Bone Mineral Density and Bone Turnover Marker in a Subclinical Thyrotoxic State in Young Premenopausal Women

BACKGROUND

Subclinical thyrotoxicosis (SCH) is characterized by normal serum thyroid hormone levels and low thyrotropin levels. The impact of this condition on the skeletal system may vary depending on its cause, yet the relationship is not fully comprehended in premenopausal women. Studies are scarce about its effects on bone health in our population.

OBJECTIVES

This study aims to evaluate the bone mineral density (BMD) and bone turnover markers in premenopausal women with SCH and determine if any differences exist based on the condition's etiology.

METHODS

A cross-sectional study was conducted at Ramaiah Medical College involving 36 participants for one year and six months after approval from the Ethics Committee. The carboxy-terminal telopeptide of type I collagen in blood and BMD were measured at the lumbar vertebrae (L1-L4) and femoral neck by dual-energy x-ray absorptiometry (Hologic v 2.0, Hologic, Massachusetts, U.S.). Statistical analysis was done using IBM SPSS Statistics for Windows, Version 20 (Released 2011; IBM Corp., Armonk, New York, United States).  Results: The mean age of the study population was 35.2 ± 7.2 years. The etiology was Graves' disease [n=11 (33.3%)], iatrogenic [n=14(38.8%)], toxic adenoma [n=6 (15.1%)], and multi-nodular goiter [n=5 (15.1%)]. The mean BMI was 23.5 ± 3.8 kg/m2, and the mean levels of corrected calcium, phosphorus, and 25 hydroxy-vitamin D were 9.12 ± 0.25 mg/dl, 2.95 ± 0.34 mg/dl, and 29.4 ± 6.4 ng/ml, respectively. The mean BMD at hip and spine was 0.81 ±0.16 g/cm2 and 0.92±0.08 g/cm2 respectively. The mean Z-score was (-0.02 ± 0.8) and (-0.92± 0.08) at the hip and spine. No significant difference was observed in the BMD at the hip (p = 0.14) or spine (p = 0.44) between the endogenous and exogenous subclinical thyrotoxic subgroups. At the same time, the carboxy-terminal telopeptide of type I collagen was significantly different between the two groups (p<0.05).

CONCLUSION

In our cross-sectional study of premenopausal women with SCH, BMD at the hip or spine as measured by dual-energy X-ray absorptiometry did not reveal any significant reduction. The subclinical thyrotoxic state may not have an adverse effect on bone health in premenopausal females with sufficient levels of serum 25-hydroxy-vitamin D in the short term.

Bringing an end to diabetes stigma and discrimination: an international consensus statement on evidence and recommendations

People with diabetes often encounter stigma (ie, negative social judgments, stereotypes, prejudice), which can adversely affect emotional, mental, and physical health; self-care, access to optimal health care; and social and professional opportunities. To accelerate an end to diabetes stigma and discrimination, an international multidisciplinary expert panel (n=51 members, from 18 countries) conducted rapid reviews and participated in a three-round Delphi survey process. We achieved consensus on 25 statements of evidence and 24 statements of recommendations. The consensus is that diabetes stigma is driven primarily by blame, perceptions of burden or sickness, invisibility, and fear or disgust. On average, four in five adults with diabetes experience diabetes stigma and one in five experience discrimination (ie, unfair and prejudicial treatment) due to diabetes, such as in health care, education, and employment. Diabetes stigma and discrimination are harmful, unacceptable, unethical, and counterproductive. Collective leadership is needed to proactively challenge, and bring an end to, diabetes stigma and discrimination. Consequently, we achieved unanimous consensus on a pledge to end diabetes stigma and discrimination.

Communicative compathy and chronic care

The concepts of sympathy and empathy are well entrenched in social and medical literature. In this article, we explore a relatively less explored construct, compathy. Compathy, defined as feelings that are shared with others, is a higher level of emotional maturity, which helps in achieving better quality care. We propose further discussion and debate on how to measure, attain, and maintain compathy in chronic care practice.

Improving emotional and psychosexual well-being screening in women living with polycystic ovary syndrome: experiences from the United Kingdom and India

With increasing evidence of emotional well-being disorders associated with polycystic ovary syndrome (PCOS), effective screening processes are of utmost importance. We studied the impact of using questionnaires to screen for emotional and psychosexual well-being across different models of care for PCOS. We analysed the data from the surveys to assess the difference in the prevalence of emotional and psychosexual ill-being across ethnicity and region. In this prospective cohort study, we invited all women attending consultations for PCOS in Birmingham, UK, and Bengaluru and Navi Mumbai, India. Those who consented to participate in the study were invited to complete a pre-clinic survey about socio-demographic data, Hospital Anxiety and Depression Scale (HADS), Body Image Concern Inventory (BICI), Beliefs about Obese Person scale (BAOP), and Female Sexual Function Index score (FSFI) and a post-clinic survey on clinic experience, lifestyle advice, and specialist referral. A total of 115 women were included in this study. The rate of questionnaire completion was 98.3% (113/115), 97.4% (112/115), 93.04% (107/115), and 84.3% (97/115) for HADS, BICI, BAOP, and FSFI, respectively. In the post-clinic survey, 28.8% reported they were screened for anxiety, 27.1% for depression, and 45.8% for body image concerns. The prevalence of anxiety, depression, and body dysmorphic disorder through pre-clinic survey was 56.5% (50.0% UK vs 59.5% India, P = 0.483), 16.5% (13.9% UK vs 17.7% India, P = 0.529), and 29.6% (36.1% UK vs 26.6% India, P = 0.208), respectively. Surveys with validated questionnaires can improve screening for emotional and psychosexual well-being associated with PCOS which may be missed by ad hoc screening during consultations.

Experiences and expectations of physician communication: A focus group discussion with Indian patients with type 2 diabetes mellitus

OBJECTIVES

This pilot study aimed to: (a) understand the experiences of Indian patients with type 2 diabetes mellitus and their expectations of their physicians during a medical consultation, (b) serve as a preliminary study to inform the development of a larger project exploring and improving patients' communication experiences, and (c) assess whether the pilot study findings indicate the viability of using the Relationship: Establishment, Development, and Engagement model of communication as the conceptual framework for the larger project.

METHODS

Using convenience sampling, 11 patients participated in a focus group discussion. Conventional content analysis was used.

RESULTS

Two themes were generated: (a) A plethora of negative feelings: experiences of the physician's verbal and nonverbal communication styles, and (b) 'I know what I want': Expectations of communication by patients from their physician.

CONCLUSIONS

The medical encounter with the physician elicited a range of negative experiences and clear expectations from the patients with type 2 diabetes mellitus. This pilot points to the need for (a) a mixed methods approach to comprehensively examine the communication needs of patients with type 2 diabetes mellitus from their physician, (b) understand physicians' communication practices, and (c) using these findings, culturally adapt and test the Relationship: Establishment, Development, and Engagement to improve physicians' communication skills in India.

Emotional and psychosexual well-being is influenced by ethnicity and birthplace in women and individuals with polycystic ovary syndrome in the UK and India

OBJECTIVE

To assess the association of ethnicity and birthplace on emotional and psychosexual well-being in women with polycystic ovary syndrome (PCOS).

DESIGN

Cross-sectional study.

SETTING

Community recruitment via social media campaigns.

POPULATION

Women with PCOS completing an online questionnaire in September-October 2020 (UK) and May-June 2021 (India).

METHODS

The survey has five components, with a baseline information and sociodemographic section followed by four validated questionnaires: Hospital Anxiety and Depression Scale (HADS); Body Image Concern Inventory (BICI); Beliefs About Obese Persons Scale (BAOP); and Female Sexual Function Index (FSFI).

MAIN OUTCOME MEASURES

We used adjusted linear and logistic regression models, adjusting for age, education, marital status and parity, to evaluate the impact of ethnicity and birthplace on questionnaire scores and outcomes (anxiety and/or depression, HADS ≥ 11; body dysmorphic disorder (BDD), BICI ≥ 72).

RESULTS

A total of 1008 women with PCOS were included. Women of non-white ethnicity (613/1008) reported higher rates of depression (OR 1.96, 95% CI 1.41-2.73) and lower BDD (OR 0.57, 95% CI 0.41-0.79) than white women (395/1008). Women born in India (453/1008) had higher anxiety (OR 1.57, 95% CI 1.00-2.46) and depression (OR 2.20, 95% CI 1.52-3.18) but lower BDD rates (OR 0.42, 95% CI 0.29-0.61) than women born in the UK (437/1008). All sexual domains, excluding desire, scored lower for non-white women and women born in India.

CONCLUSIONS

Non-white women and women born in India reported higher emotional and sexual dysfunction, whereas white women and women born in the UK reported higher body image concerns and weight stigma. Ethnicity and birthplace need to be considered for tailored, multidisciplinary care.

Pheochromocytoma: Clinical Experience From a Single Tertiary Care Center in India

INTRODUCTION

Pheochromocytoma is a catecholamine-secreting tumor arising from adrenomedullary chromaffin cells that has a varied clinical presentation. Identification of this tumor, which has episodic symptoms, is a diagnostic challenge for clinicians. Diagnosis at an appropriate time is important because it is associated with significant morbidity and mortality. This study aims to mitigate the limited availability of data in our geographical area.

AIMS AND OBJECTIVES

To assess the clinical, biochemical, and radiological features and outcomes of patients diagnosed with pheochromocytoma at our center.

MATERIALS AND METHODS

This is a retrospective study. Patients diagnosed with pheochromocytoma during 2015-2023 were included in the study. Clinical, biochemical, and radiological data were collected at presentation, post-surgery, discharge, and until the last follow-up; data were retrieved from hospital records. Statistical analysis was done using IBM Corp. Released 2011. IBM SPSS Statistics for Windows, Version 20.0. Armonk, NY: IBM Corp.

RESULTS

This study included 19 patients, of whom 10 (52.6%) were female. The most common clinical presentation was a hypertensive crisis in patients with pre-existing hypertension (63.1%), followed by headache (47.3%). The classical triad of headache, palpitation, and sweating was seen in only three patients (15.7%). The mean tumor size was 5.01±2.06 cm, with a range of 2.5 to 12 cm. All patients underwent adrenalectomy; six patients (31.5%) had perioperative complications, with post-operative hypotension being the most common at 21% (n = 4), followed by an acute coronary event during alpha blockade in one patient (0.05%) and an intra-operative hypertensive crisis in one patient (5%). A biochemical remission rate post-surgery was achieved in 17 (89.47%) patients.

CONCLUSIONS

Hypertensive crisis in patients with pre-existing hypertension was the predominant presenting feature in most of our patients. Female predominance was noted (52.3%) compared to males. Perioperative complications were observed in 31.5% of patients, with post-operative hypotension being the most common complication.

IDEA Group Consensus Statement on Medical Management of Adult Gender Incongruent Individuals Seeking Gender Affirmation as Male

Gender-affirming hormone therapy (GAHT) is the most frequent treatment offered to gender-incongruent individuals, which reduces dysphoria. The goal of therapy among gender-incongruent individuals seeking gender affirmation as male is to change their secondary sex characteristics to affect masculine physical appearances. GAHT greatly improves mental health and quality of life among gender incongruent individuals. India-specific guideline for appropriate care for gender-incongruent individuals is almost absent. This document is intended to assist endocrinologists and other healthcare professionals interested in gender incongruity for individuals seeking gender affirmation as male. A safe and effective GAHT regimen aims to effect masculinising physical features without adverse effects. In this document, we offer suggestions based on an in-depth review of national and international guidelines, recently available evidence and collegial meetings with expert Indian clinicians working in this field. Clinicians represented in our expert panel have developed expertise due to the volume of gender incongruent individuals they manage. This consensus statement provides protocols for the hormone prescribing physicians relating to diagnosis, baseline evaluation and counselling, prescription planning for masculinising hormone therapy, choice of therapy, targets for monitoring masculinising hormone therapy, clinical and biochemical monitoring, recommending sex affirmation surgery and peri-operative hormone therapy. The recommendations made in this document are not rigid guidelines, and the hormone-prescribing physicians are encouraged to modify the suggested protocol to address emerging issues.

Changes in HbA1c and weight in people with Type 2 Diabetes after continuous glucose monitoring based Diabefly-Pro digital therapeutics program: Analysis of real-world data (Preprint)

BACKGROUND

Digital therapeutic platforms facilitate health care through patient-centered strategies based on multidisciplinary teams and shared decision-making. Such platforms can be used for developing a dynamic model of diabetes care delivery, which can help in improving glycemic control by promoting long-term behavior changes in people with diabetes.

OBJECTIVE

This study aims to evaluate the real-world effectiveness of the Fitterfly Diabetes CGM digital therapeutics program for improving glycemic control in people with type 2 diabetes mellitus (T2DM) after the completion of 90 days in the program.

METHODS

We analyzed deidentified data of 109 participants in the Fitterfly Diabetes CGM program. This program was delivered through the Fitterfly mobile app coupled with continuous glucose monitoring (CGM) technology. This program consists of 3 phases: the first phase is observation, wherein the patient's CGM readings are observed for 7 days (week 1); the second phase is the intervention; and the third phase aims at sustaining the lifestyle modification introduced during the second phase. The primary outcome of our study was the change in the participants' hemoglobin A_1c (HbA_1c) levels after program completion. We also evaluated the changes in participant weight and BMI after the program, changes in the CGM metrics in the initial 2 weeks of the program, and the effects of participant engagement in the program on improving their clinical outcomes.

RESULTS

At the end of the 90 days of the program, the mean HbA_1c levels, weight, and BMI of the participants were significantly reduced by 1.2% (SD 1.6%), 2.05 (SD 2.84) kg, and 0.74 (SD 1.02) kg/m² from baseline values of 8.4% (SD 1.7%), 74.45 (SD 14.96) kg, and 27.44 (SD 4.69) kg/m² in week 1, respectively (P<.001). The average blood glucose levels and time above range values showed a significant mean reduction by 16.44 (SD 32.05) mg/dL and 8.7% (SD 17.1%) in week 2 from week 1 baseline values of 152.90 (SD 51.63) mg/dL and 36.7% (SD 28.4%), respectively (P<.001 for both). Time in range values significantly improved by 7.1% (SD 16.7%) from a baseline value of 57.5% (SD 25%) in week 1 (P<.001). Of all the participants, 46.9% (50/109) showed HbA_1c reduction ≥1% and 38.5% (42/109) showed weight loss ≥4%. The average number of times the mobile app was opened by each participant during the program was 108.80 (SD 127.91) times.

CONCLUSIONS

Our study shows that participants in the Fitterfly Diabetes CGM program showed a significant improvement in their glycemic control and reduction in weight and BMI. They also showed a high level of engagement with the program. Weight reduction was significantly associated with higher participant engagement with the program. Thus, this digital therapeutic program can be considered as an effective tool for improving glycemic control in people with T2DM.

Indian physicians' attitudes and practice regarding menopause and its management: a focus group discussion

OBJECTIVES

To explore Indian physicians' attitudes and practice toward menopause and its management. To contribute to the larger project aimed at developing communication skills and decision aids for Indian physicians and women.

METHODS

Using a cross-sectional design, purposive sampling, and a qualitative methodology, 10 Indian physicians (female, 6; male, 4; mean age, 51.5 years) who were practicing either endocrinology or gynecology were recruited to participate in a virtual focus group discussion. Questions explored physicians' attitudes toward menopause and their approach toward addressing menopause and related concerns with their patients. The focus group was analyzed using qualitative content analysis.

RESULTS

Three main themes emerged: (1) "The only way to get over it is to accept it": Attitudes toward menopause, (2) "More than menopausal hormone therapy, it is empathy that's required": Physiological and psychological symptom management and (3) Matching the empathic intent with skills: A need for training in the management of menopause.

CONCLUSIONS

The study findings underscore the need to introduce Indian physicians to empathic communication skills training, involve, and educate physicians about the international and national clinical guidelines regarding menopausal hormone therapy and alternative therapies, and techniques for distress screening and early referrals.

VIDEO SUMMARY

http://links.lww.com/MENO/B17.

Management of Glucocorticoid-Induced Hyperglycemia

Glucocorticoids are potent immunosuppressive and anti-inflammatory drugs used for various systemic and localized conditions. The use of glucocorticoids needs to be weighed against their adverse effect of aggravating hyperglycemia in persons with diabetes mellitus, unmask undiagnosed diabetes mellitus, or precipitate glucocorticoid-induced diabetes mellitus appearance. Hyperglycemia is associated with poor clinical outcomes, including infection, disability after hospital discharge, prolonged hospital stay, and death. Furthermore, clear guidelines for managing glucocorticoid-induced hyperglycemia are lacking. Therefore, this consensus document aims to develop guidance on the management of glucocorticoid-induced hyperglycemia. Twenty expert endocrinologists, in a virtual meeting, discussed the evidence and practical experience of real-life management of glucocorticoid-induced hyperglycemia. The expert group concluded that we should be proactive in terms of diagnosis, management, and post-steroid care. Since every patient has different severity of underlying disease, clinical stratification would help understand patient profiles and determine the treatment course. Patients at home with pre-existing diabetes who are already on oral or injectable therapy can continue the same as long as they are clinically stable and eating adequately. However, depending on the degree of hyperglycemia, modification of doses may be required. Initiating basal bolus with correction regimen is recommended for patients in non-intensive care unit settings. For patients in intensive care unit, variable rate intravenous insulin infusion could be temporarily used, but under supervision of diabetes inpatient team, and patients can be transitioned to subcutaneous insulin once stable baseline assessment and continual evaluation are crucial for day-to-day decisions concerning insulin doses. Glycemic variability should be carefully monitored, and interventions to treat patients should also aim at achieving and maintaining euglycemia. Rational use of glucose-lowering drugs is recommended and treatment regimen should ensure maximum safety for both patient and provider. Glucovigilance is required as the steroids taper during transition, and insulin dosage should be reduced subsequently. Increased clinical and economic burden resulting from corticosteroid-related adverse events highlights the need for effective management. Therefore, these recommendations would help successfully manage GC-induced hyperglycemia and judiciously allocate resources.

The Weight of Words: Indian Physicians' Perspectives on Patient Communication to Promote Diabetes Adherence

BACKGROUND

Effective communication by physicians can lead to improved patient adherence, resulting in better patient outcomes and increased patient satisfaction. This study: (i) examined communication with patients when they were non-adherent, (ii) examined attitudes toward common communication cues, and (iii) explored communication approaches to encourage diabetes adherence used by Indian physicians.

METHODS

Using a concurrent mixed methods approach, Indian physicians, specialized in diabetes and/or endocrinology were recruited, to complete a survey containing quantitative (n = 834) and qualitative (n = 648) questions. The questions included (i) whether physicians expressed disappointment and used scare tactics for non-adherent patients, (ii) to rate the importance of common communication cues when promoting adherence, and (iii) nested, qualitative questions to understand their communication approach to promote adherence. The data were analyzed using descriptive statistics and qualitative content analysis, respectively.

RESULTS

The quantitative study reported that the majority of the physicians sometimes showed their disappointment in their patient's progress (44.4%), sometimes used scare tactics to convey disease severity due to non-adherence (34.3%), and rated all communication cues as most important. The qualitative findings revealed that physicians used paternalistic (authoritative, educational, authoritarian) or collaborative (multistakeholder, patient-centered) approaches and the language cues of fear, blame, and threats to promote patient adherence.

CONCLUSION

These findings highlight the need for communication skill training programs for Indian physicians focused on empathic, non-verbal, supportive, and inclusive techniques so as to promote patient adherence. Further, these trainings need to use role-playing, video recording, and peer feedback methods to show physicians how to implement these skills during patient interactions.

The Weight of Words: A Mixed Methods Study to Understand Indian Doctors’ Perspectives and Experiences of Patient Communication

Background: Effective doctor communication can lead to increased treatment adherence and improved self-management among individuals living with diabetes. Yet, there is limited research in India which examines how doctors communicate, especially in terms of verbal and nonverbal communication. Aims: (1) To examine communication in clinic (verbal, nonverbal and basic content) among Indian doctors specialized in diabetes and endocrine care, and (2) to explore doctors’ styles of verbal and nonverbal communication. Methods: Using a mixed methods design, a survey containing quantitative (n=834) and qualitative (n=648) elements was filled out by doctors specialized in the fields of diabetes and endocrinology in India. Questions in the quantitative section included questions such as addressing patients’ illness-related concerns, acknowledging challenges of using insulin, and non-verbal behaviours. The qualitative section focussed on elaborating some responses made to the quantitative section, such as questions about explaining the cause of illness, listing words and phrases that may potentially impact patients, and explaining why the patients need to be initiated on insulin. The data was analysed using descriptive statistics and qualitative content analysis, respectively. Results: The findings of the quantitative study showed that the majority of the doctors (i) always greeted their patient as they entered the room (43.2%), (ii) addressed the risk of developing diabetes with patients’ siblings/children (87.9%), (iii) always acknowledged the challenges of using insulin (42.8%), and (iv) never asked patients’ experiences at the end of the consultation (31.9%). All common communication cues were rated as extremely important; eye contact (48.7%), tone of voice (41.5%), body language (39.6%), and words and phrases (41.8%). The qualitative findings revealed that doctors preferred to use verbal communication such as using authoritative language, educating patients using facts, analogies and behavioural information, employing empathetic language on occasion. Doctors also reported using negative words that portrayed fear, blame and disengagement in order to promote adherence. Discussion and Conclusion: The findings suggest that doctors rely on verbal rather than nonverbal communication when interacting with patients, with fear messages being a favoured means of ensuring adherence. It is possible that this may be because, while recognizing the value of nonverbal methods, doctors lack training in using these techniques in communication. Therefore, developing a communication skill training program for Indian doctors focussed on empathic and nonverbal communication can help to improve consultation and patient outcomes (e.g., adherence, patient satisfaction).

Intensification of Gla-100 with Prandial Insulin: A Stepwise Progression Toward Glycemic Control

The inadequate control of postprandial glucose (PPG) excursions, are linked in some studies with cardiovascular disease. Even though basal insulins, such as insulin glargine 100 U/mL (Gla-100), maintain overall glycemic control, effective PPG control eventually requires intensification of therapy by adding prandial insulins. Compared to conventional basal-bolus or premixed approaches, a stepwise basal-plus or basal-prandial intensification regimen involving the addition of one, two, or three prandial insulins to basal therapy such as Gla-100, has received much attention in recent times. This intensification approach is comparable to other conventional approaches in terms of glycemic control, and offers the additional advantages of fewer hypoglycemic events, personalization of therapy, and a simple self-management algorithm for titration. Owing to such benefits, recent guidelines recommend its use over other approaches for initiating intensification. It is preferred by both physicians and patients and is a better alternative to immediately embarking on a full basal-bolus regimen or introducing premixed insulin preparations for intensification of therapy.

Challenges in Women with Diabetes During the COVID-19 Pandemic

The coronavirus disease 2019 (COVID-19) pandemic has created significant challenges for healthcare systems across the world. The disease seems to infect men and women in equal numbers, though trends suggest that men have greater morbidity. This has been attributed to differences in immunological response, expression of angiotensin-converting enzyme 2 (ACE2), prevalence of comorbidities, and health-related behaviours, such as smoking. However, this cannot be taken to mean that women are somehow protected. Advanced age, smoking, diabetes, hypertension, cardiovascular disease and chronic obstructive pulmonary disease have emerged as the leading contributors to increased morbidity and mortality from the disease. Women with diabetes form a vulnerable group as they often receive suboptimal diabetes care and support, even though they have a high burden of comorbidities and complications. While there are challenges in healthcare delivery during the pandemic, cardiometabolic care cannot be compromised, which calls for exploring new avenues of healthcare delivery, such as telemedicine. Pregnant women with diabetes should continue to receive quality care for optimal outcomes, and the psychological health of women also needs special consideration. The management of hyperglycaemia during COVID-19 infection is important to reduce morbidity and mortality from the infection. The gendered impact of outbreaks and quarantine goes beyond biomedical and psychological aspects, and the socioeconomic impact of the pandemic is likely to affect the long-term care of women with diabetes, which creates an urgent need to create effective policies and interventions to promote optimal care in this vulnerable group.

Serum CCL 18 Levels in Women with Polycystic Ovarian Syndrome

BACKGROUND

Polycystic ovarian syndrome (PCOS) is one of the most common metabolic disorders seen in women of the reproductive age group, with the majority of them having insulin resistance. There is a need to identify sensitive markers of insulin resistance. CC chemokine ligand 18 (CCL 18) secreted from white adipose tissue is upregulated in individuals with insulin resistance.

OBJECTIVES

To study the correlation between serum CCL 18 levels and insulin resistance in PCOS.

MATERIALS AND METHODS

This case-control study included 45 PCOS women and an equal number of age and body mass index (BMI) matched controls. Estimation of serum CCL 18, serum testosterone, fasting plasma glucose, fasting insulin, HbA1c, and ultrasonography of abdomen and pelvis was done and HOMA IR was calculated.

RESULTS

Serum CCL 18 level was higher in women with PCOS when compared to controls. The mean level of serum CCL 18 (ng/mL) in the PCOS group and control group was 28.32 ± 4.17 and 11.90 ± 4.91, respectively (P < 0.001). Blood pressure, waist circumference, waist-hip ratio, modified Ferriman Gallway score (FG) score serum total testosterone, fasting serum insulin, and HOMA IR showed a relationship with serum CCL 18 levels. Serum CCL 18 was an independent predictor of PCOS (P < 0.05). A serum CCL 18 cutoff level of 18.84 ng/mL showed 93.3% sensitivity and 91.7% specificity in distinguishing PCOS subjects from healthy individuals.

CONCLUSION

There is a significant correlation of serum CCL 18 level with insulin resistance in PCOS subjects and serum CCL levels can be considered as a marker of PCOS.

IDEA Group Consensus Statement on Medical Management of Adult Gender Incongruent Individuals Seeking Gender Reaffirmation as Female

Cross sex hormone therapy (CSHT) is a strongly desired medical intervention for gender incongruent individuals. The goal is to change secondary sex characteristics to facilitate gender presentation that is consistent with the desired sex. When appropriately prescribed CSHT can greatly improve mental health and quality of life for gender incongruent individuals. Appropriate care for gender incongruent individuals in India is almost absent due to lack of country specific guideline and lack of training amongst the medical professionals. This document is intended to assist endocrinologists and physicians whose adult gender incongruent client is seeking gender reaffirmation as female (transfeminine). These individuals require a safe and effective CSHT regimen that will suppress endogenous male hormone secretion and maintain physiologic levels of female sex hormone. In this document, we offer suggestions based on an in-depth review of Guidelines of Endocrine Society, The World Professional Association for Transgender Health guidelines, the Sappho Good Practice Guide of India and collegial meetings with expert Indian clinicians working in this field. Clinicians represented in our expert panel are not gender specialists by training but have developed expertise due to the volume of gender incongruent individuals they manage. This consensus statement on medical management provides protocols for the prescribing clinician relating to diagnosis, baseline evaluation and counselling, prescription planning for feminizing hormone therapy and anti-androgen therapy, targets for monitoring hormone therapy, choice of therapy, clinical and biochemical monitoring, recommending sex reaffirmation surgery and peri-operative hormone therapy. The recommendations made in this document should not be perceived as a rigid set of guidelines and the treating clinicians are encouraged to modify our suggested protocols to address emerging issues.

Serum Fibroblast Growth Factor 21 Levels in Patients with Hyperthyroidism and its Association with Body Fat Percentage

BACKGROUND

Most of the actions of thyroid hormone (TH) on body metabolisms like maintenance of basal metabolic rate (BMR) and body fat are similar to that of fibroblast growth factor 21 (FGF21). We hypothesized that in patients with hyperthyroidism, the pathological changes in the BMR, body fat are mediated by TH through FGF21.

OBJECTIVES

To study the association of serum FGF21 levels with hyperthyroidism and correlate body fat percentage with serum FGF21 levels in hyperthyroid patients.

STUDY DESIGN

Case-control prospective follow-up study.

METHODOLOGY

A total of 68 hyperthyroid patients and age, sex-matched healthy controls who fulfilled the inclusion and exclusion criteria were studied. Among them, 45 cases were followed up at 3 to 6 months after the achievement of euthyroidism. Body fat percentage was calculated from Jackson and Pollock 3 site equation and Siri equation. BMR percentage was calculated by the Gale formula.

RESULTS

The mean age in years in the cases was similar to that of controls (36.14 ± 10.01 vs. 36.57 ± 10.53, P = 0.81). The serum FGF21 levels at baseline were significantly elevated in patients with hyperthyroidism compared to controls [median 406.6 pg/ml (interquartile range, 262.9-655.6) vs. 252.3 (125.1-341) P < 0.001] and declined dramatically following treatment with anti-thyroid drugs [405 (275.5-680.4) vs. 203.6 (154.6-230.6) P < 0.001]. Serum FGF21 levels negatively correlated with body fat percentage (r = -0.268, P = 0.002). After adjusting to various confounding factors, serum FGF21 was independently associated with hyperthyroidism and was significant. (OR [95%CI] 3.78 (1.046-13.666) P = 0.043).

CONCLUSION

Serum FGF21 levels were elevated in hyperthyroid patients and decreased following treatment with anti-thyroid drugs. It was independently associated with hyperthyroidism. There may be a future therapeutic role of FGF21 inhibition in the reversal of these changes in addition to anti-thyroid drugs in patients with hyperthyroidism.

Neck Circumference to Height Ratio is a Reliable Predictor of Liver Stiffness and Nonalcoholic Fatty Liver Disease in Prediabetes

BACKGROUND AND OBJECTIVES

Nonalcoholic fatty liver disease (NAFLD) and dysglycemia are public health challenges. There is urgent need for anthropometric surrogates for NAFLD screening. This study evaluated role of neck circumference (NC) and neck-height ratio (NHtR) as predictors of liver stiffness measure (LSM) in individuals with prediabetes (IPD).

METHODS

In a cross-sectional study, 188 IPD from 1130 screened individuals underwent anthropometry, ultrasonography, Fibroscan^® for LSM, dyslipidemia, insulin resistance (IR), and fetuin-A assessment.

RESULTS

Hypertension, hypertriglyceridemia, low high-density lipoprotein cholesterol (HDL-C), metabolic syndrome (MetS), NAFLD, and significant liver stiffness (SLS) (LSM >8.5kPa) were observed in 53.7%, 31.4%, 71.3%, 73.9%, 24.5%, and 11.2% prediabetes individuals, respectively. Prediabetes with NAFLD had significantly higher body mass index (BMI), NC, NHtR, glycated hemoglobin, triglycerides, fatty liver index (FLI), and LSM. Prediabetes in highest NHtR quartile had significantly higher BMI, hypertension, MetS, fasting glucose, glycated hemoglobin, homeostatic model assessment-IR, NAFLD, LSM, SLS, and lower HDL-C. Stepwise forward linear regression revealed that NHtR, FLI, and LDL-C were best predictors of LSM, at baseline (Model-1), after adjusting for age and sex (Model-2), and adjusting model-2 plus systolic and diastolic blood pressure (Model-3). NHtR and NC (in females) and NHtR and BMI (in males) had largest area under the curves for predicting LSM, NAFLD, and MetS. NHtR ≥21.54 cm/m (sensitivity: 90%; specificity: 52.5%; females) and ≥21.62 cm/m (sensitivity: 80%; specificity: 49.4%; males) was best predictor of SLS.

INTERPRETATION AND CONCLUSION

NHtR is a reliable tool for community screening of NAFLD and liver stiffness in prediabetes.

Impact of Self-monitoring of Blood Glucose Log Reliability on Long-term Glycemic Outcomes in Children with Type 1 Diabetes

INTRODUCTION

Logbooks of self-monitoring of blood glucose (SMBG) are useful in the modulation of insulin regimens, which aid in achieving glycemic control in type 1 diabetes mellitus (T1DM). However, discrepancies in SMBG charting may impede its utility. This study aimed to assess the accuracy of log entries and its impact on long-term glycemic control.

METHODS

SMBG in logbooks was compared with readings in glucometer memory and discrepancies between the two were evaluated in 101 children with T1DM. The relationship between these discrepancies and glycated hemoglobin (HbA1c) over 44 months was assessed.

RESULTS

Errors in glucose charting were observed in 32.67% children. The most common observed error was omission (42.42%), followed by fabrication (27.27%), erroneous (18.18%), and others (12.12%). Age was not significantly different among children having accurate versus inaccurate SMBG logs. During follow-up of 44 months, children with accurate SMBG logs consistently had lower HbA1c as compared to children having inaccurate logs, which was statistically significant at 4, 16, 20, and 28 months' follow-up. The same was reflected in the proportion of children achieving HbA1c <7% and 7%-9%. Of the 14 children who had omissions, 9 had omission of high values only, 3 patients had omission of low values only, 1 had omission of both high and low values, and 1 had omission of normal values. Among logs with fabrication, parents were responsible in 2 of 9 incidents. In the remaining 7, it was the child himself/herself. Children with fabrication consistently had the highest HbA1c values among the different types of inaccurate blood glucose chartings, which was statistically significant at 32 and 36 months of follow-up.

CONCLUSIONS

Reliability of SMBG logs is a significant problem among children with T1DM at our center. Children with accurate logs of SMBG readings were more likely to have better glycemic control on long-term follow-up.

Immunoglobulin G4 related thyroid disorders: Diagnostic challenges and clinical outcomes

Ig-G4 related disease (IgG4RD) is a heterogeneous disorder with multi-organ involvement recognised as a separate entity at the start of this century only. It is currently one of the hottest areas of clinical and translational research across specialties. Thyroid involvement in IgG4RD is rare, believed to occur in less than 4% of cases, may be isolated or may be associated with other organ involvement. As of today Riedel's thyroiditis, fibrosing variant of Hashimoto's thyroiditis, and few patients of Graves' orbitopathy represent the types of IgG4-related thyroid disease (IgG4RTD). This disorder is frequently confused with malignancy due to the intense sclerosis of thyroid resulting in hard texture on palpation compounded by often-associated compressive symptoms. Diagnosis involves establishing high circulating levels of IgG4 > 135 mg/dL, increased serum IgG4 to IgG ratio of > 8%, immunohistochemistry showing dense lymphoplasmacellular inflammatory infiltrate consisting of IgG4-positive plasma cells with storiform fibrosis and obliterative phlebitis, and increased IgG4 positive plasma cell > 10 cells per high-power field when at least three fields are evaluated. Glucocorticoids are the primary form of therapy in IgG4RD. However, their role in IgG4RTD needs to be evaluated. As of today levothyroxine supplementation for resulting hypothyroidism, appropriate management of Graves' disease, and surgical excision of thyroid in case of compressive symptoms remain the primary treatment options. (Endokrynol Pol 2016; 67 (5): 520-524).

Neck height ratio is an important predictor of metabolic syndrome among Asian Indians

BACKGROUND AND AIMS

The predictive potential of neck circumference (NC) based indices (a measure of upper body fat distribution) for predicting metabolic syndrome (MetS) and its components among Indians is not known. This study aimed to evaluate the role of NC and neck height ratio (NHtR) as independent predictors of MetS and its components as compared to traditional anthropometric indices.

MATERIALS AND METHODS

A total of 451 individuals from 867 screened individuals, 30-80 years age, without any co-morbid state who gave informed written consent underwent clinical, anthropometric, and biochemical assessment.

RESULTS

Patients with MetS in both the sexes had significantly higher NC, NHtR, glycated hemoglobin, fasting glucose, and dyslipidemia (higher triglycerides, total cholesterol/high-density lipoprotein cholesterol (HDL-C) ratio, low-density lipoprotein cholesterol/HDL-C ratio, and lower HDL-C). In both sexes, individuals in the highest tertile of NC had significantly greater central and generalized obesity, lower HDL-C, and significantly higher MetS. Receiver operating characteristic analysis revealed waist circumference (WC) to have the largest area under the curve for predicting MetS in both sexes, followed by NHtR, NC, and body mass index. NC and NHtR of >34.9 cm (sensitivity 78.6%; specificity 59.3%) and >21.17 cm/m (sensitivity 80.7% and specificity 64.6%) respectively for men and >31.25 cm (sensitivity 72.3%; specificity 64.4%) and >20.48 cm/m (sensitivity 80.4% and specificity 60%) respectively for women were the best values for identifying MetS. Increased NC and NHtR had odds ratio of 1.52 (95% confidence interval [CI]: 1.37-1.68; P < 0.001) and 1.96 (95% CI: 1.67-2.29; P < 0.001) respectively in identifying MetS.

CONCLUSION

NC and NHtR are good predictors of MetS and cardiovascular risk factors in Asian Indians. NHtR is reliable and perhaps an even better index than NC with regards to cardiovascular risk prediction.

Poncet’s disease: An unusual presentation of tuberculosis in a diabetic lady

Authors describe a 53-year-old woman who presented to their diabetes clinic with a three week history of multiple painful and swollen joints. She had been diagnosed with type 2 diabetes 5 years back. On examination, both knee joints and left ankle were swollen. A soft tissue swelling appeared over the medial end of the left clavicle few days later. Rheumatoid arthritis, collagen vascular diseases and other common causes of polyarthritis were ruled out by appropriate investigations. Non steroidal anti-inflammatory drugs failed to give satisfactory pain relief and the arthritis persisted. Conventional cultures of synovial fluid samples including cultures for tuberculosis were negative. Computed tomography showed a space occupying lesion involving the left sternoclavicular joint. Fine needle aspiration from the lesion was performed and acid-fast bacilli were demonstrated in the smear using Ziehl-Neelsen stain. The explanation of her arthritis was therefore tuberculous arthritis in left sternoclavicular joint and reactive arthritis in the rest of the joints. A diagnosis of Poncet’s disease was considered in her case. We treated her with standard anti-tuberculosis drugs and the arthritis resolved within a few days. She remained symptom-free at her 2 years’ follow-up.

Thyroid associated orbitopathy with ocular myasthenia in primary hypothyroidism: Keep those eyes open

Thyroid associated orbitopathy, although seen most commonly with thyrotoxicosis, is also known to occur in primary hypothyroidism. Myasthenia gravis is an autoimmune condition with an established association with autoimmune thyroid disease. We report the case of a patient who presented with recent onset unilateral ptosis that was fatigable with a history of proptosis since a year. On examination, she had a goiter, bilateral proptosis, restriction of upward gaze and adduction both eyes and normal pupils. Investigations revealed primary hypothyroidism with anti-thyroid peroxidase positive and anti-acetylcholine receptor antibody positive. Computerized tomography orbit showed thickening of medial and inferior rectus characteristic of thyroid orbitopathy. A diagnosis of primary hypothyroidism with thyroid orbitopathy with ocular myasthenia gravis was made. Patient is on Levothyroxine and anticholinesterase medications and is on follow-up. We present this case to highlight that the presence of ptosis in a patient with thyroid orbitopathy should alert the clinician to the possible coexistence of myasthenia gravis.

Pituitary dysfunction in infective brain diseases

Infectious diseases of the central nervous system (CNS) are increasingly being recognized as important causes of hypopituitarism. Although tuberculosis is the most common agent involved, non-mycobacterial agents like viruses, bacteria, fungus, and protozoa are important causes in our country. Involvement post infections could be due to a strategically located tuberculoma, or pituitary abscess, or meningoencephalitis. Although it might not be reasonable to screen all patients with CNS infections for hypopituitarism, awareness of the possibility and clinical follow-up for suggestive symptoms is required.

Precocious puberty: A blessing in disguise!

Germ cell tumors may lead to incomplete isosexual male precocity and are commonly located in the pineal gland. Germinomas of the basal ganglia are almost always unilateral and precocious puberty is a rare manifestation in them. We report a 9.5-year-old boy who presented with incomplete isosexual precocity due to bilateral basal ganglia germinoma.

Growth hormone deficiency, secondary hypothyroidism, and empty sella following treatment of childhood macroprolactinoma

Macroprolactinoma are rare in childhood, especially in the first decade. A 9-year-old girl presented with headache, vomiting, and decreased vision for 8 months. A diagnosis of macroprolactinoma was made following documentation of elevated serum prolactin (958 ng/ml) with a contrast enhancing macroadenoma (30 × 27 × 28 mm) on magnetic resonance imaging of pituitary. Anterior pituitary function was normal. Cabergoline therapy resulted in resolution of all symptoms in 2-8 months. Revaluation at 10 months of cabergoline therapy revealed normal serum prolactin (14 ng/ml), normal pituitary function, with 91% decrease in adenoma size (11.5 × 13.6 × 12.7 mm). Evaluation at 36 months of cabergoline therapy for growth arrest and weight gain for past 6 months revealed low serum prolactin, growth hormone deficiency, and secondary hypothyroidism with empty sella. She had biochemical as well as structural resolution of prolactinoma. This report highlights the development of multiple pituitary hormone deficiency with empty sella, an uncommon side effect of cabergoline therapy for macroprolactinoma.

Needle aspirate PTH in diagnosis of primary hyperparathyroidism due to intrathyroidal parathyroid cyst

Parathyroid cysts are rare (0.8–3.41% of all parathyroid lesions) and usually arise secondary to cystic degeneration of parathyroid adenomas. Intrathyroidal parathyroid cysts are extremely rare with only three cases reported till date. We present a 24-year-old female with clinical and biochemical features of primary hyperparathyroidism (PHPT; Ca²⁺: 12.1 mg/dl; intact parathyroid hormone (iPTH): 1283 pg/ml) and poor radiotracer uptake with minimal residual uptake in the left thyroid lobe at 2 and 4 h on Tc^99m sestamibi imaging. Neck ultrasonography (USG) revealed 0.6×1 cm parathyroid posterior left lobe of thyroid along with 22×18 mm simple thyroid cyst. USG-guided fine-needle aspiration (FNA) and needle tip iPTH estimation (FNA-iPTH) from parathyroid lesion was inconclusive (114 pg/ml), necessitating FNA of thyroid cyst, which revealed high iPTH (3480 pg/ml) from the aspirate. The patient underwent a left hemithyroidectomy. A >50% drop in serum iPTH 20 min after left hemithyroidectomy (29.4 pg/ml) along with histopathology suggestive of intrathyroidal cystic parathyroid adenoma (cystic lesion lined by chief cell variant parathyroid cells without any nuclear atypia, capsular or vascular invasion surrounded by normal thyroid follicles) confirmed that the parathyroid cyst was responsible for PHPT. This report highlights the importance of FNA-iPTH in localizing and differentiating a functional parathyroid lesion from nonfunctional tissue in PHPT.

Pituitary gigantism: a case report

OBJECTIVE

To present a rare case of gigantism.

CASE REPORT

A 25-year-old lady presented with increased statural growth and enlarged body parts noticed since the age of 14 years, primary amenorrhea, and frontal headache for the last 2 years. She has also been suffering from non-inflammatory low back pain with progressive kyphosis and pain in the knees, ankles, and elbows for the last 5 years. There was no history of visual disturbance, vomiting, galactorrhoea, cold intolerance. She had no siblings. Family history was non-contributory. Blood pressure was normal. Height 221 cm, weight 138 kg, body mass index (BMI)28. There was coarsening of facial features along with frontal bossing and prognathism, large hands and feet, and small goitre. Patient had severe kyphosis and osteoarthritis of knees. Confrontation perimetry suggested bitemporal hemianopia. Breast and pubic hair were of Tanner stage 1. Serum insulin like growth factor-1 (IGF1) was 703 ng/ml with all glucose suppressedgrowth hormone (GH)values of >40 ng/ml. Prolactin was 174 ng/ml. Basal serum Lutenising Hormone (LH), follicle stimulating Hormone (FSH) was low. Oral glucose tolerance test (OGTT), liver and renal function tests, basal cortisol and thyroid profile, Calcium, phosphorus and Intact Parathyroid hormone (iPTH) were normal. Computed tomographyscan of brain showed large pituitary macroadenoma. Automated perimetry confirmed bitemporal hemianopia. A diagnosis of gigantism due to GH secreting pituitary macroadenoma with hypogonadotrophichypogonadism was made. Debulking pituitary surgery followed by somatostatin analogue therapy with gonadal steroid replacement had been planned, but the patient refused further treatment.

Refractory rickets due to Fanconi's Syndrome secondary to Wilson's disease

Renal tubular disorders are an important cause of refractory rickets. Wilson's disease, an inherited disorder of copper metabolism has varied presentations. We present a case of refractory rickets due to Fanconi's syndrome attributable to Wilson's disease. An adolescent girl presented with pain in the hip and knee joints and a knock-knee deformity since six years. She had received multiple doses of cholecalciferol with little improvement. There was no history of seizures, polyuria, jaundice, intake of drugs, or similar complaints in the family. Examination revealed a severely short stature with widening of the wrist joint and genu valgum. Examination of the central nervous system (CNS) was normal. Skeletal radiographs showed features suggestive of rickets at the hip and knee joints. Routine biochemistry was normal, 25-hydroxyvitamin D [25(OH)D] was adequate (57.1 ng/dL), with normal corrected calcium (9.24 mg/dL), low phosphate (2.76 mg/dL), elevated bone-specific alkaline phosphatase, and normal renal functions. Twenty-four-hour urine revealed phosphaturia, kaliuresis, and glucosuria with normal blood sugars and aminoaciduria. Blood gas analysis revealed normal anion gap metabolic acidosis with a urine pH of 7. Ammonium chloride (NH4CL) challenge test revealed proximal tubular acidosis. A search for causes revealed Kayser-Fleischer rings. The diagnosis of Wilson's disease was confirmed by low serum ceruloplasmin levels (6.5 mg/dL; normal: 18-35 mg/dL) with high 24-hour urine copper levels (433 mcg; normal: 20-50 mcg). She was started on a replacement of alkali, phosphate, calcium, and vitamin D, with zinc acetate for Wilson's disease. Rickets as a presenting feature of Wilson's disease has been reported rarely. Recognition of this entity is important, as treatment of the primary condition may improve tubular function as well.

The "Double A" phenotype: Portending Allgrove's syndrome and averting adrenal crisis

INTRODUCTION

Allgrove's syndrome is a rare autosomal-recessive disorder with only about 70 cases reported thus far and is characterized by alacrima, achalasia, and ACTH insensitivity among other clinical features. However, it has a widely variable clinical presentation, which may result in such cases remaining undiagnosed.

OBJECTIVE

To report a patient with impending Allgrove's syndrome and to highlight the importance of clinical suspicion in diagnosing the same.

MATERIALS AND METHODS

A 2.5-year-old girl was diagnosed with impending Allgrove's syndrome on the basis of clinical presentation, barium swallow study, Schirmer's test, and hormonal evaluation.

RESULTS

A 2.5-year-old girl, born of non-consanguineous marriage, presented with failure to thrive and developmental delay with occasional vomiting on taking solid or semi-solid food for past 6 months. Examination revealed stunted weight (SDS of -4.4) and height (SDS of -4.76), and barium swallow showed presence of achalasia. On direct questioning, her mother mentioned presence of decreased tears on crying since birth, and Schirmer's test confirmed the presence of dry eyes. Baseline ACTH was slightly elevated with normal basal and post-ACTH stimulation serum cortisol. Based on these findings, impending Allgrove's syndrome was diagnosed with a plan for follow-up study of adrenal function.

CONCLUSIONS

Allgrove's syndrome may be an under diagnosed disorder as aclarima is often overlooked. However, a high index of clinical suspicion may help in avoiding adrenal crisis by diagnosing the condition early.