Approach to management of hypo and hyperthyroidism in Bangladesh: a nationwide physicians' perspective survey

Introduction

Thyroid disorders are common clinical conditions globally. The objective of the present study was to evaluate the physicians' approach to the diagnosis and treatment of thyroid disorders in Bangladesh.

Methods

The present nationally representative cross-sectional study was conducted among 662 physicians of different levels (general practitioners as well as specialists) from different hospitals in Bangladesh from January to June 2023. A self-administered semi-structured questionnaire including information about demographics and practice patterns for the diagnosis and management of thyroid disorders was used for data collection. Descriptive statistics were used to analyze the data.

Results

The American Thyroid Association (ATA) guidelines were the most commonly followed guidelines for the diagnosis and management of thyroid disorders (60%), followed by the American Association of Clinical Endocrinologists (AACE) guidelines (18%) and the European Thyroid Association (ETA) guidelines (9%). Serum TSH, free T3 and free T4 levels were the most frequently used diagnostic tests for the evaluation and follow-ups of both hypothyroid and hyperthyroid states in adults, pregnant women and children, followed by total T3 and total T4 levels. Other tests, such as anti-TPO antibody, anti-TG antibody, anti-TPO, ultrasound scan of the thyroid gland, etc., were rarely used by the participating physicians. Levothyroxine at a dose of 25 to 50 mcg and carbimazole at a dose of 30 to 45 mg were the most frequently used drugs for hypothyroid and hyperthyroid patients, respectively. Almost 65% of the physicians suggested routine thyroid function tests before surgery. In addition, more than 90% of the physicians agreed that thyroid screening for pregnancy, neonates, school children and adults would be mandatory.

Conclusion

The majority of the physicians participating in our study followed relevant guidelines for the diagnosis and management of thyroid disorders in Bangladesh. However, there are still some gaps to be improved, as a good number of physicians did not follow specific guidelines for these disorders.

Status of lipid control in Bangladeshi subjects with type 2 diabetes mellitus on lipid-lowering drugs: a multicenter, facility-based, cross-sectional study

BACKGROUND

Achievement of lipid targets is crucial in patients with type 2 diabetes mellitus (T2DM) to mitigate the risk of cardiovascular diseases (CVD). Data on lipid-control status among patients with T2DM in Bangladesh are scarce. This study was conducted to determine the lipid-control status among patients with T2DM who were on lipid-lowering drugs in the country.

METHODS

This cross-sectional study was conducted in the diabetes outpatient departments of several tertiary hospitals in Bangladesh from January 2022 to December 2022. Adults of both sexes diagnosed with T2DM for at least one year and were on the lipid-lowering drug(s) for a minimum of 3 months were included in the study by consecutive sampling. Patients' data were collected by face-to-face interviews, and blood samples were collected for fasting lipid profile. The lipid target was set at < 200 mg/dL for total cholesterol (TC), < 150 mg/dL for triglyceride (TG), < 100 mg/dL for low-density lipoprotein cholesterol (LDL-C), > 40 mg/dL for high-density lipoprotein cholesterol (HDL-C), and < 160 mg/dL for non-HDL cholesterol (non-HDL-C).

RESULT

Three thousand sixty patients (age 44.7 ± 13.3 years, female 57%) with T2DM were evaluated. Overall, almost 81% of the study subjects achieved the LDL-C target. Besides, TC, TG, HDL-C, and non-HDL-C targets were achieved by 40.8, 21.6, 66.3, and 44.1% of patients, respectively. However, all the lipid parameters were under control in only 8.8% of patients. Almost 77.6% of the patients with ischemic heart disease, 81.5% of patients with stroke, and 65% of patients with CKD had LDL levels < 70 mg/dL. Only 10.03% achieved the HbA1c target of < 7%. 7.4% of patients achieved both HbA1c < 7% and LDL < 100 mg/dL and 5% achieved both HbA1c < 7% and LDL < 70 mg/dL. Advanced age (aOR 0.97, 95% CI 0.96, 0.98, p < 0.001), longstanding T2DM (aOR 0.53, 95% CI 0.39, 0.72, p < 0.001), and non-statin therapy (aOR 0.25, 95% CI 0.16, 0.37, p < 0.001) were negatively associated with lipid control (LDL < 100 mg/dL) while using oral hypoglycemic drugs or insulin (aOR 2.01, 95% CI 1.45, 2.77, p < 0.001) and having cardiovascular comorbidity (aOR 3.92, 95% CI 3.00, 5.12, p < 0.001) were positively associated with lipid control.

CONCLUSION

Though most patients with T2DM achieved their target LDL level, the prevalence of both glycemic and overall lipid control was low in our study despite lipid-lowering therapy.

Comparison of fasting and random lipid profiles among subjects with type 2 diabetes mellitus: an outpatient-based cross-sectional study in Bangladesh

BACKGROUND

Despite the wide acceptability of fasting lipid profiles in practice, emerging evidence suggests that random lipid profiles might be a convenient alternative for lipid measurement. The objective of the present study was to compare the fasting and random lipid profile among subjects with type 2 diabetes mellitus (T2DM).

METHODS

The present cross-sectional study included 1543 subjects with T2DM visiting several endocrinology outpatient clinics throughout Bangladesh from January to December 2021. The fasting lipid profile was measured in the morning following 8-10 h of overnight fasting, and the random lipid profile was measured at any time of the day, irrespective of the last meal. The values of fasting and random lipids were compared using the Wilcoxon signed-rank test and Spearman rank correlation coefficients.

RESULTS

In this study, a good level of correlation was observed between fasting and random lipid levels [r = 0.793, p < 0.001 for triglyceride (TG); r = 0.873, p < 0.001 for low-density lipoprotein cholesterol (LDL-C); r = 0.609, p < 0.001 for high-density lipoprotein cholesterol (HDL-C); and r = 0.780, p < 0.001 for total cholesterol (TC)]. In addition, TG and TC levels increased by 14% and 0.51%, respectively, in the random state compared to the fasting state (p- <0.05), while LDL-C levels decreased by 0.71% (p-value 0.42). No change was noticed in the HDL-C level. The difference between fasting and random lipid profiles was similar irrespective of patients' age, sex, BMI, glucose-lowering drug(s), and lipid-lowering therapy.

CONCLUSIONS

Random lipid profile correlates significantly with fasting lipid profile with little difference. Hence, it might be a reliable alternative for fasting lipid profile in patients with T2DM.

Sexual dysfunction in women with type 2 diabetes mellitus: A single-centre cross-sectional study from Bangladesh

Objective

Sexual dysfunction among women with diabetes is a common but neglected health issue worldwide. The objective of the present study was to investigate the prevalence of sexual dysfunction and its associated factors among women with type 2 diabetes mellitus (T2DM).

Subjects and methods

This cross-sectional comparative study comprises 150 women with diabetes and 100 healthy women without diabetes who visited the endocrinology outpatient department of Mymensingh Medical College Hospital (MMCH). The data were collected from July to December 2019. Sexual dysfunction was assessed by the 19-item Female Sexual Function Index (FSFI). Informed consent was obtained before participation. Collected data were analysed by SPSS 26.

Results

More women with diabetes than control subjects reported sexual dysfunction (79% vs. 72%; p = 0.864). The global FSFI score was lower among the diabetes patients than among the healthy controls (20.8 ± 7.2 vs. 23.7 ± 4.8; p < 0.001). Patients with T2DM scored significantly lower in the domains of desire (p = 0.04), lubrication (p = 0.01), orgasm (p = 0.01), and satisfaction (p < 0.001), but not the domain of arousal (p = 0.09). A prolonged duration of diabetes was the primary contributor to orgasm problems (adjusted odds ratio, aOR 1.3, 95% CI 1.1-1.7) and painful intercourse (aOR 1.2, 95% CI 1.1- 1.5).

Conclusion

Sexual problems are frequent in women with diabetes. Inclusion of sexual health in comprehensive diabetes management is crucial to address this problem as well as to improve the quality of life of female diabetes patients.

Comparison of simplicity, convenience, safety, and cost-effectiveness between use of insulin pen devices and disposable plastic syringes by patients with type 2 diabetes mellitus: a cross-sectional study from Bangladesh

INTRODUCTION

Insulin pen devices and disposable plastic insulin syringes are two common tools for insulin administration. This study aims to compare the simplicity, convenience, safety, and cost-effectiveness of insulin pens versus syringe devices in patients with type 2 diabetes mellitus (T2DM).

METHODS

A cross-sectional study was conducted at 14 diabetes clinics throughout Bangladesh from November 2021 to April 2022 among adults with T2DM injecting insulin by pen devices or disposable insulin syringes at least once a day for at least one year by purposive sampling. The simplicity, convenience, and safety of insulin devices were assessed using a structured questionnaire, and the study subjects were scored based on their answers; higher scores indicated a poorer response. Total scores for simplicity, convenience, and safety were obtained by adding the scores for relevant components. Their average monthly medical expense and cost of insulin therapy were recorded. The median values of the total scores and monthly expenses were compared between pen devices and disposable syringe users.

RESULTS

737 subjects were evaluated; 406 were pen users, and 331 were vial syringe users. The pen users had lower median scores for simplicity [6.0 (5.0-8.0) vs. 7.0 (5.0-9.0), p = 0.002], convenience [4.0 (3.0-6.0) vs. 5.0 (4.0-6.0), p < 0.001], and safety [7.0 (6.0-8.0) vs. 7.0 (6.0-9.0), p = 0.008] than vial syringe users. Pen devices were more expensive than vial syringes in terms of average medical expense per month [BDT 5000 (3500-7000) vs. 3000 (2000-5000), p < 0.001], the total cost of insulin therapy per month [BDT 2000 (1500-3000) vs. 1200 (800-1700), p < 0.001] and cost per unit of insulin used [BDT 2.08 (1.39-2.78) vs. 0.96 (0.64-1.39), p < 0.001]. Non-significant differences in favor of pens were observed in HbA1c levels [8.7 (7.8-10) vs. 8.9 (7.9-10)%, p = 0.607] and proportions of subjects having HbA1c < 7% (6.9 vs. 6.3%, p = 0.991).

CONCLUSION

Insulin pens are simpler, more convenient, and safe but more expensive than vial syringes. Glycemic control is comparable between pen and syringe users. Long-term follow-up studies are needed to determine the clinical and economic impacts of such benefits of insulin pens.

Prothrombin time and activated partial thromboplastin time in women with gestational diabetes mellitus

Impact of gestational diabetes mellitus (GDM) on the coagulation system still remains unclear and there is limited data available regarding haemostatic changes in GDM in Bangladesh. This study was aimed at determining plasmaprothrombin time (PT), activated partial thromboplastin time (APTT) in women with GDM. This cross sectional study encompassed 44 GDM (age: 28.5±3.8 years, BMI: 27.2±4.0kg/m2; mean±SD) and equal number of pregnant women with normal glucose tolerance (NGT) diagnosed on the basis of WHO criterion 2013 at or after 24 weeks of gestation to see PT and APTT. Plasma glucose was measured by glucose oxidase method, PT and APTT by automated coagulation analyzer. There was no statistically significant difference between the GDM and NGT groups for PT (12.3±0.5 vs. 12.2±0.4 sec, mean±SD; P=0.40) or APTT (30.53±1.01 vs. 30.9±4.5 sec, mean±SD; P=0.56). In conclusion, PT and APTT do not differ between women with or without GDM. BSMMU J 2022; 15(3): 146-150

Vitamin D supplementation on prediabetic adults with vitamin D deficiency: a double-blind placebo-controlled randomized clinical trial

Hypovitaminosis D (<20 ng/mL) is thought to increase insulin resistance and meta-inflammation contributing to the pathogenesis of diabetes mellitus (DM). Correcting vitamin D deficiency in people with prediabetes might halt its progression to DM. The aim of this study was to examine the effect of vitamin D supplementation on insulin resistance, glycemic status, and inflammation in prediabetic adults with vitamin D deficiency. This doubleblind randomized placebo-controlled trial was done among 27 newly detected prediabetic adults with hypovitaminosis D randomly assigned to 60,000 IU of vitamin D weekly for eight weeks followed by monthly for the next four months or placebo along with lifestyle modification in both groups [vitamin D (n= 14) vs. Placebo (n=13). They were comparable in terms of sex, age and borlymass index. Glycemic status, fasting plasma glucose (FPG) and Hemoglobin A1C (HbA1C), insulin resistance (homeostasis model assessment of insulin resistance (HOMA-IR) and inflammatory marker high sensitivity C reactive protein (hs-CRP) were measured at baseline and after six months of intervention. Vitamin D levels (ng/mL) increased in both groups from baseline (vitamin D vs. placebo: 12.2±5.9 vs. 3.9±3.5, mean±SD). FPG (mmol/L) significantly decreased in the Vitamin D group (before vs. after: 5.9±0.6 vs. 5.5±0.7, P=0.016, mean±SD), whereas HbA1C (%) and hs- CRP (mg/L) significantly increased in the placebo group (before vs. after- HbA1C: 5.8±0.3 vs. 6.0±0.4, P<0.001; hs-CRP: 5.0±4.4 vs. 5.6±4.9, P=0.039, mean±SD). Percent changes in glycemic status, HOMA-IR, and hs-CRP were statistically similar between the groups. Our study failed to demonstrate the positive effects of vitamin D supplementation on reducing glucose, insulin resistance, or inflammatory marker in prediabetic adult patients with hypovitaminosis D. BSMMU J 2022; 15(3): 167-174

Hypothyroidism in Bangladesh: Is Autoimmunity the Next Big Threat?

In many low and middle-income countries, iodine-deficient hypothyroidism leads to complex public health consequences. However, increasing evidence from population-based studies has linked thyroid autoimmunity with excess iodine intake. The iodine supplementation program in Bangladesh was a success story. This cross-sectional study aims to assess the pattern and predictors of autoimmunity among Bangladeshi hypothyroid patients. In this study, 154 consecutive, newly detected, biochemically-confirmed patients with primary hypothyroidism were recruited from the Endocrinology outpatient department of Bangabandhu Sheikh Mujib Medical University and tested for anti-thyroid peroxidase and anti-thyroglobulin antibody levels from October 2015 and November 2016. Patterns of thyroid autoimmunity were assessed via descriptive statistics. Predictors of autoimmunity were assessed with multivariable mixed-effect logistic regression. The mean age of participants was 36.1±11.0 years, and 70.1% were female. The frequency of thyroid autoimmunity in the study subjects was very high, 89.0% were positive for either anti-TPO or anti-Tg antibodies and 48.7% were positive for both. More participants were positive for anti-TPO antibodies (82.5%) than anti-Tg antibodies (55.2%). The risk of autoimmunity was associated with the thyroid's structural abnormalities but not with functional status. Weight gain and hypertension were associated with autoimmunity, whereas diabetes was protective against autoimmunity.

Efficacy and Safety of Empagliflozin in Patients with Type 2 Diabetes Mellitus Fasting During Ramadan: A Real-World Study from Bangladesh

AIM

In Bangladesh, there is a large population of Muslims with type 2 diabetes mellitus (T2DM) who fast during Ramadan. Changes in the pattern of meal and fluid intake during this long-fasting hours may increase the risk of hypoglycaemia, hyperglycaemia, and dehydration. Our key point of focus was to evaluate the efficacy and safety of Empagliflozin, a sodium-glucose co transporter 2 inhibitor (SGLT2i), in patients with T2DM while fasting during Ramadan.

METHODS

This was a 24-weeks, multi-centre, open-label, two-arm parallel-group study. In this prospective type of observational study, we enrolled patients taking Empagliflozin and Metformin with or without a DPP-4 inhibitor in one group (n = 274) and a parallel group (n = 219) who were treated with Metformin with or without a DPP-4 inhibitor. The primary endpoint of this study was HbA1c reduction, weight loss and the number of reported or symptomatic hypoglycemic events. In secondary endpoints, we evaluated the changes from baseline in blood pressure, estimated glomerular filtration rate (eGFR), serum creatinine, and serum electrolyte, the proportion of volume depletion (≥1 event) and incidence of other adverse events (AEs) of interest potentially related to SGLT2 inhibitor.

RESULTS

During Ramadan, HbA1c reduction was significant in Empagliflozin arm (-0.49% vs -0.12%); [p < 0.001]. From before to the end of the study, significant weight reduction was seen in the Empagliflozin arm (-1.4 kg vs -0.09 kg); [p < 0.001]. We observed no significant increase in the incidence of hypoglycemia (0.7% vs 0.4%, p = 0.267) and volume depletion (2.6% vs 1.8%; p = 0.55) in both arm. All these milder forms events did not require any hospital admission. There was no report of serious adverse events or any discontinuation, or reduction of prescribed doses of empagliflozin during Ramadan.

CONCLUSION

Empagliflozin is efficacious and safe for treating adults with T2DM during Ramadan.

Vitamin D Status in Prediabetes and its Different Categories

Objectives: Data regarding vitamin D level and status among categories of prediabetes are scarce in the literature. This study is aimed to determine the level and status of vitamin D among adults with prediabetes and its different categories. Materials and methods: This crosssectional study was carried out in 111 newly detected adults with prediabetes according to American Diabetes Association 2018 criteria and 74 matched healthy control (normal glucose tolerance). People with prediabetes were categorized into impaired glucose tolerance, impaired fasting glucose and their combination group. Participants were recruited consecutively from the Department of Endocrinology, BSMMU to measure serum 25 hydroxyvitamin D by high performance liquid chromatography and serum intact parathormone, calcium, albumin and phosphate by chemiluminescent enzyme-labeled immunometric assay. Results: Vitamin D level and status were not significantly different between people with prediabetes & control and also in different categories of prediabetes. Severe vitamin D deficiency was significantly higher in people with prediabetes (27.5% vs 10%, p= 0.05). There were no associations between different blood glucose levels with vitamin D among adults with prediabetes. Conclusions:Vitamin D was not associated with prediabetes or its categories. Bangladesh Journal of Medical Science Vol. 21(1) 2022 Page : 120-128

Precocious puberty: diagnosis and management

Precocious puberty is commonly defined as puberty that starts before age 8 years in girls and 9 years in boys. The causes of it may range from a variant of normal development to various pathologic conditions. The etiology of precocious puberty is classified by the underlying pathogenesis into gonadotropin dependent central precocious puberty and peripheral precocious puberty which is independent of gonadotropin but due to different other causes. Variants of precocious puberty include premature thelarche, premature puberche and isolated premature menarche which imply onset of isolated changes without any other signs of sexual development. Precocious puberty might have an impact on final stature owing to premature epiphyseal fusion and also it has got influence on psychosocial wellbeing. Evaluation includes a detailed history, physical examination, biochemical testing and imaging directed towards suspected etiology. Gonadotropin releasing hormone (GnRH) analogues are effective for treatment of central precocious puberty. Treatment of peripheral precocious puberty should be based on the specific cause. Pubertal variants are usually non-progressive and need no treatment but should be monitored carefully. BIRDEM Med J 2022; 12(1): 62-69

Divergences in Clinical, Anthropometric, Metabolic, and Hormonal Parameters among Different Phenotypes of Polycystic Ovary Syndrome Presenting at Endocrinology Outpatient Departments: A Multicenter Study from Bangladesh

Background

Polycystic ovary syndrome (PCOS) is a heterogeneous androgen-excess disorder. Data comparing the PCOS phenotypes in Bangladesh are scarce.

Objectives

The objective of this study was to find out the distribution of Rotterdam classified PCOS phenotypes and to compare the phenotypes concerning clinical, anthropometric, metabolic, and hormonal parameters.

Subjects and Methods

In this cross-sectional study, 370 PCOS cases in the age group of 20-45 years diagnosed by the Rotterdam consensus criteria were recruited from the endocrinology outpatient departments of several tertiary hospitals of Bangladesh. Metabolic syndrome (MetS) was diagnosed using the International Diabetes Federation criteria.

Results

The prevalence of phenotypes A, B, C, and D were 59.2%, 14.1%, 11.9%, and 14.9%, respectively. More than one-third (34.6%) of the women had pre-hypertension (pre-HTN)/hypertension (HTN), 34.1% had abnormal glucose intolerance (AGT), 93.0% had dyslipidemia, and 57.0% had MetS. The hyperandrogenic phenotypes (A, B, and C) had higher prevalence of pre-HTN/HTN, AGT, dyslipidemia, and MetS compared to the normoandrogenic phenotype D, though the differences were statistically insignificant. The clinical and biochemical markers of hyperandrogenism (Ferriman-Gallwey score, hirsutism, acne, and serum testosterone levels) did not differ among the hyperandrogenic phenotypes. The serum prolactin level was highest in phenotype C. No differences were observed in most other clinical, anthropometric, metabolic, and hormonal parameters among the four phenotypes.

Conclusion

Phenotype A is the most prevalent phenotype of PCOS in our setting. The prevalence of MetS was considerably high. Most of the clinical, anthropometric, and metabolic parameters were similar across the four PCOS phenotypes in this study.

Insulin Injection Practice and Injection Complications - Results from the Bangladesh Insulin Injection Technique Survey

INTRODUCTION

Diabetes mellitus is highly prevalent in Bangladesh and insulin is often needed for diabetes control. We lack sufficient data on the insulin injection technique and injection-related complications.

METHODS

The Bangladesh Insulin Injection Technique Survey (BIITS) was conducted in 2018 in 18 centres throughout Bangladesh, involving 847 patients taking insulin for at least 6 months. All of the study subjects were interviewed using a structured questionnaire focusing on key insulin injection parameters.

RESULTS

The mean duration of insulin use by the study subjects was 3.84 (± 4.05) years and the mean daily dose of insulin was 41 (± 25) units. A total of 71.6% participants performed ≤2 injections/day and premixed insulins were the most commonly used insulins. Mean glycated haemoglobin (HbA1c) was 9.5% (± 2%). The proportion of syringe users and pen-device users was 68.1% and 31.9%, respectively. Most of the participants injected in the abdomen and rotated the injection site(s). The majority lifted the skinfold correctly and inserted the needle at a 90-degree angle, but their dwell times after injections were not adequate. A total of 9.2% of the subjects had injection-site lipohypertrophy (LH) and among them, 38.5% injected into the lesion. Patients with LH had higher HbA1c. Higher duration of insulin use (≥5 years), reusing needles more often (>10 times), and injecting at angles other than 90 degrees were independent predictors of LH. The incidences of hypoglycaemia (36.7%) and hyperglycaemia (67.4%) were very high, and subjects with LH had higher chances of both hypoglycaemia and hyperglycaemia. Though most (92.1%) of the patients received education about insulin injection initially, it was not repeated in the recent follow-up and was found to be ineffective.

CONCLUSION

A huge gap between the insulin administration guidelines and current practice was observed in this study. Complications of insulin injections were also common. Healthcare providers should pay more attention to insulin education and re-evaluate injection practices from time to time.

Antithyroid Antibody Status in Non-Pregnant Adult Bangladeshi Patients with Subclinical Hypothyroidism

Sub clinical hypothyroidism (SCH) is common in clinical practice. Autoimmunity is thought to be the most important cause of SCH. In this cross-sectional study, we investigated 120 SCH patients and 100 healthy controls attending the Endocrinology Outpatient Department of Bangabandhu Sheikh Mujib Medical University (BSMMU), Dhaka, Bangladesh from June 2014 to April 2015 for anti-thyroid antibodies (anti-TPO and anti-Tg). Measurement of serum TSH, FT4, anti-TPO, and anti-Tg antibodies were done by using the chemiluminescent sequential immunometric assay. SCH patients had a higher mean age; the frequencies of female subjects, those having family history of thyroid disease or other autoimmune diseases, and goiter were higher in SCH group than in the control group. Forty-five percent (45%) of SCH patients were positive for anti-thyroid antibodies (23.3% for both anti-TPO and anti-Tg, 16.7% for only anti-TPO, and 5% positive for only anti-Tg) in comparison to only 10% anti-thyroid antibody positive controls (none for both antibodies, 8% for only anti-TPO, and 2% positive for only anti-Tg). The SCH subjects in the lower age group, females and with a TSH >10μIU/mL had the higher frequency of thyroid autoimmunity. Female gender, high socioeconomic condition, the presence of other autoimmune diseases, the presence of goiter and TSH >10μIU/mL were associated with higher odds of anti-thyroid antibody positivity in the SCH group, though none were statistically significant. The frequency of anti-thyroid antibody was higher in SCH and was more prevalent among the females, younger patients and those having a goiter, other autoimmune diseases, and TSH >10μIU/mL.

Spontaneous hypoglycemia: a review

Spontaneous hypoglycemia is an important entity that may affect multiple organs. The differential diagnosis is broad in individuals with hypoglycemia in the absence of diabetes mellitus. Multiple etiologies may be present concurrently. Drugs, critical illnesses, hormone deficiencies, and non-islet cell tumors should be considered in those who are ill or taking medications. In apparently healthy individuals, endogenous hyperinsulinism due to insulinoma, functional β-cell disorders, or insulin autoimmune conditions are possible, as are accidental, surreptitious or factitious causes of hypoglycemia. Investigations should be guided by clinical scenario. Irrespective of the exact cause of the spontaneous hypoglycemia, treatment consists of correcting the glycemic state and preventing recurrence by alleviating underlying pathology. This review discusses the causes, diagnosis and management of spontaneous hypoglycemia. IMC J Med Sci 2019; 13(1): 001

Fine needle aspiration cytological diagnosis of thyroid nodule with its clinical correlation

<p><strong>Background:</strong> Nodular goiter is common in Bangladesh. Thyroid nodules are important for their malignant potential especially the solitary and cold ones and when functionally euthyroid. <strong></strong></p><p><strong>Objectives:</strong> This study was designed to investigate the frequency of malignancy and cellular aberration detected by fine needle aspiration cytology (FNAC) in euthyroid nodules and its correlation with clinical findings.<strong> </strong></p><p><strong>Methods:</strong> Subjects with nodular goiter attending Endocrine out patient department [n=150, nonpregnant, age (mean± SD): 37±12 years; sex (male: female): 21:129] were recruited for this study. All subjects underwent clinical risk stratification, estimation ofFT4 and TSH as well as ultrnsonogram (USG) and isotope scan of thyroid. Thyroid nodules were categorized into malignant, suspicious, benign and indeterminant on the basis of cellular character by FNAC. Statistical analysis was done by Chi-square and multiple regression analysis.<strong> </strong></p><p><strong>Results:</strong> Patients were mostly females (86%) and 4.7% had family history of thyroid problems. Some had recent changes of size (14.7%), pain in the nodule (4%) and dysphagia (6%). Nodules were solitary in 45.3% and the rest (54.7%) had multinodular goiter. Enlarged regional lymph node was found in 12.7% patients. About 41 % were partially-cold followed by cold nodules (26.7%), patchy (16.7%), isoform (12%) and hot (4%) by isotope scan. Frequency of malignant (10%) character was highest in cold nodules followed by uniform (5.6%), patchy (4.0%) and partially cold (1.6%) while none in hot nodules; which were 22.5%, 11.1 %, 4.0%, 9.8% and 16.7% respectively for suspicious nodules. About 17% showed cellular aberration and 4.7% were clearly malignant, whereas 124 (82.7%) were benign. Of the malignant, 4 were solitary and 3 were multinodular; which were 10 and 9 among the suspicious ones. A significant number (77%, 20 out of 26) among the malignant/suspicious nodules fell into moderate to high risk category (x²=22.861, p&lt;0.001), while 23.1 % of the FNAC proven malignant/suspicious nodules were of low risk category. Enlarged lymph nodes (p&lt;0.001), increased diameter of nodules of &gt;4 cm (p=0.039) and recent changes in nodular size (p=0.042) were independently and signifi­cantly related to cellular aberration. <strong></strong></p><p><strong>Conclusions:</strong> FNAC is a useful tool for cellular diagnosis of thyroid nodules. Clinical suspicion for malignancy strongly correlates with the FNAC findings. But a good number of clinically Low risk categories would escape malignant cellular character unless FNAC is done.</p>

Association of altered thyroid function and prolactin level in polycystic ovarian syndrome

Polycystic ovarian syndrome (PCOS) is a common disorder for female with fertile age. Along with other clinical and biochemical manifestations, thyroid function and prolactin level may be altered in patients with PCOS. This study aimed to evaluate the clinical and biochemical status, as well as alteration of thyroid stimulating hormone (TSH), prolactin (PRL) level in patients with PCOS. Present study comprised of 100 diagnosed PCOS patients according to revised Rotterdem Consensus criteria. All patients were studied for serum testosterone, LH (lutenizing hormone), FSH (follicle stimulating hormone), blood glucose, lipid profile as well as TSH, FT4 (free thyroxin) and prolactin level. Out of 100 PCOS patients 97 had hirsutism, 64 had acanthosis nigricans, where menstrual irregularities were in 94 patients. Diastolic blood pressure (74±1.1 vs. 77±0.9, mmHg; p=0.017), total cholesterol (163±5.3 vs. 193±6.2 mg/dl; p<0.001), low density lipoprotein (LDL, 104±3.7 vs. 124±4.9 mg/dl; p=0.002) and frequency of acanthosis (25% vs. 75%; p<0.001) were significantly higher among the patients having BMI>25 Kg/m2 than those of have ? 25 Kg/m2. Among the fertile women (n=53), 47% had primary and 41.5% had secondary infertility; whereas of the total patients, 21% had altered thyroid function and 6.1% had raised prolactin (PRL, ng/ml) level. Differences of TSH (4.1±3.6 vs. 3.5±6.8, mIU/L; p=0.725) was not significant; whereas level of PRL (13.87±6.9vs. 9.4±5.2 ng/ml; p=0.018) was significantly higher in the group of primary infertility. Hirsutism, menstrual disturbance and acanthosis were very common in PCOS. Both primary and secondary sterility were also commonly observed and PRL was higher in primary infertility. About one fifth of PCOS had altered thyroid function.Bangladesh Med J. 2016 Jan; 45 (1): 1-5

Increased frequency of positive antithyroid antibody in nodular goiter

<p><strong>Background:</strong> Nodular goiter is mostly a benign thyroid tumor. A change of frequency of nodular goiter in areas with sufficient iodine intake has been documented in several reports. However, contrary to common belief it may also be associated with autoimmunity is being observed recently by many investigators.</p><p><strong>Objectives:</strong> To observe association between thyroid autoimmunity and nodular goiter.</p><p><strong> Methods:</strong> This cross sectional study included two hundred cases and one hundred controls. Clinically suspected nodular thyroid patients were confirmed by USG. Selection of healthy control was done after exclusion of nodule clinically and by USG. Data were collected through a structured questionnaire.</p><p><strong>Results:</strong> Frequency of positive anti-thyroid antibodies was significantly higher in nodular goiter cases, when anti-TPO and anti-TG considered together (42.5% vs. 25.0%; χ²=8.792, p=0.003) as well as individually (anti-TPO: 37.0% vs. 20.0%; χ²=8.955, p=0.004 and anti-TG: 31.0% vs. 9.0%; χ²=17.861, p&lt;0.001) in the patients with nodular goiter than that of control. Conversely, there was no statistical difference between STN and MNG for antibody status when considered together (41.lvs. 42.5%; χ²=0.093; p=0.769) or separately (for anti-TPO: 34.2% vs. 38.6%; χ²=0.374, p=0.648 and anti TG: 27.4% vs. 33.1%; χ²=0.698, p=0.431). Also there was no statistical disparity for frequency of positivity of the two antibodies in STN (p=0.359) and MNG (p=0.167).</p><p><strong>Conclusion:</strong> Significant number of nodular goiter cases was positive for anti-thyroid antibodies.</p>

Effects of neonatally induced strabismus on binocular responses in cat area 18

Responses to binocular visual stimulation were compared in cortical area 18 of normal cats and in cats in which one eye was exodeviated by surgery early in postnatal life. In contrast to normal cats where most units (58%) were binocularly activated, relatively few units (10%) in strabismic cats were activated well by stimulation of either eye. Rather individual units were driven mainly via one eye or the other but not both. In addition, there was a tendency for more units to be driven well via the unoperated eye than via the exodeviated eye. Fewer cells preferring vertically oriented than horizontally oriented stimuli were found in area 18 of strabismic cats. This trend was observed for cells driven by either the normal or deviated eye and was especially marked among the small number of binocularly activated cells. Generally binocular responses and binocular interactions were found with stimulation at corresponding retinal points. In a few striking instances, however, the receptive fields of binocular neurons were located on noncorresponding retinal points at loci which would enable the cat to correlate the two images of an external object despite the large divergent strabismus. Quantitative responses to binocular stimuli presented at varied disparities and to stimuli with varied directions of motion in depth were compared in normal and strabismic cats. Despite the large strabismus, a reduced fraction of cortical neurons displayed substantial binocular interactions. In fact, binocular facilitation was as marked in the population of cells studied in strabismic cats as it was in normal animals. The major effect of strabismus was a reduction in the strength of binocular inhibition when units were tested with sideways motion. Disparity-specific responses to motion toward or away from the organism were little affected by strabismus. The degree of binocular facilitation and binocular inhibition among the cell population was similar in normal and strabismic cats. A subpopulation of units encountered in strabismic cats showed strong disparity-specific interactions for motion toward or away from the animal without equivalent modulation for sideways moving stimuli. Units with these properties were not found in normal animals and may, therefore, represent a special adaptation of the strabismic animals.

Prior strabismus protects kitten cortical neurons from the effects of monocular deprivation

The effects of 8 days of monocular eyelid suture beginning at 45 days of age were compared in normal kittens and in kittens which had been made strabismic by surgery early in life. In both groups of animals, monocular deprivation increased the relative strength of inputs from the non-deprived eye at the cortical level, but this effect was clearly less pronounced in the strabismic animals. The reduced effect of monocular deprivation in strabismic animals was observed mainly in the cortical hemisphere contralateral to the deprived eye.