sertoli cell function and/or number remains normal (normal inhibin B, AMH). Inhibin B and FSH seems best predictor/marker of Sertoli cell function.
  1,294 228 -
Endocrine Labomas
Deep Dutta, Subhankar Chowdhury
December 2012, 16(8):275-278
Laboratory endocrinology forms an integral part of 21 st century endocrinology. Perhaps, no other specialty of medicine is as closely associated with laboratory as endocrinology. This review intends to highlight the challenges faced by an endocrinologist before interpreting a hormone assay report. This review by no means is holistic but intends to highlight some of the pitfalls of laboratory endocrinology and arouse further interest in this important but neglected section of endocrinology. Lack of standardization, as well as rigorous implementation is some of the major challenges facing endocrine assays in our country. It is essential to be aware not only of the details of the method of analysis of a hormone, the pre-analytical requisites, but also disease-specific analytical issues to prevent unnecessary concern both for the patient, as well as the treating physician, as well as needless investigations. Problems with interpretation of serum prolactin, thyroglobulin, steroid hormone assays, rennin assay and vitamin-D assay have been highlighted.
  1,288 215 -
Idiopathic hypoparathyroidism and systemic sclerosis: An association likely missed
Deep Dutta, Ram Narayan Das, Sujoy Ghosh, Satinath Mukhopadhyay, Subhankar Chowdhury
December 2012, 16(8):396-398
Hypoparathyroidism in systemic sclerosis is extremely rare with only a single case reported till date. Idiopathic hypoparathyroidism with systemic sclerosis was diagnosed in a 59-year-old gentleman who had presented with recurrent seizures, instability of gait, skin thickening and tightening over both legs and forearms, and arthritis. Examination was significant for positive Trousseau sign and cerebellar ataxia. Evaluation revealed bilateral symmetrical cerebellar and basal ganglia calcification, sensorineural deafness, low serum calcium, elevated serum phosphorus, normal magnesium, normal vitamin D, low plasma parathyroid hormone, high titer of thyroid peroxidase antibody, positive centromere pattern antinuclear antibody, strongly positive anti-topoisomerase-1 (Scl-70) antibody, nonvisualization of parathyroids on neck ultrasonography and skin biopsy suggestive of hyperkeratosis, increased collagen in dermis, and perivascular lymphomononuclear cell infiltration compatible with scleroderma. Last evaluated 10 months after the diagnosis, his ataxia had improved, he remained seizure-free, Trousseau sign was negative, and he had low-normal calcium calcium with calcium carbonate and calcitriol supplementation and switch from phenytoin to valproate. Further studies are warranted to study the use of serum calcium as a screening test for hypoparathyroidism in patients with systemic sclerosis.
  1,312 151 -
Cretinism revisited
Ankit Srivastav, Indira Maisnam, Deep Dutta, Sujoy Ghosh, Satinath Mukhopadhyay, Subhankar Chowdhury
December 2012, 16(8):336-337
Objective: Cretinism is a condition of severely stunted physical and mental growth due to untreated congenital hypothyroidism. It has been largely eliminated in the developed world, though we still continue to see cases in India. Case Report: A 22-year-old male was brought to our Endocrine clinic by his brother due to his "not growing up." The patient was 83 cm in height (SDS - 16.98) and weighed 13.9 kg (<3 rd percentile). He had dull look, puffy face with thick lips, macroglossia, and umbilical hernia. There was sexual infancy with prepubertal testes (<3 ml). He could sit without support, but could not stand, or walk without support and could only talk in monosyllables. He was born full term by normal vaginal delivery, and cried immediately after birth. The developmental milestones were delayed, and not achieved till date. He is the eldest of seven siblings, rest six of whom have no complaints. An X-ray of hand was done showing bone age of less than 1 year. A thyroid profile showed TSH >150 IU/ml, free T4 and T3 below the assay range. Ultrasound of neck showed absent thyroid tissue in neck. Iodine-131 uptake scan was consistent with thyroid aplasia. Diagnosis was myxematous cretinism due to thyroid aplasia was made, and patient was started on thyroxine supplementation. Conclusion: This case represents the most severe form of untreated congenital hypothyroidism presenting as severely stunted physical and mental growth with delayed bone and sexual maturation.
  947 501 -
Multiple endocrine neoplasia type 1
RV Thakker
December 2012, 16(8):272-274
Multiple endocrine neoplasia type 1 (MEN1) is characterized by the occurrence of parathyroid, pancreatic islet and anterior pituitary tumors. Some patients may also develop carcinoid tumors, adrenocortical tumors, facial angiofibromas, collagenomas, and lipomas. MEN1 is an autosomal-dominant disorder, due to mutations in the tumor suppressor gene MEN1, which encodes a 610 amino acid protein, menin. Thus, the finding of MEN1 in a patient has important implications for family members because first-degree relatives have a 50% risk of developing the disease and can often be identified by MEN1 mutational analysis. Patients with MEN1 have a decreased life-expectancy and the outcomes of current treatments, which are generally similar to that for the respective tumors occurring in non-MEN1 patients, are not as successful because of multiple tumors, which may be larger, more aggressive, and resistant to treatment, and the concurrence of metastases. The prognosis for MEN1 patients might be improved by pre-symptomatic tumor detection and undertaking treatment specific for MEN1-tumors. Thus, it is recommended that MEN1 patients and their families should be cared for by multi-disciplinary teams comprising relevant specialists with experience in the diagnosis and treatment of patients with endocrine tumors.
  1,167 270 -
Hypothyroidism in metabolic syndrome
Sunil Kumar Kota, Lalit Kumar Meher, SVS Krishna, KD Modi
December 2012, 16(8):332-333
Aim: Metabolic syndrome (MetS) and hypothyroidism are well established forerunners of atherogenic cardiovascular disease. Considerable overlap occurs in the pathogenic mechanisms of atherosclerotic cardiovascular disease by metabolic syndrome and hypothyroidism. Insulin resistance has been studied as the basic pathogenic mechanism in metabolic syndrome. [1] This cross sectional study intended to assess thyroid function in patients with metabolic syndrome and to investigate the association between hypothyroidism and metabolic syndrome. Materials and Methods: One hundred patients with metabolic syndrome who fulfilled the National Cholesterol Education Program- Adult Treatment Panel (NCEP-ATP) III criteria [ 3 out of 5 criteria positive namely blood pressure ≥ 130/85 mm hg or on antihypertensive medications, fasting plasma glucose > 100 mg/dl or on anti-diabetic medications, fasting triglycerides > 150 mg/dl, high density lipoprotein cholesterol (HDL-C) < 40 mg/dl in males and < 50 mg/dl in females, waist circumference > 102 cms in men and 88 cms in women] were included in the study group. [2] Fifty patients who had no features of metabolic syndrome (0 out of 5 criteria for metabolic syndrome) were included in the control group. Patients with liver disorders, renal disorders, congestive cardiac failure, pregnant women, patients on oral contraceptive pills, statins and other medications that alter thyroid functions and lipid levels and those who are under treatment for any thyroid related disorder were excluded from the study. Acutely ill patients were excluded taking into account sick euthyroid syndrome. Patients were subjected to anthropometry, evaluation of vital parameters, lipid and thyroid profile along with other routine laboratory parameters. Students t-test, Chi square test and linear regression, multiple logistic regression models were used for statistical analysis. P value < 0.05 was considered significant. Results: Of the 100 patients in study group, 55 were females (55%) and 45 were males (45%). Of the 50 persons in control group, 26 (52%) were females and 24 (48%) were males. The baseline characteristics of two groups are depicted in. The two groups were similar with respect to age and sex distribution. However, body mass index, waist circumference, mean systolic pressure, diastolic pressure, fasting blood sugar, total cholesterol, LDL-C, triglycerides and TSH were significantly higher in study group compared to control group. HDL-C was significantly lower in study group.
  1,100 334 -
Empty sella syndrome - beyond being an incidental finding
Vikrant Ghatnatti, Dipti Sarma, Uma Saikia
December 2012, 16(8):321-323
Introduction: Empty sella is characterized by the herniation of the subarachnoid space within the sella, which is often associated with some degree of flattening of the pituitary gland. This study was undertaken to evaluate the clinical and hormonal profile in patients with empty sella. Aims and Objectives: To evaluate the clinical and hormonal profile of the patients with an empty sella. Materials and Methods: Patients undergoing a CT/MRI at our center, for various reasons but with the finding of the empty sella were included in this study. A detailed history and clinical examination was done. Apart from routine tests, hormonal evaluation included serum thyroid stimulating hormone, T4, cortisol (8 am), prolactin, total testosterone, follicle stimulating hormone, leutinizing hormone, and fasting Insulin like Growth factor 1 (IGF 1) were done. Results: A total of 34 patients, diagnosed radiologically to have empty sella, were evaluated and of them 24 had primary empty sella (PES) and 10 had secondary empty sella (SES). In subjects with PES, 12 out of 24 (50%) had endocrine dysfunction. The most common endocrine dysfunction noted was hyperprolactinemia, which was seen in 5 (20.8%) patients and the most common hormonal deficiency was isolated GH deficiency seen in four patients (12.5%). Conclusion: The high incidence of endocrine abnormalities in patients with PES mandates that these patients should routinely be subjected to endocrine evaluation to detect these deficiencies early, and appropriate replacement instituted where necessary, thus ensuring them of a better quality of life.
  1,150 266 -
Physicians' perceptions of a national consensus guideline on insulin therapy: Data from the IMPACT study
Sanjay Kalra, C. R. A. Moses, V Seshiah, BK Sahay, A Kumar, AJ Asirvatham, V Balaji, AK Das, S Akhtar, R Shetty
December 2012, 16(8):426-427
Introduction : The effectiveness and impact of the Indian insulin guideline in clinical practice was evaluated by the Improving Management Practices and Clinical Outcomes in Type 2 Diabetes (IMPACT) Study. The study also evaluated the participating physicians' perceptions on the use of IIG versus RCP for management of diabetes. Materials and Method : This 26 week multicenter, open label, randomized, prospective study aimed to evaluate effectiveness of Indian insulin guideline (IIG) versus routine clinical practice (RCP) in patients with type 2 diabetes (T2D). Results : Out of 426 physicians who completed the physicians' perception questionnaire, 189 (44.4%) felt that it was "easy" to initiate insulin in their patients using IIG. Cost of therapy (52.3%), followed by poor adherence (40.3%), and lack of motivation among physicians (40.4%) were the most important reasons cited for delay in initiation of insulin therapy. Two hundred and thirty three (54.7%) physicians felt that insulin titration was made "easy" in their patients using IIG, while 104 (24.4%) had a neutral approach. A total of 222 physicians (52.1%) felt it was "convenient" applying IIG in their practice, and 239 (67.8%) physicians felt "satisfied" with using IIG for achieving the targeted HbA1c <7%. One hundred and seventy seven (41.5%) physicians felt that there was scope for improving the IIG further by simplifying and revising the titration charts [117 (27.5%)]. Conclusion : Primary care physicians in India have perceived the IIG to be easy algorithm to initiate and titrate insulin therapy. These results will encourage the use and facilitate future revision of the guideline.
  1,127 277 -
Panhypopituitarism with empty sella a sequel of pituitary hyperplasia due to chronic primary hypothyroidism
Deep Dutta, Indira Maisnam, Sujoy Ghosh, Pradip Mukhopadhyay, Satinath Mukhopadhyay, Subhankar Chowdhury
December 2012, 16(8):282-284
Asymptomatic reversible pituitary hyperplasia is common in patients with untreated primary hypothyroidism. Occurrence of empty sella (ES) in this scenario is extremely rare (only three reports till the date) and panhypopituitarism has not been reported in such patients. We report a 27 year man with severe short stature (height-133 cm; standard deviation score-7.36) and delayed puberty who had symptoms suggestive of hypothyroidism along with chronic persistent headache since 6 years of age. Pituitary imaging done for headache at 11 years age showed pituitary hyperplasia. He was diagnosed of primary hypothyroidism for the 1 st time at 21 year age, a diagnosis which was likely missed for 15 years. Levothyroxine therapy leads to resolution of all symptoms and a height gain of 28 cm over last 6 years. Evaluation for lack of progression of puberty along with chronic nausea, vomiting, fatigue and weight loss for the last 1 year revealed secondary hypocortisolism (9 am cortisol-4.8 mcg/dl; ACTH-3.2 pg/ml), growth hormone deficiency (IGF-1: 65 ng/ml; normal: 117-325 ng/ml) and hypogonadotrophic hypogonadism (9 am testosterone: 98 ng/dl; [280-1500] LH-0.01 mIU/L [1.14-5.75]) with ES on magnetic resonance imaging (MRI) brain. Uncontrolled thyrotroph hyperplasia due to chronic untreated primary hypothyroidism for 15 years may have been damaging the adjacent corticotrophs, somatotrophs and gonadotrophs resulting in panhypopituitarism and empty sella. This is perhaps the first report of panhypopituitarism with empty sella syndrome developing in a patient with pituitary hyperplasia, a sequel of chronic untreated primary hypothyroidism.
  1,146 210 -
Plurihormone secreting pituitary macroadenoma masquerading as thyrotoxicosis: Clinical presentation and diagnostic challenges
Indira Maisnam, Deep Dutta, Rajesh Jain, Sujoy Ghosh, Satinath Mukhopadhyay, Subhankar Chowdhury
December 2012, 16(8):315-317
Thyroid stimulating hormone (TSH) secreting adenomas are the rarest type of pituitary adenomas (1:1000000 in the population; 0.2- 2.8% of adenomas). Plurihormonal thyrotropic adenomas are even rarer usually having cosecretion of growth hormone (GH) and prolactin. We report perhaps for the first time, TSH, GH, adrenocorticotrophic hormone (ACTH) and gonadotropins secreting pituitary macroadenoma diagnosed in a 40 year lady presenting with features of thyrotoxicosis for 5 months, amenorrhea for 3 months and newly diagnosed diabetes and hypertension for 2 months along with headache, nausea, and vomiting, who had acromegaloid habitus, grade-II goitre, increased uptake on Technitium-99 pertechnate thyroid scan (4.1%; normal: 0.24-3.34%), with increased T3 (5.98 pg/ ml; 1.5-4.1), increased T4 (2.34 ng/dl; 0.9-1.8), inappropriately high TSH (2.32 μIU/ml; 0.4-4.2), insulin like growth factor-1 (711 ng/ ml; 109-264), non-suppressed post-glucose GH (15.9 ng/ml; <1 ng/ml), normal estradiol (52 pg/ml; 21-251), inappropriately high luteinizing hormone (53.5 mIU/ml; 1.1-11.6), inappropriately high follicle stimulating hormone (59 mIU/ml; 3-14.4), non-suppressed overnight dexamethasone cortisol (5.8 mcg/dl; <2), elevated ACTH (58 pg/ml 5-15), withdrawal bleed on progestrogen challenge, bitemporal hemianopia on automated perimetry and pituitary macroadenoma on MRI imaging of sella. Thyroid hormone resistance was ruled out by documenting normal sex hormone binding globulin and ferritin levels. Her clinical and biochemical phenotype was not suggestive of multiple hormone resistance seen in pseudohypoparathyroidism. This report intends to highlight the challenges in the diagnosis of plurihormonal thyrotropic adenoma.
  1,179 170 -
Where do conventional OADs stand
Rakesh Kumar Sahay, V Sri Nagesh
December 2012, 16(8):252-255
The last two decades have witnessed unprecedented activity in the field of OADs with many new drugs becoming available. Concerns with OAD include cardiovascular safety, fear about hypoglycemia, weight gain etc. In this article we attempt to review OADs , sulfonylureas in particular, in the light of the newer agents.
  1,060 272 -
Rathke's cyst with ectopic neurohypophysis presenting as severe short stature with delayed puberty
Deep Dutta, Ajitesh Roy, Sujoy Ghosh, Pradip Mukhopadhyay, Ranen Dasgupta, Satinath Mukhopadhyay, Subhankar Chowdhury
December 2012, 16(8):288-290
Ectopic neurohypophysis (EN) is found in nearly half of children with growth hormone deficiency (GHD). Rathke's cyst (RC) is uncommon in children and when present, hypopituitarism is found in nearly half of them. We present a fourteen and half-year-old girl with severe short stature and delayed puberty who on evaluation was found to have GHD, secondary hypocortisolism, and hypogonadism. Imaging revealed hypoplastic anterior pituitary, stalk agenesis, EN at tuber cinereum and intrapituitary RC. This is perhaps the first report of simultaneous occurrence of EN and RC, which was seen in a girl with multiple pituitary hormone deficiency. A primary defect in pituitary development may explain this simultaneous occurrence of EN and RC and hence this severe anterior pituitary function deficit.
  1,166 161 -
Recurrent stroke as a presenting feature of acquired partial lipodystrophy
Namburi R Prasad, Ponnala A Reddy, Bindu Menon, TS Karthik, Faizal Ahmed, Mithun Chakravarthy
December 2012, 16(8):455-457
Acquired partial lipodystrophy (PL) (Barraquer-Simons syndrome) is a rare condition with onset in childhood, and it is characterized by progressive loss of subcutaneous fat in a cephalocaudal fashion. This report describes a case of acquired PL in a 16-year-old girl, who had progressive loss of facial fat since 3 years. Systemic lupus erythematosus (SLE), anticardiolipin antibody, primary hypothyroidism, diabetes, and dyslipidemia may antedate the development of complications such as cerebrovascular stroke and cardiovascular disease. The girl had developed recurrent left hemiparesis, and withdrawn from school due to poor performance.
  1,178 146 -
Endocrinology and the essential list
Sanjay Kalra, Sarita Bajaj, Ambrish Mithal
December 2012, 16(8):133-135
  1,043 266 -
Low density Lipoprotein cholesterol target: Changing goal posts
Ganapathi Bantwal, Belinda George
December 2012, 16(8):233-235
Elevated low density lipoprotein cholesterol (LDL) has been identified as one of the strongest correctable risk factors for cardiovascular disease in patients with diabetes. The reduction in cardiovascular events with pharmacological therapy aimed at LDL lowering is well documented in both primary prevention and secondary prevention. In this article, we review the evolving trend of aggressive LDL cholesterol lowering strategies.
  1,064 234 -
Selenium and the thyroid: A close-knit connection
Ashok K Bhuyan, Dipti Sarma, Uma K Saikia
December 2012, 16(8):354-355
Introduction: In areas with severe selenium deficiency higher incidence of thyroiditis has been reported due to a decreased activity of selenium-dependent glutathione peroxidase enzyme within thyroid cells. Aims and Objective: To study the effect of selenium supplementation in patients with autoimmune thyroid disease. Materials and Methods: This is a blinded placebo-controlled prospective study done in 60 patients with autoimmune thyroid disease (as defined by an anti-thyroid peroxidase antibody (TPOAb) level more than 150 IU/ml) irrespective of the baseline thyroid status. Patients with overt hyperthyroidism who are on antithyroid drugs, patients on any other medication, which may alter the immunity status of the patients, and pregnant patients were excluded from the study. Patients were randomized into two age and TPOAb-matched groups; 30 patients received 200 μg of sodium selenite/day, orally, for 3 months, and 30 patients received placebo. All hypothyroid patients were given l-thyroxine replacement. Results: Of 30 patients in the selenium treated group, 6 patients were overtly hypothyroid, 15 were subclinical hypothyroid, 6 were euthyroid, and 3 were subclinical hyperthyroid. The mean TPOAb concentration decreased significantly by 49.5% (P < 0.013) in the selenium treated group versus 10.1% (P < 0.95) in the placebo-treated group. Conclusion: Selenium substitution has a significant impact on inflammatory activity in thyroid-specific autoimmune disease. It would be of interest to determine whether early treatment with selenium in patients with newly developed autoimmune thyroiditis may delay or even prevent the natural course of these diseases.
  1,085 209 -
Varied presentations of Sheehan's syndrome at diagnosis: A review of 18 patients
Delmalya Sanyal, Moutusi Raychaudhuri
December 2012, 16(8):300-301
Introduction: Sheehan's syndrome (SS) occurs due to ischemic pituitary necrosis as a result of severe postpartum hemorrhage (PPH). Aims and Objectives: The aim of the present study was to review the presenting features of SS at diagnosis. Materials and Methods: We retrospectively reviewed 18 cases of SS at diagnosis. Presenting clinical features, laboratory data, pituitary hormone deficiencies, and magnetic resonance imaging (MRI) of the sella were analyzed. Results: Age ranged from 28-71 years with a mean age of 47 ± 14.44 years. Time to diagnosis of SS was 6-33 years with a mean of 15.35 ± 6.74 years. Four (22.2%) patients were referred from emergency for hyponatremia, one each (5.6%) for hypotension, hypoglycemia, and vomiting. Three (16.7%) patients presented with asthenia and weight loss, two (11.1%) with slightly raised thyroid stimulating hormone (TSH). Only six (33.3%) presented with classic features of amenorrhea. None presented with isolated lactational failure or apoplexy after PPH. Seventeen (94.4%) patients had lactational failure; thirteen (72.2%) did not menstruate following last delivery. Lactotroph and gonadotroph failure were present in all at diagnosis but corticotrophs preservation was documented in three (16.7%) and thyrotroph in two (11.1%) patients. Twelve (66.7%) patients had empty sella while six (33.3%) had partial empty sella on MRI. Conclusion: SS has variable features at diagnosis and may present to different specialties. The clinical features of hypopituitarism are often subtle, leading to delay in diagnosis. History of PPH, lactational failure and cessation of menses are important clues. Thyrotroph, corticotroph axis may be preserved in some SS patients.
  1,008 278 -
Contemporary issues in primary amenorrhea: An experience from a Tertiary Care Center
Ashok Krishna Bhuyan, Dipti Sarma, Uma Kaimal Saikia
December 2012, 16(8):387-388
Introduction: Amenorrhea is classified as primary if menstrual bleeding has never occurred in the absence of hormonal treatment. The clinical significance of a lack of regular menstrual cycles extends beyond reproductive concerns. Episodes of amenorrhea as short as 90 day may have implications for bone and cardiovascular health. Aims and Objective: To evaluate all patients presenting with primary amenorrhea in the Endocrinology OPD of Gauhati Medical College and Hospital. Materials and Methods: A total of 14 patients presenting to the Endocrinology OPD from March 2010 to May 2012 with a history of primary amenorrhea were included in the study. All patients were subjected to a detailed history, a thorough clinical examination, and relevant biochemical, hormonal, and radiological investigations. Result: In our study, the average age of presentation was 17.23 ± 4.2 years. Out of the 14 patients presenting with primary amenorrhea, 5 patients (35.71%) were found to have Turner's syndrome, 2 (14.28%) had XX (pure) gonadal dysgenesis, 2 (14.28%) patients had XY gonadal dysgenesis (Swyer syndrome), 2 (14.28%) patients had Müllerian agenesis, 2 (14.28%) patients had hypothalamic amenorrhea, and 1 (7.14%) patient was found to have multiple pituitary hormone deficiency. Conclusion: In concordance with other studies, Turner's syndrome, Müllerian agenesis, and gonadal dysgenesis are the commonest causes of primary amenorrhea in our study. However, in contrast to certain Western reports, primary amenorrhea rather than short stature remains the commonest cause for seeking medical evaluation in patients with Turner's syndrome.
  1,035 232 -
Postmenopausal osteoporosis: Our experience
RN Mehrotra, Alok Ranjan, Rahul Lath, R Ratnam
December 2012, 16(8):421-422
Introduction: There is very little published literature about experience with osteoporosis treatment from our country. Materials and Methods: It is a retrospective analysis of first 50 patients enrolled in our clinic for osteoporosis. Postmenopausal women with T score of less than -2.5 or history suggestive fragility fracture with supportive bone mineral density (BMD) were included. Patients having hypercalcemia, abnormal renal function, myeloma and on long-term steroids were also excluded. Results: Nearly 34% subjects were below the age of 60 years, 47% of subjects were between 60 and 70 years, whereas 18% were above 70 years. Nearly 6% had family history of osteoporosis s or history of osteoporotic fractures. Nearly 20% subjects had fracture prior to starting of any treatment. A total of 86% (40/46) had evidence of Vitamin D (VD) deficiency. Nearly 80% of patients were treated with bisphosphonates, 12% were treated with injectable bisphosphonates, and 8% were treated with teriperatide. Nearly 16% patients had duration of more than 5 years of experience with bisphosphonates. Follow up BMD was available in 25 subjects. BMD had improved significantly in 68% of subjects. In 24% the BMD was stable (the change was less than least significant change (LSC)). In 8% BMD had shown a significant decline while being on treatment. Conclusion: Postmenopausal osteoporosis occurs in relatively younger women in our country. Majority of them are VD deficient. Oral bisphosphonates is the most common used drug; it is fairly well tolerated and effective.
  1,029 234 -
Inflammation and Incretins
Amitabh Hatwal
December 2012, 16(8):239-241
Nutrient excess results in systemic inflammation in diabetes contributing to insulin resistance, dyslipidaemia and increased cardiovascular risk. GLP-1 agonists and DPP-4 inhibitors, which are now well accepted therapies for diabetes may play a unique role in modulating this inflammatory process. Incretin based therapies have shown beneficial anti-inflammatory effects on surrogate markers but cardiovascular outcome data is still lacking.
  1,018 233 -
Endocrine manipulations in cancer prostate: A review
Rajesh Rajput, Ashish Sehgal
December 2012, 16(8):199-204
Prostate cancer is an androgen dependent condition where Dihydrotestosterone promotes the growth of the neoplastic tissue. Androgen deprivation has been the mainstay of therapy for this condition. This can be achieved by surgical or medical means. Types of medical regimens are intermittent maximal or sequential androgen blockade.
  1,060 180 -
High-density lipoprotein cholesterol: How High
G Rajagopal, V Suresh, Alok Sachan
December 2012, 16(8):236-238
The high-density lipoprotein cholesterol (HDL-C) is considered anti-atherogenic good cholesterol. It is involved in reverse transport of lipids. Epidemiological studies have found inverse relationship of HDL-C and coronary heart disease (CHD) risk. When grouped according to HDL-C, subjects having HDL-C more than 60 mg/dL had lesser risk of CHD than those having HDL-C of 40-60 mg/dL, who in turn had lesser risk than those who had HDL-C less than 40 mg/dL. No upper limit for beneficial effect of HDL-C on CHD risk has been identified. The goals of treating patients with low HDL-C have not been firmly established. Though many drugs are known to improve HDL-C concentration, statins are proven to improve CHD risk and mortality. Cholesteryl ester transfer protein (CETP) is involved in metabolism of HDL-C and its inhibitors are actively being screened for clinical utility. However, final answer is still awaited on CETP-inhibitors.
  999 240 -
Bariatric surgery and diabetes
Andrew Collier
December 2012, 16(8):230-232
Obesity is a relatively new and serious world-wide epidemic. Obesity is a stronger predictor in mortality than either poverty or smoking, and obesity is also now more prevalent than malnutrition. The prevalence of obesity continues to increase, ironically, the rate of increase of obesity is highest amongst the morbidly obesity. Obesity is the result of many factors resulting in concert, including poor dietary habits, reduced physical activity and genetic predisposition. With the rapid increase in obesity there has been a pronounced increase in obesity-related metabolic disorders including type 2 diabetes, hyperlipidemia, hypertension and many others. These co-morbidities are responsible for more than 2.5 million deaths, worldwide. The loss of life expectancy due to obesity is profound. In comparison to a normal weight individual Caucasian, a 25-year-old morbidly obese man has a 22% reduction in the expected remaining life span, representing an approximate loss of 12 years of life.
  1,005 233 -
Outcome in acromegaly: A retrospective analysis
Debmalya Sanyal, Moutusi Raychaudhuri
December 2012, 16(8):291-293
Introduction: Many of the treatment modalities recommended for acromegaly are either too expensive or not available in large parts of India. There is a dearth of treatment and outcome data in Indian patients. Aims and Objectives: The purpose of this study was to analyze the treatment modalities used and the respective outcomes which include remission, recurrence, hypopituitarism, other complications, and mortality. Materials and Methods: This is a retrospective data analysis of 15 acromegaly patients treated at a tertiary care hospital in eastern India. A remission criteria of nadir growth hormone level <1 μg/dl after Oral Glucose tolerance test (OGTT) and normal age related IGF-1 levels was used. Results: All patients (100%) had macroadenomas. Surgery could not be done in five (33%); three (19.8%) refused, two (13.2%) had comorbidities. Transsphenoidal surgery (TSS) achieved remission in four out of ten (40%). Conventional radiotherapy (CRT) failed in all five patients and caused hypopituitarisn in three (60%). Cabergoline (CAB) either alone or following surgery achieved remission in one out of four (25%) though symptomatic relief and tolerability were remarkable. One patient (7%) had pituitary apoplexy with remission, two patients (14.3%) died due to CVA. Conclusions: TSS remains the treatment of choice in acromegaly, though in macroadenomas the success is limited. A sizeable proportion of patients refuse or are unfit for surgery. As most of the recommended options are very costly or unavailable, alternative treatment options generally used are CRT or CAB which have limited efficacy. Incidence of hypopituitarism, following CRT is very high.
  1,045 185 -
Status of 25(OH)D levels in pregnancy: A study from the North Eastern part of India
A Dasgupta, UK Saikia, D Sarma
December 2012, 16(8):405-407
Introduction: An increased prevalence of vitamin D deficiency has been reported from across the globe including India. Various studies have shown an intrinsic relation between various parameters of maternal and fetal wellbeing with maternal vitamin D status during pregnancy. Aims: To look for any association of vitamin D status during pregnancy with the modifiable factors - extent of sun exposure, sunscreen use, vegetarian diet, dietary calcium intake, and multivitamin supplementation. Materials and Methods: A total of 50 pregnant females, aged 20-40 years were studied during the first trimester of pregnancy. Fifty age and body mass index (BMI) matched females were taken as controls. Serum 25(OH)D was measured by radioimmunoassay (Diasorin). Result: Forty-two percent of the cases were found to have vitamin D deficiency and 14% were found to have vitamin D insufficiency, whereas 20% of the controls had vitamin D deficiency and 24% had vitamin D insufficiency (P =0.0375). There was a significant association of 25(OH)D levels with extent of sun exposure, sunscreen use, and vegetarian diet. There was no association of 25(OH)D levels with multivitamin supplementation or dietary calcium intake. Conclusion: Vitamin D deficiency was less in our study group as compared with that reported in other Indian studies. Sun exposure, sunscreen use, and vegetarian diet are important modifiable variables significantly associated with vitamin D status in pregnancy.
  952 271 -
Hypophosphatemic rickets: A case of recurrent pathological fractures
Arjun Baidya, Subhankar Chowdhury, Satinath Mukhopadhyay, Sujoy Ghosh
December 2012, 16(8):402-404
Introduction: Renal phosphate-wasting disorders are the most common form of hereditary rickets and osteomalacia in western countries, but are rarely reported in India. Therefore, we report here a case of hypophosphatemic rickets. Aim and objective: To report a case of hypophosphatemic rickets presenting with recurrent pathological fractures. Material and Methods: A 34-year-old premenopausal lady presented with recurrent pathological fractures, bone pain, and muscle weakness since 14 years of age. A thorough history was taken followed by clinical examination, and relevant biochemical and radiological investigations were done. Results: Height was 125 cm, arm span 145 cm, body weight 30 kg, and body mass index (BMI) 19.2 kg/m΂. Dental caries, kyphoscoliosis, shortening of left lower limb, bilateral coxa vara deformity of knee, muscle weakness, and bone tenderness were present. Calcium was 9.4 mg/dL, phosphorus: 1.8 mg/dL, albumin: 4.0 gm/dL, alkaline phosphatase: 360 U/L, creatinine: 0.4 mg/dL, a normal ammonium chloride (NH 4 Cl) loading test,24-hour urine calcium excretion: 102 mg/day, 25-hydroxyvitamin D3 [25(OH)D3]: 21.6 ng/mL, intact parathyroid hormone (PTH): 43.74 pg/mL, fraction excretion of phosphate (PO4): 40%, tubular maximum reabsorption of phosphate per unit of glomerular filtrate (TmP/GFR): 0.65 mg/dL, and fibroblast growth factor (FGF)23: 321.4 RU/mL. Skeletal X-rays showed multiple old fractures and pseudofractures. Magnetic resonance imaging (MRI) of the whole body showed no evidence of tumor. Fludeoxyglucose ( 18 F)-positron emission tomography (FDG-PET) computed tomography (CT) scan revealed metabolically active marrow with multiple areas of fracture and FDG-avid lesions in both lungs but no CT-based findings. Conclusion: Hypophosphatemic rickets or osteomalacia, possibly hereditary, is a rare cause of recurrent pathological fractures.
  1,004 206 -
Adrenal myelolipoma with keratoconus: A novel clinical association
Deep Dutta, KS Shivaprasad, Sujoy Ghosh, Satinath Mukhopadhyay, Subhankar Chowdhury
December 2012, 16(8):364-366
Adrenal myelolipoma is a benign metaplastic collection of reticuloendothelial cells and adipose tissue, believed to be secondary to chronic stimulation of the adrenals. Keratoconus is the most common corneal ectasia of unknown pathogenesis. Altered expression of proteinases, proteinases inhibitors, and cytokines are believed to have a role. We report for the first time, the occurrence of adrenal myelolipoma in a 52-year-old man with bilateral keratoconus with right corneal scarring for 13 years, who had presented with abdominal pain and heaviness for 4 weeks. Computerized tomography abdomen revealed 7.4 × 7.0 × 6.6 cm hypo-dense variegated left adrenal mass [-71 to -51 Hounsfield Unit (HU)] with smooth borders and poor contrast uptake, suggestive of adrenal myelolipoma, which was biochemically non-functional in view of normal overnight dexamethasone suppressed cortisol (1.4 mcg/dl), 24 h urinary fractionated metanephrines [metanephrines 57 mcg/day (53-341); normetanephrines 95 mcg/day (88-444)], androgen levels [dehydroepiandrostenedione-sulphate 112 mcg/dl (21-123); testosterone 542 ng/dl (275-1200)] with normal visualization of the contralateral adrenal. The cause of this association could not be determined. However, it may be hypothesized that altered adrenal steroid metabolism may have some role in the development of myelolipoma in our patient with keratoconus; in view of increased occurrence of myelolipoma in patients with congenital adrenal hyperplasia (CAH), isolated report of keratoconus in twins with CAH and mice model of keratoconus demonstrating the role of androgens in the development of keratoconus.
  1,060 147 -
Physician perceptions and practices in management of diabetes in India: Results from the IMPROVE Control program
AG Unnikrishnan, SK Wangnoo, SR Joshi, S Banerjee, A Kumar, S Kalra, R Channabasavaiah, R Shetty
December 2012, 16(8):428-429
Introduction: The impact of IMPROVE Control Training program was evaluated by a non-interventional study and validated by a physician perception questionnaire. From a survey on 1086 physicians providing diabetes care in India, we report their practices and perceptions about diabetes care and insulin therapy. Materials and Methods: The responses were collected using a questionnaire validated by the IMPROVE Control Steering Committee. Results: Majority [558 (51.4%)] of the physicians accepted the ADA defined HbA1c target of <7% as the standard for good glycemic control in their practice. However, 541 (49.8%) of the physicians agreed that only 20-40% of their patients were able to achieve this target. For patients who do not achieve the glycemic control with oral anti-diabetic drugs (OADs) within 6 months of initiation of therapy, initiation of an optimal insulin regimen was the preferred choice for 492 (45.3%) of the participating physicians. Premixed insulin was preferred for initiating insulin therapy in patients with type 2 diabetes, by 676 (62.2%) of the participants [as compared to basal by 375 (34.5%) participants]. Once daily premixed insulin, intensified to twice daily was preferred as most optimal insulin regimen for initiation and subsequent intensification of insulin therapy [487 (44.8%) participants]. Most of the participants preferred adopting a multi-targeted approach for treating diabetes, hypertension, and dyslipidemia. Conclusions: Physicians prefer treatment goals similar to those recommended in the current guidelines of the American Diabetes Association for managing their patients with diabetes. Premixed insulin is preferred for initiation and intensification of insulin therapy.
  973 227 -
Effect of mild physical activity in obese and elderly women with type 2 diabetes
Krishna G Seshadri, Vidya Ananthakrishnan, Bubblu Tamilselvan, Rajendran Amarabalan, Ram Nagendra Kumar
December 2012, 16(8):453-454
Background: Elderly, obese women with diabetes who have limitations in mobility often are unable to walk for a sustained period of time. We need to find a way to increase physical activity in these subjects. Aim: To evaluate the effect of low-intensity, repetitive, home-based walking regimen on glycemic control in elderly, obese women with diabetes. Research Design: A 24-week open, 2 arms, and prospective study. Materials and Methods: A total of 18 elderly people with type 2 diabetes were recruited. Nine subjects were instructed to walk for 5 minutes per hour for most waking hours for 24 weeks. The rest were given standard advice regarding diet and exercise. Glycemic control, HbA1c, weight, BMI, subjects' physical fitness, QOL, and distance walked in 6 minutes were determined before and after the intervention. Intervention: A mild physical activity of 5 minutes walking/hour everyday and antidiabetic medications prescribed as per clinic procedure. Results: There was a significant reduction in HbA1c within the study group (8.76% to 7.43%) (P = 0.08) vs rise in the control group (8.34% to 9.34%) (P = 0.07). There was a significant weight loss within the group which exercised (P = 0.01), but there was no significant difference between the groups. Conclusion: Repetitive low-intensity activity is effective in improving glycemic control and weight management in elderly obese women.
  965 217 -
Insulin resistance and lipid alterations in subclinical hypothyroidism
Atluri Sridevi, B Vivekanand, G Giridhar, A Mythili, K. A. V Subrahmanyan
December 2012, 16(8):345-346
Introduction: It is known that dyslipidemia and increased insulin resistance were associated with overt hypothyroidism, but their association with subclinical hypothyroidism is conflicting. Aim was to evaluate insulin resistance and lipid alterations in subclinical hypothyroidism. Methods: Fifty consecutive cases of subclinical hypothyroidism are the subjects of the study. The cases are compared with age, gender and BMI matched controls. Lipid profile, insulin levels, FPG are assessed after overnight fast. Insulin resistance is calculated using HOMA-IR . The correlation between TSH& lipid prolife, TSH & IR was assessed. Results: Total cholesterol (169.37±32.83 vs. 154.5±18.71, p= 0.031) & low density lipoprotein cholesterol (105.76±26.92vs 93.80±16.67, p=0.037) were significantly higher in cases compared to controls. High density lipoprotein cholesterol (44.23±4.65 vs 42.26±3.20, p=0.0507) was lower in cases which showed a trend towards significance. Triglycerides (97.64±39.44 vs. 92.96±43.49,p=0.65) , fasting insulin levels (11.74±7.16 vs 9.77±5.54,p=0.211) and Insulin resistance (2.30±1.49 vs. 1.78±1.09, p=0.11) were elevated but did not differ significantly between the two groups. Conclusion: Subclinical hypothyroidism is associated with elevation of TC , LDL-C and non significant increase in TG and insulin resistance. Both lipid profile and insulin resistance did not correlate with severity of hypothyroidism.
  922 237 -
Baseline results indicate poor glycemic control and delay in initiation and optimization of insulin therapy: results from the improving management practices and clinical outcomes in type 2 diabetes study
CR Anand Moses, V Seshiah, BK Sahay, A Kumar, AJ Asirvatham, V Balaji, S Kalra, S Akhtar, R Shetty, AK Das
December 2012, 16(8):432-433
Introduction: Improving management practices and clinical outcomes in type 2 diabetes (IMPACT), was a prospective, open-label, 26- week, comparative, multi-center study to compare efficacy and safety of the Indian insulin guideline (IIG) group versus routine clinical practice (RCP) group in patients with type 2 diabetes. Materials and Methods: A total of 20,653 patients from 885 centers across India were enrolled and treated with premixed insulin therapy as per IIG or routine care. Results: Most of the participating centers (81.7%) reported following a diabetes guideline in their practice routinely but only 20.4% targeted HbA1c <7%. Very few of the physicians (2.7%) reported that most of their patients (>75%) achieved an HbA1c <7%. Most of the physicians (39.8%) also agreed that only 10-25% of the patients agree to start insulin therapy at the first counseling. Mean duration of diabetes before initiating insulin in patients using oral anti-diabetic drugs (OADs) was 7 years, indicating a delay in initiating insulin therapy. The difference in mean daily dose of insulin at initiation vs. at 26 weeks was only 0.8 U (25.8 ± 11.3 at initiation compared to 26.6 ± 9.5, respectively, p = ns) suggesting lack of treatment optimization. Weekly titration till achieving HbA1c <7% was done in 51.1% of the patients and only 8.9% performed self-titration. Conclusion: Baseline glycemic control in these patients was poor and reflects a delay in initiating insulin therapy. Data also reflect a lack of optimization of insulin doses.
  927 218 -
Unusual presentation of Kallmannn syndrome with contiguous gene deletion in three siblings of a family
Sri Venkat Madhu, Saket Kant, Vikram Venkappayya Holla, Rakesh Arora, Sahaj Rathi
December 2012, 16(8):326-328
We report the case of 3 brothers aged 34, 24, and 22 years, unmarried, who presented to our endocrinology clinic with absence of secondary sexual characters. There was no such history in other siblings, but their maternal uncle had similar complaints. On examination, all 3 had pre-pubertal appearance, voice, and genitalia along with anosmia and bimanual synkinesia. Cryptorchidism was noticed in 2 while third person had small hypoplastic testes. It was also noted that all 3 patients had icthyosis mainly involving trunk, back, and limbs. The hormonal assays were consistent with isolated hypogonadotrophic hypogonadism. IQ testing revealed mental retardation in the 2 patients. Ultrasound showed ectopic right kidney in one patient, atrophic right kidney in the second patient while the third patient had normal kidneys. MRI brain of all the patients showed poorly visualized olfactory tract and bulb. Kallmann syndrome (KS) was diagnosed based on hormonal evaluation and MRI results. Of the four types of KS: Synkinesia, renal anomaly, and X-linked pedigree pattern in our patients pointed towards X-linked type 1 KS as the possible cause. But, icthyosis and mental retardation are not usual presentation of type 1 KS. They are usually seen as a result of contiguous gene deletion of KAL1, steroid sulfatase (STS), and mental retardation (MRX) gene on X chromosome. Hence, the possible gene defect in our cases is inherited defect in contiguous gene deletion. The contiguous gene deletion as the cause of KS in 3 patients of same family is very rare and worth reporting. Also, the significance of phenotype-genotypic association in Kallmann syndrome is discussed
  984 157 -
Gynaecomastia as the initial presentation of thyrotoxicosis
Triranjan Sanyal, Deep Dutta, KS Shivprasad, Sujoy Ghosh, Satinath Mukhopadhyay, Subhankar Chowdhury
December 2012, 16(8):352-353
Gynaecomastia is a well-recognized manifestation of thyrotoxicosis occurring in a widely variable percentage. Some studies have reported the percentage to be high as 40% while others report it being around 10%. The variation can be attributed to the difference in the criteria used to define gynae-comaslia or racial factors. However, thyrotoxicosis presenting with gynaceomastia as an intial manifestation is very rare. Only handful case reports are found in literature. Here we present a case of 35-year-old Indian male, with thyrotoxcosis who presented initially with painful bilateral gynaceomastia.
  974 164 -
Dyslipidemia, metabolic syndrome, and liver enzymes in impaired glucose tolerance and new onset untreated, type 2 diabetes Indian subjects
Debmalaya Sanyal, Sujoy Ghosh, Pradip Mukherjee, Satinath Mukherjee, Subhankar Chowdhury
December 2012, 16(8):434-435
This cross-sectional clinic-based study assessed and compared lipid profile, presence of metabolic syndrome (MetS), and liver enzymes in subjects with IGT, new onset treatment naive T2DM, and normal glucose tolerance (NGT). Introduction: Type 2 diabetes (T2D) and IGT patients have increased dyslipidemia, MetS, and alterations in liver enzymes. Aims and Objectives: To assess and compare lipid profile, presence of MetS, and liver enzymes in subjects with IGT, new onset treatment naοve T2DM, and NGT. Materials and Methods: This cross-sectional clinic-based study examined 152 IGT and 158 recently detected T2D subjects aged between 30 and 69 years, never treated with any anti-hyperglycemic, anti-hypertensive, and lipid lowering drugs. One hundred and sixty age- and gender-matched controls with NGT were also selected. Anthropometry, lipid profile, dyslipidemia (ADA criteria), presence of MetS (NCEP, IDF), liver enzymes, insulin resistance (HOMA-IR and QUICKI), and β-cell function (HOMA β) were analyzed in all subjects. Results: T2D and IGT subjects had significantly higher BMI, waist circumference, blood pressure (BP), HOMA-IR, QUICKI, fasting insulin, HOMA-β, MetS, triglyceride, LDL-C, SGPT, GGT, and lower HDL-C compared to NGT (control). High LDL-C (>100 mg/dl) was the commonest dyslipidemia followed by low HDL-C and hypertriglyceridemia in IGT and T2D. We found no significant differences in BMI, waist circumference, insulin resistance, total/LDL-C/HDL-C, and presence of MetS between T2D and IGT subjects. Diabetics exhibited significantly higher BP, triglyceride, SGPT, GGT, lower fasting insulin, and HOMA-β-cell function compared to IGT. Conclusions: IGT and recent onset T2D individuals had similar increased cardiovascular risk markers, liver enzymes, and prevalence of MetS. High LDL-C was the commonest dyslipidemia in IGT and T2D. T2D subjects had higher triglyceride, BP, SGPT, GGT compared to IGT.
  919 214 -
Hyperparathyroidism: Cancer and Mortality
Soumik Goswami, Sujoy Ghosh
December 2012, 16(8):217-220
Hyperparathyroidism is a commoner endocrinopathy today with a large number of asymptomatic patients in contrast to the scenario five decades ago. Surgery is indicated for patients fulfilling the NIH criteria who are mostly symptomatic while individuals with mild disease are managed conservatively. Several studies indicate increased risk of malignancy involving several sites and related mortality in primary hyperparathyroidism (PHPT) with the risk persisting for several years after surgery. PHPT is associated with structural & functional cardiac abnormalities and premature death from increased cardiovascular disease with risk normalising only several years after surgery. Mortality risk is associated with pre-operative serum calcium & parathormone and parathyroid adenoma weight. However, the issue of existence of similar risk and surgical benefit in mild PHPT is mired in controversy although some studies have shown an association and beneficial trends with surgery. With current evidence, it would be prudent to follow up PHPT patients for malignancy and cardiovascular disease and possibly adopt a more liberal attitude towards surgery.
  934 181 -
Megaduodenum in a patient with acromegaly
Belinda George, D Vinay, J Moolechery, V Mathew, R Anantharaman, V Ayyar, G Bantwal
December 2012, 16(8):324-325
Introduction: Acromegaly is associated with enlargement of all organs including the gastro intestinal system. However, there are no previous reports of occurrence of megaduodenum in patients with acromegaly. Discussion: We present the case of a 47 year old male who was diagnosed to have acromegaly 13 years ago and had undergone transsphenoidal surgery twice with incomplete removal of the pituitary macro-adenoma and received radiotherapy following the second surgery. Patient has been on replacement therapy for hypocortisolism, hypothyroidism and hypogonadism since 10 years. Post glucose growth hormone level continued to remain unsuppressed; however, patient never received any medical therapy for acromegaly. He was evaluated with esophago-gastro-duodenoscopy for recurrent abdominal pain and distension, which showed an elongated and tortuous megaduodenum. These findings were verified with a barium study which revealed dilated stomach, first and second part of duodenum with no evidence of a distal obstruction. Conclusions: We report this finding in view of the rare association.
  972 137 -
Metabolic bone disease: Newer perspectives
Anil Bhansali
December 2012, 16(8):140-141
  835 264 -
2 year followup of patients with diabetes mellitus nephropathy showing albuminuria reversal following angiotensin converting enzyme inhibitors
S Gopinath, B Amirtha Ganesh, K Manoj, Rubiya
December 2012, 16(8):447-449
Introduction: Two-year follow-up of patients with diabetes mellitus (DM) nephropathy shows albuminuria reversal following angiotensin converting enzyme (ACE) inhibitors. Aim: To study about a clinical profile of 2-year follow-up of patients with DM nephropathy showing albuminuria reversal following ACE inhibitors. Materials and Methods: Twenty patients were taken up for study with duly informed consent and suggested for glycemic profile with HbA1C. Baseline renal function, urine microscopy, albuminuria, and other microvascular complications such as neuropathy and retinopathy. These patients were followed up for a period of 2 years with every month follow-up and monthly dose titration of ACE inhibitors, enalapril (Quote: Dr. M. K. Mani), to a maximum tolerable dose and checked after 1 week for raise in creatinine and potassium. Inclusion Criteria: Twenty patients, who have attended a secondary level diabetic clinic with diabetic nephropathy and are on regular follow-up for 2 years, were selected. Exclusion Criteria: Sick patients requiring parenteral feeds, IV antibiotics, co-morbid conditions such as autonomic gastroparesis and diabetic foot infections, type 1 diabetes and other known kidney disease, chronic kidney disease on dialysis are excluded from the study. Expected Result: Reversal of albuminuria. Conclusion: Enalapril is a safe, cheaper ACE inhibitors and the good dose titration coupled with early screening for DM nephropathy really help in halting the progression of chronic kidney disease from DM nephropathy.
  910 175 -
Baseline characteristics of the IMPROVE control study population: A study to evaluate the effectiveness of a standardized healthcare professionals training program
SK Sharma, V Seshiah, BK Sahay, AK Das, PV Rao, S Shah, S Akhtar, R Shetty
December 2012, 16(8):471-473
Introduction: The IMPROVE Control Training program was designed by Indian Academy of Diabetes (IAD), and a non-intervention study was conducted to evaluate the effectiveness of this standardized healthcare professionals (HCPs) training program on achieving treatment goals in patients with diabetes mellitus and its impact on standard of care. Materials and Methods: This multi-center, parallel group, open-label, non-randomized, non-intervention study included patients with type 2 diabetes who had an HbA1c >9 at time of diagnosis or an HbA1c >7% even after 6 months of initiation of therapy with anti-diabetic agents (Oral anti diabetic agents (OADs) and/or insulin). The data recorded at baseline included demographic characteristics, medical history, and the treatment regimens. Results: The study included 20,493 patients with diabetes, of which 13,295 (64.9%) were men. The mean [standard deviation (SD)] duration of diabetes was 6.4 (4.2) years and 6608 (32.2%) reported complications of diabetes. Poor glycemic control [HbA1c = 9.4 (1.3), FPG (mg/dl) = 181.2 (45.7); mean (SD)] was observed. The postprandial glucose was also high [post-breakfast, lunch, and dinner values in mg/dl were 263.6 (68.5), 278.1 (69.6), and 250.2 (63.7), respectively] in these patients. Failure of OADs was the most common reason cited for initiation of insulin. Premixed insulin was rated the regimen of choice for initiating therapy by the physicians (62.2% vs. 34.5% who preferred basal insulin). Conclusion: The baseline results confirm the poor glycemic control and the delayed initiation and/or inadequacy of treatment in subjects with type 2 diabetes. These results also highlight the need for early and optimal insulin-based therapy.
  913 166 -
Evolving adrenal insufficiency
Ajitesh Roy, Rana Bhattacharjee, Soumik Goswami, Anubhav Thukral, S Chitra, Partha Pratim Chakraborty, Dayanidhi Meher, Sujoy Ghosh, Satinath Mukhopadhyay, Subhankar Chowdhury
December 2012, 16(8):369-370
Introduction: Tuberculosis is the most common cause of Addison's disease in India. The exact status of adrenal reserve in tuberculosis is still an enigma and recovery of adrenal function is unpredictable. Objective: We report a case with a pre-Addisonian state and unchanged adrenal size after 1 year treatment. Materials and Methods: A 31-year patient with adrenal tuberculosis was diagnosed and treated with anti tubercular drugs (ATDs) and steroid. Results: A 31-year male, presented with fever and weight loss for 3½ months with anorexia, nausea, hyperpigmentation of skin, and buccal mucosa and weakness with past h/o adequately treated pulmonary tuberculosis at 3 years of age. On examination, the patient was anemic. A non-tender, firm right (Rt.) submandibular lymphnode was palpable. Investigations revealed: High erythrocyte sedimentation rate (ESR), negative HIV, and sputum for acid fast bacilli (AFB). Initial cortisol was high but subsequently became low with negative short synacthin test (SST). Computed tomography showed bilateral (B/L) enlarged hypodense adrenal mass with inconclusive fine needle aspiration cytology (FNAC) and negative AFB culture. Rt. submandibular lymph node FNAC showed caseating granuloma. ATDs and steroids were started, the lymphadenopathy regressed and symptoms subsided. However, after 1 year of treatment steroid withdrawal failed and adrenal size remained the same. Conclusion: The adrenal has considerable capacity to regenerate during active infection and ultimately become normal or smaller in size. However, in the case reported here, they failed to regress. Reversal of adrenal function following ATD is a controversial issue. Some studies have shown normalization following therapy, while others have contradicted it similar to the finding in our case.
  879 195 -
Newer anabolic therapies in osteopororsis
Monika Mittal, Naibedya Chattopadyay
December 2012, 16(8):279-281
Osteoporosis is one of the top 10 global diseases of 21 st century. The altered bone turnover rate has been attributed to impaired activity of osteoblasts and over-activity of osteoclasts. Anti-resorptive and bone forming therapies are the two choices available for the treatment of osteoporosis. In the mini-review, we will discuss the experimental therapeutics of emerging osteoanabolic strategies
  841 220 -
The "double a" phenotype: Portending allgrove's syndrome and averting adrenal crisis
Soumik Goswami, Ajitesh Roy, Rana Bhattacharjee, KS Shivaprasad, Partha P Chakraborty, Chitra Selvan, Anubhav Thukral, Kaushik Biswas, Sujoy Ghosh, Satinath Mukhopadhyay, Subhankar Chowdhury
December 2012, 16(8):367-368
Introduction: Allgrove's syndrome is a rare autosomal-recessive disorder with only about 70 cases reported thus far and is characterized by alacrima, achalasia, and ACTH insensitivity among other clinical features. However, it has a widely variable clinical presentation, which may result in such cases remaining undiagnosed. Objective: To report a patient with impending Allgrove's syndrome and to highlight the importance of clinical suspicion in diagnosing the same. Materials and Methods: A 2.5-year-old girl was diagnosed with impending Allgrove's syndrome on the basis of clinical presentation, barium swallow study, Schirmer's test, and hormonal evaluation. Results: A 2.5-year-old girl, born of non-consanguineous marriage, presented with failure to thrive and developmental delay with occasional vomiting on taking solid or semi-solid food for past 6 months. Examination revealed stunted weight (SDS of -4.4) and height (SDS of -4.76), and barium swallow showed presence of achalasia. On direct questioning, her mother mentioned presence of decreased tears on crying since birth, and Schirmer's test confirmed the presence of dry eyes. Baseline ACTH was slightly elevated with normal basal and post-ACTH stimulation serum cortisol. Based on these findings, impending Allgrove's syndrome was diagnosed with a plan for follow-up study of adrenal function. Conclusions: Allgrove's syndrome may be an under diagnosed disorder as aclarima is often overlooked. However, a high index of clinical suspicion may help in avoiding adrenal crisis by diagnosing the condition early.
  918 141 -
Vitamin D deficiency presenting like hypophosphatemic osteomalacia
Rajneesh Mittal, Pramila Kalra, Mala Dharmalingam
December 2012, 16(8):413-415
Introduction: Osteomalacia is one of the most common osteometabolic diseases. It is typically caused by lack of vitamin D and is characterized by mineralization deficiency of the osteoid matrix in the cortical and trabecular bone. Indians are at particularly high risk for developing osteomalacia, because of their traditional clothing style and skin color. This condition is frequently misdiagnosed and it can present with bone pain and muscle weakness. Objective: We report a case of osteomalacia with predominant hypophosphatemia. Case report: A 41-year-old male presented with gradually progressive quadriparesis for past 6 months. Patient had low phosphorous (1.9 mg/dl) with calcium being 8.1 mg/dl and 25(OH)Vitamin D3 levels being 8.12 ng/ml. The patient was thought to have concomitant Vitamin D deficiency with possibility of tumor-induced osteomalacia. Further evaluation for the same was planned. However, patient was given a trial of Vitamin D supplementation before further investigations and had dramatic improvement in the form that muscle power improved gradually over next 6 weeks and was able to climb stairs after 2 months. Retrospectively patient gave a history of being at home for many months and there was no exposure to sunlight at all. The biochemical parameters normalized within 4 weeks of starting Vitamin D and serum alkaline phosphatase showed drastic reduction after 6 weeks. All his family members were screened and found to have Vitamin D deficiency including recent born twins having rachitic changes. This was a case of vitamin D deficiency, in 41-year-old male, which presented more like hypophosphatemic osteomalacia but characteristic history of lack of sunlight exposure and dramatic improvement with only vitamin D3 supplementation confirmed the diagnosis. Conclusion: The presentation of vitamin D deficiency can be varied and high index of suspicion is important for treatment of this common but frequently misdiagnosed condition.
  886 169 -
Improving management practices and clinical outcomes in type 2 diabetes study: Prevalence of complications in people with type 2 diabetes in India
Ashok Kumar Das, V Seshiah, BK Sahay, A Kumar, AJ Asirvatham, V Balaji, S Kalra, R Channabasavaiah, R Shetty, C. R. A. Moses
December 2012, 16(8):430-431
Introduction: Diabetes is the fourth leading cause of disease-related death and almost 80% of diabetes-related deaths occur in developing countries. Optimal glycemic control, in particular HbA1c level less than 7% with effective management of dyslipidemia and hypertension can reduce development of diabetes-related complications. Delay in initiating/or optimizing appropriate anti-diabetic therapy including insulin could be a possible cause of the increase in complications. Method: Improving management practices and clinical outcomes in type 2 diabetes (IMPACT) was a prospective, open-label, 26-week, comparative, multi-center study to compare efficacy and safety of the Indian insulin guideline (IIG) group versus routine clinical practice (RCP) group in type 2 diabetes patients. A total of 20,653 subjects from 885 centers across India were enrolled. Results: A total of 4695 patients (22.7%) (IIG, 4113 [22.6%]; RCP, 582 [23.5%]) had macrovascular complications and 8640 patients (41.8%) (IIG, 7486 [41.2%]; RCP, 1154 [46.6%]) had microvascular complications. Of 4695 patients with macrovascular complications, 2850 patients (60.7%) had coronary heart disease followed by 1457 patients (31.0%) with peripheral vascular disease. Of all the microvascular complications recorded, 5627 patients (65.1%) had peripheral neuropathy followed by 3313 patients (38.3%) with retinopathy. Conclusion: The rates of complications were high in patients with type 2 diabetes at the time of being initiated on insulin therapy in India.
  846 208 -
Association of vitamin D levels, lipid profile and intima media thickness in HIV positive patients
Sarita Bajaj, Vatsala Misra, Anudita Bharghav, AK Gupta, KK Sonkar, Ibandalin
December 2012, 16(8):411-412
Background: People with HIV are living decades longer than before due to combination ART; however, complications including CVD< osteoporosis and non AIDS defining malignancies are higher than in the general population. Many of the emerging complications related to chronic HIV infection represent disease processes where vitamin D is known to play an important role. Objectives: A single point cross sectional case control study was conducted in a tertiary care hospital to determine the prevalence of vitamin D deficiency and its association with carotid intima media thickness (CIMT) in HIV patients and to study the association of lipid profile with HIV infection. Out of the 45 HIV positive cases, vitamin D deficiency was found in 42 cases (93.33%) whereas only 33 out of 45 (73.33%) healthy controls. Fifty one point eleven percent of cases had dyslipidemia compared to 15.55% of controls. A positive association was seen between CD4 levels and 25 hydroxy vitamin D. An inverse co-relation between CD4 count and triglycerides and VLDL levels while a positive co-relation with total cholesterol, LDL cholesterol and HDL cholesterol levels was seen. No significant difference was seen in CIMT in cases and controls.
  876 175 -
Genetic characterization of growth hormone 1 gene in patients with isolated growth hormone deficiency
Shweta Birla, Viveka P Jyotsna, Arundhati Sharma, Rajesh Khadgawat, MK Garg, Vandana Jain
December 2012, 16(8):310-312
Introduction: Growth hormone (GH) secretion and release is a complex and highly regulated process. Any alteration disturbing synthesis, secretion or biological action of GH, results into growth hormone deficiency (GHD). GHD is of two types-isolated growth hormone deficiency (IGHD) and combined pituitary hormone deficiency (CPHD),of which IGHDis more common. The genes implicated in its etiology are growth hormone 1(GH1) and receptor of growth hormone-releasing hormone (GHRHR). Mutations within the coding region and/or either entire or partial deletions of the GH1gene lead to IGHD. In addition,GH1 possesses upstream regulatory elements and a promoter with binding sites for various transcription factors, which control its expression. Aim: The study was planned with an aim to identify entire GH1 locus deletion, mutations in the GH1 coding region and sequence variations (polymorphisms) in the promoter region of the gene in patients with IGHD. Materialsand Methods: Thirty patients clinically diagnosed with IGHD and 30 healthy individuals who formed the controls were enrolled for the study. Genomic DNA was isolated from peripheral blood sample and processed for amplification of the desired regions followed by direct sequencing and/or restriction endonuclease digestion. Results: Out of the 30 IGHD patients screened, 20% of the cases showed consanguinity and 16% had a positive family history. Seven percentage of the patients showed homozygous deletion of the GH1gene while rest of them had heterozygous deletion. Screening of the coding region of GH1 showed sequence variations in exon 1 in 20% of the patients whereas the promoter region showed the presence of polymorphisms-rs2005171 in 20%, rs2005172 in 15% and rs11568828 in 18% of the cases. The haplotype comprising rs2005171 and rs2005172 was observed in four patients. Conclusion: The present study is an attempt to characterize the GH1 locus in IGHD patients. To the best of our knowledge this is the first study of its kind where entire GH1locus, upstream regulatory elements and promoter region have been studied. Such an analysis would provide valuable information on the etiology of IGHD.
  864 175 -
Comparision between body mass index and abdominal obesity for the screening for diabetes in healthy individuals
S Gopinath, B Amirtha Ganesh, K Manoj, Rubiya
December 2012, 16(8):441-442
Aim: To study about the usefulness of Waist-Height Ratio as a clinical marker in patients with Metabolic Syndrome. Materials and Methods: A clinic-based study of patients attending a secondary level Diabetic Clinic and correlation of their Anthropometry data like waist circumference, height to other parameters namely body mass index (BMI), Waist-Hip Ratio, Blood pressure, Glycemic Control, Lipid Profile, and Duration of Diabetes. Inclusion Criteria: Randomly selected 10 000 patients attending a secondary level diabetic clinic. Exclusion Criteria: Type 1 DM, Gestational Diabetes. Result: Waist-Height Ratio is a better parameter than Waist-Hip Ratio and it is significant in applying for people with different Stature with Normal BMI. Conclusion: Waist-Height Ratio is a better and easier tool when compared with BMI or Waist-Hip Ratio and can be used for assessment of Cardio-metabolic parameter for public health.
  844 189 -
Prospective randomized controlled intervention trial: Comprehensive Yogic Breathing Improves Cardiac autonomic functions and Quality of life in Diabetes
VP Jyotsna, Smita Ambekar, Rajiv Singla, Ansumali Joshi, Anju Dhawan, Neeta Kumar, Nandita Gupta, V Sreenivas, KK Deepak
December 2012, 16(8):489-491
Aims and Objectives: To assess the effect of Comprehensive Yogic Breathing Program on glycemic control, quality of life, and cardiac autonomic functions in diabetes. Material and Methods: This is a prospective randomized controlled intervention trial. Cardiac autonomic functions were assessed in 120 diabetics. Patients were randomized into two groups, one group receiving standard therapy for diabetes (n = 56) and the other group receiving standard therapy for diabetes and comprehensive yogic breathing program (n = 64). Standard therapy included advice on diet, walk, and oral antidiabetic drugs. Comprehensive yogic breathing program was an interactive session in which Sudarshan kriya yoga, a rhythmic cyclical breathing, preceded by Pranayam was taught under guidance of a certified teacher. Change in fasting, post prandial blood sugars, glycated hemoglobin, and quality of life were assessed. Cardiac autonomic function tests were done before and six months after intervention. Results: There was significant improvement in psychological (P = 0.006) and social domains (P = 0.04) and total quality of life (P = 0.02) in the group practicing comprehensive yogic breathing program as compared to the group following standard therapy alone. In the group following breathing program, the improvement in sympathetic cardiac autonomic functions was statistically significant (P = 0.01), while the change in the standard group was not significant (P = 0.17). When both parasympathetic and sympathetic cardiac autonomic functions were considered, there was a trend toward improvement in patients following comprehensive yogic breathing program (P = 0.07). In the standard therapy group, no change in cardiac autonomic functions was noted (P = 0.76). The parameters of glycemic control were comparable in both groups. Conclusion: There was significant improvement in quality of life and cardiac autonomic functions in the diabetes patients practicing comprehensive yogic breathing program compared to those following standard treatment alone.
  934 24 -
Reassessment of elicitation of myoedema in evaluation of overt hypothyroidism: A pilot study
Karthik Balachandran, G Vignesh, DM Mahesh, P Girish, C Sadishkumar Kamalanathan, Jaya Prakash Sahoo, Abdoul Hamide
December 2012, 16(8):356-357
Introduction: There is a need to reassess the significance of myoedema in evaluation of overt hypothyroidism in the current day clinical practice. It is commonly checked for by flicking across the biceps belly expecting a transient mound at the points of tactile stimuli with mild pressure. Aim and Objective: To assess elicitation of myoedema in overt hypothyroidism (defined arbitrarily as TSH >50 mIU/L in primary hypothyroidism and fT4 <0.6 ng/dl in secondary hypothyroidism). Results: The 28 primary overt hypothyroid (OH) patients were divided into three groups as mild, moderate, and severe depending on TSH levels as those with 50-100, 100-150, and >150 mIU/L. Myoedema was elicited in 8 of 13 in the severe OH group, in 2 of 7 in moderate OH group and in 1 of 8 in the mild OH group. In the group of secondary hypothyroidism, myoedema was elicitable in one of two patients. The odds ratio for presence of both myoedema and clinical features of myopathy in a group of overt hypothyroid patients with TSH >150 mIU/L as compared to <150 mIU/L was 17.5. Similarly, the odds ratio for the presence of only myoedema was 6.4 while the odds ratio for presence of only clinical features of myopathy was 3.67. While the odds ratios involving presence of myoedema neared statistical significance, that with the presence of clinical features of myopathy alone did not. Conclusion: Examination for eliciting myoedema is useful when evaluating a case of overt hypothyroidism.
  791 164 -
Tuberous Sclerosis: An uncommon cause of hyperprolactinemia
Sunil Kumar Kota, Lalit Kumar Meher, SVS Krishna, KD Modi
December 2012, 16(8):302-303
Tuberous Sclerosis is a multi system genetic disorder affecting skin, central nervous system,kidney,heart and lungs. We present a case report of a 26 year old female with tuberous sclerosis who presented with galactorrhea and menstrual irregularities due to hyperprolactinemia.
  790 136 -
Efficacy and safety of rapid escalation of cabergoline in comparison to conventional regimen for macroprolactinoma: A prospective, randomized trial
Ashu Rastogi, Rama Walia, Pinaki Dutta, Anil Bhansali
December 2012, 16(8):294-296
Introduction: Cabergoline (CAB) is conventionally started at a dose of 0.25-0.5 mg once a week with dose escalation at 1to 3months intervals. Previously, we and others have shown that rapid escalation and high doses of CAB can lead to normalization of serum PRL as early as 8.2 weeks in 93% of the patients. We hypothesize that rapid escalation of CAB doses, may help in both the earlier normalization of PRL and also significant shrinkage of tumor mass. Study Design: Randomized, prospective, interventional trial. Subjects and Methods: Forty two patients (male or female) with macroprolactinoma were randomized to conventional (group A) or rapid escalation (group B) of CAB dosing. In group B, CAB was started at a dose of 0.5 mg twice a week followed by a weekly hike of 1 mg/week, based on serum PRL and then monthly. The end point of the present study was a composite of normoprolactinemia and tumor shrinkage ≥50% from baseline. PRL and visual field analysis (weekly), other hormonal work up periodically and magnetic resonance imaging (sella) was performed monthly. Results: A total of 19 patients in each group completed a minimum follow-up of 6 months. There was a reduction of 72.7 ± 26.2% in group A and 84.1 ± 15.0 in group B (P = 0.24) within a week of CAB therapy. The duration of CAB treatment to normalize PRL was 10.2 ± 9.2 week(2-36) in group A and 7.2 ± 6.2 weeks(1-24) in group B (P = 0.28). There was no difference in the tumor shrinkage in either of the groups (92.3% [46.7-100%] in group A and 90.5% [66.6-100%] reduction in group B). The composite end point was achieved in 14 patients in group A (73.6%) and 16 patients in group B (84.2%) (P = 0.69). The composite end point was achieved in 13.1 ± 9.5 weeks (group A) versus 16.5 ± 14.1 weeks (group B) (P = 0.61). Discussion: This is first head to head comparative trial showing that a rapid hike of CAB dose is not associated with earlier normalization of PRL or reduction in tumor volume as compared to conventional monthly hike. There is no difference in the number of patients or duration required to achieve the composite end point. We obtained much earlier PRL normalization (8.4 weeks) as compared to previous studies (36-72 weeks), probably because PRL was not assessed as frequently as in the present study. Rapid escalation of CAB was well tolerated. Conclusion: A weekly or a conventional 4 weekly escalation of CAB have a similar efficacy with regards to the achievement of normoprolactinemia and significant tumor shrinkage for macroprolactinoma.
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Profile of vitamin D in a cohort of physicians and diabetologists in Kolkata
Arjun Baidya, Subhankar Chowdhury, Satinath Mukhopadhyay, Sujoy Ghosh
December 2012, 16(8):416-417
Introduction: Vitamin D deficiency has been documented across all age groups and both sexes from India. However, there is paucity of data on vitamin D deficiency in a particular cohort of population. Objectives: To assess the vitamin D status in a cohort of physicians and diabetologists in Kolkata. Material and Methods: An observational cross sectional study carried out in the month of December 2011 in a cohort of 40 physicians and diabetologists in Kolkata. Results: A total of 40 subjects were studied. Mean age of the cohort was 52.22 ± 10.91.Mean serum vitamin D level was 13.02 ± 4.77 ng/ml. Nearly 92.5% and 5.0% of subjects had vitamin D deficiency and insufficiency, respectively. Conclusions : Vitamin D deficiency is highly prevalent in physicians and diabetologists in Kolkata.
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Profile of type 2 diabetes mellitus without overt complications of diabetes mellitus at a tertiary care center
Rajiv Singla, S Ambekar, Kumar Nand, MB Singh, N Gupta, VP Jyotsna
December 2012, 16(8):468-470
Introduction and Objectives: Internal audit of an aspect of a disease at repeated intervals helps in predicting the new emerging trends. This study was planned to assess the profile of patients with diabetes mellitus (DM) without overt complications. Materials and Methods: Patients with HbA1c between 6% and 9% on oral hypoglycemic agents and who did not have clinically overt complications of diabetes were recruited from outpatient clinic of Department of Endocrinology and Metabolism at All India Institute of Medical Sciences (AIIMS) from April 2009 to October 2011. Results: A total of 91 patients (53 males and 38 females) were recruited over 3 years of period. Their mean age was 49.65 ± 11.22 years (range in years) and mean duration of diabetes was 48.09 ± 41.44 (range: 1-180) months. Biochemical evaluation revealed mean fasting blood sugar (FBS): 126.69 ± 25.80 mg/dl and mean HbA1c: 7.12 ± 0.81%. Family history of DM was present in 60.43% of patients, 6.59% were active smokers and 46.15% were obese (waist circumference ≥90 cm in males and ≥80 cm in females). All but 6.59% (n = 6) of patients were dyslipidemic and only 25 of these were on antidyslipidemic treatment. Isolated low HDL was most common abnormality (25.27%, n = 23), followed by combination of low HDL and raised LDL (17.58%, n = 16). Evaluation of complications showed retinopathy in just one patient, nephropathy in 17.68%, and neuropathy in 10.97%. MINI neuropsychiatric scale for depression was positive in four patients and four patients were on antidepressants. Conclusion: Type 2 diabetes mellitus (T2DM) patients have very high prevalence of dyslipidemia even in patients with good glycemic control. This study allowed us to realize lacunae in our clinical practice regarding need for better care of lipid parameters.
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Goniometry in limited joint mobility
S Gopinath, K Manoj, Rubiya
December 2012, 16(8):443-444
Aim: To study about the utility of goniometry in screening for limited joint mobility (LJM) in patients attending a secondary level Diabetic Clinic. Materials and Methods: Randomly selected data of 100 patients attending a secondary level diabetic clinic without any complications were used. Baseline neuropathy assessments, namely monofilament and biothesiometry were done. Range of movement around the ankle joint and 1 st metatarsal joint was done using goniometry. Both the results were compared. Inclusion Criteria: Selected 100 patients attending a secondary level diabetic clinic and on regular follow-up were included in the study. Exclusion Criteria: Sick patients requiring parenteral feeds, IV antibiotics, co-morbid conditions such as microvascular complication, autonomic gastroparesis, and diabetic foot infections were excluded from the study. Conclusion: Goniometric screening for LJM is a cheap and effective screening tool for detecting early structural deformity producing a higher plantar pressure and ulcer, and thereby preventing them at early stage.
  698 155 -
Predictors of bone mineral density in patients with Sheehan's syndrome
Ramesh Gomez, Subhash B Yadav, Eesh Bhatia
December 2012, 16(8):313-314
Sheehan's syndrome is a leading cause of panhypopituitarism.It is associated with osdteoporosis due to a number of factors like gonadal and growth hormone deficiency; and other factors.In our study, 58 % of patients had osteopenia and 37% had osteoporosis at lumbar spine. Duration of illness had a significant inverse relationship with bone mineral density.
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Dyshormonogenetic goiter and associated non-thyroidal anomalies
Khalid J Farooqui, Tanveer A Rather, Shariq R Masoodi, Shoukat H Khan, Arshad I Wani
December 2012, 16(8):342-344
Background: Dyshormonogenetic goiter (DG) refers to familial goitres owing to an inherited defect in the metabolism of thyroid hormones and accounts for 10-15% of all cases of congenital hypothyroidism. Aim and Objective: To identify dysmorphic features, cardiac and urogenital anomalies in patients with DG following in the pediatric endocrinology clinic. Materials and Methods: Eight adolescents following the pediatric endocrinology clinic for hypothyroidism and associated stigmata were identified with dyshormonogenesis using 99mTc radionuclide thyroid scintigraphy and confirmation by the Perchlorate discharge test during a 6-month period from January to July 2012. Screening for associated malformations was done using clinical examination, echocardiography and ultrasonography of abdomen. Results: The eight patients (two boys and six girls) had a mean age of 9.87 years. The mean duration of goitre was 36.12 months. Two patients had mental retardation and delayed developmental milestones one of whom had ectopic left kidney on renal scintigraphy. Mitral regurgitation was seen in one patient whereas renal anomalies in the form of ectopic kidney and small/contracted kidney with grade III hydronephrosis was seen in two patients. Penoscrotal hypospadias was identified in one of the patients who also had small/contracted kidney with grade III hydronephrosis and underwent pyeloplasty for the same. Dysmorphic features in the form of high arched palate, depressed nasal bridge and low set ears was seen in one patient. Conclusion: DG is associated with other extra-thyroidal congenital anomaly, some of which may need to be treated.
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Cardiovascular disease risk in young women with polycystic ovary syndrome
A Guleria, S Syal, A Kapoor, P Tiwari, P Dabadhgao
December 2012, 16(8):393-395
Introduction: Polycystic ovary syndrome (PCOS) is a common disorder in women of reproductive age group. Insulin resistance and the consequent hyperinsulinemia seem to be the central pathophysiological mechanism that links PCOS to its associated metabolic derangements. Women with PCOS exhibit a number of risk factors for coronary artery disease. We studied risk of CVD using two surrogate markers, carotid intima-media thickness (CIMT) and brachial artery flow-mediated dilation (FMD). Aims and objectives: To study cardiovascular disease risk in young women (18-35 years age) with PCOS using CIMT and FMD. Materials and Methods: Sixty women with PCOS (age: 23.8 ± 4.5 years; body mass index [BMI]: 23.5 ± 4.2 kg/m 2 ) were compared with 30 age- and BMI-matched healthy controls (age: 26.3 ± 5.4 years; BMI: 22.6 ± 3.8 kg/m 2 ). Diagnosis of PCOS was made using the Rotterdam criteria. Fasting blood sample was analyzed for glucose, insulin, lipid profile, high sensitivity C-reactive protein (hsCRP), high molecular weight adiponectin (HMWADP), and interleukin 6 (IL6). CIMT and FMD were performed. Results: PCOS patients had a higher waist to hip ratio (W/H) [0.86 ± .07 vs. 0.80 ± .05] and free testosterone index (FTI) [6.6 ± 6.5 vs. 2.0 ± 1.0] in comparison to controls. There was no difference in the two groups in lipid profile parameters and HOMA IR. CIMT was significantly higher (0.59 ± .1 mm vs. 0.50 ± .05 mm, P value <.001) and FMD lower (10.3 ± 3.9% vs. 15.2 ± 5.5%, P value < .001) in cases when compared to controls. FMD negatively correlated with W/H ratio (r: -0.257) and hsCRP (r: -0.347), while IMT showed positive correlation with IL6 (r: 0.325) and hsCRP (r: 0.303) and a negative correlation with high-density lipoprotein (HDL) [r: -0.224], all P values < .05. Conclusions: Patients with PCOS have evidence for increased CVD risk as shown by endothelial dysfunction manifested by increased CIMT and a lower FMD.
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