Novel Approaches in the Management of Type 2 Diabetes and Associated Vascular Complications

Diabetes mellitus (DM) is growing in pandemic proportion and affects the affluent and developing nations equally. India has the dubious distinction of being known as the diabetes capital of the world. Epidemiological studies have shown that DM is under diagnosed and inadequately treated in our country. Insulin resistance and β-cell dysfunction are the two key pathophysiological determinants of the DM. The disease has metamorphosed during the last couple of decades with a significant change in the clinical presentation. Simultaneously, the therapeutic options for the management of DM have also increased in the last decade. This article highlights the research conducted by us over the last decade in the areas of pathogenesis, management, and complications of DM.

Thyrotoxic periodic paralysis: A retrospective, observational study from India

Background & objectives:

Thyrotoxic periodic paralysis (TPP) is an endocrine emergency presenting with acute-onset flaccid paralysis in a patient having thyrotoxicosis accompanied by hypokalaemia. This study was conducted to evaluate the clinical profile of patients with TPP presenting to three centres in India.

Methods:

This retrospective, observational study was conducted at three tertiary care Armed Forces medical centres, located at Lucknow, Kolkata and Delhi. The history, clinical features, treatment details and outcomes were evaluated.

Results:

Of the 244 patients with thyrotoxicosis, 15 were diagnosed with TPP and included in the study. These 15 patients (14 male and 1 female) had 32 episodes of TPP which were analyzed. The mean age was 30.2±6.2 yr (range: 21-39), and overt thyrotoxicosis was seen in all patients except one who had subclinical hyperthyroidism. Graves’ disease was the most common cause of thyrotoxicosis (13/15) and the remaining two patients had subacute thyroiditis and gestational thyrotoxicosis. Hypokalaemia (serum potassium <3.5 mmol/l) was seen in 12 patients, and the mean serum potassium was 3.2±0.9 mmol/l (range: 2.1-4.9). All patients had flaccid weakness, predominantly involving the lower limb with no bulbar, respiratory or cranial nerve involvement. The average duration of paralysis was 10.6±5.7 h (range: 3-28 h).

Interpretation & conclusions:

Our study demonstrated an early age of presentation and presence of clinical and biochemical thyrotoxicosis in majority of patients with TPP. Hypokalaemia may not always be evident in patients with TPP.

Risk factors for contrast-induced nephropathy after coronary angiography

Contrast-induced nephropathy (CIN) is of concern after the use of radiocontrast media for coronary angiography (CAG) and percutaneous coronary intervention (PCI). We studied the incidence of CIN and its risk factors in patients undergoing CAG. In this prospective study, we included all patients with normal renal parameters undergoing CAG with nonionic radiocontrast media. We excluded patients with known chronic kidney disease, baseline creatinine more than 1.5 mg/dL, significant hypotension, anemia, and patients with acute myocardial infarction undergoing emergency PCI. Serum creatinine was done at baseline and serially for seven days after the procedure. Appropriate statistical tests were used to analyze the results and P <0.05 was considered statistically significant. The study population (n = 500, 348 males and 152 females) had a mean age of 56.6 ± 12.5 years. Twelve patients (2.4%) developed CIN and were equally distributed irrespective of the age, diabetes, or PCI procedure. CIN was observed to be more common in patients with hypertension than in those without hypertension (P = 0.0158). The total volume of contrast administered to CIN group (175 ± 59.3) was not significant as compared to that of non-CIN (159.1 ± 56) group (P = 0.334). None of the patients in our study required renal replacement therapy, and there was no mortality. CIN is observed in 2.4% of patients undergoing CAG and had a self-limiting course. Hypertension is the only observed risk factor, and further large-scale studies are necessary to delineate the novel risk factors for CIN in the general population with normal kidney function.

Levothyroxine Dosing after Delivery in Women Diagnosed with Hypothyroidism During Pregnancy-A Retrospective, Observational Study

BACKGROUND

Pregnancy leads to profound alteration in thyroid function and dysthyroidism contributes to adverse pregnancy outcomes. Though the management of hypothyroidism during pregnancy is highlighted, the same is often neglected during postpartum. We have evaluated the postpartum levothyroxine (LT4) dose change in patients with new onset hypothyroidism.

METHODS

We conducted this retrospective, observational study between 2014 and 2016 using the medical records of patients with new onset hypothyroidism during pregnancy. We included patients who continued with LT4 after delivery (as per predetermined protocol) and the availability of 2-year follow up record. We excluded patients who stopped LT4 and use of other drugs that affect the thyroid function tests (TFT) after delivery. The patients were divided into 2 groups for comparison [Group 1-Overt hypothyroidism (OH) and Group 2-Subclinical hypothyroidism (SCH)] based on the initial TFT reports. The data were analyzed using appropriate statistical methods and a P value of less than 0.05 was considered significant.

RESULTS

A total of 159 women continued using LT4 after delivery and the final follow up data were available for 130 patients only. LT4 dose up titration was observed more in group 1 than in group 2 (P = 0.0336). In both the groups, the presence of goitre, thyroid autoimmunity and a repeat pregnancy are associated with increasing LT4 requirement.

CONCLUSION

Majority of patients with OH during pregnancy require more than half of the final dose after delivery. Goitre and autoimmunity are associated with higher LT4 dose after delivery.

The Bhubaneswar Declaration on Sports Endocrinology, 2018

Sports and endocrinology are complex interrelated disciplines. Sports and exercise modulate endocrine and metabolic health, and are used to prevent and manage disease. Endocrine and metabolic function influence participation and performance in sports activity. The Bhubaneswar Declaration, released on the occasion of the Endocrine Society of India Conference, resolves to promote the science of sports endocrinology. The authors commit to optimize endocrine health in sports persons, encourage safe use of sports to promote health, and prevent misuse of endocrine interventions in sports.

Association of Vitamin D and Parathyroid Hormone with Insulin Sensitivity, Beta Cell Function and Gestational Diabetes in Pregnancy: A Cross-Sectional, Observational Study

INTRODUCTION

Vitamin D (25OHD) and parathyroid hormone (PTH) are associated with dysglycemia, and we investigated them in gestational diabetes mellitus (GDM).

METHODS

In this cross-sectional, observational study, we included 75 pregnant women between 24 and 28 weeks of gestation. A fasting venous sample was collected for plasma glucose (FPG), insulin, PTH and 25OHD. Glucose and insulin samples were collected hourly after 75 g glucose load for 2 h. Insulin sensitivity was estimated by the Matsuda index (MI) and beta cell function by the insulin secretion sensitivity index (ISSI-2). The subjects were stratified into three groups and tertiles according to the 25OHD and PTH, respectively. Appropriate statistical tests were used to compare the MI, ISSI-2 and GDM among the groups.

RESULTS

GDM was seen in 14/75, and of these patients, 2 were 25OHD deficient, 7 insufficient and 5 had sufficient 25OHD. MI and ISSI-2, though not correlated with the 25OHD, decreased from the lower to higher PTH tertile (P < 0.001). FPG, AUCgluc (area under the curve glucose) and prevalence of GDM increased from the lower to higher PTH tertile (P < 0.001).

CONCLUSION

Increased PTH was associated with decreased insulin sensitivity, beta cell function and GDM in pregnancy, irrespective of the underlying 25OHD level.

Profile of pulmonary embolism in service personnel posted at high altitude area

Background

We evaluated the clinical presentation and risk factors of pulmonary embolism (PE) in soldiers posted at high altitude areas (HAA).

Methods

We conducted a retrospective analysis of all cases of PE presented to us between March 2011 and Aug 2014. The patients were serving at an altitude between 10,000 and 22,000 ft above sea level and PE was diagnosed using the pulmonary CT angiography. Screening for the deep vein thrombosis (DVT) and procoagulant conditions was done at presentation and after six months of treatment. The patients were managed as per the American College of Cardiology (ACC) guidelines and descriptive statistics were used to present the data.

Results

The patients (53 males) had a mean age of 33 ± 4.2 year and were serving at a mean altitude of 12,176 ± 448 feet (ranged between 10,000 and 20,500) at the onset of symptoms. Dyspnea (79%) and tachycardia (68%) were the commonest symptom and sign, respectively. D dimer was positive in 96.2% of the cases while nonspecific T inversion in the ECG was seen in 54.7% of the patients. Procoagulant work up revealed a hereditary thrombophilic condition in 9 out of 53 patients. A total of 44 cases were idiopathic and DVT of lower limb veins was seen in 2 patients. There was no mortality in our case series.

Conclusion

PE is a common complication of HAA and hereditary thrombophilia contributes in a minority of the patients. Further studies are needed to ascertain the risk factors of PE at HAA.

A randomized, controlled trial comparing the metformin, oral contraceptive pills and their combination in patients with polycystic ovarian syndrome

BACKGROUND

Polycystic ovarian syndrome (PCOS) is a condition characterized by insulin resistance (IR) and hormonal dysfunction. We conducted a randomized, controlled trial comparing the effects of metformin, oral contraceptive pills (OCP) and their combination in PCOS.

MATERIALS AND METHODS

We randomized 90 newly diagnosed PCOS (age 18-40 year, symptom duration >6 months) patients into three groups (Group 1-Metformin, Group 2-OCP, and Group 3- Metformin + OCP) in this prospective study. We excluded patients with past use of insulin sensitizers and hormone therapy. We evaluated for the hyperandrogenism (acne, acanthosis, hirsutism, and hormone panel), IR by homeostasis model assessment (HOMA-IR), inflammation (high-sensitivity C-reactive protein, fibrinogen, and ferritin), and body composition (% fat, android/gynoid ratio) markers at baseline and 6 months after therapy. The data were analyzed using appropriate statistical methods and P < 0.05 was considered statistically significant.

RESULTS

The study population had a mean age 23.2 ± 4.4 years and body mass index of 28.4 ± 6.1 kg/m2. The improvement in the clinical parameters was similar in all the groups. The combination therapy showed a better response in reducing inflammatory markers, IR, and body composition than either of the groups using a single drug. Metformin alone has resulted in a minor reduction of the androgens. None of the patients developed significant adverse effect to the given therapy.

CONCLUSION

PCOS is managed with either metformin or OCP in many patients. The combination improves the hyperandrogenism, body composition, and reduces the inflammatory markers.

A long term follow-up study from India assessing the risk of diabetes mellitus in service population

OBJECTIVE

The data about the incidence of diabetes is scarce from developing countries. We studied the incidence of type 1 (T1DM) and type 2 DM (T2DM) in a cohort of young military personnel followed for a long duration.

METHODS

The data for this descriptive epidemiologic study was derived from the electronic medical records (EMR) of the male service personnel enrolled between 1990 and 2015. All subjects were recruited before 18 years of age in good health and the onset of DM was derived from the EMR. We calculated the incidence rates as per person years using appropriate statistical methods.

RESULTS

Our study population includes 51,217 participants (median age 33 years, range 17-54) with a mean follow up of 12.5 years, giving a cumulative follow up duration of 613,925 person-years (py). A total of 251 patients developed T2DM and 15 patients developed T1DM during the study period. The incidence rate of T2DM was 0.41 per 1000 py and that of T1DM was 2.44 per 100,000 py.

CONCLUSION

Our cohort had low incidence rates of diabetes when compared with other studies from India and abroad. Active military service with good life style measures may offer protection from the DM.

Combined steroid and lignocaine injection in resistant cases of tennis elbow: A prospective, interventional study from India

Background

Tennis elbow or lateral epicondylitis is a chronic, painful condition and is often resistant to conventional therapy. We evaluated the benefits of a combined steroid and lignocaine injection in resistant cases of tennis elbow.

Materials and Methods

In this prospective, interventional study, we included chronic lateral epicondylitis patients resistant to analgesics and physiotherapy. The pain was assessed by visual analog scale (VAS), and we included patients with a baseline VAS >4. All patients were given local infiltration at the painful site with methylprednisolone (1 ml) and lignocaine (1 ml) by the peppering technique. The primary outcome was the change in VAS from the baseline at the end of 7 and 28 days. The improvement is classified as good, moderate, or mild based on the reduction in VAS score by 3, 2, 1, respectively. Descriptive statistics and appropriate tests were used to analyze the results.

Results

The study population (n = 63; male: female - 33:30) had a mean age of 36.2 ± 4.5 years and disease duration of 17.4 ± 5.8 weeks. After 1 week, 55 patients showed good improvement, three patients showed moderate improvement, two patients showed mild improvement, and three patients had no improvement. The improvement persisted till 28 days in all the patients and one patient who had not improved after 7 days did not report for 28 days follow-up.

Conclusion

Local infiltration with steroids and lignocaine is a useful modality of therapy for tennis elbow, especially in patients where ultrasonic therapy and conservative measures have failed.

Etiopathological differentiation of diabetes mellitus in lean, young adults

OBJECTIVE

Classification of diabetes mellitus (DM) into type 1 or type 2 is difficult in lean, young individuals. We studied the β-cell function, insulin resistance (IR) and autoimmunity in young patients with recent onset DM.

METHODS

In this cross-sectional study, we included patients (age below 35 years) with recent onset DM (<6 months) and normal body weight for evaluation. The detailed clinical examination was done to identify markers of IR. Autoimmune DM was diagnosed using glutamic acid decarboxylase 65 (GAD₆₅), insulin autoantibody (IAA) and islet cell antibody (ICA). Homeostasis model assessment (HOMA) models of HOMA-B and HOMA- IR were used for estimation of β-cell function and IR respectively. The patients were divided into four groups based on, the autoimmunity (A) and ketosis (K) as group 1 (A+K), group 2 (A-K+), group 3 (A+K-) and group 4 (A-K-). Appropriate statistical tests +)were used to analyze the results.

RESULTS

The study population (n=75, all males) had a mean age of 28.9±4.3years, body mass index 20.6±1.9kg/m², fasting plasma glucose 177.1±31.4mg/dl and HbA1c of 9.9±2.1% at presentation. The number of patients in groups 1 to 4 are 8, 5, 10 and 52 respectively (p<0.0001). HOMA-IR was higher in groups 2 and 4 (4.1±1.3, 3.6±1.1 respectively), whereas HOMA-B was higher in group 4 (3.6±1.5) alone (p=0.0005).

CONCLUSION

Type 2 DM is the most common etiology even in young, lean adults in India. Further studies with large numbers are required to confirm our findings.

A clinical study of insulin resistance in patients with chronic pancreatitis

OBJECTIVE

Insulin resistance (IR) and beta cell dysfunction are the pathophysiological determinants of the diabetes mellitus (DM). We investigated the presence of IR in patients with chronic pancreatitis (CP) and compared the same with the underlying etiology.

METHODS

In this cross-sectional, observational study, we included serial patients of CP presented to our hospital. The study population is in different stages of CP and are grouped as alcoholic CP (Group 1; N=67) and tropical CP (Group 2; N=35). IR was estimated by the homeostasis model assessment (HOMA) method. The results were analyzed by appropriate statistical methods.

RESULTS

The study participants (85M and 17F) had a mean age 40.8±12.6 yr, CP duration 3.7±4.7 yr and body mass index (BMI) of 22.5±3.2kg/m². DM was seen in 54 patients with average glycosylated hemoglobin of 7.5±1.6%. A total of 9 patients had HOMA-IR more than 3 suggestive of IR with no significant difference between the two groups. The duration of the DM correlated negatively with glycemic parameters and BMI showed a positive correlation with the fasting insulin and HOMA-IR.

CONCLUSION

IR was seen in a minority of patients with CP and is not a significant contributor to the pancreatogenic diabetes.

Incidence of parathyroid disorders in Indian adult male population: A 25-year follow-up study

CONTEXT AND OBJECTIVE

Detailed information on the epidemiology of parathyroid disorders in India is lacking. Most of the available data pertain to primary hyperparathyroidism (PHPT) rather than the overall burden of parathyroid disorders. We studied the incidence of parathyroid disorders in a cohort of service personnel followed for a long duration.

DESIGN, SETTING AND PATIENTS

The data for this retrospective, descriptive epidemiological study were derived from the electronic medical records (EMR) of health care personnel enrolled between 1990 and 2015. Subjects were recruited between the ages of 17 and 20 years in good health, and the data pertaining to parathyroid disorders were derived from the EMR.

MAIN OUTCOMES MEASURES

We calculated the incidence rates per person-years of parathyroid disorders using appropriate statistical methods.

RESULTS

Our analysis includes 51 217 participants (median age 33, range 17-54 years) with a mean follow-up of 12.5 years. Yearly evaluation of the data gave cumulative follow-up duration of 613 925 person-years. PHPT was diagnosed in 37 patients and hypoparathyroidism in 16 patients, giving incidence rates of 6 and 2.6 per 100 000 person-years, respectively. Only one patient was diagnosed with pseudohypoparathyroidism (0.16 per 100 000 person-years). Of the 37 patients with PHPT, 16 (43%) developed postsurgical hypoparathyroidism.

CONCLUSIONS

Our cohort had a low incidence of PHPT when compared to Western populations. Long-term epidemiological studies are essential to identify the demographic trends of metabolic bone disorders in India.

Visceral Adipose Tissue as a Risk Factor for Diabetes Mellitus in Patients with Chronic Pancreatitis: A Cross-sectional, Observational Study

INTRODUCTION

Visceral adipose tissue (VAT) is a risk factor for diabetes and we investigated the amount of VAT in patients with chronic pancreatitis (CP).

METHODS

Serial patients with CP seen between January 2015 and June 2016 were included in this cross-sectional, observational study. The study population was divided into alcoholic CP (group 1; N = 67) and tropical CP (group 2; N = 35). VAT was estimated using bioelectric impedance analysis (BIA) and dual energy X-ray absorptiometry (DEXA) methods. The results were analyzed by appropriate statistical methods.

RESULTS

The study participants (85 male, 17 female) had a mean (SD) age of 40.8 (12.6) years, CP duration of 3.7 (4.7) years, and body mass index of 22.5 (3.2) kg/m². Pancreatogenic diabetes was seen in 54 patients and the total body fat percentage was lower in the alcoholic CP group. VAT mass was similar in both the groups (p = 0.8749). CP patients with diabetes had a higher VAT mass (436 vs. 341 g) than those without diabetes (p = 0.0132). DEXA and BIA correlated in estimation of total body fat (p < 0.0001) but not in VAT (p = 0.0922).

CONCLUSION

VAT is a determinant in the development of diabetes, even in patients with CP. DEXA is a better modality for VAT estimation in comparison to BIA.

Postpartum Follow-up in Women Diagnosed with Subclinical Hypothyroidism during Pregnancy

BACKGROUND

Management guidelines about the thyroid disease in pregnancy are silent about the postpartum course of new onset subclinical hypothyroidism (SCH). Hence, we analyzed the 2 years outcome of SCH diagnosed during pregnancy.

MATERIALS AND METHODS

We conducted this retrospective study using the medical records of patients with new onset SCH during pregnancy between 2010 and 2013 (n = 718). Patients who stopped their levothyroxine after delivery with a 2-year follow-up record were included. We excluded patients with known thyroid disorders and continuous use of drugs that affect the thyroid results. The patients were divided into two groups (Group 1 - euthyroid and Group 2 - hypothyroid) based on the final outcome after 2 years. The data were analyzed using appropriate statistical methods and a P < 0.05 was considered statically significant.

RESULTS

A total of 559 (77.8%) women stopped levothyroxine after delivery, and the final follow-up data were available for 467 patients only. At the end of 2 years, 384 (82.2%) remained euthyroid, and the remaining 83 (17.8%) developed hypothyroidism. SCH and overt hypothyroidism were seen in 22 and 61 patients, respectively. Group 2 patients had higher mean age (25.5 vs. 23.6 years), goiter (51 vs. 2%), initial thyroid stimulating hormone (7.9 vs. 5.1 μIU/mL), and thyroid antibody positivity (76 vs. 13%) (P < 0.001).

CONCLUSION

The majority of patients with SCH during pregnancy remain euthyroid after delivery. Advanced age, goiter, positive family history, and thyroid autoimmunity increase the future risk of hypothyroidism in patients with SCH diagnosed during pregnancy.

Mortality audit of medical patients at armed forces hospitals

The mortality statistics of the medical patients at our tertiary care hospitals are sparse and lacking. We studied the mortality characteristics of the patients admitted to medical wards and intensive care unit at two hospitals based on the available fatal documents. Our objectives include analysis of the cause of death, duration of stay and presence of sepsis. The deceased (103 males, 47 females) had a mean age of 64.6 ± 15.5 yrs and mean duration of stay 7.1 ± 12.3 days. Infections and sepsis syndrome (33%), respiratory (17%), neurological (15%) and cardiovascular disorders (10%) were the top four causes of the mortality. Comorbid ailments were present in 71% of the deceased and the ventilator was used in 39% of them prior to the death. Age of the patients did not show any correlation with the duration of hospital stay (P = 0.8322). Infections and sepsis syndrome are the major reasons of death in medical patients. Mortality audit helps in identifying the prevalent causes of death in the hospital.

Effect of Antithyroid Therapies on Bone and Body Composition: A Prospective, Randomized, Clinical Study Comparing Antithyroid Drugs with Radioiodine Therapy

BACKGROUND

Thyrotoxicosis is associated with loss of body weight and bone mineral content (BMC). Antithyroid drugs (ATD) and radioiodine therapy (RIT) are the common options for the management of thyrotoxicosis. We evaluated the effect of ATD and RIT on BMC and body composition.

MATERIALS AND METHODS

In this prospective study, we randomized 60 patients of thyrotoxicosis (20-50 years, treatment naïve, males) to receive either ATD (Group 1) using carbimazole or RIT (Group 2). We excluded patients with significant ophthalmopathy and thyroid malignancy. The patients were followed serially for 1 year. Body composition was analyzed using the bioimpedance method and BMC by dual-energy X-ray absorptiometry technique. The data were analyzed using appropriate statistical measures.

RESULTS

The patients had a mean age of 33 ± 4.2 years and mean symptoms duration of 8.2 ± 2.7 months before the diagnosis. A total of 51 patients had Graves' disease, and the remaining 9 had toxic multinodular goiter. BMC at lumbar spine and femoral neck improved with both the therapies similarly at the end of 1 year. The body weight, protein, and fat content also increased after 1 year of observation similar between the two groups. None of the observed parameters showed a difference with regard to the mode of ATD.

CONCLUSION

ATD and RIT have comparable effects on the bone and body composition in the management of thyrotoxicosis. Further long-term studies are needed to confirm the observed findings.

Occult endocrine dysfunction in patients with cirrhosis of liver

BACKGROUND

Liver dysfunction leads to endocrine disturbance due to the alteration in protein metabolism or synthesis. We studied the presence of occult endocrine dysfunction in liver cirrhosis and compared the same with underlying etiology.

MATERIALS AND METHODS

We evaluated thirty patients with liver cirrhosis in this cross-sectional, observational study. All subjects were assessed for pituitary, thyroid, adrenal, and gonadal function. The patients were divided into Group 1 (cirrhosis, n = 30) and Group 2 (controls, n = 15) and the data were analyzed with appropriate statistical tests.

RESULTS

The study participants (20 males, 10 females) had a mean age of 54.5 ± 12.4 years and duration of the cirrhosis 5.1 ± 2.7 years. Four patients were in Child Class A, 11 and 15 patients were in Child Classes B and C, respectively. Eleven out of thirty patients (37%) had endocrine disorders, that include subclinical hypothyroidism (n = 3), primary hypothyroidism (n = 1), Sick Euthyroid syndrome (n = 3), central hypothyroidism (n = 2), secondary hypogonadism (n = 3) and growth hormone deficiency in three patients. Two patients had partial hypopituitarism and one patient had complete hypopituitarism.

CONCLUSION

Occult endocrine dysfunction of thyroid and gonadal axes is common in patients with cirrhosis of the liver. The hormonal abnormalities are not different based on the etiology of the cirrhosis.

Liraglutide as an Alternative to Insulin for Glycemic Control in Intensive Care Unit: A Randomized, Open-label, Clinical Study

Background:

Intravenous insulin is the cornerstone in the management of hyperglycemia in the Intensive Care Unit (ICU). We studied the efficacy of liraglutide compared with insulin in the ICU.

Materials and Methods:

In this prospective, open-labeled, randomized study, we included 120 patients (15–65 years, either sex) admitted to ICU with capillary blood glucose (CBG) between 181 and 300 mg/dl. We excluded patients with secondary diabetes and APACHE score >24. The patients were divided into two groups (n = 60) based on the CBG: Group 1 (181–240) and Group 2 (241–300). They were randomized further into four subgroups (n = 30) to receive insulin (Groups 1A and 2A), liraglutide (Group 1B), and insulin with liraglutide (Group 2B). The primary outcome was the ability to achieve CBG below 180 mg/dL at the end of 24 h. The secondary outcomes include mortality at 1 month and hospital stay. Data and results were analyzed using Mann-Whitney U-test, paired t- test, and Chi-square tests.

Results:

The mean age of the patients (93M and 27F) was 57.1 ± 13.9 years, hospital stay (16.9 ± 7.5 days), and CBG was 240.5 ± 36.2 mg/dl. The primary outcome was reached in 26, 27, 25, and 28 patients of Groups 1A, 2A, 1B, and 2B, respectively. The 30-day mortality and hospital stay were similar across all the four groups. Hypoglycemia was common with insulin and gastrointestinal side effects were more common with liraglutide (P < 0.001).

Conclusion:

Liraglutide is a viable alternative to insulin for glycemic control in the ICU. Further studies with a larger number of patients are required to confirm our findings.

Correlation of Vitamin D with metabolic parameters in polycystic ovarian syndrome

BACKGROUND

Polycystic ovarian syndrome (PCOS) and hypovitaminosis D are the two most common endocrine disorders in young women leading to many adverse metabolic consequences. We evaluated the correlation of 25-hydroxy Vitamin D (25OHD) with metabolic parameters and insulin resistance in PCOS.

MATERIALS AND METHODS

We included 100 PCOS patients (age 18-40 years, duration >6 months) serially, in this cross-sectional study. We excluded patients with past use of insulin sensitizers and hormone therapy. All patients underwent a physical examination, body fat estimation, and a single fasting blood sample was analyzed for the biochemical parameters. The patients were divided into 2 groups as per the 25OHD level: Group 1 (Deficient, <30 ng/mL) and Group 2 (normal). The data were analyzed using appropriate statistical methods, and a P < 0.05 was considered statistically significant.

RESULTS

The study population had a mean age of 28.6 ± 6.3 years, body mass index (BMI) 30.4 ± 6.1 kg/m² and body fat of 39.1 ± 13%. A total of 90 women had 25OHD deficiency, and hypovitaminosis D was observed more in younger, obese patients. Patients with hypovitaminosis D had a higher BMI (P = 0.0124), low- high-density lipoprotein (P = 0.0094), calcium (P ≤ 0.0001), and elevated testosterone (P = 0.0412) in comparison with normal 25OHD patients. None of the metabolic parameters showed significant correlation with 25OHD (P > 0.05).

CONCLUSION

Hypovitaminosis D is very common in PCOS patients and exacerbates the metabolic abnormalities. It is essential to screen all the PCOS patients for 25OHD deficiency, and further large-scale studies are required to confirm our findings.

Prevalence of left ventricular dysfunction in rheumatoid arthritis

Background:

Rheumatoid arthritis (RA) is a polyarticular disorder with many extra-articular features. Cardiovascular disorders, including heart failure (HF), are the leading causes of mortality in RA patients. We studied the prevalence of left ventricular dysfunction (LVD) in patients with RA.

Materials and Methods:

In this cross-sectional study, we evaluated 100 consecutive patients with RA (aged >18 years and duration >1 year) for the presence of LVD. We excluded patients with known cardiac and systemic disorders that may contribute to LVD. LVD is defined by the presence of either left ventricular systolic dysfunction (LVSD) or left ventricular diastolic dysfunction (LVDD), evaluated by the echocardiography. Descriptive statistics and relevant tests were used to analyze the results.

Results:

The study participants (n = 100; 80F and 20M) had a mean age of 45 ± 11.8 years, duration of disease 7.4 ± 5.4 years, and disease activity score of 3.5 ± 1.1. A total of 46 patients had symptoms of HF, but only 14% of them had signs of HF. LVD was seen in 59 (LVSD-4, LVDD-50, and both together in 5) patients, and none of the participants had severe grades of LVSD and LVDD. LVD showed no relation to the age of the patients (P = 0.186) and it was more with increasing duration of RA (P < 0.001) and higher disease activity (P = 0.042).

Conclusion:

LVD is more common in RA patients, which increases the associated morbidity and mortality. Higher threshold is required by the family practitioners to perform a screening echocardiography in long-standing RA patients.

Prevalence of hypothalamo pituitary dysfunction in patients of traumatic brain injury

BACKGROUND

Traumatic brain injury (TBI) is common in young soldiers of armed forces leading to significant morbidity and mortality. We studied the prevalence of hypopituitarism following TBI and its association with trauma severity.

MATERIALS AND METHODS

We conducted a 12-month prospective study of 56 TBI patients for the presence of hormonal dysfunction. Hormonal parameters were estimated during the early phase (0-10 days posttraumatically) and after 6 and 12 months. Dynamic testing was done when required, and the results were analyzed by appropriate statistical methods.

RESULTS

Hormonal dysfunction was seen in 39 of the 56 (70%) patients at initial assessment. Persisting pituitary deficiencies are seen in 7 and 8 patients at the end of 6 months and 12 months, respectively. Hypogonadotropic hypogonadism, hypothyroidism, and growth hormone deficiency are the most common diagnoses. Initial severe TBI and plurihormonal involvement predicted the long-term hypopituitarism.

CONCLUSION

Early hypopituitarism was common in severe TBI, but recovers in majority. Evaluation for the occult pituitary dysfunction is required during the rehabilitation of TBI patients.

Voice and endocrinology

Voice is one of the advanced features of natural evolution that differentiates human beings from other primates. The human voice is capable of conveying the thoughts into spoken words along with a subtle emotion to the tone. This extraordinary character of the voice in expressing multiple emotions is the gift of God to the human beings and helps in effective interpersonal communication. Voice generation involves close interaction between cerebral signals and the peripheral apparatus consisting of the larynx, vocal cords, and trachea. The human voice is susceptible to the hormonal changes throughout life right from the puberty until senescence. Thyroid, gonadal and growth hormones have tremendous impact on the structure and function of the vocal apparatus. The alteration of voice is observed even in physiological states such as puberty and menstruation. Astute clinical observers make out the changes in the voice and refer the patients for endocrine evaluation. In this review, we shall discuss the hormonal influence on the voice apparatus in normal and endocrine disorders.

Sleep disorders in Pregnancy: Glycaemic implications

Sleep is one of the essential biorhythms of the body that helps in optimum restoration of many body functions. The sleep-wake cycle is determined by the circadian centre and is responsible for the anabolic functions in the body. Infants require about 14 to 18 hours of sleep per day, which reduces gradually to about 8 hours in adults. Urbanization and evolutionary changes have altered the sleep hygiene and shortened the sleep duration. This lead to various sleep disorders like sleep disordered breathing, insomnia and narcolepsy. Sleep disorders lead to adverse cardio-metabolic consequences, including insulin resistance and hyperglycaemia. Pregnancy poses an enormous burden on the homeostasis of the women with alteration in many physiological functions. The sleep disorders during pregnancy lead to adverse foeto-maternal outcomes with long term cardiovascular implications. In this article, I review the pathophysiology of sleep disorders during pregnancy and their glycaemic implications.

Occult endocrine dysfunction in patients of cerebrovascular accident

Background:

Cerebrovascular disorders are common conditions leading to significant morbidity and mortality in the population. Occult endocrine disorders also contribute to the morbidity and we studied the prevalence of endocrine dysfunction in patients of cerebrovascular accident (CVA).

Materials and Methods:

We evaluated 30 patients of CVA (aged 18-75, admission within 72 h of symptoms and positive neuroimaging) in this prospective, observational study. All subjects were assessed clinically and biochemically for hormonal dysfunction at admission and for mortality at the end of 1 month. The patients were divided into two groups: Group 1 (infarct, n = 20) and Group 2 (hemorrhage, n = 10) and the data were analyzed with appropriate statistical tests using GraphPad Prism Software, version 6.

Results:

The study participants (24M:6F) had a mean age of 60.7 ± 11.4 years and body weight of 67.2 ± 11.4 kg. Fourteen out of 30 patients showed results consistent with an endocrine disorder, including sick euthyroid syndrome (SES) and central hypothyroidism (n = 10), secondary hypogonadism (n = 3), subclinical hypothyroidism (n = 1), and growth hormone (GH) deficiency in two patients. The endocrine conditions did not differ significantly between both the groups and nine out of 30 patients succumbed to their illness within 1 month. None of the hormonal parameters studied, could predict the 30 day mortality.

Conclusion:

Endocrine disorders are common in acute stage of CVA and commonest finding is a SES. Hormonal dysfunction did not differ based on the etiology of the CVA. Long-term follow-up is essential to understand the morbidity contributed by the hormonal alterations.

A trigger-happy soldier with bilateral ptosis and dysphagia

Muscular dystrophy encompasses a group of disorders characterized by the progressive weakness of the skeletal muscles. These disorders are mostly inherited and have characteristic age and muscle group predilection. Lingual muscle involvement is an unusual feature in patients with the muscular dystrophy and helps in the differential diagnosis. We recently encountered a serving soldier presenting with complaints of bilateral ptosis and dysphagia of 5 years duration. Examination showed bilateral ptosis, percussion myotonia, generalized muscular atrophy including that of tongue muscles, and a characteristic hatchet facies. Investigations revealed elevated creatine kinase and myotonic discharges on electromyography leading to a diagnosis of myotonic dystrophy type 1. Muscular dystrophy has a varied presentation and can pose a diagnostic problem in clinical practice. We present the case to highlight the differential diagnosis of tongue atrophy in patients with muscular dystrophy.

Amenorrhea, ptosis and high insulin requirement in a young girl

Lipodystrophy is an uncommon condition leading to excessive insulin requirement and menstrual abnormalities in young girls with diabetes. Neurological symptoms are uncommon in patients of generalized or partial lipodystrophy. We recently encountered a young girl, who presented with high insulin requirement, amenorrhea and neurological symptoms. Detailed evaluation led to the diagnosis of congenital lipodystrophy and we describe the same in this report. We also highlight the atypical features of the congenital lipodystrophy and the reasons for the excessive insulin requirement in patients with diabetes mellitus.

Recovery from rabies, a universally fatal disease

BACKGROUND

Rabies is a zoonosis transmitted via the bites of various mammals, primarily dogs and bats. Known since antiquity, this disease may have the deadliest human fatality rates and is responsible for approximately 65,000 deaths worldwide per year.

CASE PRESENTATION

We report the case details of a 13-year-old boy from India belonging to a South Asian ethnicity, who presented with altered sensorium one month following a dog bite. He did not receive the active rabies immunization and was managed with supportive therapy. The patient had extensive T2W (T2 weighted)/fluid attenuation and inversion recovery (FLAIR) hyper intensities involving the deep gray matter of the cerebral hemispheres, hippocampus, brainstem, and cerebellum. The diagnosis was confirmed by the demonstration of the rabies antigen from a nuchal skin biopsy and a corneal smear. The patient had a slow but significant recovery over four months and was discharged from the hospital in stable condition with severe neurological sequelae.

CONCLUSION

We report a unique case of survival after infection with a universally fatal disease.

Profile of infections in renal transplant recipients from India

Background:

Infectious disorders are a major cause of concern in renal transplant recipients (RTRs) leading to considerable morbidity and mortality. We studied the profile and outcomes of infectious disorders in a cohort of RTR.

Materials and Methods:

In this prospective, observational study, we evaluated all RTR who presented with the features of infection. We also included asymptomatic patients with microbiological evidence of infection. We excluded patients with acute rejection, drug toxicity, and malignancy. Descriptive statistics were used to analyze the results.

Results:

The study population (n = 45, 35 male and 10 female) had a mean age of 35.5 ± 10.4 years and follow-up after transplant was 2.1 ± 1.7 years. Urinary tract infection (UTI, n = 15) is the most common infection followed by tuberculosis (TB, n = 8), cytomegalovirus (n = 6), candidiasis (n = 7), and hepatitis (n = 11). Miscellaneous infections such as cryptosporidiosis and pneumocystis were seen in 10 patients. Simultaneous infections with two organisms were seen in 7 patients. Four patients succumbed to multiorgan dysfunction following sepsis, another 4 patients developed chronic graft dysfunction, while the remaining 35 RTR had a good graft function.

Conclusion:

Infectious complications are very common in the posttransplant period including UTI and TB. Further large scale studies are required to identify the potential risk factors leading to infections in RTR.

Discordance between lipid markers used for predicting cardiovascular risk in patients with type 2 diabetes

AIMS

Non-high density lipoprotein cholesterol (non-HDL-C) is gaining importance over low density lipoprotein cholesterol (LDL-C) as cardiovascular risk marker in patients with type 2 diabetes. It represents the overall lipid burden and is a surrogate marker for the apolipoprotein B. We studied the discordance between the old (LDL-C) and the new (non-HDL-C) lipid markers in a large group of diabetes patients.

METHODS

The lipid profile data of all diabetes (T2DM, aged 18-75, using oral or injectable anti diabetic agents) patients was analyzed in this study. We excluded patients with type1 diabetes, secondary forms of diabetes and gestational diabetes. Elevated lipid parameters (LDL>100mg/dL and non HDL-C>130mg/dL) were defined as per the guidelines of Adult Treatment Panel III.

RESULTS

The study participants (409 M:360 F) had a mean age of 47.3±12.4 years, BMI of 28.4±5.6kg/m(2) and an A1c of 8.8±2.2%. Elevated LDL-C was observed in 383 patients (49.8%) and elevated non HDL-C in 418 (54.4%) patients. Of the 383 patients with elevated LDL-C, 346 (90.3%) had corresponding elevated levels of non-HDL-C and out of 418 patients with elevated non HDL-C, 346 (83%) had elevated LDL-C. Discordance between the elevated LDL-C and non-HDL-C values were greater among patients with low triglyceride levels when compared with those with high triglycerides (Pearson's χ(2) test=67.7; P<0.001).

CONCLUSION

Our data suggest a significant discordance between the LDL-C and non-HDL-C in patients with diabetes. This discordance leads to the residual cardiovascular risk in diabetes patients.

Occult endocrine dysfunction in patients with cirrhosis of liver

BACKGROUND

Liver dysfunction leads to endocrine disturbance due to the alteration in protein metabolism or synthesis. We studied the presence of occult endocrine dysfunction in liver cirrhosis and compared the same with underlying etiology.

MATERIALS AND METHODS

We evaluated thirty patients with liver cirrhosis in this cross-sectional, observational study. All subjects were assessed for pituitary, thyroid, adrenal, and gonadal function. The patients were divided into Group 1 (cirrhosis, n = 30) and Group 2 (controls, n = 15) and the data were analyzed with appropriate statistical tests.

RESULTS

The study participants (20 males, 10 females) had a mean age of 54.5 ± 12.4 years and duration of the cirrhosis 5.1 ± 2.7 years. Four patients were in Child Class A, 11 and 15 patients were in Child Classes B and C, respectively. Eleven out of thirty patients (37%) had endocrine disorders, that include subclinical hypothyroidism (n = 3), primary hypothyroidism (n = 1), Sick Euthyroid syndrome (n = 3), central hypothyroidism (n = 2), secondary hypogonadism (n = 3) and growth hormone deficiency in three patients. Two patients had partial hypopituitarism and one patient had complete hypopituitarism.

CONCLUSION

Occult endocrine dysfunction of thyroid and gonadal axes is common in patients with cirrhosis of the liver. The hormonal abnormalities are not different based on the etiology of the cirrhosis.

Clinical audit of patients using DPP4 inhibitors in longstanding type 2 diabetes

AIMS

Dipeptidyl peptidase-4 inhibitors (DPP 4i) are oral hypoglycemic agents and are supposed to be beneficial in the early stages of diabetes. In this study, we evaluated the role of DPP4i in long standing type 2 diabetes mellitus (T2DM).

MATERIALS AND METHODS

This retrospective data analysis was conducted from the patient records. All the patients (T2DM>5 years; Age>50 years; Gliptin use >12 months) were divided into 2 groups based on the duration of T2DM: Group A (<10 years) and Group B (>10 years). We excluded patients with type 1 diabetes and drug default of more than one month. Our primary objective was to study the change in HbA1c and secondary objectives were change in body weight and insulin requirement. Data are presented as mean ± S.D and comparison between the groups was done using Mann-Whitney and Fisher's exact tests.

RESULTS

The study participants (n=501) had a mean age (64.2 ± 8.2 yr), diabetes duration (10.1 ± 4.9 yr), body weight (65.3 ± 9.5 kg), BMI (23.4 ± 3.9 kg/m(2)) and HbA1c of 9.7 ± 1.3%. The use of gliptins resulted in similar HbA1c reduction between the groups (p=0.8405) and greater reduction of insulin requirement in group B (p=0.0433) at the end of one year. Body weight and hypoglycemia episodes did not differ between the groups.

CONCLUSION

DPP4 inhibitors give similar benefit irrespective of the duration of diabetes and our data gives reassurance about their role in long standing diabetes.

Prevalence of vitamin D deficiency across the spectrum of glucose intolerance

Background

Vitamin D deficiency (VDD) is inversely associated with insulin resistance. We studied the prevalence of VDD across the spectrum of glucose intolerance, including normal glucose tolerance (NGT), prediabetes (PD) and type 2 diabetes (T2D).

Methods

We conducted this cross-sectional, observational study by serially including the PD and T2D patients seen between June and December 2014. We excluded patients with major illness, secondary diabetes and use of vitamin D or glucocorticoids. VDD was defined as serum 25-hydroxy vitamin D (25OHD) less than 30 ng/mL. The study population was divided into 3 groups: T2D (Group 1; n = 274), PD (Group 2; n = 62) and NGT controls (Group 3; n = 270) for the analysis and appropriate statistical methods were used.

Results

The study participants (n = 606, 28 % males) had a mean age of 43.2 ± 13.6 years, BMI of 27.7 ± 5.9 kg/m², HbA1c of 6.6 ± 2 % and mean 25OHD of 18.8 ± 15.7 ng/mL. VDD was seen in 85 % of the entire study population including 84 % in T2D, 77 % in prediabetes and in 87 % of the controls. The mean 25OHD levels were lower in the control group (16.8 ng/mL) when compared with T2D and prediabetes (19.9 and 22.4 ng/mL) respectively (P = 0.0124). Univariate analysis showed higher odds of VDD in females (P < 0.0001) but no association with diabetes, age, BMI and HbA1c.

Conclusion

Our data showed that VDD is prevalent in the majority of the population, irrespective of the underlying glucose intolerance. Further studies are required to determine the association between the vitamin D and diabetes.

Endocrine dysfunction in patients of leprosy

BACKGROUND

Leprosy is a chronic granulomatous disease and affects many internal organs in addition to the skin and peripheral nerves. Endocrine dysfunction is often silent and is often missed in patients of leprosy leading to significant morbidity. We studied the presence of occult endocrine disorders in leprosy patients and compared the same with disease parameters.

MATERIALS AND METHODS

We evaluated 40 patients of leprosy (aged 18-70 years, any duration) in this cross-sectional, observational study. All subjects were assessed for pituitary, thyroid, adrenal, gonadal function, and dynamic testing was done when deemed necessary. The participants were divided into two groups: Group 1 (Leprosy, n = 40) and Group 2 (Controls, n = 20) and the data were analyzed with appropriate statistical tests.

RESULTS

The study participants (35 males, 5 females) had a mean age of 36.4 ± 11.3 years, and duration of the disease was 2.5 ± 5.5 years. Eleven out of 40 patients showed results consistent with an endocrine disorder, including subclinical hypothyroidism (n = 4), sick euthyroid syndrome (n = 3), growth hormone (GH) deficiency (n = 2), primary hypogonadism (n = 2) and secondary hypogonadism in one patient. One patient had partial hypopituitarism (GH deficiency and secondary hypogonadism) and none of the controls showed any hormonal dysfunction. Testosterone levels showed inverse correlation with the number of skin patches (P = 0.0006).

CONCLUSION

Occult endocrine dysfunction is seen in a quarter of patients with leprosy. Thyroid and gonadal axes abnormalities are common, and the severity is more in lepromatous forms of the disease. Further large studies are required to confirm the findings observed in our study.

Twins and endocrinology

Twins are two independent babies delivered during the same pregnancy and are divided as monozygotic or dizygotic based on their origin. Dizygotic twins are similar to two siblings and have different genetic information. In contrary, monozygotic twins have a similar genetic identity and provide a unique opportunity to evaluate the contribution of genetic and environmental factors of the disease. The endocrine and metabolic disorders affect a large number of the population including the twins. Diabetes, obesity, and autoimmune thyroid disease are the most common endocrine disorders in general practice. It is essential to understand the genetic basis of endocrine disorders for therapy, prognostication and risk assessment for future generations. In this article, we review the endocrine disorders in relation to their occurrence in monozygotic twins to highlight the genetic and environmental contribution.

Clinical profile of patients using normal, high and very high insulin doses in type 2 diabetes

AIMS

Insulin requirement varies between patients with diabetes due to insulin resistance. The clinical profile of patients based on their insulin requirement has not been studied earlier. We stratified the patients based on total daily insulin requirement (TDIR) and studied their clinical profile and carbohydrate consumption.

MATERIALS & METHODS

Sixty patients with type 2 diabetes (aged 30-75 years, using stable insulin dose for last 6 months, HbA1c between 6-7.5%, negative screening tests for Acromegaly and Cushing's disease) participated in this clinical observational study. All patients with major illness, surgery or diabetic ketoacidosis were excluded. The patients were divided into 3 groups: Group 1 (TDIR<1 U/kg, n=30), Group 2 (TDIR 1-2 U/kg, n=20) and Group 3 (TDIR>2U/kg, n=10). Data are presented as mean±S.D and comparison between three groups was done using one way ANOVA test.

RESULTS

The patients (27M: 33F) had mean age 54.3 ± 12.3 years, diabetes duration 10.1±4.7 years and an A1c of 7±0.38%. Patients in group 3 had lower body weight, BMI and highest carbohydrate consumption when compared with the other two groups (P<0.05). Hypoglycemic episodes and complications did not differ between the groups.

CONCLUSION

Our data showed that the low body weight and high carbohydrate intake are associated with increased insulin requirement. The clinical implications of our study are to check the carbohydrate intake in patients with high insulin requirement.

Publication trends of a biomedical journal from India

BACKGROUND

The details about the research productivity of the biomedical journals published from India is lacking. We analyzed the publishing trends and the research productivity of the Journal of the Association of Physicians of India (JAPI).

MATERIALS AND METHODS

This was a bibliometric analysis of a biomedical journal. The data was obtained from the website of JAPI about the publications between 2000 and 2011. The articles were analyzed for the type (original article, case reports, correspondence, pictorial image, reviews, editorials, philately and miscellaneous), subspecialty (endocrinology, cardiology, etc), and place of the research work (Mumbai, Delhi, etc). Descriptive statistics giving data in numbers and percentages were used.

RESULTS

JAPI published 2977 articles over last 12 years (12 volumes and 134 issues). Case reports (29.5%), original articles (22.6%), and correspondence (20.5%) constitute 3/4 of the published articles. JAPI showed a gradual declining trend of published articles per issue (29.5 in 2000 to 17 in 2011). The data about 1798 research articles was analyzed further. Most of the articles belong to the Endocrinology, neurology, and infectious diseases. Mumbai is the leader over past 12 years in contributing toward the articles followed by other three metros.

CONCLUSION

JAPI showed a declining trend in the number of published articles over last decade. Metro cities contributed the maximum research articles and the subspecialty coverage skewed in favor of Endocrinology.

Multiple cysts in kidneys: a case report

Von Hippel-Lindau (VHL) disease, which is an autosomal dominant inherited disease, is characterized by highly vascularized tumors in different organs. We report a 42-year-old male who presented to our hospital with diarrhea and weight loss of six months' duration. Ultrasonography of the abdomen revealed bilateral polycystic kidneys with multiple cystic and solid components as well as polycystic pancreas. A computerized tomography scan of the abdomen revealed bilateral multiple simple and complex renal cysts, cystic lesions in the head and body of the pancreas and a non-enhancing lesion in the left adrenal gland. The features raised the possibility of VHL syndrome and a biopsy of the kidney revealed atypical cells with a suspicion of malignancy. He underwent bilateral nephrectomy and is on maintenance dialysis since then.

Microprolactinoma with visual field defect: An unsuspected etiology

Microprolactinomas present usually with menstrual disturbance and galactorrhoea. The presence of visual field defects is not expected in these patients as the tumor does not involve structures outside the sella. Visual field defects in a case of microprolactinoma confuse the clinician and warrant extensive search for an alternate etiology. We present a young lady with microprolactinoma and visual field defects. Etiological work-up revealed a diagnosis of idiopathic intracranial hypertension (IIH) associated with microprolactinoma. Treatment with Acetazolamide and Cabergoline completely resolved the clinical symptoms and visual defects. The unusual occurrence of IIH in a case of microprolactinoma as the cause of visual field defect is highlighted in our case report.

Adjuvant gonadotropin releasing hormone analog in gonadotoxic chemotherapy for preservation of fertility

Chemotherapy induced infertility is a problem which is growing and often neglected. Fertility preservation strategy is an important component of the management in young patients with cancer. Gonadotropin releasing hormone analog therapy helps in ovarian suppression and the evidence is inconclusive for its benefit in fertility preservation. Other medical benefits with these drugs include reduction of vaginal bleeding in patients with thrombocytopenia.

The readability of editorials in popular Indian medical journals

INTRODUCTION

The essence of communication is to convey a message, and readability tests have been developed to quantify this aspect of language. There is limited research on the readability tests of journal contents from India. In this study, we performed readability tests on the editorials of four popular Indian medical journals.

MATERIALS AND METHODS

THE READABILITY TESTS (FLESCH SCORE, FLESCH GRADE, AND TEXT STATISTICS) WERE CALCULATED FROM THE FOLLOWING JOURNALS: Indian Journal of Endocrinology and Metabolism (IJEM), Journal of Association of Physicians of India (JAPI), Journal of Indian Medical Association (JIMA), and International Journal of Diabetes in Developing Countries (IJDDC). The editorials published in these journals over the last 2 tears were included in this analysis.

RESULTS

A total of 64 editorials (IJEM - 19, JAPI - 18, JIMA - 16, IJDDC - 11) were analyzed in this study. The mean readability score was (IJEM 34.8 ± 9.5; JAPI 31.4 ± 11.4; JIMA 29.6 ± 10.1; IJDDC 26.1 ± 17.7) not different between the journals (P = 0.2666). Flesch score was less variable in IJEM an d JIMA than in JAPI and IJDDC (P = 0.0167). The editorials from IJEM and JAPI had a lower Flesch grade than the remaining two journals (P = 0.0253). The readability score was directly proportional to the sentence count and inversely proportional to the words per sentence (P < 0.0001).

CONCLUSION

Our results suggest that the editorials from all the medical journals have equal readability scores. The sentence count and words per sentence are important to achieve a high readability score while writing for a journal.

Resistant prolactinoma: Is it monoclonal or polyclonal?

Prolactinomas are solitary benign neoplasms and resistance to dopamine agonists occur in a small percentage of prolactinomas. Multiple pituitary adenomas are reported in less than 1% of pituitary adenomas and rarely result in resistant prolactinoma. We recently encountered an interesting patient of hyperprolactinemia with multiple pituitary microadenomas. Dopamine agonist use resulted in prolactin normalization and subsequent pregnancy resulted in drug withdrawal. Repeat evaluation after delivery showed a macroprolactinoma and dopamine agonist therapy resulted in biochemical cure without reduction in tumor size. We report the case for its presentation with multiple microadenomas progressing to macroprolactinoma suggesting polyclonal in origin.