Osteoporosis in Indians

Osteoporosis is characterized by low bone mass with micro architectural deterioration of bone tissue leading to enhance bone fragility, thus increasing the susceptibility to fracture. Although exact numbers are not available, based on available data and clinical experience, on estimated 25 million Indians may be affected. Osteoporotic fractures in India occur commonly in both sexes, and may occur at a younger age than in the West. Recently published data have clearly demonstrated widespread vitamin D deficiency across India, at all ages and in both sexes, particularly in the urban areas. Poor sunlight exposure, skin pigmentation and a vitamin D-deficient diet are some obvious causes for this finding. Indians have low BMD as compared to the western Caucasians. This could be attributed to differences in skeletal size; however, the high prevalence of vitamin D deficiency is a major factor in the low BMD and poor bone health of Indians. Healthy lifestyle (diet, exercise and sunlight exposure) can have a major positive impact on the bone metabolism and bone health of Indians. These public health measures are recommended for the population at large as they are efficacious, safe and cost-effective. The peak bone mass of the population can be increased significantly by appropriate and timely intervention in children. Pharmacological interventions are expensive and should therefore be targeted to only those at high risk of fractures.

The assessment of osteoporosis risk factors in Iranian women compared with Indian women

BACKGROUND

Osteoporosis is an important public health problem in older adults. It is more common in postmenopausal women and not only gives rise to morbidity but also markedly diminishes the quality of life in this population. There is lack of information about the risk factor of osteoporosis in developing countries. In this study we aimed to assess the risk factors for osteoporosis in postmenopausal women from selected BMD centers of two developing Asian countries (Iran and India).

METHODS

This study is a multicenter interview-based study conducted in selected hospitals and health centers from urban areas in Iran and India. The case group included postmenopausal osteoporotic women who were identified as patients with bone density higher than 2.5 SD below average of young normal bone density (in L1-L4) spine region interest and/or total femoral region) by using DEXA method. The controls were chosen from postmenopausal women with normal bone density (in L1-L4 spine and total femoral regions using DEXA method) matching in age groups was strategy of choice.The sample sizes included from Iran a total of 363 subjects (178 osteoporotic and 185 normal) and from India a total of 354 subjects (203 osteoporotic and 151 normal).

RESULTS

The significant (p < 0.05) risk factors in present study population with their Odds Ratios (in parenthesis, respectively in Iran and India) were as follow:Lower education defined as less than class 12 or nil college (2.1) (2.7), duration of menopause greater than 5 years: (2.2) (1.4), Menarche age (after 14 years): (1.9) (1.6), Menopause age (before 45 years): (1.1) (2), Parity more than 3: (1.1) (1), Bone and joint problem (2.3) (2.2). Calcium supplementation (0.6) and HRT (0.4) were shown as protective factors and steroid therapy (3.3) was found as a risk factor in Iran. Calcium supplementation more than 1 year (0.3) was shown as a protective factor in India.Pure vegetarianism: (2.2) and Red meat consumption more than 4 times per week (1.4) was shown as a risk factor in Indian and Iranian subjects respectively. Regular consumption of Soya (0.3), almond (0.5), fish (0.5), fruits (0.4) and milk tea 4 cups per day and more (0.4) appeared to be significant protective factors in India. Regular consumption of cheese (0.5), milk (0.5), chicken (0.4), egg (0.6), fruit (0.4), tea 7 cups per day and more (0.3) were found to be significant protective factors in Iran. Exercises were shown as protective factor in Iran (0.4) and India (0.4). There were no significant differences in association of risk factors and osteoporosis between Iranian and Indian subjects.

CONCLUSION

Osteoporosis in Iranian and Indian subjects also appears to be associated with several known risk factors that well described in the literature. There were no significant differences in association of risk factors and osteoporosis between Iranian and Indian subjects. It was shown a protective role of certain nutritional dietary components and also exercises in both populations and can be exploited in preventive educational strategies on osteoporosis in these populations.

Does Paget's disease exist in India?: A series of 21 patients

OBJECTIVE

Paget's disease of bone has been described as a few case reports from India. The aim of the present study is to document the existence of Paget's disease (PD) in India.

MATERIAL AND METHODS

We describe demography, clinical manifestations, biochemical and radiological profile and the treatment outcome of 21 patients of PD.

RESULTS

Mean (+/-SD) age of these patients at presentation was 49.2 +/- 17.6 years and the male to female ratio was 2.5:1. Common clinical manifestations included backache, headache and bone pains. Others were fracture, joint pain, deafness, gait ataxia, visual impairment and difficulty in biting. Two patients presented with hydrocephalus and one had recurrent paraparesis. Fifteen (71.4%) patients had polyostotic and six (28.6%) had monoostotic Paget's disease. More commonly involved bones were skull and spine (61.9%) followed by pelvis (38.1%), femur (33.3%), tibia (9%) and ulna (9%). Mean (+/-SD) serum alkaline phosphatase at diagnosis was 1514 +/- 1168 IU/L and nine months after treatment with bisphosphonates decreased to 454 +/- 406 IU/ L(P<0.03).

CONCLUSION

This illustrates that Paget's disease does exist in India and a high index of suspicion is required to clinch the diagnosis.

Correlates of Type 2 diabetes mellitus in children, adolescents and young adults in north India: a multisite collaborative case-control study

AIMS

In this study we describe the clinical, anthropometric and biochemical characteristics of patients with early onset Type 2 diabetes mellitus (T2DM) (< 30 years of age) and compare them with healthy, non-diabetic individuals.

METHODS

In this multisite collaborative study, 51 patients with T2DM (40 male, 11 female) and 69 non-diabetic individuals of similar age and gender distribution (controls) as the cases (46 male and 23 female) were investigated. The following parameters were measured; anthropometry [body mass index (BMI), waist circumference, waist-hip ratio (WHR) and skin-fold thickness at four sites], percentage body fat (%BF) and lipid profile.

RESULTS

The mean (SD) age of diagnosis of T2DM was 21.4 (6.1) years. A significantly higher number of cases had a history of T2DM in first-degree relatives as compared with controls (82.3 vs. 23.2%, P < 0.001). The mean values and the prevalence of abnormal values of measures of generalized obesity (BMI and %BF) and abdominal obesity (waist circumference and WHR) were significantly higher in cases as compared with controls. Hypertriglyceridaemia [OR (95% CI): 4.6 (1.1-20.0)], high WHR [7.9 (2.5-24.4)] and family history of T2DM [7.3 (2.3-23.0)] were independently associated with T2DM. Age and gender adjusted odds ratios of T2DM were 23.3 (5.2-103.6), 37.7 (9.0-158.5) and 86.4 (17.0-438.5), respectively, with the following set of risk factors; hypertriglyceridaemia and high WHR, hypertriglyceridaemia and family history of T2DM, and high WHR and family history of T2DM. Finally, the presence of all three risk factors increased the odds of T2DM to 112.1 (10.8-1164.7).

CONCLUSIONS

Early identification of the simple clinical, anthropometric and biochemical parameters which are strongly associated with early onset T2DM in young Asian Indians may be useful for primary prevention.

Changes in bone mineral density following treatment of osteomalacia

Osteomalacia is characterized by defective mineralization and low bone mineral density (BMD). Clinical and biochemical improvements typically occur within a few weeks of starting treatment, though the bone mineral deficits may take longer to correct. We report a case series of 26 patients with frank osteomalacia (pseudo fractures on X-rays, elevated serum total alkaline phosphatase and parathyroid hormone, normal/low serum calcium and phosphorus, and low serum 25-hydroxy vitamin D) who were followed-up for changes in BMD during treatment using dual- energy X-ray absorptiometry (DXA). There were 23 patients with nutritional vitamin D deficiency, 2 with malabsorption syndrome, and 1 with renal tubular acidosis. All patients were treated with vitamin D and calcium; the 3 patients with associated disorders were treated accordingly. At baseline, there was low BMD at all sites tested. The rate of increase in vertebral and hip BMD was rapid in the initial few months, which subsequently slowed down. In contrast to the large increases in BMD at the femoral neck and lumbar spine, the radial BMD did not recover. At the time when most patients had marked clinical and biochemical improvement (2.8+/-1.4 mo), the vertebral and hip BMD, although improved from baseline, had not completely recovered. Bone loss at the forearm (cortical site) appears to be largely irreversible. Although the clinical correlates of these changes are presently unclear, BMD measurements are useful in assessing the initial severity of bone loss as well as the response to therapy.

Vitamin D status and its relationship with bone mineral density in healthy Asian Indians

Synthesis of vitamin D takes place in the skin under the effect of sunlight. The Indian subcontinent is situated between 8.4 degrees N and 37.6 degrees N latitudes and has adequate sunshine throughout the year. Thus, it has been presumed that Indians are vitamin D sufficient. We measured serum 25-hydroxy vitamin D [25(OH)D] ( n=92) and 1,25-dihydroxy vitamin D [1, 25(OH)(2)D] ( n=65) levels in healthy hospital staff, using (125)I radioimmunoassay. Serum intact parathyroid hormone (PTH) concentration was estimated by immunoradiometric assay. Bone mineral density was estimated using a dual energy X-ray absorptiometer (Hologic QDR 4500A). Using a serum 25(OH)D level of 15 ng/ml as a cutoff, 66.3% (61/92) of the subjects were found to be vitamin D deficient. Of these, 20.6% (19/92) subjects had severe vitamin D deficiency (<5 ng/ml), 27.2% (25/92) had moderate vitamin D deficiency (5-9.9 ng/ml), while 18.5% (17/92) had mild vitamin D deficiency (10-14.9 ng/ml). When a serum 25(OH)D level of 20 ng/ml was used as a cutoff, 78.3% subjects were diagnosed to be vitamin D deficient/insufficient. The serum 1,25(OH)(2)D level was within the normal range (40.6+/-20.1 pg/ml; mean +/- SD). Mean (+/-SD) serum intact PTH, estimated in a limited number of subjects (n=15), was 72.3 (+/-21.0) pg/ml (range 36-100 pg/ml). There was a significant correlation between daily sun exposure and 25(OH)D levels (r=0.731, P<0.001). The serum 25(OH)D level correlated with BMD at the femoral neck and Ward's triangle (r=0.50, P=0.020 and r=0.46, P=0.037, respectively). Our findings show that vitamin D deficiency is common in urban north Indian hospital staff. The possible reasons include inadequate sunlight exposure and skin pigmentation in Indians. The serum 1,25(OH)(2)D level is not a good indicator of vitamin D deficiency. A low serum 25(OH)D level is possibly one of the reasons for lower bone mineral density among Indians.

Primary hyperparathyroidism in India

Background

Primary hyperparathyroidism (PHPT) in Indians has some unique clinical features, such as early age of onset, extreme osteopenia, crippling bone involvement, large parathyroid tumours, higher proportion of malignancy and severe, prolonged postparathyroidectomy hungry bone syndrome. The current study aimed to study (1) whether these features of PHPT in Indians are due to a variant form of PHPT and (2) pathogenetic factors of such variant disease.

Methods

Clinical, investigative and pathological features of 29 consecutive patients with PHPT (24 females, five males) who underwent parathyroidectomy at 13–60 (mean 38) years of age were reviewed. Spearman's correlation coefficient was calculated between serum calcidiol levels and biochemical variables, bone mineral density (BMD) before surgery and parathyroid tumour weight.

Results

Median duration of symptoms was 2·5 (range 1–26) years. Mean total serum calcium, iPTH and ALP levels were 12·4 mg dl−1 (normal 8·5–10·8 mg dl−1), 955 pg ml−1 (normal 9–55 pg ml−1) and 850 units l−1 (normal 35–125 units l−1) respectively, while mean(s.d.) serum calcidiol and calcitriol concentrations were 14(6) ng ml−1 and 52(29) pg ml−1 (versus 9(9) and 30(14) pg ml−1 in matched controls). All patients had symptomatic osteitis fibrosa cystica and eight were bedridden. Single or multiple spontaneous fractures occurred in 14 patients, brown tumours in 20, and long bones were barely visible on plain films in four. BMD z-scores at distal radius and lumbar spine (mean) were −4·2 and −3·8. Palpable parathyroid tumours occurred in 14 patients and nine had renal damage, mainly nephrocalcinosis. Parathyroidectomy invariably resulted in long-standing severe hypocalcaemia, necessitating intravenous calcium infusion for 6 days on average, and long-term oral calcium and vitamin D supplementation. The mean parathyroid gland weight was 8·6 (range 2–36·6) g and signs of carcinoma were found in four. There was a negative correlation (P &lt; 0·05) between serum calcidiol and serum iPTH, and serum ALP and parathyroid gland weight.

Conclusion

PHPT in Indians manifests as severe, symptomatic musculoskeletal and renal disease. In spite of the severe hyperparathyroidism, the serum calcium levels are only moderately raised. These patients have signs of rapid parathyroid tumour growth resulting in large adenomas and a high proportion of parathyroid carcinomas. The signs of rapid cell proliferation, excessive calcium insensitivity of PTH release and peripheral PTH resistance may clarify roles of widely prevalent vitamin D deficiency in pathogenesis of this variant of PHPT.

Unique clinical characteristics of primary hyperparathyroidism in India

Background

The features of primary hyperparathyroidism (PHPT) in developing countries have rarely been examined. This study explored the clinical characteristics of PHPT in India with the hypothesis that this may improve understanding of the pathogenesis of the disease worldwide.

Methods

Consecutive patients with PHPT (24 women, five men) were examined prospectively before and after parathyroidectomy.

Results

All patients had osteitis fibrosa cystica with a median symptom duration of 2·5 (range 1–26) years. Single or multiple fragility fractures were present in 14 patients (eight were bedridden); 20 had brown tumours. Mean preoperative serum calcium was 3·1 mmol/l, while mean serum intact parathyroid hormone (iPTH) and total alkaline phosphatase (ALP) levels were 17-fold and 12-fold higher than normal respectively. Nine patients had overt renal damage, mainly nephrocalcinosis. Parathyroidectomy invariably resulted in severe hypocalcaemia, necessitating long-term vitamin D treatment. The mean parathyroid gland weight was 8·6 (range 2·0–36·6) g and features of carcinoma were found in four patients. Serum calcidiol level correlated inversely (P &lt; 0·05) with serum iPTH and ALP, and parathyroid gland weight.

Conclusion

PHPT in Indians is a severe, symptomatic disorder with skeletal, muscular and renal manifestations at a young age. The presence of this severe variant of PHPT in vitamin D-sufficient Indians, and the lack of skeletal disease in other vitamin D-deficient populations, raises the possibility of additional pathogenetic factors.

Recovery pattern of patients with osteitis fibrosa cystica in primary hyperparathyroidism after successful parathyroidectomy

BACKGROUND

After parathyroidectomy, recovery of osteitis fibrosa cystica, which continues to dominate presentation of primary hyperparathyroidism in India has not been documented objectively.

METHODS

We followed up clinical recovery, biochemic markers of bone turnover, bone mineral density, and skeletal radiology in 51 patients with primary hyperparathyroidism and osteitis fibrosa cystica for 9 to 124 months (median, 32 months).

RESULTS

After parathyroidectomy, 46 patients had hypocalcemia. During postoperative week 1, bone pain improved in 71%. During 3 months, appendicular fractures healed in all 33 such patients, and 6 of 7 patients who were bedridden could walk. Mean bone mineral density increments (percent change/y) seen at various sites at 1 week, 3, 6, and 12 months were distal forearm--37, 28, 23, 21; lumbar spine--165, 104, 101, 106; and total hip--168, 157, 166, 133. Follow-up radiographs demonstrated prompt recovery though disorderly remineralization. Brown tumors and fractures showed hyperdensities within 3 months. Brown tumors regressed partially in 6 of 27 patients after 6 months.

CONCLUSIONS

After parathyroidectomy, patients with primary hyperparathyroidism have early, marked, and sustained recovery of osteitis fibrosa cystica. Early (1 week) bone mineral density increments of > 100%/y hint at the skeleton's ability to promptly restore itself. Densitometric recovery is prompt at cancellous (lumbar spine), but not at cortical (forearm) bone sites. Contour defects and bony tumors persist, and may need corrective osteotomies.

Role of vitamin D and calcium nutrition in disease expression and parathyroid tumor growth in primary hyperparathyroidism: a global perspective

Since the classic description by Fuller Albright in the 1940s, primary hyperparathyroidism has evolved from a disease with classic signs and symptoms to a disease in search of symptoms! Since that time, two major events have occurred. First, in the United States, United Kingdom, and in most European countries, there has been a steady rise in the apparent incidence of the disease. Second, there has been a dramatic shift in the pattern of presentation. A majority of patients with primary hyperparathyroidism in countries with multichannel screening panels are asymptomatic. Skeletal and renal complications are uncommon, and osteitis fibrosa is rare. In contrast, the clinical presentation of primary hyperparathyroidism has changed very little in other regions such as the East, the Middle East, and some parts of the southern hemisphere over the same period of observation. Accordingly, we assessed the influence of vitamin D and calcium nutrition on the disease expression and parathyroid tumor growth in patients with primary hyperparathyroidism from different parts of the world. Between 1945 and 1950, both the prevalence of osteitis fibrosa and parathyroid tumor weight declined dramatically in the United States, coinciding with fortification of milk with vitamin D. In contrast, osteitis fibrosa and parathyroid tumor weight changed very little in parts of the world where vitamin D depletion is endemic. Furthermore, for a comparable degree of vitamin D depletion, Asian Indians have significantly larger tumors compared with Americans (3.95 +/- 2.23 vs. 0.66 +/- 2.84 g; p < 0.001). Within the United States, blacks have larger tumors compared with whites (0.78 +/- 2.87 vs. 0.58 +/- 2.78 g; p < 0.01). However, the slopes of regression between serum 25-hydroxyvitamin D, the best index of vitamin D nutrition, and parathyroid tumor weight, the best available index of parathyroid growth, were not significantly different between Asian Indians, whites, and blacks. We conclude that vitamin D and calcium nutrition of the population affect both the clinical expression and parathyroid tumor growth in patients with primary hyperparathyroidism. It will be of interest to see if the pattern of presentation of primary hyperparathyroidism changes when better nutritional policies are implemented in developing countries.

Parathyroid carcinoma

INTRODUCTION

Parathyroid carcinoma is a rare tumor with an incidence of 0.5 to 4%. Preoperative differentiation from benign adenoma is very difficult. Several features, though nonspecific, have been used in differentiating parathyroid carcinoma from the adenoma.

MATERIAL AND METHOD

A retrospective analysis during the period of nine years, four cases of parathyroid carcinoma were diagnosed on the basis of per-operative local invasion and on histological evidence of capsular invasion and vascular invasion.

RESULT

We have different observations to make. Diagnosis of parathyroid carcinoma which was done on the basis of intra operative suspicion only. One patient died on 6th post operative day due to development of pancreatitis. At the follow-up of two years there was no local recurrence or distant metastasis.

CONCLUSION

It is preferable to have a high index of suspicion for parathyroid carcinoma when these features are present than to miss the opportunity for surgical cure by failing to consider it in the differential diagnosis.

Juvenile rheumatoid arthritis with amyloid goiter: report of a case with review of the literature

Clinically significant enlargement of the thyroid owing to amyloid deposition is a rare occurrence. A 23-yr-old female, a case of juvenile rheumatoid arthritis, developed rapidly increasing thyromegaly during the course of her illness with complaints of dyspnea and dysphagia. Thyroid function tests were within normal limits. Fine-needle aspiration cytology proved inconclusive. Total thyroidectomy was done for symptomatic relief with a preoperative clinical impression of malignancy. Histopathologic findings were consistent with amyloid goiter. The findings of this case are presented, to emphasize the difficulties in making a definite preoperative diagnosis, along with a brief review of the literature.

Pseudovitamin D deficiency rickets--a report from the Indian subcontinent

Pseudovitamin D deficiency rickets (also called vitamin D dependent rickets type I) is one of the types of inherited rickets and is caused by a deficit in renal 25-hydroxyvitamin D 1alpha-hydroxylase. This form of rickets has not been reported from the Indian subcontinent. Three patients with this disorder are presented. These patients were all females aged 3-20 years and presented with growth failure and skeletal deformities. All had florid clinical and radiological rickets. The biochemical abnormalities seen included hypocalcaemia, hypophosphataemia, and hyperphosphatasia. All patients had grossly raised 25-hydroxyvitamin D concentrations and markedly low to undetectable concentrations of 1,25-dihydroxyvitamin D. A disturbing feature of this study was the late referral of the patients.

Calcitropic hormonal status in north Indian patients with end-stage renal disease

BACKGROUND

Bone disease in chronic renal failure has a wide spectrum that includes both high and low turnover conditions. Specific preventive and therapeutic measures require knowledge of the nature of bone involvement. Bone biopsy with static and dynamic histomorphometry is the gold standard for characterization of renal bone disease. However, non-invasive biochemical tests, especially serum intact parathyroid hormone (PTH), have a good correlation with histomorphometry. We studied the clinical and biochemical profile of bone disease in a sample of north Indian patients with chronic renal failure.

METHODS

Twenty-nine patients of chronic renal failure were evaluated clinically, radiologically (subperiosteal erosions on hand X-rays) and biochemically (serum calcium, phosphorus, total alkaline phosphatase, intact PTH, osteocalcin, 25-hydroxyvitamin D, 1,25-dihydroxyvitamin D). Bone histomorphometry could be done in 4 patients.

RESULTS

Serum intact PTH within or below the non-uraemic normal range, an index of low bone turnover, was seen in 17 (58.6%) patients. Serum osteocalcin, a bone formation marker, was within or below the non-uraemic normal range in 65.5% patients. Serum intact PTH and osteocalcin had a significant positive correlation (r = 0.6). Patient groups with clinical or radiological evidence of bone disease had serum intact PTH and osteocalcin levels comparable to those lacking such features. Serum intact PTH and total alkaline phosphatase were lower in haemodialysed (n = 25) patients than in those who had not received haemodialysis (n = 4). Low (< 10 ng/ml) serum 25-hydroxyvitamin D levels were seen in 7 (24%) patients while 1,25-dihydroxyvitamin D was low (< 15.9 pg/ml) in 20 (69%) patients. The biochemical parameters accurately reflected the bone histology (n = 4).

CONCLUSIONS

Our data show that the majority of north Indian patients with chronic renal failure have biochemical evidence of low bone turnover. Empirical use of calcium salts and active vitamin D analogues without documentation of parathyroid status carry the risk of further suppression of bone turnover.

Hereditary hypophosphataemic rickets: report of a family from the Indian subcontinent

Nutritional deficiency continues to be an important cause of rickets in the underdeveloped and developing parts of the world. In the western hemisphere, predominantly non-nutritional forms of rickets and osteomalacia are now seen. In this report we discuss a family with X-linked hypophosphataemic rickets from the Kashmir region of the Indian subcontinent (which is an uncommon entity here).

Correlation of cell counts and indices in testicular FNAC with histology in male infertility

OBJECTIVE

To evaluate the value of percentage cell counts and cell indices in testicular fine needle aspiration cytology (FNAC) in male infertility and their correlation with histologic categories as seen in open testicular biopsies.

STUDY DESIGN

Differential cell counts were performed, and cell indices, including spermatic index, Sertoli cell index and sperm-Sertoli cell index, were calculated in testicular fine needle aspiration (FNA) smears in 30 azoospermic males whose open testicular biopsies were classified as normal spermatogenesis in 10 cases, maturation arrest in 5, hypospermatogenesis in 6, Sertoli cell only syndrome in 5 and tubular/peritubular sclerosis in 4.

RESULTS

In normal spermatogenesis, FNA smears showed up to 40% Sertoli cells, and spermatozoa were the predominant spermatogenetic cell type. There was a progressive increase in Sertoli cell percentage and Sertoli cell index and reduction in spermatozon percentage, spermatic index and sperm-Sertoli cell index with increasing severity of reduction in spermatogenesis in different histologic categories. The differences between mean counts and indices in normal spermatogenesis and other histologic categories were statistically significant (P < .01).

CONCLUSION

The percent cell counts and cell indices in testicular FNAC correlate with histologic categories and are useful in evaluating male infertility.

Ectopic ACTH syndrome due to bronchial carcinoid tumour--a case report

A patient is reported who had Cushing's syndrome and carcinoid tumour of the bronchus. The case illustrates the difficulty in preoperative localization of the ectopic ACTH source and the surgical management of such patients.

Cloning and characterization of a calcium-sensing receptor from the hypercalcemic New Zealand white rabbit reveals unaltered responsiveness to extracellular calcium

The extracellular Ca2+ (Ca(0)2+)-sensing receptor (CaR) recently cloned from mammalian parathyroid, kidney, brain, and thyroid plays a central role in maintaining near constancy of Ca(0)2+. We previously showed that the hypercalcemia normally present in New Zealand white rabbits is associated with an elevated set point for Ca(02+)-regulated PTH release (the level of Ca(0)2+ half-maximally inhibiting hormonal secretion). This observation suggested an alteration in the Ca(02+)-sensing mechanism in the rabbit parathyroid, a possibility we have now pursued by isolating and characterizing the rabbit homolog of the CaR. The cloned rabbit kidney CaR (RabCaR) shares a high degree of overall homology (> 90% amino acid identity) with the bovine, human, and rat CaRs, although it differs slightly in several regions of the extracellular domain potentially involved in binding ligands. By Northern analysis and/or immunohistochemistry, a similar or identical receptor is also expressed in parathyroid, thyroid C cells, small and large intestine, and in the thick ascending limb and collecting ducts of the kidney. When expressed transiently in HEK293 cells and assayed functionally through CaR agonist-evoked increases in Ca(i)2+, the rabbit CaR shows apparent affinities for Ca(0)2+, Mg(0)2+, and Gd(0)3+ that are indistinguishable from those observed in studies carried out concomitantly using the human CaR. Therefore, at least as assessed by its ability to increase Ca(i)2+ when expressed in HEK293 cells, the intrinsic functional properties of the rabbit CaR cannot explain the hypercalcemia observed in vivo in the New Zealand white rabbit.

Pulse oximetry for the assessment of autonomic neuropathy in diabetic patients

Altered vascular responses to various thermal stimuli correlate well with the changes of autonomic neuropathy. These responses were assessed by the use of pulse oximetry. Standard cardiac autonomic function tests were performed in normal subjects (n = 12), diabetic patients without autonomic neuropathy (n = 8), and diabetic patients with autonomic neuropathy (n = 7). Autonomic functions in the same patients then were assessed by estimating the severity of vasospasm in response to cold stimulus with the help of pulse oximetry. Percentage fall in oxygen saturation at 15, 30, 60, 90, and 120 sec of exposure to cold stimulus was recorded on pulse oximeter. Time required for recovery and presence or absence of rebound rise following removal of cold stimulus were noted. In diabetics with autonomic neuropathy, the rate of fall in percentage oxygen saturation was significantly slower (p < 0.0001), less intense (p < 0.0001) and with delayed subsequent recovery (p = 0.013), compared to normal subjects. Rebound rise in oxygen saturation was absent in all the diabetics with autonomic neuropathy, compared to 2 of 12 normal subjects (p < 0.0001). We conclude that pulse oximetry may be a potentially useful, simple, and noninvasive bedside method for assessment of diabetic autonomic neuropathy.

Growth hormone-producing pituitary tumours: clinical profile and results of surgery

BACKGROUND

Growth hormone-producing pituitary tumours present with a wide variety of manifestations. The optimum diagnostic work up, management and follow up of such patients is complex and involves a multidisciplinary approach. There is paucity of data from India with regard to the clinical presentation and results of surgery for growth hormone-producing tumours.

METHODS

We studied the first 50 patients presenting during 1989-94 with growth hormone-producing pituitary tumours to our centre. The work up included detailed endocrine and radiological assessment. The surgical outcome was analysed for 35 patients who were operated (trans-sphenoidal 29, transcranial 6) at our centre.

RESULTS

All the patients had macroadenomas [mean (SD) diameter 3.12 (0.87) cm]. Seventy-five per cent of the patients had supra- and/or parasellar extension and 57% had visual field defects. Tumour size correlated with the preoperative basal (r = 0.57) and glucose-suppressed (r = 0.54) growth hormone levels. Thirty-three of the 35 patients operated at our centre (trans-sphenoidal 28, transcranial 5) were available for follow up (median duration 34 months). After trans-sphenoidal surgery alone, 12 of the 28 (43%) patients had normalization of growth hormone levels (post-glucose growth hormone < 5 ng/ml), and 9 of 11 (82%) showed improvement in visual fields.

CONCLUSION

In India, growth hormone-producing pituitary tumours are usually large in size. The growth hormone levels correlate with the size of the tumour. These tumours can be effectively treated by trans-sphenoidal or transcranial surgery.

The calcium-sensing receptor: a window into the physiology and pathophysiology of mineral ion metabolism

The recent cloning of a [Ca2+]o-sensing receptor from several different tissues in several species directly demonstrates that a variety of cells can directly recognize and respond to small changes in their ambient level of [Ca2+]o through a G protein-coupled, cell surface receptor. This finding directly documents that [Ca2+]o can act as an extracellular, first messenger in addition to subserving its better known role as an intracellular second messenger. Several of the tissues expressing the CaR are important elements in the calcium homeostatic system that have long been known to be capable of sensing [Ca2+]o, such as parathyroid and thyroidal C cells. The presence of the receptor in the kidney, however, provides strong evidence that several of the long-recognized but poorly understood direct actions of [Ca2+]o on renal function could be mediated by the CaR. These actions include the up-regulation of urinary calcium and magnesium excretion in the setting of hypercalcemia, which complements the indirect inhibition of renal tubular reabsorption of calcium that results from high [Ca2+]o-mediated inhibition for PTH secretion. The impaired renal concentrating capacity in hypercalcemia is likely a manifestation of a homeostatically important interaction between the regulation of renal calcium and water handling that reduces the risk of pathological deposition of calcium in the kidney when there is a need to dispose of excess, calcium in the urine. In this regard, the availability of human syndromes of [Ca2+]o "resistance" or "overresponsiveness" due to loss-of-function or gain-of-function mutations in the CaR, respectively, have provided useful experiments in nature that have clarified the importance of the receptor in both abnormal and normal physiology. Much remains to be learned, however, about the role of the CaR in locations, such as the brain, where it likely responds to local rather than systemic levels of [Ca2+]o. In such sites, it may represent an important modulator of neuronal function, responding to [Ca2+]o as a neuromodulator or even neurotransmitter. The development of therapeutics that either activate or inhibit the function of the CaR may be useful for treating a variety of conditions in which the receptor is either under- or overactive. Finally, it would not be surprising to discover additional receptors for [Ca2+]o or for other ions (the CaR may, in fact, be an important [Mg2+]o-sensor) that could function abnormally in certain disease states and be amenable to pharmacological manipulation with ion receptor-based therapeutics.

Learning disabilities and poor motivation to achieve due to prolonged iodine deficiency

The effect of prolonged iodine deficiency on learning and motivation was studied. One hundred male children--matched for age, socioeconomic status, and formal education--were selected from both severely iodine-deficient (SID) and mildly iodine-deficient (MID) villages. Mean urinary iodine excretion was significantly lower in the SID than in the MID group (219.84 +/- 57.52 compared with 449.14 +/- 32.31 nmol/L, P < 0.001). The serum thyroxine concentration was significantly lower (90.36 +/- 6.46 compared with 123.70 +/- 15.42 nmol/L, P< 0.001) and serum thyroid-stimulating hormone (TSH) was significantly higher in the SID group than in the MID group (6.23 +/- 0.34 compared with 4.85 +/- 0.28 mU/L, P< 0.01). The children were administered maze, verbal, and pictorial learning tasks and a test of motivation. The results showed that SID children are slow learners compared with MID children. In both groups the rate of learning over trials was superior in younger (aged 9-12 y) children although the initial performance of older (aged 12-15 y) children was better (P < 0.01). SID children scored significantly lower than MID children on the achievement motivation scale (P < 0.01). The results are suggestive of neural impairment as well as poor sociopsychologic stimulation, resulting in learning disability and lowered achievement motivation. Unless iodine nutrition is improved in the community as a whole, these abnormalities may prevent millions of children from the SID areas from achieving their full potential even if learning opportunities are made available to them.

Calcitonin-secreting cells of the thyroid express an extracellular calcium receptor gene

Calcitonin (CT) secretion by parafollicular cells of the thyroid (C cells) is regulated by small changes in the concentration of extracellular calcium ([Ca2+]e). Elevation of [Ca2+]e elicits a rise in the C cell cytoplasmic calcium concentration and stimulates CT release. The molecular entity through which C cells detect changes in [Ca2+]e and modulate hormone secretion is unknown. Recently, an extracellular calcium-sensing receptor (CaR) complementary DNA was isolated from bovine parathyroid gland. To assess whether parathyroid cells and C cells use similar mechanisms to detect changes in ambient Ca2+, rat, human, and sheep C cells were examined for expression of the parathyroid CaR or a related receptor isoform. Reverse transcription-polymerase chain reaction analysis identified CaR transcripts in rat and human thyroid gland. Northern blot analysis demonstrated CaR messenger RNA (mRNA) in rat thyroid gland, a human medullary thyroid carcinoma (MTC) isolate, and a highly enriched preparation of sheep C cells. Rat MTC 44-2 cells, a cell line responsive to changes in [Ca2+]e, express abundant levels of CaR mRNA. Human TT cells, a C cell line lacking the extracellular calcium-sensing function, have undetectable levels of CaR mRNA by Northern blot analysis. Western blot analysis, using antiserum specific to the parathyroid CaR, detected CaR protein in rMTC 44-2, but not TT cells. Immunostaining of both dispersed sheep C cells and rat thyroid gland sections identified C cell-specific expression of the CaR protein, and in situ hybridization analysis confirmed the C cell-specific expression of CaR mRNA in the intact rat thyroid. The nucleotide sequence of the coding region of the rMTC 44-2 CaR transcripts was found to encode the same CaR protein as that expressed in the parathyroid and kidney. The results demonstrate that C cells express the same extracellular calcium-sensing receptor that is found in parathyroid and kidney, and the presence of this receptor protein in C cell lines correlates with the extracellular calcium-sensing function. This CaR is likely to represent the primary molecular entity through which C cells detect changes in [Ca2+]e and control CT release, suggesting that activation of the same receptor can either stimulate or inhibit hormone secretion in different cell types.

Expression of G protein alpha-subunits in bovine parathyroid

A G protein-coupled Ca(2+)-sensing receptor was recently cloned from bovine parathyroid and shown to mediate divalent cation regulation of PTH secretion. To define which G proteins might be coupled to the Ca(2+)-sensing receptor in parathyroid cells, we determined which G protein alpha-subunit messenger RNAs (mRNAs) are expressed in the parathyroid. We also considered the possibility that a novel parathyroid-specific G alpha might be present. We, therefore, used the reverse transcription-polymerase chain reaction to study the expression of G alpha subunits in a bovine parathyroid mRNA preparation. Degenerate primers, corresponding to two regions conserved in every G alpha subunit, the G3 and G4 sequences, were used to amplify G alpha complementary DNA fragments that were subcloned and sequenced. We found that mRNAs corresponding to G alpha s, G alpha i2, G alpha 11, G alpha 12, and G alpha z are the predominant G alpha mRNAs expressed in the bovine parathyroid. No novel G alpha mRNA was identified. Northern blots confirmed the expression of the cloned G alpha subunits and showed lower expression of G alpha o and G alpha i1 mRNAs. Immunoblots confirmed abundant expression of G alpha s, G alpha i2, and G alpha 11 and provided evidence for expression of G alpha i1 and G alpha i3, but not G alpha o. G alpha q mRNA was not identified by the degenerate primer reverse transcription-polymerase chain reaction strategy, but the immunoblot detected G alpha q protein, albeit at considerably lower levels than G alpha 11. The abundance of G alpha 11 relative to G alpha q in bovine parathyroid is consistent with but does not prove a role for G alpha 11 in coupling the Ca(2+)-sensing receptor to phospholipase C.

The reduced responsiveness of cultured bovine parathyroid cells to extracellular Ca2+ is associated with marked reduction in the expression of extracellular Ca(2+)-sensing receptor messenger ribonucleic acid and protein

PTH secretion from dispersed bovine parathyroid cells maintained in culture becomes progressively less responsive to changes in the extracellular Ca2+ concentration (Ca2+o) over several days. We have now investigated whether this change in secretory control is associated with alterations in the expression of the Ca2+o-sensing receptor (BoPCaR) recently cloned from bovine parathyroid, which plays a central role in Ca2+o-regulated PTH secretion. BoPCaR messenger RNA levels dropped rapidly in cultured bovine parathyroid cells, as assessed by Northern analysis, decreasing by 78% within 18 h and remaining low for at least 4 days. The level of receptor protein decreased to a comparable extent (approximately 72-82%) after 3-4 days in culture, as determined by immunocytochemistry with specific antibodies directed at the extracellular domain of the receptor. The half-time for the reduction in receptor protein (approximately 2 days) was considerably longer, however, than that for BoPCaR messenger RNA, but was comparable to that for the loss of sensitivity of PTH secretion to Ca2+o. Indeed, there was a close linear correlation between maximal suppressibility of PTH secretion and the intensity of staining for the receptor protein (r = 0.88; P = 0.004). We conclude that alterations in the expression of BoPCaR could explain much of the reduced responsiveness of cultured bovine parathyroid cells to Ca2+o.

Intraoperative hypertension during thyroidectomy for Graves' disease

Hyperthyroidism is well known to be associated with cardiovascular manifestations. The authors have noted that patients of well controlled Graves' Disease often pose problems due to intrapoperative cardiovascular instability. Retrospective analysis of 137 case records of patients with Graves' disease (n = 35), toxic nodular goitre (n = 42) and those with euthyroid benign goitre (n = 60) were studied. In Graves' disease cardiovascular instability was found in the form of hypertension (n = 9) associated with tachyarrhythmia (n = 8) and bradycardia (n = 3). The incidence of first 2 of the above mentioned 3 problems was significantly higher in Graves disease (n = 9/35 patients) in contrast to a comparable group of patients with toxic nodular in (3/42 patients; P value 0.05) and euthyroid goiter (2/60 patients; P value < 0.001). Certain parameters such as high T3, T4 at the time of presentation were associated with higher incidence of these complications, in spite of very well controlled thyrotoxicosis. Whether heightened receptor sensitivity to catecholamines and higher renin-angiotensin activation explain these findings in Graves' disease, remains to be ascertained.

Non-islet cell tumour induced hypoglycaemia with acromegaloid facial and acral swelling

The syndrome of non-islet cell tumour hypoglycaemia (NICTH) has been linked with the synthesis and secretion of 'big' IGF-II. We report a patient with a large pelvic clear cell sarcoma who developed recurrent severe hypoglycaemia and in addition presented with severe soft tissue facial swelling, skin tags and nuchal hyperpigmentation. After resection of the tumour serum 'big' IGF-II returned to normal and the acromegaloid skin changes remitted.

Extraovarian endocrine abnormalities in north Indian women with premature ovarian failure

BACKGROUND

Premature ovarian failure is a rare syndrome characterized by cessation of menstruation before 35 years of age associated with an elevated gonadotropin level (serum follicle stimulating hormone > 40 IU/L) and oestrogen deficiency. Premature ovarian failure is often the result of an autoimmune process and involvement of other endocrine glands has been reported but available studies are hampered by a lack of uniformity in diagnostic criteria.

METHODS

The endocrine profile of 37 north Indian women with premature ovarian failure was studied. The investigations included measurement of serum follicle stimulating hormone, luteinizing hormone, oestradiol, prolactin, total thyroxine, total triiodothyronine and thyroid stimulating hormone. To assess adrenocortical reserve, adrenocorticotropic hormone stimulated plasma cortisol levels were estimated.

RESULTS

Eighteen (49%) patients had extraovarian endocrine abnormalities. Eight (22%) had abnormal thyroid function tests and 12 of 29 (41%) patients tested for adrenocortical reserve showed impaired response of plasma cortisol to adrenocorticotropic hormone stimulation.

CONCLUSION

Extraovarian endocrine (especially adrenocortical) involvement is frequent in patients with premature ovarian failure. Because none of the patients had overt clinical evidence of thyroid or adrenocortical disease, we suggest that tests for thyroid and adrenal function be performed routinely in females presenting with premature ovarian failure.

Human CD5+ B lymphocytes (B-1 cells) decrease in peripheral blood during pregnancy

Pregnancy is a unique immunologic state where a natural homeostasis exists between antigenically different tissues. Several earlier studies have addressed the fluctuations in the number and/or function of lymphocytes, including B cells during pregnancy, but changes within the subsets of B lymphocytes, conventional (CD5-) and B-1 (CD5+), have not been addressed. Here we demonstrate that the frequency of B-1 cells decreases dramatically during pregnancy, whereas the frequency of conventional B cells remains relatively constant. The missing B-1 cells return to pre-pregnancy levels 8-10 weeks after parturition. The polyreactive autoantibodies secreted by B-1 cells have been implicated in autoimmunity and immune regulation. The possible role of B-1 cells during pregnancy will be discussed in that context.

Reversible impairment of glucose tolerance in patients with endemic fluorosis. Fluoride Collaborative Study Group

Endemic fluorosis is a condition resulting from prolonged ingestion of drinking water which contains excess fluoride. Studies on rats have suggested that fluoride toxicity may produce glucose intolerance and abnormalities in insulin secretion. We studied glucose and insulin profiles following an oral glucose load in patients with endemic fluorosis. Twenty-five young adults (age range, 15-30 years) with endemic fluorosis, and an equal number of matched healthy control subjects with normal fluoride intake were studied. Impaired glucose tolerance was demonstrated in 10 of 25 (40%) patients with endemic fluorosis. Patients with impaired glucose tolerance had significantly higher fasting serum immunoreactive insulin (p < 0.05), higher fasting serum fluoride (p < 0.001), and a significantly lower fasting glucose to insulin ratio than that in patients with normal glucose tolerance (p < 0.001) or control subjects (p < 0.05). The fasting serum fluoride levels correlated positively with the area under the glucose curve (r = 0.80, p < 0.01) in patients with impaired glucose tolerance. Interestingly these abnormalities could be reversed when the village was provided drinking water with fluoride levels within acceptable limits. The present study shows that chronic fluoride toxicity in humans could result in significant abnormalities in glucose tolerance which are reversible upon removal of the excess fluoride.

The management of Graves' disease by Indian thyroidologists

BACKGROUND

Although effective modes for treating Graves' disease are available, there is controversy over their choice. We conducted a nation-wide survey to determine trends in the diagnosis and management of Graves' disease in India.

METHODS

A proforma was mailed to 45 practising thyroidologists who were members of the Endocrine Society of India or the Thyroid Association of India. One index case and 5 variations were provided, and the members were asked to indicate the investigations of choice, therapeutic modality and details about its implementation.

RESULTS

The overall response rate was 71% (32). For diagnosis, serum T3, T4, TSH, sensitive TSH, free T3, and free T4 were asked for by 24, 25, 6, 13, 5, and 10 responders respectively. Radioactive iodine uptake with or without a scan was obtained by 19 of the responders. Antithyroid drugs were the choice of the majority in most situations (index case: 40-year-old female with first episode of typical Graves' disease--23; 40-year-old male--20; 16-year-old male--32; 40-year-old female without goitre--25), except for the patient with relapse and the 65-year-old female where radioiodine was the choice of the majority (20 and 23 respectively).

CONCLUSION

Antithyroid drugs are the mainstay of treatment of Graves' disease in India. The predominant use of these drugs was similar to European data, but different from the practice in the USA, where radioiodine is used much more liberally.

Skeletal scintigraphic findings in endemic skeletal fluorosis

Endemic skeletal fluorosis is characterized by bone, joint and muscle pain, progressive ankylosis of various joints and crippling deformities. Whole body skeletal scintigraphy with 99Tcm-methylene diphosphonate was performed for 17 symptomatic subjects suffering from this disorder. The fluoride content of drinking water ranged from 4.1 to 12.9 mg l-1 (normal < 1 mg l-1). Urinary and serum fluoride levels were markedly elevated. Serum calcium (total and ionized), inorganic phosphorus, creatinine and albumin were essentially normal while serum alkaline phosphatase was elevated in six subjects (mean +/- S.D. 206 +/- 106; range 22-1072 IU l-1). Skeletal radiology revealed a wide spectrum of bony abnormalities. Skeletal scintigraphy revealed a picture similar to metabolic 'superscan' in all subjects, i.e. increased tracer uptake in axial and appendicular skeleton, reduced soft tissue uptake, poor or absent renal images, prominent costochondral junction and 'tie' sign in sternum. Increased uptake was present in all subjects irrespective of age, water fluoride content, serum alkaline phosphatase level and radiological abnormalities. Our findings suggest the presence of a high bone turnover state in endemic skeletal fluorosis irrespective of other variables.

Radiological spectrum of endemic fluorosis: relationship with calcium intake

Skeletal fluorosis continues to be endemic in many parts of India. Osteosclerosis and interosseous membrane calcification have long been regarded as hallmarks of this disease. Our study showed in addition a wide variety of radiological patterns: coarse trabecular pattern, axial osteosclerosis with distal osteopenia and diffuse osteopenia. Subjects with osteopenic changes had a significantly lower dietary intake of calcium than those groups having normal radiological findings, predominant osteosclerosis or coarse trabecular pattern (p < 0.001, p < 0.01, and p < 0.01 respectively). This suggests the role of calcium intake in determining the skeletal changes in endemic fluorosis.

Hyperkalemic periodic paralysis associated with thyrotoxicosis

A 32 year old male presented with episodic pure motor weakness for 1 1/2 months. On evaluation he was found to be thyrotoxic. Hyperkalemic challenge test provoked similar weakness with raised serum potassium (6 meq/L). He responded to treatment with neomercazole. Till he became euthyroid, he responded to the addition of acetazolamide to his medication. He is symptom free on antithyroid drug alone over 8 months of follow up.

Single daily dose of carbimazole in the treatment of hyperthyroidism

BACKGROUND

The antithyroid drugs, methimazole and carbimazole, are conventionally used in divided daily doses. However, these drugs have a longer intrathyroidal than a plasma half-life. We undertook this prospective, controlled study, in an area of mild iodine deficiency, to compare the efficacy of a single daily dose of carbimazole with divided doses in the treatment of hyperthyroidism.

METHODS

Nineteen patients with hyperthyroidism received 30 mg of carbimazole daily at bed time (group A) while 14 received 10 mg of carbimazole every 8 hours (group B). These patients were assessed clinically and biochemically by estimation of serum total thyroxine, total triiodothyronine and thyrotropin before and 1, 2, 3, 4 and 6 weeks after treatment.

RESULTS

There was no significant difference between mean baseline concentrations of thyroxine and triiodothyronine. After 1, 2, 3, 4 and 6 weeks there was a decline in their concentrations which was similar in both groups (p > 0.05). Euthyroidism was achieved in 4.6 +/- 1.4 weeks (range 2-6 weeks) in group A and in 3.8 +/- 1.2 weeks (range 3-6 weeks) in group B (p > 0.05).

CONCLUSIONS

We conclude that carbimazole in a single daily dose is an effective method for treating hyperthyroidism in an area of mild iodine deficiency and its efficacy is comparable to divided dose therapy. This practical and acceptable method of treatment can be specially useful in patients who find it difficult to remember to take divided doses.

Glucocorticoid-dependent transformation by human papillomavirus type 16 E7 coding and 3' noncoding sequences

The establishment of transformation of primary rodent cells by human papillomavirus (HPV) type 16 DNA requires glucocorticoid hormones (Pater et al., Nature 335, 832-835, 1988). Here we provide evidence by mutational analysis that, in the context of the hormone-regulated HPV 16 promoter/enhancer, the only protein coding sequences of HPV 16 required are those of the E7 gene. Moreover, additional sequences adjacent to the 3' end of E7 coding sequences are also essential for the establishment of the transformed phenotype. Splice donor sites, especially an E7 ORF 3' proximal one, are implicated for this cis-acting function, since specific deletion mutations of these splice sites greatly or completely reduced the frequency of transformation and the level of E7 RNA.

Iopanoic acid as an adjunct to carbimazole in the management of hyperthyroidism

BACKGROUND

The thiourea drugs take a few weeks to control the symptoms of hyperthyroidism whilst iodine containing radiographic contrast agents (iopanoic acid and sodium ipodate) have a more rapid effect. There is no report on the use of iopanoic acid administered in conjunction with carbimazole, so we evaluated the efficacy of this combination in the early medical management of patients with hyperthyroidism.

METHODS

Thirty hyperthyroid patients diagnosed by clinical and biochemical criteria were randomized into two treatment groups. Group A (n = 16) received iopanoic acid (500 mg orally twice a day for the first 3 weeks) and carbimazole (30 mg orally in three divided doses) while group B (n = 14) received carbimazole alone. Clinical examination and estimation of serum total T3, total T4 and TSH were done by radioimmunoassay at the start of therapy, weekly for 4 weeks and then at 6, 8 and 12 weeks.

RESULTS

In the initial 3 weeks, iopanoic acid induced a significantly greater fall in mean serum total T3 levels (Z = 2.298, p < 0.02) and a slower fall in mean serum total T4 (Z = 2.396, p < 0.05) in group A patients compared to those in group B. This was accompanied by earlier clinical improvement in group A patients. The mean serum total T3 and T4 values rose to higher levels in group A at 4 weeks, one week after discontinuation of iopanoic acid. At the end of 12 weeks, however, there was no significant difference in the mean serum total T3 and T4 levels between the two groups (p > 0.05). Biochemical euthyroidism (i.e. total T3 < 3 nmol/L and total T4 < 170 nmol/L) was achieved later in group A patients than in group B (10.4 +/- 5.0 weeks v. 3.6 +/- 1.2 weeks, p < 0.0001).

CONCLUSIONS

Iopanoic acid given together with carbimazole induces rapid clinical improvement in hyperthyroid patients than carbimazole alone. However, the delayed achievement of euthyroidism may preclude its routine use in the management of patients with hyperthyroidism except in those with thyrotoxic emergencies.