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   2016| September-October  | Volume 20 | Issue 5  
    Online since September 14, 2016

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The inositols and polycystic ovary syndrome
Bharti Kalra, Sanjay Kalra, JB Sharma
September-October 2016, 20(5):720-724
DOI:10.4103/2230-8210.189231  PMID:27730087
This review describes the rationale, biochemical, and clinical data related to the use of inositols in polycystic ovary syndrome (PCOS). It covers studies related to the mechanism of action of myo-inositol and D-chiro-inositol (MDI), with randomized controlled trials conducted in women with PCOS, and utilizes these data to suggest pragmatic indications and methods for using MDI combination in PCOS. Rationally crafted inositol combinations have a potential role to play in maintaining metabolic, endocrine, and reproductive health in women with PCOS.
  4,005 899 6
Sodium-glucose cotransporter 2 inhibition and health benefits: The Robin Hood effect
Sanjay Kalra, Arpit Jain, Jignesh Ved, AG Unnikrishnan
September-October 2016, 20(5):725-729
DOI:10.4103/2230-8210.183826  PMID:27730088
This review discusses two distinct, yet related, mechanisms of sodium-glucose cotransporter 2 (SGLT2) inhibition: Calorie restriction mimicry (CRM) and pro-ketogenic effect, which may explain their cardiovascular benefits. We term these adaptive CRM and pro-ketogenic effects of SGLT2 inhibition, the Robin Hood hypothesis. In English history, Robin Hood was a "good person," who stole from the rich and helped the poor. He supported redistribution of resources as he deemed fit for the common good. In a similar fashion, SGLT2 inhibition provides respite to the overloaded glucose metabolism while utilizing lipid stores for energy production.
  3,877 678 12
Voice and endocrinology
KVS Hari Kumar, Anurag Garg, NS Ajai Chandra, SP Singh, Rakesh Datta
September-October 2016, 20(5):590-594
DOI:10.4103/2230-8210.190523  PMID:27730065
Voice is one of the advanced features of natural evolution that differentiates human beings from other primates. The human voice is capable of conveying the thoughts into spoken words along with a subtle emotion to the tone. This extraordinary character of the voice in expressing multiple emotions is the gift of God to the human beings and helps in effective interpersonal communication. Voice generation involves close interaction between cerebral signals and the peripheral apparatus consisting of the larynx, vocal cords, and trachea. The human voice is susceptible to the hormonal changes throughout life right from the puberty until senescence. Thyroid, gonadal and growth hormones have tremendous impact on the structure and function of the vocal apparatus. The alteration of voice is observed even in physiological states such as puberty and menstruation. Astute clinical observers make out the changes in the voice and refer the patients for endocrine evaluation. In this review, we shall discuss the hormonal influence on the voice apparatus in normal and endocrine disorders.
  3,945 529 8
Study of Vitamin B 12 deficiency and peripheral neuropathy in metformin-treated early Type 2 diabetes mellitus
Rudra Prasad Roy, Kaushik Ghosh, Manas Ghosh, Amitava Acharyya, Ambarish Bhattacharya, Mrinal Pal, Sisir Chakraborty, Nilanjan Sengupta
September-October 2016, 20(5):631-637
DOI:10.4103/2230-8210.190542  PMID:27730072
Background: Long-term therapy with metformin was shown to decrease the Vitamin B 12 level and manifested as peripheral neuropathy. Aim: The aim of this study is to define the prevalence of Vitamin B 12 deficiency in early Type 2 diabetic patients (duration ≤5 years or drug treatment ≤3 years) and the relationship among metformin exposure and levels of cobalamin (Cbl), folic acid, and homocysteine (Hcy) with severity of peripheral neuropathy. Methodology: This is a cross-sectional study involving randomly selected ninety patients (male 56, female 34) between age groups of 35 and 70 years, comparing those who had received >6 months of metformin (Group A) (n = 35) with those without metformin (Group B) (n = 35) and patients taking metformin with other oral hypoglycemic agent (Group C) (n = 20). Comparisons were made clinically, biochemically (serum Cbl, fasting Hcy, and folic acid), and with electrophysiological measures (nerve conduction studies of all four limbs). Comorbidities contributing to neuropathy were excluded from the study. Results: Group A patients (54.28%) were prone to develop peripheral neuropathy comparing Group B (28.57%) and Group C (35%). There was significantly low plasma level of Cbl in Group A (mean 306.314 pg/ml) than in Group B (mean 627.543 pg/ml) and Group C (mean 419.920 pg/ml). There was insignificant low-level plasma folic acid in Group A (16.47 ng/ml) than in Group B (16.81 ng/ml) and Group C (22.50 ng/ml). There was significantly high level of Hcy in Group A (mean 17.35 µmol/L) and Group C (mean 16.99 µmol/L) than in Group B (mean 13.22 µmol/L). Metformin users even for 2 years showed evidence of neuropathy on nerve conduction velocity though their body mass index and postprandial blood sugar were maintained. There was significant difference in between groups regarding plasma Cbl, folic acid, and Hcy level as significance level <0.05 in all three groups (F [2, 87] = 28.1, P = 0.000), (F [2, 87] = 7.43, P = 0.001), (F [2, 87] = 9.76, P = 0.000). Post hoc study shows significant (P < 0.05) lowering of Cbl and Hcy level in Group A (mean = 306.314, standard deviation [SD] = 176.7) than in Group C (mean = 419.92, SD = 208.23) and Group B (mean = 627.543, SD = 168.33). Discussion: Even short-term treatment with metformin causes a decrease in serum Cbl folic acid and increase in Hcy, which leads to peripheral neuropathy in Type 2 diabetes patients. A multicenter study with heterogeneous population would have increased the power of the study. We suggest prophylactic Vitamin B 12 and folic acid supplementation or periodical assay in metformin user.
  3,347 826 9
Women in India with Gestational Diabetes Mellitus Strategy (WINGS): Methodology and development of model of care for gestational diabetes mellitus (WINGS 4)
Arivudainambi Kayal, Viswanathan Mohan, Belma Malanda, Ranjit Mohan Anjana, Balaji Bhavadharini, Manni Mohanraj Mahalakshmi, Kumar Maheswari, Ram Uma, Ranjit Unnikrishnan, Gunasekaran Kalaiyarasi, Lyudmil Ninov, Anne Belton
September-October 2016, 20(5):707-715
DOI:10.4103/2230-8210.189230  PMID:27730085
Aim: The Women In India with GDM Strategy (WINGS) project was conducted with the aim of developing a model of care (MOC) suitable for women with gestational diabetes mellitus (GDM) in low- and middle-income countries. Methodology: The WINGS project was carried out in Chennai, Southern India, in two phases. In Phase I, a situational analysis was conducted to understand the practice patterns of health-care professionals and to determine the best screening criteria through a pilot screening study. Results: Phase II involved developing a MOC-based on findings from the situational analysis and evaluating its effectiveness. The model focused on diagnosis, management, and follow-up of women with GDM who were followed prospectively throughout their pregnancy. An educational booklet was provided to all women with GDM, offering guidance on self-management of GDM including sample meal plans and physical activity tips. A pedometer was provided to all women to monitor step count. Medical nutrition therapy (MNT) was the first line of treatment given to women with GDM. Women were advised to undergo fasting blood glucose and postprandial blood glucose testing every fortnight. Insulin was indicated when the target blood glucose levels were not achieved with MNT. Women were evaluated for pregnancy outcomes and postpartum glucose tolerance status. Conclusions: The WINGS MOC offers a comprehensive package at every level of care for women with GDM. If successful, this MOC will be scaled up to other resource-constrained settings with the hope of improving lives of women with GDM.
  3,089 507 8
Endocrinology in the Ramayana
Sanjay Kalra, Manash P Baruah, Bharti Kalra
September-October 2016, 20(5):716-719
DOI:10.4103/2230-8210.190563  PMID:27730086
This article is one of a series of publications which highlight the possible endocrine conditions and interventions listed in the ancient texts. This compendium lists episodes from the Indian epic Ramayana and from the associated genealogy of Lord Rama's dynasty, the Suryavanshis. These episodes are chosen for their relevance to endocrinology and are listed in a gland-based order. It is hoped that this communication will encourage further work on endocrine literary forensics.
  2,789 301 -
Relationship of glycemic control markers - 1,5 anhydroglucitol, fructosamine, and glycated hemoglobin among Asian Indians with different degrees of glucose intolerance
Thyparambil Aravindakshan Pramodkumar, Ramamoorthy Jayashri, Kuppan Gokulakrishnan, Kaliyaperumal Velmurugan, Rajendra Pradeepa, Ranjit Mohan Anjana, Viswanathan Mohan
September-October 2016, 20(5):690-695
DOI:10.4103/2230-8210.190559  PMID:27730082
Objective: 1,5 anhydroglucitol (1,5 AG) is emerging as a marker of short-term glycemic control. We measured levels of 1,5 AG, fructosamine (FA), and glycated hemoglobin (HbA1c) in Asian Indians with different degrees of glucose intolerance. Materials and Methods: We recruited 210 individuals with normal glucose tolerance (NGT; n = 60), impaired glucose tolerance (IGT; n = 50), and Type 2 diabetes mellitus (T2DM; n = 100) from a large tertiary diabetes center in Chennai in Southern India. Anthropometric measurements were obtained using standardized techniques. Serum 1,5 AG (enzymatic colorimetric assay), FA (NBT/kinetic), and HbA1c (high-performance liquid chromatography) estimations were performed. Results: 1,5 AG levels were significantly lower in the T2DM followed by IGT compared with the NGT group (7.9 vs. 18.8 vs. 21.8 µg/ml, P < 0.05). FA and HbA1c were higher in T2DM and IGT compared with NGT individuals (313 vs. 237 vs. 200 µmol/L, P < 0.001) (8.3 vs. 5.8 vs. 5.3%, P < 0.001).1,5 AG showed a significant negative correlation with FA (r = −0.618, P < 0.001) and HbA1c (r = −0.700, P < 0.001). 1,5 AG decreased with increasing quartiles of postprandial glucose (P for trend <0.001). However, even among individuals with HbA1c ≤7%, 27% individuals had decreased 1,5 AG plasma level (<10 µg/ml). Conclusion: Circulatory levels of 1,5 AG correlate negatively with FA and HbA1c, and may provide an additional marker to assess glycemic control in patients with Type 2 diabetes.
  2,617 471 4
Clinicopathologic assessment of hypogonadism in men with type 2 diabetes mellitus
Theophilus E Ugwu, Rosemary T Ikem, Babatope A Kolawole, Ignatius U Ezeani
September-October 2016, 20(5):667-673
DOI:10.4103/2230-8210.190554  PMID:27730078
Objective: To determine the prevalence of hypogonadism in men with type 2 diabetes mellitus and evaluate its clinical and pathologic correlates. Subjects and Methods: In a cross-sectional survey of 200 type 2 diabetic males aged 32-69 years, total testosterone (TT), follicle stimulating hormone, luteinizing hormone, waist circumference (WC), glycated hemoglobin, and lipids were measured. Clinical assessment of androgen deficiency was done using the androgen deficiency in aging male (ADAM) questionnaire. Overt hypogonadism was defined as a combination of positive ADAM score and TT < 8 nmol/L while possible hypogonadism was defined as positive ADAM score with TT 8-12 nmol/L. Results: Overt and possible hypogonadism occurred in 29.5% and 23% of the participants, respectively. Majority (76.3%) of the subjects who had overt hypogonadism had the  hypogonadotrophic pattern. Hypogonadal subjects were significantly older (P = 0.014) and had higher mean WC (P = 0.009) than eugonadal ones. Erectile dysfunction was the most common symptom, occurring in 79.7% of overtly hypogonadal subjects. There was a significant negative correlation between WC and serum TT (r = −0.41, P = 0.001). Conclusion: There is a high frequency of symptomatic hypogonadism in men with type 2 diabetes and the frequency increases with advancing age and visceral adiposity.
  2,244 293 4
Oxidative stress in hypothyroid patients and the role of antioxidant supplementation
Sumit Kumar Chakrabarti, Sujoy Ghosh, Sandip Banerjee, Satinath Mukherjee, Subhankar Chowdhury
September-October 2016, 20(5):674-678
DOI:10.4103/2230-8210.190555  PMID:27730079
Context: The available data concerning oxidant stress and antioxidant capacity in hypothyroidism are scanty and inconclusive. While some authors suggest that tissues may be protected from oxidant damage because of a hypometabolic state in hypothyroidism, others report increased oxidative stress in hypothyroidism. Selenium acts as a cofactor for the thyroid hormone (TH) deiodinases that activate and then deactivate various THs and their metabolites. Selenium may inhibit thyroid autoimmunity. Aims: The study was designed, first, to study the impact of oxidative stress in patients of primary hypothyroidism due to autoimmune thyroiditis, by estimation of serum malondialdehyde (MDA) as a biomarker of oxidative stress. Second, to study the change in MDA level pre- and post-L-thyroxine treatment. Finally, to look into the possible role of selenium supplementation on oxidative stress in autoimmune hypothyroidism. Subjects and Methods: Patients attending endocrine outpatient department (OPD) services of IPGMER and SSKM hospital were considered for the study. Sixty treatment-naive adult patients (age > 18 years) with hypothyroidism were included in the study. The patients were divided into two groups, each comprised thirty patients. One group was treated with L-thyroxine and placebo (Group A). The other group received L-thyroxine replacement along with selenium (100 mcg twice a day) as antioxidant supplementation (Group B). The patients were blinded about selenium and placebo. The study duration for both groups was 6 months. The starting dose of L-thyroxine was 1.6 mcg/kg body weight free thyroxine (FT4), and thyroid-stimulating hormone (TSH) was repeated after 12 weeks. L-thyroxine dose adjustments were done if needed. MDA was assessed at the beginning and at the end of the study, i.e., after 6 months of treatment. The control cohort was composed of thirty healthy adults. Only overt hypothyroidism (OH) cases were included in the study. Statistical Analysis Used : Normality of data was determined using Anderson-Darling test, Shapiro-Wilk test, and QQ plot. P values were calculated using ANOVA and post hoc Bonferroni tests for normally distributed data. Correlation analysis was carried out using Pearson correlation test. P < 0.05 considered to be statistically significant. Results: After treatment in Group A patients, FT4 showed a significant increment while TSH value decreased. MDA level reduced after treatment, (P < 0.001). After treatment in Group B patients, FT4 showed increment while TSH value decreased (P < 0.05). After treatment, there was a drop in estimated MDA level (P < 0.001). MDA level shows a significant drop in both groups after treatment. In Group B, there is more decline in the MDA percentage but did not reach statistical significance. By performing repeated measure MANOVA, no significant difference was found in the MDA levels between the two groups. MDA reduction when expressed as percentage showed reduction of 39.5% in patients of Group A. Similarly, Group B patients showed a percentage reduction of 45.4%. Conclusions: Oxidative stress compounds hypothyroidism. Hypothyroidism is a state of increased oxidative stress. In this study, biomarker, MDA level is high in treatment-naive primary hypothyroid patients. After treatment with L-thyroxine, the stress marker is reduced to a significant extent. MDA can be used as a useful biomarker to measure and monitor oxidative stress. The role of the addition of antioxidant in the form of selenium remained inconclusive.
  1,834 433 17
Long-term efficacy of liraglutide in Indian patients with Type 2 diabetes in a real-world setting
Parjeet Kaur, Shama Mahendru, Ambrish Mithal
September-October 2016, 20(5):595-599
DOI:10.4103/2230-8210.183825  PMID:27730066
Background: Long-term efficacy of liraglutide, a glucagon-like peptide-1 analog, on body weight and glycemic control has not been studied in Indian Type 2 diabetes mellitus (T2DM) subjects. Aim: To evaluate the effect of liraglutide on glycemic control and body weight for 1 year in Indian T2DM patients. Methods: Liraglutide was prescribed to 96 obese patients with T2DM and followed up for 1 year. Clinical parameters were measured at baseline and 3, 6, 9, and 12 months. Dosage of liraglutide and other medications was adjusted according to clinical judgment. Results: 1 year data were available for 74 patients. Mean age was 50.9 ± 9.6 years. Mean duration of diabetes was 11.6 ± 6.3 years. Glycosylated hemoglobin (HbA1c) significantly decreased from 8.9 ± 1.3% at baseline to 7.4 ± 1.2% at 1 year. Body weight significantly declined from 98.9 ± 16.0 kg at baseline to 93.8 ± 15.0 kg at 1 year. After an initial decline, subset of patients had an increase in mean HbA1c (n = 30/74) and mean body weight (n = 33/74) after 6 months of liraglutide initiation. Baseline HbA1c and baseline body weight were positively associated with a reduction of HbA1c and body weight at 1 year, respectively. No major side effects occurred. Conclusion: Liraglutide treatment resulted in a significant and sustained reduction in HbA1c and body weight over 1 year in Indian T2DM patients. Magnitude of reduction of HbA1c and body weight at 1 year was positively associated with baseline HbA1c and baseline weight, respectively.
  1,819 348 2
Antithyroid drugs in Graves' disease: Are we stretching it too far?
Muthukrishnan Jayaraman, Anil Kumar Pawah, CS Narayanan
September-October 2016, 20(5):600-604
DOI:10.4103/2230-8210.190525  PMID:27730067
Introduction: Early and durable achievement of euthyroid or hypothyroid status with low likelihood of relapse is the key to effective treatment of Graves' disease (GD). Although antithyroid drugs (ATDs) are commonly used first-line agents, likelihood of remission remains highest with radioactive iodine (RAI) therapy and surgery. Data regarding efficacy and economical superiority of RAI therapy over ATDs are lacking from India. This study was designed to study the response to long-term (>12 months) use of ATDs in GD with respect to attainment of remission and to compare the cost of treatment with ATDs versus RAI therapy beyond 12 months. Settings: The study was conducted in a tertiary care center. Study Design: This was a retrospective analysis. Materials and Methods: Patients of GD in our follow-up from February 2009 to March 2016 who had received ATDs for a duration exceeding 12 months were retrospectively analyzed. Patients who underwent radioablation after a period of at least 12 months on ATDs were analyzed and their status was recorded after a minimum of 6 months after radioablation. Patients who remained hyperthyroid beyond 12 months and received RAI therapy were further compared with those who continued on ATDs, for achievement of euthyroid or hypothyroid status. Cost analysis was done for follow-ups and treatment and compared. Statistical Analysis Used : All analyses were done using Fisher's exact test for categorical and descriptive statistics for numerical data. Results: Use of ATDs leading to euthyroid and hypothyroid status in GD patients was only significant beyond 24 years when compared to those at <12-18 months therapy (P = 0.0262 and P = 0.0217, respectively). The patients who ended up with hypothyroid status were significantly greater in RAI group compared to ATD group (P = 0.0003). Cost of therapy per patient beyond 12 months was lower in the RAI group compared to the ATD group (cost difference Rs. 5435.00). Conclusions : Within limitations, our study demonstrates that RAI is effective and economical option in GD.
  1,736 378 1
Timely insulin use: Need for social marketing
Sanjay Kalra, Rakesh Sahay
September-October 2016, 20(5):586-589
DOI:10.4103/2230-8210.190521  PMID:27730064
  1,642 300 1
Evaluation of accuracy of ambulatory glucose profile in an outpatient setting in children with type 1 diabetes
Anjana Hulse, Suahma Rai, KM Prasanna Kumar
September-October 2016, 20(5):643-647
DOI:10.4103/2230-8210.190546  PMID:27730074
Background: In children with type 1 diabetes, intensive diabetes management has been demonstrated to reduce long-term microvascular complications. At present, self-monitoring of blood glucose (SMBG) by patients at home and glycated hemoglobin estimation every 3 months are used to monitor glycemic control in children. Recently, ambulatory glucose profile (AGP) is increasingly being used to study the glycemic patterns in adults. However, accuracy and reliability of AGP in children have not been evaluated yet. Objectives: To assess the accuracy of AGP data in children with type 1 diabetes mellitus when compared with laboratory random blood sugar (RBS) levels, capillary blood glucose (CBG) measured by glucometer in the hospital, and SMBG monitored at home. Methods: Paired RBS, CBG, and AGP data were analyzed for 51 patients who wore AGP sensors for 2 weeks. Simultaneous venous and CBG samples were collected on day 1 and day 14. SMBG at home was checked and recorded by the patients for optimizing insulin doses. Accuracy measures (mean absolute deviation, mean absolute relative difference (MARD), and coefficient of linear regression of AGP on RBS, CBG, and home-monitored SMBG were calculated. Results: Seventy paired RBS, CBG, and AGP data and 362 paired home-monitored SMBG and AGP data were available. The MARD was 9.56% for AGP over RBS and 15.07% for AGP over CBG. The linear regression coefficient of AGP over RBS was 0.93 and that of AGP over CBG was 0.89 (P < 0.001). The accuracy of AGP over SMBG was evaluated over four ranges: <75, 76-140, 141-200, and >200 mg/dl. Conclusion: In this study, AGP data significantly correlate with RBS and CBG data in children with type 1 diabetes. However, a large number of samples in a research setting would help to document reproducibility of our results.
  1,435 327 7
High atherogenic index of plasma in subclinical hypothyroidism: Implications in assessment of cardiovascular disease risk
Stephen R James, Lopamudra Ray, Kandasamy Ravichandran, Sunil Kumar Nanda
September-October 2016, 20(5):656-661
DOI:10.4103/2230-8210.190550  PMID:27730076
Background: A controversy exists regarding the association between subclinical hypothyroidism (SH) and dyslipidemia. Moreover, studies on lipid ratios and atherogenic index of plasma (AIP) in SH are rare, particularly in the Indian scenario. Aim: This study aimed to investigate abnormalities in conventional lipid profile, lipid ratios, and AIP in SH and attempted to correlate thyroid stimulating hormone (TSH) and AIP in SH. Materials and Methods: In this retrospective analysis of patient records of SH subjects and euthyroid subjects, age, free triiodothyronine, free thyroxine, TSH, total cholesterol, triglycerides, high-density lipoprotein-cholesterol (HDL-C), low-density lipoprotein-cholesterol, lipid ratios, and AIP were compared between the two groups. The correlation of TSH and AIP in SH was studied. Spearman's correlation, Mann-Whitney U-test and logistic regression analysis were performed. Results: Triglyceride, triglyceride/HDL-C, and AIP were significantly higher in SH as compared to euthyroid group, but there was no correlation between TSH and AIP in SH. AIP emerged as the significant single factor associated with SH in multiple logistic regressions. Conclusion: The positive association of dyslipidemia and SH indicates a need for regular screening of these patients to enable early diagnosis and treatment of dyslipidemia. Even in patients who have a normal conventional lipid profile, lipid ratios, and AIP have to be calculated for better assessment of atherogenic risk.
  1,406 310 3
The clinical and microbiological profile of the diabetic hand: A retrospective study from South India
Sreekanth Raveendran, Dukhabandhu Naik, Samuel C Raj Pallapati, John Jude Prakash, Binu Prathap Thomas, Nihal Thomas
September-October 2016, 20(5):619-624
DOI:10.4103/2230-8210.190539  PMID:27730070
Background: Pyogenic Infections of the hand in diabetes are largely a tropical entity and published material in the area are rather meagre. Patients and Methods: This is a retrospective study on the pattern of hand infections and involves the microbiological profile of 39 cases of diabetes hand-related infections admitted to the hospital between the years 2004 and 2010. Results: This study included 39 patients, among whom 23 (59%) had necrotizing fasciitis (NF), and 16 (9-abscess and 7-tenosynovitis) had nonnecrotizing infection. Among 25 culture positive patients, polymicrobial infections were isolated in 13 (52%) patients, a single organism was isolated in 9 (36%) and 3 (12%) had sterile cultures. Out of the 41 different bacterial isolates, 51.12% were Gram-negative and 48.78% were Gram-positive. Patients with NF had a higher mean glycated hemoglobin (10.83 ± 2.59 vs. 8.64 ± 1.8%, P = 0.020), when compared to the nonnecrotizing group. Patients with NF also had more polymicrobial infections (P = 0.017), and a longer duration of hospitalization when compared to patients without NF (21.8 ± 9.96 vs. 12.7 ± 14.5 days, P = 0.021). Seven (17.94%) patients required amputation of the affected digits of which six (15.38%) had NF. Conclusion: Patients with poor glycemic control, polymicrobial infection, delay in presentation, and a prior surgical intervention at another medical center was associated with more severe necrotizing infections. The duration of hospitalization and amputation rates was greater among patients with NF.
  1,415 274 3
Carotid intimo-medial thickness: A predictor for cardiovascular disorder in patients with polycystic ovarian syndrome in the South Indian population
Neeraj Garg, Mala Dharmalingam, Vinay Prabhu, NS Murthy
September-October 2016, 20(5):662-666
DOI:10.4103/2230-8210.190552  PMID:27730077
Background: Polycystic ovary syndrome (PCOS) is a common endocrine problem, which is now recognized as not only a reproductive but also a metabolic disorder with long-term effects on women's health, it has a prevalence of 5-10% in India. Among PCOS, it has been reported to have a higher incidence of cardiovascular disorders. Epidemiological studies have demonstrated an association between an increase in the carotid intimo-medial wall thickness (CIMT) and cardiovascular dysfunction. The objective of this study was to compare the CIMT of PCOS with normal women. Materials and Methods: The cross-sectional case-control study was conducted in a tertiary care Hospital in South India. Fifty-four subjects with polycystic ovarian disease and 54 healthy women were enrolled into the study. PCOS was diagnosed by Rotterdam criteria, 2003. Both groups of women were investigated with CIMT and cardiovascular dysfunction. Results: The mean age of women with PCOS and controls were 24.4 ± 5.3 and 27.7 ± 6.0, respectively, whereas body mass index was significantly higher in PCOS than controls group. Mean carotid IMT was significantly higher in PCOS subjects (0.51 ± 0.078) than control subjects (0.44 ± 0.06). Conclusion: Higher CIMT values were observed in PCOS group compared to control group indicating the importance for measuring CIMT in women with PCOS to predict the risk of cardiovascular dysfunction (CVD).
  1,429 224 1
Clinical and laboratory profile of primary hyperparathyroidism in Kashmir Valley: A single-center experience
Raiz Ahmad Misgar, Parvez Mohiuddin Dar, Shariq Rashid Masoodi, Munir Ahmad, Khursheed Alam Wani, Arshad Iqbal Wani, Mir Iftikhar Bashir
September-October 2016, 20(5):696-701
DOI:10.4103/2230-8210.190560  PMID:27730083
Background: Although primary hyperparathyroidism (PHPT) has become an asymptomatic disease in the West, in India, PHPT is still an uncommonly diagnosed, overtly symptomatic disease with skeletal, muscular, and renal manifestations. Aims: To describe the profile and surgical outcome of 78 consecutive PHPT patients over a period of two decades at a single center. Materials and Methods: All patients who underwent evaluation and surgery for PHPT from January 1996 to December 2015 were included. Evaluation included measurement of serum total calcium, inorganic phosphorus, alkaline phosphatase, intact parathyroid hormone, 25-hydroxy Vitamin D, 24 hour urinary calcium and radiological survey. Ultrasonography neck and technetium-99m sestamibi scan were used for preoperative localization. Results: A total of 78 patients were identified during the two decades of whom 29 patients were studied retrospectively and 49 patients prospectively. Mean age of patients was 44.72 ± 12.46, and male:female ratio was 1:6. The most common presenting features were nephrolithiasis and/or nephrocalcinosis (64.10%), bone pain (44.1%), abdominal pain (39%), constipation (26%), and myopathy (14.10%). Fractures were present only in 10.25%, and brown tumors in 6.41% patients. The cure rate in our series was 96.15%. The mean parathyroid gland weight was 2.05 ± 3.03 g. None of the 41 patients in whom long-term follow-up was available, had recurrence of PHPT. Conclusions: The profile of PHPT is changing with older age at presentation, and emergence of renal stone disease and decline in overt skeletal disease as common presentation. The parathyroid weight in our study resembles that reported from developed countries.
  1,365 241 2
Metabolic profile of normal glucose-tolerant subjects with elevated 1-h plasma glucose values
Thyparambil Aravindakshan Pramodkumar, Miranda Priya, Saravanan Jebarani, Ranjit Mohan Anjana, Viswanathan Mohan, Rajendra Pradeepa
September-October 2016, 20(5):612-618
DOI:10.4103/2230-8210.190532  PMID:27730069
Aim: The aim of this study was to compare the metabolic profiles of subjects with normal glucose tolerance (NGT) with and without elevated 1-h postglucose (1HrPG) values during an oral glucose tolerance test (OGTT). Methodology: The study group comprised 996 subjects without known diabetes seen at tertiary diabetes center between 2010 and 2014. NGT was defined as fasting plasma glucose <100 mg/dl (5.5 mmol/L) and 2-h plasma glucose <140 mg/dl (7.8 mmol/L) after an 82.5 g oral glucose (equivalent to 75 g of anhydrous glucose) OGTT. Anthropometric measurements and biochemical investigations were done using standardized methods. The prevalence rate of generalized and central obesity, hypertension, dyslipidemia, and metabolic syndrome (MS) was determined among the NGT subjects stratified based on their 1HrPG values as <143 mg/dl, ≥143-<155 mg/dl, and ≥155 mg/dl, after adjusting for age, sex, body mass index (BMI), waist circumference, alcohol consumption, smoking, and family history of diabetes. Results: The mean age of the 996 NGT subjects was 48 ± 12 years and 53.5% were male. The mean glycated hemoglobin for subjects with 1HrPG <143 mg/dl was 5.5%, for those with 1HrPG ≥143-<155 mg/dl, 5.6% and for those with 1HrPG ≥155 mg/dl, 5.7%. NGT subjects with 1HrPG ≥143-<155 mg/dl and ≥155 mg/dl had significantly higher BMI, waist circumference, systolic and diastolic blood pressure, triglyceride, total cholesterol/high-density lipoprotein (HDL) ratio, triglyceride/HDL ratio, leukocyte count, and gamma glutamyl aminotransferase (P < 0.05) compared to subjects with 1HrPG <143 mg/dl. The odds ratio for MS for subjects with 1HrPG ≥143 mg/dl was 1.84 times higher compared to subjects with 1HrPG <143 mg/dl taken as the reference. Conclusion: NGT subjects with elevated 1HrPG values have a worse metabolic profile than those with normal 1HrPG during an OGTT.
  1,237 345 3
Epileptogenicity of diabetes and antiepileptogenicity of ketogenic states: Clarity or confusion?
Sanjay Kalra, AG Unnikrishnan, Yashdeep Gupta
September-October 2016, 20(5):583-585
DOI:10.4103/2230-8210.190520  PMID:27730063
  1,248 284 2
The association between diabetes and tuberculosis may be the next challenge for global tuberculosis control worldwide
Anil Kumar Agarwal, Gupta Ginisha, Gupta Preeti, S Dwivedi, P Swamai
September-October 2016, 20(5):732-733
DOI:10.4103/2230-8210.190565  PMID:27730090
  1,123 293 3
Characteristics of children and adolescents at onset of type 2 diabetes in a Tertiary Hospital in Bangladesh
Bedowra Zabeen, Jebun Nahar, Samin Tayyeb, Fauzia Mohsin, Nazmun Nahar, Kishwar Azad
September-October 2016, 20(5):638-642
DOI:10.4103/2230-8210.190544  PMID:27730073
Introduction: Recent data show that the prevalence of diabetes among children and adolescents is increasing in some ethnic groups. The worldwide epidemic of childhood obesity has been accompanied by an increase in the incidence of type 2 diabetes (T2D) in youth. Methods: The aim of this study was to describe the baseline characteristics of children and adolescents diagnosed ≤18 years who had features of T2D and presented at  Changing Diabetes in Children, Paediatric Diabetes Clinic at Bangladesh Institute of Research and Rehabilitation of Diabetes, Endocrine, and Metabolic Disorders. All patients who were newly diagnosed and came to the clinic from March 2011 to March 2015 were included. Results: Among 939 newly registered patients, 77 (8%) had a diagnosis of T2D. The age at diagnosis was 9-10 years in 11 patients (14%), 11-14 years in 46 (60%) and 15-17 years in other 20 patients (26%). Majority of the children had a positive family history of T2D (94%) and 58% were obese. Median fasting insulin (27.9 [17.3-99.3]) was high in 76% patients. Insulin was started initially along with metformin in 40 patients and could be stopped in six patients in 3 months. Conclusion: Our study reflects that T2D is emerging as a problem in children and adolescents in Bangladesh.
  1,174 234 1
Cardiac autonomic function and vascular profile in subclinical hypothyroidism: Increased beat-to-beat QT variability
Pramila Kalra, Vikram K Yeragani, KM Prasanna Kumar
September-October 2016, 20(5):605-611
DOI:10.4103/2230-8210.190527  PMID:27730068
Background: Patients with subclinical hypothyroidism (SH) may have higher incidence of coronary heart disease and autonomic dysfunction. Design of the Study: Prospective case control study. Aim and Objectives: To evaluate beat-to-beat QT variability and vascular stiffness in patients with SH compared to normal controls. Materials and Methods: We compared linear and nonlinear measures of cardiac repolarization liability using beat-to-beat QT intervals derived from the surface electrocardiogram during supine posture and vascular indices including pulse wave velocity and ankle-brachial index (ABI) during supine posture between female patients with SH and age- and sex-matched normal controls. Spectral analysis was done at very low frequency (LF) (0.003-0.04 Hz), Low frequency (LF) (0.04-0.15 Hz), and high frequency (HF) (0.15-0.4 Hz). The HF represents vagal regulation (parasympathetic) and LF represents both parasympathetic and sympathetic regulation. Results: We recruited 58 women with a mean age of 31.83 ± 8.9 years and 49 controls with mean age of 32.4 ± 9.9 years (P = NS). QT variability index (QTvi) was higher in cases compared to controls (P = 0.01). The ratio of LF/HF of R-R interval which is an index of sympathovagal tone was significantly more in cases compared to controls (P = 0.02). The difference in the left minus the right ABI was significant between cases and controls (P = 0.03). Conclusions: The cases had lower parasympathetic activity as compared to controls, and there was a predominance of sympathetic activity in cases. QTvi may be an important noninvasive tool in this group of patients to study the risk of cardiovascular mortality.
  1,141 253 1
Demographic and clinical characteristics of the children with aminoacidopathy in Isfahan Province, Central Iran in 2007-2015
Reza Najafi, Mahin Hashemipour, Omid Yaghini, Fatemeh Najafi, Amirsalar Rashidianfar
September-October 2016, 20(5):679-683
DOI:10.4103/2230-8210.190556  PMID:27730080
Context: Aminoacidopathies refer to defects in protein synthesis pathways which result in a range of biochemical disorders and clinical presentations. The enzyme defects in intermediate metabolic pathways lead to accumulation of one or more amino acids or metabolites. Despite higher prevalence rates, screening infants for inherited metabolic disorders is not run in many Middle East countries. Aim: This research is part of a larger study of inherited metabolic disorders to characterize and measure the prevalence of aminoacidopathies. Settings and Design: Cross-sectional study in the population aged 0-17 years old in Isfahan province of Iran, 2007-2015. Subjects and Methods: Demographic characteristics, history of disease, development of clinical condition and socioeconomic status were obtained from interviews as well as patient records of pediatric tertiary referral hospitals and metabolic disorders centers. Statistical Analysis Used: SPSS qualitative and quantitative analysis. Results: The incidence rate of aminoacidopathies was derived to be 9/100,000 live births. The frequency of consanguineous marriages in this group of the patients was 89.2%. Of the patients with aminoacidopathies, 76.6% required hospitalization with tyrosinemia having the highest rate overall (>10 times). The most prevalent symptoms in this group of patients were developmental disorders and convulsions while half presented with growth disorders during follow-up. Of the 35.5% patients, who died at various ages, one-third was in the maple syrup urine disease subgroup. Conclusion: Although metabolic disorders are identified as rare diseases, they are more prevalent in the studied population of Isfahan.
  1,111 180 -
Impact of preoperative imaging on surgical approach for primary hyperparathyroidism: Data from single institution in India
Parjeet Kaur, Raghav Gattani, Alka Ashmita Singhal, Deepak Sarin, Sowrabh Kumar Arora, Ambrish Mithal
September-October 2016, 20(5):625-630
DOI:10.4103/2230-8210.190540  PMID:27730071
Context: Preoperative localization of parathyroid adenoma is essential in deciding the surgical approach of parathyroidectomy. Aim: To describe clinical and biochemical profile, evaluate preoperative imaging modalities and surgical approach in patients with primary hyperparathyroidism (PHPT). Methodology: This was a retrospective study conducted at the single institution. All patients who underwent evaluation and surgery for PHPT from 2011 to 2015 were included in the study. Results: A total of 100 patients underwent surgery for PHPT. Mean (standard deviation) age was 51.6 (15.9) years with female to male ratio of 1.7:1. Forty patients had severe symptoms, and sixty had mild to moderate symptoms. The sensitivity of technetium-99m hexakis (2-methoxyisobutylisonitrile) (MIBI) scan and ultrasonography (USG) neck in identifying abnormal parathyroid gland was 93% (93/100) and 98% (98/100), respectively. The MIBI scan results of 90/93 (96.7%) patients corresponded with their surgical findings whereas preoperative USG findings of 96/98 patients (98%) showed correlation with operative findings. Intraoperative intact parathyroid hormone (IOPTH) levels at 10 min postexcision were measured in forty patients (minimally invasive parathyroidectomy = 38, bilateral neck exploration = 1, and unilateral neck exploration = 1). All patients except two had <50% fall in IOPTH. Adenoma weight was positively correlated with preoperative intact PTH. Conclusion: We found that USG has higher sensitivity (98%) than MIBI scan (93%) in localizing abnormal parathyroid gland. Moreover, USG had a higher preoperative localization accuracy (93%) than MIBI scan (90%), allowing to choose an appropriate surgical approach. A higher proportion of patients (60%) had mild/asymptomatic form of PHPT.
  1,052 237 5
Relationship of levels of Vitamin D with flow-mediated dilatation of brachial artery in patients of myocardial infarction and healthy control: A case-control study
Sarthak Malik, Subhash Giri, SV Madhu, Vinita Rathi, BD Banerjee, Nikhil Gupta
September-October 2016, 20(5):684-689
DOI:10.4103/2230-8210.190558  PMID:27730081
Background: Cardiovascular diseases (CVD) remain the leading cause of death worldwide. Vitamin D deficiency has been linked to increased risk of adverse CV events. Vitamin D deficiency may be responsible for endothelial dysfunction which in turn affects the onset and progression of coronary artery disease and its risk factors, directly or indirectly through various mechanisms. Materials and Methods: It was case-control study. A total of 50 cases of acute myocardial infarction (AMI) (aged 40-60 years), admitted to medicine emergency/CCU, were taken as per ACC/AHA 2007 guidelines. An equal number of age- and sex-matched controls were also taken. Risk factors of AMI, flow-mediated dilatation (FMD), and 25(OH)D levels were studied in all cases and controls. Correlation was also studied between FMD and 25(OH)D. Results: The mean values of FMD were 18.86 ± 5.39% and 10.35 ± 4.90% in controls and cases, respectively (P < 0.05). The endothelial dilatation after glyceryl trinitrate (GTN) was also studied and was found to be 26.175 ± 4.25% and 18.80 ± 5.72% in controls and cases, respectively (P < 0.05). The mean levels of 25(OH)D in controls and cases were 25.45 ± 12.17 and 14.53 ± 8.28 ng/ml, respectively. In this study, 56% of subjects were Vitamin D deficient, 25% were Vitamin D insufficient, and only 19% had Vitamin D in normal range. A positive correlation coefficient was found between FMD and 25(OH) Vitamin D levels (r = 0.841, P < 0.01). In this study, a positive correlation coefficient was also found between endothelial dilatation after GTN and 25(OH)D levels (r = 0.743, P < 0.01). Conclusion: In this study, it was found that FMD was markedly impaired in patients of AMI when compared to controls. It was also found that majority of the study population was Vitamin D deficient; however, the deficiency was more severe in patients of AMI. We also found out that FMD was positively correlated (r = 0.841) to the deficiency state of Vitamin D in all the study subjects.
  941 253 2
Aldose reductase (-106) C/T gene polymorphism and possibility of macrovascular complications in Egyptian type 2 diabetic patients
Azhar Mohamed Nomair, Mona Mohamed Kamal ElDeeb, Dalia Aly Maharem
September-October 2016, 20(5):648-655
DOI:10.4103/2230-8210.190549  PMID:27730075
Introduction: Over the past three decades, the number of people with diabetes mellitus (DM) has more than doubled globally, making it one of the most important public health challenges to all nations. Aldose reductase (AR) is a rate-limiting enzyme in the polyol pathway, which has been implicated in the pathogenesis of diabetic microvascular complications; however, the association of the AR gene with diabetic macrovascular complications has rarely been investigated. Aim: The study aimed to identify the possible association between C(-106) T polymorphism of the AR gene and diabetic macroangiopathy in a cohort of Egyptian patients with type 2 DM. Settings and Design: This study was conducted on 100 Egyptian subjects, the control group (n = 20) and the patient group (n = 80) with type 2 diabetes which were further subdivided into two subgroups with (n = 48) and without macroangiopathic complications (n = 32) as evidenced by carotid intima-media thickness, electrocardiography (ECG) ischemic changes, cerebrovascular insufficiency, and peripheral vascular insufficiency. Subjects and Methods: All studied subjects were subjected to detailed history taking, clinical examination, ECG, carotid ultrasonography, routine laboratory investigations, and molecular studies including the detection of AR C(-106) T gene polymorphisms using the polymerase chain reaction (PCR)/restriction fragment length polymorphism technique. Results: The genotype distribution and allele frequency of AR C(-106) T showed no statistical significance also the genotypes were not associated with any of the different studied parameters. Conclusions: The results suggest that the C(-106) T polymorphism in the AR gene is not involved in the pathogenesis of macroangiopathy in type 2 diabetes.
  958 185 1
Postpartum development of type 1 diabetes in Asian Indian women with gestational diabetes
Ranjit Unnikrishnan, Coimbatore Subramanian Shanthi Rani, Ranjit Mohan Anjana, Subash Chandrabose Uthra, Jaydeep Vidya, Ganesan Uma Sankari, Ulagamathesan Venkatesan, Saravanan Jeba Rani, Viswanathan Mohan
September-October 2016, 20(5):702-706
DOI:10.4103/2230-8210.190562  PMID:27730084
Aim: To study the postpartum conversion of gestational diabetes mellitus (GDM) to different types of diabetes among Asian Indian women. Materials and Methods: Using data from electronic medical records, 418 women with GDM seen at a tertiary diabetes care center for diabetes in Chennai in South India between 1991 and 2014 were evaluated for development of diabetes postpartum. Results: Of the 418 GDM women followed up postpartum, 388 progressed to diabetes. Of these 359 (92.5%) developed type 2 diabetes (T2DM) and 29 women (7.5%) developed type 1 diabetes (T1DM). The median time to development of T1DM was 2 years (interquartile range 2 [IQR]) while for T2DM it was 5 years (IQR 6). Women who developed T1DM had significantly lower mean body mass index (BMI) (20.4 ± 2.8 vs. 27.5 ± 4.4 kg/m 2 , P = 0.001), and higher fasting plasma glucose (222 ± 105 vs. 165 ± 62 mg/dl P = 0.008) and glycated hemoglobin levels (10.2 ± 2.7 vs. 8.5 ± 2.1% P < 0.001) compared to those who developed T2DM. Glutamic acid decarboxylase (GAD) autoantibodies were present in 24/29 (82.7%) of women who developed T1DM. Conclusion: A small but significant proportion of women with GDM progress to T1DM postpartum. Measurement of GAD antibodies in leaner women with more severe diabetes could help to identify women who are likely to develop T1DM and thus prevent their presentation with acute hyperglycemic emergencies after delivery.
  927 216 -
Pachydermoperiostosis: Incomplete form, mimicking acromegaly
SH Rahaman, D Kandasamy, VP Jyotsna
September-October 2016, 20(5):730-731
DOI:10.4103/2230-8210.190564  PMID:27730089
  773 172 2
Fasting intolerance and recurrent hypoglycemia: Ponder for Sheehan's
Hans Raj Pahadiya, Manoj Lakhotia, Ronak Gandhi, Rajpal S Yadav, Shiva Madan
September-October 2016, 20(5):739-740
DOI:10.4103/2230-8210.190593  PMID:27730095
  796 140 -
Recent trial on Vitamin D: Higher dose increases fall?
Adrija Hajra, Dhrubajyoti Bandyopadhyay
September-October 2016, 20(5):737-738
DOI:10.4103/2230-8210.190592  PMID:27730094
  648 163 -
Voluminous lateral lymph node metastasis from papillary thyroid microcarcinoma
Ibtissem Oueslati, Karima Khiari, Emna Elfeleh, Néjib Ben Abdallah
September-October 2016, 20(5):735-736
DOI:10.4103/2230-8210.190567  PMID:27730092
  665 140 -
Spontaneous ovarian hyperstimulation syndrome revealing a pituitary macroadenoma
Ibtissem Oueslati, Karima Khiari, Néjib Ben Abdallah
September-October 2016, 20(5):734-735
DOI:10.4103/2230-8210.190566  PMID:27730091
  636 157 1
PGI Endocrine training: Recollection from another Arjuna
Shriraam Mahadevan, Pavanasam Velayutham
September-October 2016, 20(5):737-737
DOI:10.4103/2230-8210.190591  PMID:27730093
  560 157 -