Prevalence and the factors associated with microalbuminuria among patients with type 2 diabetes mellitus and/or hypertension in the urban areas of Puducherry district: a cross-sectional study

BACKGROUND

Microalbuminuria is an early indicator for renal and cardiovascular diseases, especially among patients with diabetes mellitus (DM) and hypertension (HTN). We determined the prevalence and the factors associated with microalbuminuria among patients with type 2 DM and/or HTN in the urban areas of the Puducherry district in India.

METHODS

We included 225 patients aged 40-69 years with DM and/or HTN from a non-communicable diseases (NCDs) survey conducted during 2019-2020 in the urban areas of Puducherry district. The prevalence of microalbuminuria and various biological risk factors of NCDs were assessed as per the WHO STEPS methodology. The prevalence of microalbuminuria was presented as proportions (95% CI), and the adjusted prevalence ratio (aPR) was estimated using weighted forward stepwise generalized linear modelling. P-value ≤0.05 was considered statistically significant.

RESULTS

The mean (SD) age of the patients was 54 (11) years. Over one-third (38.2%) (95% CI: 31.6-44.4) of patients with DM and/or HTN had microalbuminuria. The prevalence was highest among those having both DM and HTN 48% (95% CI: 37-59), followed by those having only DM 40.6% (95% CI: 29-52.2) and only HTN 27.7% (95% CI: 18.1-38.6). The prevalence of microalbuminuria was twice (aPR = 2.1, 95% CI: 1.1-3.9) higher among women and 2.4 times (95% CI: 1.12-5.1) higher among those having both DM and HTN as compared to those with only HTN.

CONCLUSION

The prevalence of microalbuminuria among patients with DM and/or HTN is concerningly high. Population-based screening for microalbuminuria, especially among women and those having both DM and HTN, needs to be undertaken in the urban areas of Puducherry district.

SMARTSeiz: Deep Learning with Attention Mechanism for Accurate Seizure Recognition in IoT Healthcare Devices

The Internet of Things (IoT) is capable of controlling the healthcare monitoring system for remote-based patients. Epilepsy, a chronic brain syndrome characterized by recurrent, unpredictable attacks, affects individuals of all ages. IoT-based seizure monitoring can greatly enhance seizure patients' quality of life. IoT device acquires patient data and transmits it to a computer program so that doctors can examine it. Currently, doctors invest significant manual effort in inspecting Electroencephalograph (EEG) signals to identify seizure activity. However, EEG-based seizure detection algorithms face challenges in real-world scenarios due to non-stationary EEG data and variable seizure patterns among patients and recording sessions. Therefore, a sophisticated computer-based approach is necessary to analyze complex EEG records. In this work, the authors proposed a hybrid approach by combining traditional convolution neural (CN) and recurrent neural networks (RNN) along with an attention mechanism for the automatic recognition of epileptic seizures through EEG signal analysis. This attention mechanism focuses on significant subsets of EEG data for class recognition, resulting in improved model performance. The proposed methods are evaluated using a publicly available UCI epileptic seizure recognition dataset, which consists of five classes: four normal conditions and one abnormal seizure condition. Experimental results demonstrate that the suggested approach achieves an overall accuracy of 97.05% for the five-class EEG recognition data, with an accuracy of 99.52% for binary classification distinguishing seizure cases from normal instances. Furthermore, the proposed intelligent seizure recognition model is compatible with an IoMT (Internet of Medical Things) cloud-based smart healthcare framework.

Negative impact on bone homeostasis in postmenopausal women with non-metastatic breast cancer during cytotoxic chemotherapy

INTRODUCTION

The burden and mechanisms of endocrine therapy-related bone loss are well known, while there are limited data on chemotherapy-induced bone resorption. The study aimed to evaluate the effect of cytotoxic chemotherapy on bone homeostasis among postmenopausal women with non-metastatic breast cancer.

MATERIALS AND METHODS

Early and locally advanced postmenopausal non-metastatic breast cancer patients aged 45 to 65 planned for three cycles of anthracycline and four cycles of taxane chemotherapy administered along with dexamethasone (cumulative dose-256 mg) as an antiemetic from June 2018 to December 2021 were included. Bone mineral density (BMD), bone turnover markers, calciotropic hormones, pro-inflammatory cytokines, oxidative stress, and total antioxidant levels (TAS) were measured.

RESULTS

We recruited 109 patients, with early 34 (31.2%) and locally advanced breast cancer 75 (68.8%) with median age 53 (45-65) years. There was a significant decrease in the % BMD at the lumbar spine, neck of the femur, and total hip post-chemotherapy. There was a significant increase in serum C-terminal telopeptide of type I collagen (CTX) and procollagen type I N-terminal propeptide (PINP) levels post-chemotherapy. PINP/CTX ratio significantly decreased post-chemotherapy. Serum 25-OH vitamin D was significantly reduced with a compensatory increase in plasma iPTH levels. The change in CTX, PINP/CTX ratio, 25-OH vitamin D, iPTH, and oxidative stress index was more pronounced during anthracycline as taxane chemotherapy. There were no significant changes in pro-inflammatory cytokine levels.

CONCLUSION

Chemotherapy and dexamethasone as antiemetic resulted in significant bone loss, as evidenced by bone turnover markers. Further studies are required to understand the mechanism of chemotherapy-induced bone loss and the need for bone-strengthening agents during chemotherapy.

Effects of Vitamin D on Migraine: A Meta-Analysis

Objective

The aim of this study was to evaluate the difference in mean serum 25-hydroxy vitamin D level between migraineurs and nonmigraineurs, the association between hypovitaminosis D and migraine, and the effects of oral vitamin D supplementation on migraine-related symptoms as compared to placebo.

Methods

Relevant databases were searched for observational studies and randomized-controlled trials (RCTs) which evaluated the difference in mean serum 25-hydroxy vitamin D level between migraineurs and nonmigraineurs; the association between hypovitaminosis D and migraine; and the effects of vitamin D supplementation on migraine-frequency, duration, and severity. Pooled mean difference and odds ratio were calculated (random-effects model, RevMan version 5.3).

Results

Ten observational studies and two RCTs were included. The serum 25-hydroxy vitamin D level in the migraineurs was significantly lower than that in the nonmigraineurs [mean difference - 4.44 ng/mL (95% CI: -6.11, -2.77)] (low-GRADE evidence). Hypovitaminosis D was found to be significantly associated with migraine [OR: 1.95 (95% CI: 1.07, 3.58)] (low-GRADE evidence). As compared to placebo, oral vitamin D supplementation significantly reduced the monthly migraine-frequency [mean difference: -2.20 (95% CI: -3.04, -1.36)].

,

although it did not reduce the migraine-duration [mean difference: -16.00 hours per month (95% CI: -42.77, 10.76)] and migraine-severity score [standardized mean difference: -0.23 (95% CI: -0.79, 0.32)] (moderate-GRADE evidence).

Conclusion

Serum 25-hydroxy vitamin D level was significantly lower in the migraineurs than that in the nonmigraineurs, and hypovitaminosis D was significantly associated with migraine. Oral vitamin D supplementation significantly reduced migraine-frequency, but not its duration and severity.

Cytotoxic chemotherapy is associated with decreased bone mineral density in postmenopausal women with early and locally advanced breast cancer

PURPOSE

The burden and mechanisms of endocrine therapy-related bone loss have been studied in detail. However, there is limited data regarding cytotoxic chemotherapy's impact on bone health. There are no definitive guidelines for bone mineral density (BMD) monitoring and treatment with bone-modifying agents during cytotoxic chemotherapy. The study's primary objective was to evaluate the changes in BMD and fracture risk assessment tool (FRAX) scores among breast cancer women on cytotoxic chemotherapy.

METHODS

One hundred and nine newly diagnosed early and locally advanced postmenopausal breast cancer patients planned for anthracycline and taxane-based chemotherapy were recruited prospectively during the study period from July 2018 to December 2021. BMD of the lumbar spine, the femoral neck, and the total hip were assessed by dual-energy X-ray absorptiometry scan. BMD and FRAX scores were evaluated at baseline, end of chemotherapy, and 6 months of follow-up.

RESULTS

The median age of the study population was 53 (45-65) years. Early and locally advanced breast cancers were seen in 34 (31.2%) and 75 (68.8%) patients, respectively. The duration of follow-up between two BMD measurements was 6 months. The percentage of decrease in BMD at the lumbar spine, femoral neck, and total hip were - 2.36 ± 2.90, - 2.63 ± 3.79, and - 2.08 ± 2.80, respectively (P-value = 0.0001). The median risk of major osteoporotic fracture (MOF) at 10 years (FRAX score) increased from 1.7 (1.4) to 2.7% (2.4) (P-value = 0.0001).

CONCLUSION

This prospective study in postmenopausal breast cancer women shows a significant association of cytotoxic chemotherapy with the worsening of bone health in terms of BMD and FRAX score.

Performance of WHO updated cardiovascular disease risk prediction charts in a low-resource setting - Findings from a community-based survey in Puducherry, India

BACKGROUND AND AIM

The World Health Organization has revised the cardiovascular disease (CVD) risk prediction charts in 2019 for each of the 21 Global Burden of Disease regions. These charts (non-lab and lab versions) estimate the total CVD risk in an individual, of which the non-lab is for low-resource settings. We aimed to estimate the burden of ten-year risk of fatal or non-fatal CVD event in the district of Puducherry in India using 'non-lab' and 'lab' versions of WHO CVD risk prediction charts, and to evaluate the agreement between them.

METHODS AND RESULTS

We included 710 individuals aged 40-69 years who participated in a district wide non-communicable diseases survey conducted in Puducherry, India, during 2019-20. Both charts use information on age, gender, systolic blood pressure and smoking status. Additionally, lab-chart requires individual's status on diabetes mellitus and total cholesterol while non-lab requires body mass index. Population in different CVD risk levels was presented using proportions (95% confidence intervals). Agreement between lab and non-lab charts was evaluated using Cohen's Kappa (k). The lab and non-lab charts estimated 3% (95% CI: 1.7-4.2) and none of the population respectively, to have high risk (≥20%) for fatal or non-fatal CVD event over the next ten years. Both the charts showed 89.4% (95% CI:87.2%-91.7%) concordance in CVD risk prediction indicating a good level of agreement (k = 0.653).

CONCLUSION

WHO updated CVD risk prediction charts are feasible to apply when data is available and there is good agreement between non-lab and lab based charts.

High prevalence of abdominal obesities and metabolically unhealthy individuals in a highly urbanized district of India: findings of a cross-sectional survey in Puducherry

BACKGROUND

Abdominal obesities are better markers for predicting cardiovascular abnormalities than risk stratification based only on body mass index (BMI). We aimed to estimate the prevalence of abdominal adiposities using predictive equations for Asian Indian adults and to determine the prevalence of metabolically healthy subjects among those overweight/obese and with normal BMI.

METHODS

A community-based survey was conducted among those aged 18-69 years in the district of Puducherry between February 2019 and February 2020. We surveyed 2,560 individuals selected through multi-stage cluster random sampling from urban and rural areas (50 wards and 50 villages, respectively) of the district. Anthropometric measurements, such as height, weight, waist circumference, and blood pressure were recorded from each participant. Fasting blood sample was collected from each alternate participant to estimate metabolic risk factors.

RESULTS

Over four-fifths (85.6%; 95% CI: 84.2-86.9) and two-thirds (69.7%; 95% CI: 67.9-71.6) of the population in the district had high levels of intra-abdominal adipose tissue (IAAT) and total abdominal fat (TAF), respectively. Both the risk factors were significantly higher among women and urban population. About 43% (95% CI: 41-44.9) of the population had high abdominal subcutaneous adipose tissue (SCAT) with a significantly higher prevalence among the urban population. Among those overweight/obese (n = 773), almost all 99.4% (95% CI: 98.7-99.9) were metabolically unhealthy. Among subjects with normal BMI (n = 314), only about 2.9% (95% CI: 1.3-4.8) were metabolically healthy.

CONCLUSION

We highlight the substantially high prevalence of IAAT, TAF, and SCAT in the district of Puducherry. Almost all the study population was metabolically unhealthy irrespective of their BMI levels.

Real-Time Hand Gesture Recognition Using Fine-Tuned Convolutional Neural Network

Hand gesture recognition is one of the most effective modes of interaction between humans and computers due to being highly flexible and user-friendly. A real-time hand gesture recognition system should aim to develop a user-independent interface with high recognition performance. Nowadays, convolutional neural networks (CNNs) show high recognition rates in image classification problems. Due to the unavailability of large labeled image samples in static hand gesture images, it is a challenging task to train deep CNN networks such as AlexNet, VGG-16 and ResNet from scratch. Therefore, inspired by CNN performance, an end-to-end fine-tuning method of a pre-trained CNN model with score-level fusion technique is proposed here to recognize hand gestures in a dataset with a low number of gesture images. The effectiveness of the proposed technique is evaluated using leave-one-subject-out cross-validation (LOO CV) and regular CV tests on two benchmark datasets. A real-time American sign language (ASL) recognition system is developed and tested using the proposed technique.

Is the rural population of Puducherry district healthy in terms of the burden of non-communicable diseases? Findings from a cross-sectional analytical survey

Introduction:

Epidemiological transition remains a key contributor to the rising prevalence of non-communicable diseases (NCDs) across developing nations. Population-specific NCD risk factors estimates derived using World Health Organization (WHO) 'STEP-wise approach' are crucial for devising evidence-based public health interventions to combat NCDs.

Objective:

To estimate the prevalence of behavioral and biological risk factors for NCDs among the rural adult population of Puducherry district in India.

Methodology:

STEPS survey was conducted by following all three steps (behavioral, physical measurements and biochemical risk factors) of NCD risk factor assessment. A total of 790 participants were selected from 50 villages through multistage cluster sampling method. STEPS instrument was used to assess behavioral risk factors, physical measurements and biochemical (fasting blood glucose and total cholesterol) risk factors.

Results:

Tobacco use and alcohol consumption were present among 11.3% (95% Confidence Interval (CI): 9-13.6%) and 19.2% (95% CI: 16.5-22.4%) of the population, respectively. Low physical activity, inadequate intake of fruits and vegetables, overweight and obesity were observed among 29.3% (95% CI: 26.2-32.7%), 89.8% (95% CI: 87.6-92%), 15.6% (95% CI: 13.1-18.3%) and 38.9% (95% CI: 35.4-42.2%), respectively. About 28.2% (95% CI: 25.2-31.6%) had hypertension and 24.4% (95% CI: 20-29%) had diabetes mellitus. Abdominal obesity was twice highly prevalent among women. Tobacco and alcohol use were more common among men, whereas low physical activity, obesity and hypercholesterolemia were higher among women.

Conclusion:

Public health interventions to promote healthy lifestyle need to be initiated especially to increase physical activity, intake for fruits and vegetables, and quitting of tobacco and alcohol consumption in the rural population of Puducherry.

Association of Circulating Brain-Derived Neurotrophic Factor with Cognition among Adult Obese Population

Background

Obesity has a strong association with the risk of developing cognitive impairment and dementia at a later age. Brain-derived neurotrophic factor (BDNF) and its receptor appear to be important components in cognitive function and are also involved in energy homeostasis. The level of circulating BDNF and its association with cognition has yet to be delineated clearly. In this work we studied the association of circulating BDNF with cognition among the adult obese population.

Methods

The study involved 132 healthy participants between 18 and 40 years of age and of both sexes. The participants were categorized into an obesity group (n=66) and a non-obese group (n=66) based on their body mass index (Asian criteria). The level of cognitive performance was assessed by the event-related potentials P300 (ERPs-P300), mini-mental state examination (MMSE), both visual and auditory reaction times (VRT and ART, respectively), and other pen and paper tests related to memory and executive function. Serum BDNF, glycemic and lipid profiles were estimated.

Results

We found significant differences in the ERPs-P300 latency (P<0.001) and amplitude (P=0.002) between the non-obese and obese group. The MMSE score was significantly reduced while VRT (P=0.005) and ART (P=0.001) were larger in the obese group. BDNF levels (P<0.001) were significantly reduced and negatively associated with the obese group. ERPs-P300 latency was negatively associated (r=–0.674, P=0.001) whereas amplitude (r=0.507, P<0.001) was positively associated with the BDNF levels in the adult obese population.

Conclusion

We found reduced circulating BDNF levels in obese adults and that lower BDNF levels were strongly associated with cognitive decline in the obese adult population.

Effect of cytotoxic chemotherapy on bone health among breast cancer patients. Does it require intervention?

BACKGROUND

Breast cancer (BC) is one of the most common malignancies worldwide. Although the burden and mechanisms of endocrine therapy-related bone loss are known, the evidence is scanty regarding the impact of cytotoxic chemotherapy on bone health. We have attempted to summarize the effect of cytotoxic chemotherapy on bone health in BC patients.

METHODS

A comprehensive literature search was performed via MEDLINE and Cochrane library databases to evaluate the effect of chemotherapy on bone health among women with BC. We included articles related to skeletal-related events, bone mineral density, bone turnover markers, osteoporosis-specific quality of life, bisphosphonate, and other bone-directed therapy. We excluded articles that included patients with metastatic breast cancer and patients receiving hormonal therapy.

DISCUSSION

Bone microenvironment in cancer is directly or indirectly influenced by clinical, hormonal, nutritional, and treatment factors. Calcitonin, parathyroid hormone, calcitriol, and estrogen are the major hormonal regulators. Bone turnover markers, namely bone formation and resorption markers, have been used to predict bone loss, fracture risk, and monitoring treatment response. Chemotherapeutic drugs such as anthracyclines and taxanes synergistically affect BMD and quality of life. Calcium, vitamin D, bisphosphonates, and denosumab are supplemented to prevent excess bone resorption. Bone-targeted anti-resorptive agents have been studied as potential anticancer agents in the adjuvant treatment of breast cancer.

CONCLUSION

This review summarizes the negative effect of chemotherapy on bone health of BC patients and the importance of preventing or treating bone loss.

L Score as a Novel Anthropometric Measure for Obesity Screening in Adult Individuals: An Exploratory Study

BACKGROUND: Obesity is one of today’s most neglected public health problems, affecting every region of the world. Early identification of increased weight gain among the population is paramount to prevent the attendant complications associated with obesity. OBJECTIVES: The primary objective of this study was to measure the distribution of L score in the representative population and the secondary objective was to identify an association between L score values and other measures of obesity such as body mass index, waist circumference, waist-to-height ratio, neck circumference (NC), and total body fat percentage. METHODS: This study was conducted in the departments of plastic surgery and endocrinology of a tertiary care institute. The L score (a measure of fullness of the lateral retromalleolar fossa in the lower limb) was assessed in all the participating individuals. Statistical analysis was performed using the Statistical Package for the Social Sciences version 19.0. p < 0.05 was considered as statistically significant in statistical analysis. RESULTS: Among the 50 participants taken in this study, 24 had L score 0, 15 had score 1, and 11 had score 2. The participants with L score 1 and 2 had higher obesity, higher NC, and more body fat percentage compared to those having score 0. All the participants with L score 2 were overweight and had central obesity. CONCLUSIONS: The L score measure has a potential for simple and rapid screening of at-risk population for overweight and obesity.

Effect of vitamin D supplementation on clinical outcome and biochemical profile in South Indian population with vitamin D-deficient chronic urticarial - A randomized double-blind placebo controlled trial

BACKGROUND

Chronic urticaria (CU) is a debilitating inflammatory skin disease. Prior studies have shown reduced concentrations of vitamin D in CU and there are limited reports of potential beneficial role for vitamin D supplementation in the treatment of subjects with CU. We assessed the effect of vitamin D supplementation in vitamin D deficient CU patients on the clinical outcome and inflammatory markers in South Indian patients with CU.

METHODS

This randomized controlled trial involved 120 vitamin-D deficient CU patients. Urticaria activity score (UAS7) and autologous plasma skin test (APST) status was assessed in all cases. CU patients were supplemented with vitamin D with a dose of 60,000 IU fortnightly for a period of 12 weeks and those in the placebo arm received matched placebo. Five milliliters of blood was drawn from all study subjects at baseline and after 12 weeks for assessing inflammatory markers.

RESULTS

We observed a significant reduction in UAS7 scores after 12 weeks in the vitamin D treated group in comparison to that of placebo. We also noted a significant reduction of the inflammatory cytokines in the vitamin D treated group.

CONCLUSION

Supplementation with vitamin D among patients with vitamin D deficient CU significantly decreases disease severity which is probably mediated through reduction of systemic inflammation.

An unusual cause of pulmonary calcification

Metastatic pulmonary calcification (MPC) is an uncommon entity resulting from abnormalities in calcium-phosphorus homoeostasis. Most cases reported in the literature are among patients with chronic kidney disease receiving haemodialysis. Primary hyperparathyroidism is a relatively common condition affecting calcium homoeostasis, in which MPC can rarely occur. We report the case of one such patient who presented with severe hypercalcaemia and features of interstitial lung disease. Radiographic imaging was normal and the diagnosis was clinched by diffuse pulmonary uptake in ^99mTechnetium-methylene diphosphate scan.

Effect of metformin on exercise capacity: A meta-analysis

AIMS

To evaluate the effect of metformin on various parameters of exercise capacity [oxygen consumption (VO₂), peak oxygen consumption (VO_2peak), heart rate (HR), exercise test duration, respiratory exchange ratio (RER), rating of perceived exertion (RPE), lactate and ventilatory anaerobic threshold (VAT)].

METHODS

Studies reporting change in VO₂ or VO_2peak after metformin administration were included. Subgroup analyses were performed as applicable. Mean difference with 95% CIs were pooled using random-effects model [RevMan (v5.3)].

RESULTS

There were no changes in VO₂ and VO_2peak in the overall population [VO₂: n = 388, mean difference: -0.12 ml/kg/min, 95% CI: -0.74, 0.51, p = 0.71 (i² = 0%, p = 0.99); VO_2peak: n = 345, mean difference: 0.41 ml/kg/min, 95% CI: -0.51, 1.33, p = 0.38 (i² = 0%, p = 0.89)], healthy volunteers and patients (type 2 diabetes mellitus, insulin resistance, impaired glucose tolerance/impaired fasting glucose and metabolic syndrome). For patients with insulin resistance, there was a decrease in VO_2peak, but not VO₂. In the overall population, there was a significant decrease in HR and RER, a significant increase in RPE, and no changes in exercise test duration and VAT. In addition, there was an increased VAT in the healthy volunteers.

CONCLUSIONS

In the overall population, metformin did not affect VO₂, VO_2peak, exercise test duration and VAT, although it significantly decreased HR, RER and increased RPE.

Varicella causing remission of Cushing's disease

An 18-year-old male with Cushing's disease presented with generalised skin eruptions and backache. He was diagnosed with varicella infection. During the course of the illness, he developed persistent vomiting. Hormonal evaluation suggested adrenal insufficiency. MRI of brain showed features of pituitary apoplexy. Initially, he required hydrocortisone replacement. Later on his hypothalamic-pituitary-adrenal axis recovered and he is currently asymptomatic without any treatment.

The effect of hypothyroidism on serum irisin level in patients with nondiabetic chronic kidney disease: A pilot study with a cross-sectional design

Both chronic kidney disease (CKD) and hypothyroidism are associated with decreased serum irisin level. The presence of hypothyroidism may influence serum irisin level in CKD patients. The objective of this study was to evaluate the effect of hypothyroidism on serum irisin level in patients with nondiabetic CKD. Two hundred nondiabetic CKD patients aged between 18 and 65 years with glomerular filtration rate <60 mL/min/1.73 m² were included in this study. Forty-three (21.5%) patients had hypothyroidism (overt and subclinical both). Forty hypothyroid and forty euthyroid CKD patients matched for age and Body Mass Index underwent body composition, biochemical [fasting plasma glucose (FPG) and C-reactive protein], and hormonal (fasting irisin and insulin) evaluation. Body composition analysis including visceral adipose tissue was done by dual-energy X-ray absorptiometry. Homeostatic model assessment 2 insulin resistance was calculated from FPG and insulin levels. The median serum irisin levels were not significantly different between hypothyroid and euthyroid CKD patients [95 (47.74-261.52) vs. 66 (28.25-224.50) ng/mL, P = 0.30]. There was also no difference in renal function, body composition and other metabolic parameters between the two groups. To conclude, the presence of hypothyroidism does not alter serum irisin level in patients with nondiabetic CKD.

Effect of Frey's procedure on islet cell function in patients with chronic calcific pancreatitis

BACKGROUND

Frey's procedure involves both drainage and resection of the pancreas in subjects with chronic calcific pancreatitis (CCP). The procedure may affect the pancreatic endocrine function after surgery. The present study was to evaluate the effect of Frey's procedure on both beta and alpha cell function in CCP patients.

METHODS

Thirty CCP patients who underwent Frey's procedure were included. According to the glycemic status, patients were divided into the diabetes mellitus (DM), prediabetes, and normal glucose tolerance (NGT) groups. Islet cell function was assessed before and 3 months after surgery.

RESULTS

At baseline, there was a significant difference in beta cell function among the three groups [NGT group 1.71 (1.64-2.07) vs prediabetes group1.50 (0.83-1.61) vs DM group 0.33 (0.12-0.55), P < 0.0001], but the insulin resistance was not different among them. Post glucose hyperglucagonemia representing alpha-cell dysfunction during oral glucose tolerance test was present in all of them, but showed no significant difference [NGT group 0.15 (0.06-0.31) vs prediabetes group 0.32 (0.05-0.70) vs DM group 0.07 (0.02-0.18), P = 0.20]. Frey's procedure did not change beta cell function and insulin resistance. However, alpha-cell dysfunction deteriorated after surgery [0.10 (0.03-0.27) vs 0.33 (0.09-0.68), P = 0.004].

CONCLUSIONS

Although Frey's procedure does not affect the beta cell function and insulin resistance in CCP patients, the alpha-cell dysfunction deteriorates after surgery.

Osteoporosis and malignancy: a dicey combination

Osteoporosis is the most common metabolic bone disorder worldwide, especially in women. Postmenopausal status is the most common risk factor for osteoporosis in elderly women. The operational diagnosis of osteoporosis is usually made with the help of central dual energy X-ray absorptiometry scan. Clinically, osteoporosis is suspected in the background of one or more fractures of the hip, vertebra, proximal humerus or pelvis in the absence of local disease or high-energy trauma. Serious underlying illness can present with vertebral fractures and can be missed if other clues from clinical examination and investigations are overlooked. We report a case emphasising this aspect.

Puzzling thyroid function test

A 13-½-year-old boy was referred to the Department of Endocrinology as a case of thyrotoxicosis for initiation of antithyroid medication. His chief complaint was a swelling in front of the neck, which was incidentally noted by his mother 2 weeks prior to presentation. He denied any history of symptoms suggestive of hyperthyroidism or ophthalmological involvement. His physical examination was unremarkable except for a grade 2 goitre. Thyroid function test revealed elevated free triiodothyronine and tetraiodothyronine in the face of an unsuppressed thyroid-stimulating hormone level. Technetium-99 uptake scan showed increased uptake indicating enhanced thyroid activity. However, he was clinically euthyroid. This raised the possibility of resistance to thyroid hormones, which was confirmed by documenting similar thyroid function test abnormalities in other members of his family and genetic testing. The family was reassured of the benign nature of the condition.

Systematic Review on Vitamin D Level in Apparently Healthy Indian Population and Analysis of Its Associated Factors

BACKGROUND

Vitamin D which is involved in the maintenance of bone mineral homeostasis has been found to portray various pleiotropic effects. Although it has been widely accepted that serum 25-hydroxy Vitamin D level above 30 ng/ml is considered optimal for the biological actions of Vitamin D, there is a need to explore the levels of Vitamin D reported among Indians from various regions of the country. Hence, this systematic review aims to appraise the status of Vitamin D levels reported from apparently healthy Indians across various parts of India.

METHODOLOGY

A comprehensive literature search was carried out to identify the range of Vitamin D levels among apparently healthy individuals from various parts of India, with the search term "Vitamin D and India" in the search portals of PubMed, Google Scholar, Indmed, and ScienceDirect. A total of 2998 articles were retrieved by the above search strategy, of which only forty studies fulfilled the criteria to be included in the systematic review. Studies done in various states were compiled under the respective zones based on the classification of Indian zones as specified in Zonal maps of India.

RESULTS

The level of Vitamin D from all the forty included studies ranged from 3.15 ± 1.4 to 52.9 ± 33.7 ng/ml. The effect size of Vitamin D level was higher in the South Zone compared to other zones.

CONCLUSION

The present study shows that Vitamin D deficiency is prevalent among apparently healthy Indians living in different regions of India, irrespective of their exposure to sunlight.

Effect of 12 Weeks of Yoga Therapy on Quality of Life and Indian Diabetes Risk Score in Normotensive Indian Young Adult Prediabetics and Diabetics: Randomized Control Trial

Introduction

India has become the epicentre for diabetes, a stress-related disorder affecting the working skills and day-to-day lifestyle management of younger population. Most of the studies have reported the effect of yoga on improving Quality of Life (QoL) in diabetic patients with other comorbidities. Till date, no randomized control trial reports are available to show the effect of yoga therapy on QoL and Indian Diabetes Risk Score (IDRS) in normotensive prediabetic and diabetic young individuals.

Aim

To determine the effect of 12 weeks of yoga therapy on QoL and IDRS among normotensive prediabetic and diabetic young Indian adults.

Materials and Methods

A randomized control trial was conducted in Endocrinology Outpatient Department (OPD). Normotensive participants (n=310) aged 18-45 years were divided into healthy controls (n=62), prediabetics (n=124) and diabetics (n=124). Study group subjects were randomly assigned to Group II (n=62, prediabetes-standard treatment), Group III (n=62, prediabetes-standard treatment + yoga therapy), Group IV (n=62, diabetes-standard treatment) and Group V (n=62, diabetes-standard treatment + yoga therapy). Flanagan QoL scale, IDRS questionnaire, Fasting Plasma Glucose (FPG) and insulin were assessed pre and post 12 weeks of intervention. Statistical analysis was done using Student's paired t-test and one-way ANOVA.

Results

Pre-post intervention analysis showed significant improvement in QoL scale with p<0.01 in Group II and Group IV; p<0.001 in Group III and Group V respectively. There was significant reduction in IDRS in Group II (p<0.05); p<0.001 in Group III, Group IV and Group V respectively. Significant difference (p<0.001) in QoL scale and IDRS were found when study groups with standard treatment along with yoga therapy were compared to standard treatment alone.

Conclusion

Yoga therapy along with standard treatment for 12 weeks improved QoL and attenuated the diabetes risk among Indian prediabetics and diabetics compared to standard treatment alone.

The Serological and Biochemical Markers of Adrenal Cortex and Endocrine Pancreas Dysfunction in Patients with Hashimoto's Thyroiditis: A Hospital-based Pilot Study

BACKGROUND

The prevalence of both islet cell and adrenal autoimmunity among Asian Indian hypothyroidism patients with Hashimoto's thyroiditis (HT) is lacking in literature.

OBJECTIVES

The objective of this study was to assess the proportion of Addison's disease (AD) and type 1 diabetes mellitus (T1DM) in patients with HT.

MATERIALS AND METHODS

The patients with hypothyroidism due to HT were included in this study over 2 years. Primary hypothyroidism was defined as high serum thyroid-stimulating hormone (>5.5 mIU/L) with or without low thyroxine level. HT was defined by the presence of high thyroid peroxidase antibody (Ab) titer (>35 IU/ml). Autoimmune markers of AD and T1DM, i.e., adrenal (21-hydroxylase) Ab, glutamic acid decarboxylase (GAD) Ab, and insulinoma-associated antigen-2 (IA-2) Ab were measured among them. In addition, 250 μg adrenocorticotropic hormone (ACTH) stimulation test was done in patients with adrenal Ab. Similarly, beta cell function was assessed in patients with GAD and/or IA-2 Ab.

RESULTS

Out of 150 patients screened, 136 patients were included in this study. Seven patients had adrenal Ab while 15 had IA-2 Ab. The GAD Ab was not present in any of the patients in the study. ACTH stimulation test was done in four of seven patients with adrenal Ab and beta cell function was assessed in 8 of 15 patients with islet cell Ab. All patients with adrenal Ab had normal adrenal function and 1 out of 15 with IA-2 Ab developed diabetes mellitus during follow-up.

CONCLUSIONS

Either adrenal or islet cell Ab was found in 16% Asian Indian hypothyroidism patients with HT.

Association of Sympathovagal Imbalance With Cognitive Impairment in Type 2 Diabetes in Adults

OBJECTIVE

Sympathovagal imbalance (SVI) has been reported to be associated with metabolic derangements in type 2 diabetes. We investigated the association of SVI with cognitive impairment in patients with type 2 diabetes.

METHODS

Patients with a new diagnosis of type 2 diabetes (n=43) and age-matched healthy control subjects (n=43) were recruited for the study. Body mass index and blood pressure measurements were recorded. SVI was assessed by spectral analysis of heart rate variability (HRV), and cognitive function was assessed by recording the positive wave that appears in 300 milliseconds from application of stimulus in event-related potential tracing (P300). Insulin resistance was determined by the homeostatic model assessment of insulin resistance (HOMA-IR) formula using blood glucose and insulin data, and oxidative stress was assessed by estimation of malondialdehyde. Association of various factors with cognitive impairment was evaluated by Pearson correlation analysis, and independent contributions of these factors to cognitive impairment were assessed by multiple regression analysis.

RESULTS

P300 latency was significantly prolonged in the diabetes group compared with the control group. Ratio of low-frequency to high-frequency power (LF-HF ratio) of HRV, the marker of SVI was found to be significantly correlated and linked with P300. Malondialdehyde and HOMA-IR were correlated with LF-HF ratio.

CONCLUSION

Treatment-naïve patients with type 2 diabetes have SVI and considerable cognitive impairment. Insulin resistance and oxidative stress contribute to cognitive impairment, and SVI could be the physiologic link to cognitive impairment in treatment-naïve patients with type 2 diabetes.

Does one-to-one demonstration with insulin pads by health-care providers improves the insulin administration techniques among diabetic patients of a Tertiary Care Teaching Hospital in South India?

OBJECTIVES

The study was aimed to capture the effect of using injection pads as a tool in educating the diabetic patients who were on insulin. The attitude and practice of the patients in storage of insulin vials and disposal of insulin syringes were also assessed.

MATERIALS AND METHODS

A facility based Quasi-experimental study was carried out among the diabetic patients on insulin, attending diabetic clinic in endocrinology OPD in a tertiary care hospital, Puducherry. One to one intervention was given to the study participants or their attendants (who were involved in injecting insulin), by a trained investigator regarding all the steps of insulin administration. The insulin administration practices before and immediately after the intervention was assessed using a checklist.

RESULTS

In total 91 patients were included for the study with mean (SD) age of 53.9 (10.6) years and of them 76% were females. The attitude and practices of the study participants, such as hand washing before handling insulin, checking the expiry date, storage of insulin, inspection of injection site, rolling and cleaning the vial, withdrawal of the syringe up to the required dose, pushing the plunger after inserting the syringe into the vial, checking and removal of air bubbles, cleaning the injection site and allow to dry and injection technique improved significantly after the intervention (P < 0.05).

CONCLUSION

This study findings shows that using injection pads for educating patients helps them to practise better insulin administration. The findings from the study can be applied in routine care and has to be explored further in diabetic patient management.

Effect of Gender on the Total Abdominal Fat, Intra-Abdominal Adipose Tissue and Abdominal Sub-Cutaneous Adipose Tissue among Indian Hypertensive Patients

INTRODUCTION

Abdominal obesity is a better marker of adverse metabolic profile than generalized obesity in hypertensive subjects. Further, gender has effect on adiposity and its distribution.

AIM

Effect of gender on obesity and the distribution of fat in different sub-compartments of abdomen among Indian hypertensive subjects.

MATERIALS AND METHODS

This observational study included 278 adult subjects (Males-149 & Females-129) with essential hypertension from a tertiary care centre in north India over one year. A detailed history taking and physical examination including anthropometry were performed in all patients. Total Abdominal Fat (TAF) and abdominal adipose tissue sub-compartments like Intra-Abdominal Adipose Tissue (IAAT) and Sub-Cutaneous Adipose Tissue (SCAT) were measured using the predictive equations developed for Asian Indians.

RESULTS

Female hypertensive subjects had higher Body Mass Index (BMI) with more overweight (BMI ≥ 23kg/m(2)), and obesity (BMI≥ 25 kg/m(2)). Additionally, they had higher prevalence of central obesity based on both Waist Circumference (WC) criteria (WC≥ 90 cm in males and WC≥ 80 cm in females) and TAF criteria {≥245.6 cm(2) (males) and ≥203.46 cm(2) (females)} than male patients. But there was no difference in the prevalence of central obesity based on Waist Hip Ratio (WHR) criteria (WHR ≥0.90 in males and WHR ≥ 0.85 in females) between two genders. High TAF & IAAT were present in more females although there was no difference in the distribution of high SCAT between two genders.

CONCLUSION

Female hypertensive subjects were more obese with higher abnormal TAF & IAAT compared to male patients. However, there was no difference in the distribution of high SCAT among them.

Attenuated baroreflex sensitivity in normotensive prediabetes and diabetes in Indian adults

PURPOSE/AIM OF THE STUDY

Though attenuated baroreflex sensitivity (BRS) is known to promote cardiovascular disease (CVD) risk in diabetics, its status in prediabetes has not been reported. Also, the link of BRS to CVD risk in normotensive diabetics has not been reported. This study aimed to evaluate the association of BRS to CVD risk in normotensive prediabetics and diabetics.

MATERIALS AND METHODS

Participants (n = 154) of 18-45 years were divided into normoglycemics (n = 52), prediabetics (n = 64) and diabetics (n = 38) based on American Diabetes Association criteria. Body mass index, waist-hip ratio, waist-height ratio, body fat mass index, basal heart rate, systolic blood pressure, diastolic blood pressure, rate pressure product, BRS, heart rate variability (HRV), fasting plasma glucose, fasting insulin, lipid profile and atherogenic index of plasma (AIP) were measured. Indian Diabetes Risk Score (IDRS) and homeostatic model assessment of insulin resistance were calculated.

RESULTS

There was significant increase in all the parameters except BRS, HRV and high-density lipoprotein in prediabetics and diabetics compared to normoglycemics. All these parameters were significantly altered in prediabetics compared to diabetics. Significant negative correlation was found between BRS and other parameters in prediabetics and diabetics.

CONCLUSIONS

BRS was attenuated in normotensive prediabetics and diabetics with high IDRS, insulin resistance, AIP, dyslipidemia and reduced HRV that predisposes them to CVD risk. The study demonstrates CVD risk quite early in the prediabetics with reduced HRV, high body fat, hyperinsulinemia, insulin resistance, AIP and rate pressure product.

Vitamin D Status and Cardio-Metabolic Risk in Indian Postmenopausal Women

INTRODUCTION

The prevalence of chronic and non-communicable health disorders like cardiovascular diseases and metabolic syndrome is increasing worldwide including in India. The various risk factors for these health issues need to be addressed. The role of vitamin D deficiency in the causation of all these abnormal health conditions among postmenopausal women is a matter of debate now-a-days.

AIM

To determine the correlation of serum vitamin D levels with various cardio-metabolic risk factors and metabolic syndrome (MetS) in postmenopausal women (PMW).

MATERIALS AND METHODS

Total of 64 PMW were included in this cross-sectional study. Clinical (waist circumference, body mass index, blood pressure) and biochemical (fasting plasma glucose, lipid profile and serum 25-hydroxyl vitamin D levels) parameters were measured. MetS was defined using modified National Cholesterol Education Program Adult Treatment Panel III (NCEP ATP-III) guidelines. Serum 25-hydroxyl vitamin D levels <50 nmol/l, between 52.5-72.5 nmol/l and >75 nmol/l were classified as deficient, insufficient and sufficient, respectively.

RESULTS

MetS was prevalent in 33 (52%) subjects. There were no differences in serum vitamin D levels or proportion of vitamin D deficient individuals in those with and without MetS. 33 women (52%) had vitamin D deficiency. Cardio-metabolic risk profile was similar in both vitamin D deficient and replete women.

CONCLUSION

Despite a high prevalence of vitamin D deficiency and MetS in Indian PMW, serum vitamin D concentrations do not correlate with the cardio-metabolic risk factors or MetS.

Effect of steroid replacement on thyroid function and thyroid autoimmunity in Addison's disease with primary hypothyroidism

BACKGROUND

Steroid replacement without thyroxine supplementation normalizes thyroid function test (TFT) in some but not all Addison's disease patients with primary hypothyroidism. Both autoimmune and nonautoimmune mechanisms contribute to this improvement in TFT. However, the documentation of the change in thyroid autoimmunity after cortisol replacement is very limited in the literature. The aim of this study was to determine the effect of steroid replacement on TFT and anti-thyroid peroxidase antibody (anti-TPO-Ab) titer in Addison's disease with primary hypothyroidism.

MATERIALS AND METHODS

This observational study was conducted in a tertiary care center in South India. Six Addison's disease patients with primary hypothyroidism, who were only on steroid replacement, were included in the study. Low serum cortisol (<83 nmol/L) with high plasma adrenocorticotropic hormone (>22 pmol/L) and/or hyperpigmentation of skin/mucous membranes was considered as the diagnostic criteria for Addison's disease. Primary hypothyroidism (both overt and subclinical) was defined as high thyroid stimulating hormone (TSH) with/without low free thyroxine (fT4). TFT and anti-TPO-Ab were performed before and after steroid replacement in all of them.

RESULTS

Poststeroid replacement, there was a normalization of TSH in all but one subjects. In overt hypothyroidism patients, fT4 also normalized. The improvement in TFT was not associated with decreasing titer of the anti-TPO-Ab in all six patients. However, there was a significant difference in TSH after steroid replacement compared to the baseline status.

CONCLUSIONS

The concept of normalization of primary hypothyroidism with cortisol replacement in patients with Addison's disease should be recognized to avoid iatrogenic thyrotoxicosis caused by thyroxine replacement. Both autoimmune and nonautoimmune mechanisms contribute to these alterations.

Papillary thyroid carcinoma and subclinical thyrotoxicosis: Brief insight into the thyroid regulators other than thyroid stimulating hormone

Papillary thyroid carcinoma (PTC) is the most common thyroid malignancy. It usually develops in euthyroid patients with history of long standing Hashimoto's thyroiditis. Here, we describe the development of PTC in a seronegative patient with subclinical thyrotoxicosis. We suggest that any cold nodule having high-risk features on ultrasonography in hyperthyroid patients should be thoroughly evaluated for the possibility of a thyroid malignancy and the possible role of nonthyroid stimulating hormone regulatory molecules, in thyroid carcinogenesis needs to be further explored.

Predictors for diagnosing metabolic syndrome among hypertensive patients in a tertiary care centre

Metabolic syndrome (MS) was present in 71% of adult hypertensive subjects according to modified National Cholesterol Education Program Adult Treatment Panel III (NCEP ATP-III) criteria in a tertiary care health centre. Female gender and higher body mass index (BMI) were predictors for MS among these patients. BMI cut off of 23 (overweight) had sensitivity of 94% and positive predictive value of 75% for diagnosing MS among them.

Radioiodine therapy in patients with Graves' disease and the effects of prior carbimazole therapy

The use of radioiodine as the first line of treatment in Graves' disease is restricted in India because of its limited availability and an unrealistic risk perception associated with it. Additionally, the effectiveness of radioiodine ablation in Graves' disease is influenced by many factors. Prior medical antithyroid therapy is one such important factor.

AIMS

To analyze the efficacy of low dose radioiodine therapy (5 mCi) in treatment of naive patients of Graves' disease in comparison to that in which it was already primed with an antithyroid drug, carbimazole.

SETTINGS AND DESIGN

A non-randomized, interventional study conducted in the Department of Medicine and Endocrinology of a tertiary care institute in South India.

MATERIALS AND METHODS

The study had two groups; Group A (36 treatment naive, uncomplicated Graves' disease patients) and B (34 Graves' disease patients on carbimazole prior to radioiodine therapy). Both groups had baseline clinical, biochemical evaluation and were reassessed at 3 and 6 months for evaluating the clinical status for possible documentation of cure.

RESULTS

The cure rate was 61.1% in drug naive group and 58.8% in pretreated group at 6 months following radioiodine (P = 0.845). Higher baseline 999m technicium (99m Tc) uptake, male gender, BMI and higher baseline free thyroxine (fT4) level predicted treatment failure following radioiodine therapy.

CONCLUSIONS

Administration of carbimazole prior to low dose radioiodine therapy does not alter the efficacy of radioiodine. Low fixed dose (5 mCi) of radioactive iodine may be a safe and effective primary therapeutic option in Graves' disease patients pretreated with antithyroid drugs.

Differential response of idiopathic sporadic tumoral calcinosis to bisphosphonates

CONTEXT

Tumoral calcinosis is a disorder of phosphate metabolism characterized by ectopic calcification around major joints. Surgery is the current treatment of choice, but a suboptimal choice in recurrent and multicentric lesions.

AIMS

To evaluate the efficacy of bisphosphonates for the management of tumoral calcinosis on optimized medical treatment.

SETTINGS AND DESIGN

The study was done in the endocrine department of a tertiary care hospital in South India. We prospectively studied two patients with recurrent tumoral calcinosis who had failed therapy with phosphate lowering measures.

MATERIALS AND METHODS

After informed consent, we treated both patients with standard age adjusted doses of bisphosphonates for 18 months. The response was assessed by X ray and whole body 99mTc-methylene diphosphonate bone scan at the beginning of therapy and at the end of 1 year. We also estimated serum phosphate levels and urinary phosphate to document serial changes.

RESULTS

Two patients (aged 19 and 5 years) with recurrent idiopathic hyperphosphatemic tumoral calcinosis, following surgery were studied. Both patients had failed therapy with conventional medical management - low phosphate diet and phosphate binders. They had restriction of joint mobility. Both were given standard doses of oral alendronate and parenteral pamidronate respectively for more than a year, along with phosphate lowering measures. At the end of 1 year, one of the patients had more than 95% and 90% reduction in the size of the lesions in right and left shoulder joints respectively with total improvement in range of motion. In contrast, the other patient (5-year-old) had shown no improvement, despite continuing to maintain normophosphatemia following treatment.

CONCLUSIONS

Bisphosphonate therapy in tumoral calcinosis is associated with lesion resolution and may be used as a viable alternative to surgery, especially in cases with multicentric recurrence or treatment failure to other drugs.

Feto-maternal outcomes in women with and without gestational diabetes mellitus according to the International Association of Diabetes and Pregnancy Study Groups (IADPSG) diagnostic criteria

BACKGROUND

Gestational diabetes mellitus (GDM) is responsible for majority of pregnancies complicated with diabetes mellitus. Both the screening (universal vs. selective) and the diagnostic criteria of GDM has been the subject of considerable controversy.

METHODS

This prospective cohort study was undertaken at Pondicherry Institute of Medical Sciences, Puducherry from August 2011 to July 2012. All the patients attending antenatal clinic underwent oral glucose tolerance test (OGTT) with 75g of anhydrous glucose between 24 and 32 weeks of gestation. Those patients diagnosed as GDM according to IADPSG diagnostic criteria were treated with diet and physical activity with or without insulin. All the antenatal and perinatal outcomes were noted.

RESULTS

The prevalence of GDM in our study was 27% (83/304). Out of all the GDM patients, 87% (72/83) cases were diagnosed by raised FBS alone or with other two values. A significant family history of diabetes mellitus was found among GDM mothers compared to non-GDM group (10.8% vs. 3.6%, p=0.01). Insulin was required only in 8 patients for glycemic control. The GDM patients delivered at significantly lower gestational age (p=0.02) with more antenatal complications (25% vs. 12%, p=0.02). Among neonatal outcomes, there was a significant difference only in the need for NICU admission>24h between GDM and non-GDM groups (p=0.02).

CONCLUSION

The prevalence of GDM increases with universal screening using IADPSG diagnostic criteria in India. The antenatal complications are present in up to one fourth of these patients.

Congenital hypothyroidism - An usual suspect at an unusual age: A case series

Menorrhagia is the most common menstrual irregularity in hypothyroid women. However, it is an uncommon presentation of congenital hypothyroidism (CH). In the era of newborn screening across the world, when CH is extremely rare, we came across four cases of CH due to delayed diagnosis, presenting in adulthood with severe menorrhagia.

Acute lymphocytic leukaemia presenting as a metabolic bone disease

A 7-year-old boy presented with the acute onset of low backache of 2 months duration. An x-ray of thoracolumbar spine revealed multiple vertebral fractures, and biochemical evaluation showed hypercalcaemia with a suppressed parathyroid hormone which raised the possibilities of malignancy, granulomatous conditions or vitamin D toxicity. Despite the absence of blast cells in his blood, the bone marrow biopsy was unequivocally diagnostic of acute lymphoblastic leukaemia.

Pregnancy in polycystic ovary syndrome

Polycystic ovary syndrome affects 6 to 15% of reproductive age women worldwide. It is associated with increased risk of miscarriage, gestational diabetes mellitus, hypertensive disorders of pregnancy, preterm delivery, and birth of small for gestational age infant. Many studies on issues relating to pathophysiology and management of these complications have been published recently. These issues are being reviewed here using relevant articles retrieved from Pubmed database, especially from those published in recent past.

Reassessment of elicitation of myoedema in evaluation of overt hypothyroidism: A pilot study

INTRODUCTION

There is a need to reassess the significance of myoedema in evaluation of overt hypothyroidism in the current day clinical practice. It is commonly checked for by flicking across the biceps belly expecting a transient mound at the points of tactile stimuli with mild pressure.

AIM AND OBJECTIVE

To assess elicitation of myoedema in overt hypothyroidism (defined arbitrarily as TSH >50 mIU/L in primary hypothyroidism and fT4 <0.6 ng/dl in secondary hypothyroidism).

RESULTS

The 28 primary overt hypothyroid (OH) patients were divided into three groups as mild, moderate, and severe depending on TSH levels as those with 50-100, 100-150, and >150 mIU/L. Myoedema was elicited in 8 of 13 in the severe OH group, in 2 of 7 in moderate OH group and in 1 of 8 in the mild OH group. In the group of secondary hypothyroidism, myoedema was elicitable in one of two patients. The odds ratio for presence of both myoedema and clinical features of myopathy in a group of overt hypothyroid patients with TSH >150 mIU/L as compared to <150 mIU/L was 17.5. Similarly, the odds ratio for the presence of only myoedema was 6.4 while the odds ratio for presence of only clinical features of myopathy was 3.67. While the odds ratios involving presence of myoedema neared statistical significance, that with the presence of clinical features of myopathy alone did not.

CONCLUSION

Examination for eliciting myoedema is useful when evaluating a case of overt hypothyroidism.

Internal jugular vein adrenocorticotropic hormone estimation for diagnosis of adrenocorticotropic hormone-dependent Cushing's syndrome: Ultrasound-guided direct jugular vein sample collection

AIM OF STUDY

To assess the utility of internal jugular vein (IJV) / peripheral adrenocorticotropic hormone (ACTH) gradient in determining the etiology of ACTH- dependent Cushing's syndrome.

MATERIALS AND METHODS

Patients with ACTH-dependent Cushing's syndrome, (except children less than 12 years), had IJV blood collection under ultrasound guidance using a linear 7 MHZ probe. Blood was collected with a 21 G needle at the level of mandible with the patient in supine position. Six ml of blood was collected sequentially from right and left internal jugular veins for ACTH and prolactin estimation. Peripheral blood for ACTH and prolactin was taken from a previously placed IV cannula in the antecubital vein.

RESULTS

Thirty patients (20 F, 10 M, age 14 to 50 yrs) were enrolled for this study. Source of ACTH excess was pituitary in 22, ectopic ACTH in 4, and unknown in 4 cases. Using an IJV: Peripheral ACTH ratio of ≥ 1.6, 15 out of 22 Cushing's disease patients were correctly identified. However, 1 out of 4 ectopic Cushing also had IJV: Peripheral ratio ≥ 1.6. Overall, it had sensitivity of 68% with specificity of 75% while MRI pituitary and HDDST had sensitivity of 86% and 59%, respectively, with specificity of 100% each.

CONCLUSION

IJV: Peripheral ACTH gradient was observed in 68% of patients with Cushing's disease. Simultaneous IJV and peripheral sample collection with CRH stimulation may improve sensitivity and specificity of this test.