Expert opinion on the preoperative medical optimization of adults with diabetes undergoing metabolic surgery.

Diabetes mellitus (DM) and obesity are interrelated in a complex manner, and their coexistence predisposes patients to a plethora of medical problems. Metabolic surgery has evolved as a promising therapeutic option for both conditions. It is recommended that patients, particularly those of Asian origin, maintain a lower body mass index threshold in the presence of uncontrolled DM. However, several comorbidities often accompany these chronic diseases and need to be addressed for successful surgical outcome. Laparoscopic Roux-en-Y gastric bypass (RYGB) and laparoscopic sleeve gastrectomy (LSG) are the most commonly used bariatric procedures worldwide. The bariatric benefits of RYGB and LSG are similar, but emerging evidence indicates that RYGB is more effective than LSG in improving glycemic control and induces higher rates of long-term DM remission. Several scoring systems have been formulated that are utilized to predict the chances of remission. A glycemic target of glycated hemoglobin < 7% is a reasonable goal before surgery. Cardiovascular, pulmonary, gastrointestinal, hepatic, renal, endocrine, nutritional, and psychological optimization of surgical candidates improves perioperative and long-term outcomes. Various guidelines for preoperative care of individuals with obesity have been formulated, but very few specifically focus on the concerns arising from the presence of concomitant DM. It is hoped that this statement will lead to the standardization of presurgical management of individuals with DM undergoing metabolic surgery.

Thyroid Symptomatology across the Spectrum of Hypothyroidism and Impact of Levothyroxine Supplementation in Patients with Severe Primary Hypothyroidism.

OBJECTIVE: This study aimed to determine the clinical and biochemical profile of patients with severe primary hypothyroidism (SPH) (TSH ≥40 µIU/ml) as compared to milder forms of hypothyroidism and document improvement in hypothyroidism symptoms in SPH. METHODS: Thyroid symptomatology and biochemistry were evaluated in SPH, non-severe overt primary hypothyroidism (NSOPH; TSH <40 µIU/ml), subclinical hypothyroidism (ScH) and healthy controls. A total of 598 consecutive patients of hypothyroidism were screened of which 461 patients' data were analyzed (91 SPH, 130 NSOPH and 240 ScH). Thyroid symptomatology was re-evaluated at 12 weeks follow-up in SPH following restoration of euthyroidism with levothyroxine. RESULTS: The median (interquartile range) age of patients was 35 (28-42) years with 91.6% female. The commonly noted symptomatology were shortness of breath (93.4%) and fatigueability (91.2%) in SPH, fatigueability (68.46%) and limbs swelling (43.07%) in NSOPH, and fatigueability (56.67%) and shortness of breath (32.92%) in ScH. All symptomatology were significantly higher in SPH. Delayed tendon reflex, carpel tunnel syndrome and meno-metrorrhagia were exclusive in SPH. Occurrence of menstrual irregularities was 73.62%, 28.46% and 16.25% in SPH, NSOPH and ScH, respectively. SPH patients had significantly higher cholesterol and triglycerides. There was significant improvement in symptomatology, reduction in body weight (-2.11 kg), improvement in hemoglobin (+0.64 g/L) with fall in total cholesterol (-18.96%), LDL-cholesterol (-23.46%) and triglycerides (-13.53%) following euthyroidism restoration in subjects with SPH. Common residual symptoms were fatigue (10%), poor memory (8%) and menstrual irregularities (6%). CONCLUSION: Thyroid symptomatology differs significantly across spectrum of hypothyroidism, being significantly worse in SPH. Euthyroidism restoration is associated with reversal of majority of thyroid symptomatology.

Neutrophil-lymphocyte Ratio is a Novel Reliable Predictor of Nephropathy, Retinopathy, and Coronary Artery Disease in Indians with Type-2 Diabetes.

BACKGROUND AND AIMS: Neutrophil-lymphocyte ratio (NLR) has been suggested to be a predictor of coronary artery disease (CAD), and end-organ damage in type-2 diabetes mellitus (T2DM). Similar data are lacking from Indians with T2DM. Hence, this study aimed to evaluate the role of NLR as a predictor of microvascular complications and CAD in T2DM. SUBJECTS AND METHODS: Consecutive T2DM patients attending the outpatient services of 2 different hospitals, who gave consent, underwent clinical, anthropometric evaluation, and evaluation for the occurrence of retinopathy, nephropathy, neuropathy, and CAD. RESULTS: A total of 298 patients were screened of which 265 patients' data were analyzed. Occurrence of hypertension, neuropathy, nephropathy, retinopathy, and CAD was 12.8%, 18.5%, 41.5%, 62.3%, and 3.8%, respectively. Patients in higher NLR quartiles had significantly higher diabetes duration, occurrence of nephropathy, albuminuria, retinopathy, CAD and lpwer glomerular filtration rate. Patients with more microvascular complications had significantly longer diabetes duration, blood pressure, NLR, creatinine, and urine albumin excretion. Binary logistic regression revealed NLR followed by body mass index were best predictors of microvascular complications. NLR had areas under the receiver operating characteristic curve (AUC) of 0.888 (95% CI: 0.848-0.929; P < 0.001), 0.708 (95% CI: 0.646-0.771; P < 0.001), and 0.768 (95% CI: 0.599-938; P = 0.004) in predicting albuminuria, retinopathy, and CAD, respectively. NLR of 2.00 had sensitivity and specificity of 86.4% and 69% in predicting albuminuria; sensitivity and specificity of 64.2% and 63% in predicting retinopathy; sensitivity and specificity of 80% and 47.1% in predicting CAD. CONCLUSION: NLR is inexpensive, easy to use, reliable predictor of nephropathy, retinopathy, and CAD in Indian T2DM.

Sleep Disorders in Type 2 Diabetes.

Type 2 diabetes mellitus (T2DM) has shown to be associated with higher incidence of sleep disorders, which may be due to disease itself or because of secondary complications or associated comorbidities associated with diabetes. On the other hand, shorter sleep duration and erratic sleep behavior itself have been linked with higher incidence of obesity, metabolic syndrome, and T2DM. Assessment of sleep quality and sleep disorders as a part of the comprehensive medical evaluation is recommended based on emerging evidence suggesting a relationship between sleep quality and glycemic control in persons with T2DM. In this review, we attempt to summarize common sleep disorders associated with T2DM, their impacts on glycemic and other metabolic control, and various preventive and therapeutic strategies to tackle these problems.

Neonatal Endocrine Labomas - Pitfalls and Challenges in Reporting Neonatal Hormonal Reports.

This review highlights pitfalls and challenges in interpreting neonatal hormone reports. Pre-analytical errors contribute to nearly 50% of all errors. Modern chemiluminescence assay are more accurate, have lower risk of Hook's effect, but continue to have problems of assay interference. Liquid chromatography mass spectroscopy is gold standard for most hormone assays. Neonatal hypoglycemia diagnostic cut-offs are lower than adults. Random growth hormone testing is of value in diagnosing growth hormone deficiency in neonates. 17-hydroxy-progesterone testing in first three days of life for congenital adrenal hyperplasia (CAH) remains a challenge due to cross-reactivity with maternal circulating steroids, prematurity and lack of adrenal maturation. Both T4 and TSH testing is encouraged after 48 hours of delivery for diagnosing neonatal hypothyroidism; repeat testing should be done immediately for confirmation of diagnosis. There is an urgent need to develop age- sex- and ethnicity-based normative data for different hormone parameters in neonates. Laboratory should develop their own neonatal references and avoid using ranges from manufacturers. In neonatal endocrinopathies, the clinical scenario should primarily dictate the treatment formulation with hormonal assay to supplement treatment.

Study of Neutrophil-lymphocyte Ratio as Novel Marker for Diabetic Nephropathy in Type 2 Diabetes.

INTRODUCTION: Diabetic nephropathy (DN) is a microvascular complication of diabetes. DN is clinically manifested as an increase in urine albumin excretion. Total white blood cell count is a crude but sensitive indicator of inflammation and studied in many cardiac and noncardiac diseases as an inflammatory marker such as acute myocardial infarction, stroke, and heart failure. In this study, the association of neutrophil-lymphocyte ratio (NLR) with DN is studied. PATIENTS AND METHODS: It is an observational cross-sectional study. Totally 115 diagnosed type 2 diabetes mellitus patients were registered in this study. NLR was calculated by analyzing differential leukocyte count in complete blood picture. Albuminuria was tested by MICRAL-II TEST strips by dipstick method. RESULTS: Totally 115 diabetic patients were registered. About 56 patients had DN and 59 had normal urine albumin. Mean NLR for a normal group is 1.94 ± 0.65 and in DN group is 2.83 ± 0.85 which was highly significant (P < 0.001). Estimated glomerular filtration rate (P = 0.047) and serum glutamate pyruvate transaminase (P < 0.001) were also significant. CONCLUSION: The results of our study show that there was a significant relation between NLR and DN. Therefore, NLR may be considered as a novel surrogate marker of DN in early stages.

Clinical and epidemiological study of stress hyperglycemia among medical intensive care unit patients in Central India.

BACKGROUND: Stress hyperglycemia is common in patients presenting at the emergency medical ward and is associated with poor prognosis and increased risk of mortality. AIMS AND OBJECTIVE: To study and determine the prevalence and factors associated with stress hyperglycemia. MATERIALS AND METHODS: A cross-sectional observational study was performed on 536 nondiabetic patients presented to the Intensive Care Unit (ICU) at Gandhi Medical College and allied Hamidia Hospital, Bhopal, between March 31, 2015, and May 28, 2015. A detailed history including demographic profile, presence of chronic disease, history of hospitalization and ICU admission, surgical status, and major reason for ICU admission (i.e., predominant diagnostic category) was collected. Hematological and other parameters based on profile of study population were also analyzed. RESULTS: Out of 536 patients, 109 (20.33%) had stress hyperglycemia. Out of 109 patients with stress hyperglycemia, 87 (16.23%) patients had glycated hemoglobin (HbA1c) <5.7% and 22 (4.10%) patients had HbA1c between 5.7% and 6.4%. Mean age of the study population was 40.27 ± 1.44 years, with male dominance. Mean random blood glucose level was 181.46 ± 3.80 mg/dl. Frequency of stress hyperglycemia was 24.13% in stroke, 19.54% in multiple organ dysfunction syndrome (MODS), 17.24% in chronic kidney disease (CKD), 12.64% in central nervous system (CNS) infection, 8.05% in chronic liver disease (CLD), and 8.05% in seizure patients. Association between stroke and stress hyperglycemia was significant (P = 0.036). Association between hospital stay more than 7 days and stress hyperglycemia was significant in stroke patients (P = 0.0029), CKD patients (P = 0.0036), CLD (P = 0.0099), and MODS patients (P = 0.0328). CONCLUSIONS: The factors associated with stress hyperglycemia were stroke, MODS, CKD, CNS infection, CLD, seizure patients, with prolonged hospital stay and expected proportion.

A 2016 clinical practice pattern in the management of primary hypothyroidism among doctors from different clinical specialties in New Delhi.

BACKGROUND: This study aimed to document practices in managing hypothyroidism among doctors in New Delhi, with special focus on subclinical hypothyroidism, pregnancy, and old age, and to compare it with global practices. METHODS: During an academic program attended by 394 doctors, all participants were given a questionnaire designed based on thyroid practices survey done by Burch et al. to evaluate the practice patterns. Questions were based on evaluating doctor's preferred choices in diagnosis, therapy, and follow-up of hypothyroidism in different scenarios. RESULTS: Responses from 308 questionnaires (general physicians [n = 204], obstetricians [n = 51], pediatricians [n = 27], surgeons [n = 12], endocrinologists [n = 10], and others [n = 4]) were analyzed. In the evaluation of 52-year-old female patient with primary hypothyroidism, 52% doctors would prefer thyroid ultrasonography, comparable to global rates. Nearly 96.1% doctors would have initiated levothyroxine, with a large majority of doctors (83.77%) preferred using branded levothyroxine. About 58.74% doctors preferred gradual restoration of euthyroidism. Levothyroxine dose of 25 mcg was the most preferred increment dose (46.07%) during follow-up, with 6 weekly being the most frequent dose adjustment frequency (41.57%). Most preferred target thyroid-stimulating hormone (TSH) in the 52-year-old female patient was 2.5-4.99 mU/L (63.96%), 25-year-old female patient was 1-2.49 mU/L (53.90%), and in 85-year-old female was 2.5-4.99 mU/L (45.45%). Only 68% of doctors in our study preferred keeping TSH <2.5 mU/L during the first trimester of pregnancy, in contrast to global trends of 95% (P < 0.001). CONCLUSION: There was a disproportionately high use of ultrasonography in hypothyroidism management, near exclusive preference for branded levothyroxine, widespread use of age-specific TSH targets, and low threshold for treating mild thyroid failure, a highly variable approach to both rates and means of restoring euthyroidism for overt primary hypothyroidism. There is a need for spreading awareness regarding TSH targets in pregnancy.

Study of awareness of adrenal disorders among interns and postgraduate students of Hamidia Hospital, Bhopal.

INTRODUCTION: Adrenal disorders could be a life-threatening emergency, hence requires immediate therapeutic management. For this awareness regarding its diagnosis, management, and treatment is prime important. AIMS AND OBJECTIVE: To study the awareness of adrenal disorders among interns and postgraduates students of Hamidia Hospital, Bhopal. MATERIALS AND METHODS: A cross-sectional questionnaire-based study was performed. Fifty-six participants, i.e., 1st, 2nd, and 3rd years postgraduate residents of general medicine (n = 14 × 3) and interns (n = 14) were included in the study. There were 12 questions on adrenal insufficiency, adrenal adenoma, congenital adrenal hyperplasia (CAH), nonclassical CAH (NCCAH), pheochromocytoma, and Conn's syndrome. One mark was awarded for each correct response. RESULTS: In the present study, 14 (25%) participants scored < 5 marks, 33 (58.9%) scored between 6 and 9, and 9 (16.1%) scored between 10 and 12. The mean score among the participants was 6.38 ± 2.505, with a range from 2 to 11 marks. The number of correct answers by postgraduates residents of 1st year was 101, 2nd year was 95, and 3rd year was 93 and interns scored 68 out of total 168 questions in each group. Mean awareness score for residents of 1st, 2nd, 3rd years participants and interns was 7.21 ± 2.806, 6.79 ± 2.119, and 6.64 ± 2.818 and 6.63 ± 2.505, respectively. Most of the participants recorded correct responses related to diagnosis (57.7%) followed by responses related to treatment (64.3%). Answers to a question regarding how commonly is adrenal insufficiency diagnosed in medical Intensive Care Unit, none of the individuals responded correctly. CONCLUSION: There was a lack of awareness regarding diagnosis, management, and treatment of adrenal disorders in central India. We need to prioritize training related to these illnesses in our postgraduate teaching curriculum in practice.

Etiology and clinical profile of patients with Cushing's syndrome: A single center experience.

BACKGROUND: There is little published literature on the profile of patients with Cushing's syndrome (CS) from India. The aim of this study was to compile data of CS patients treated at this hospital. MATERIALS AND METHODS: Patients referred to the endocrine services of this hospital for diagnosis/treatment of CS from January 1985 to July 2012 were the subjects for this study. All patients had detailed medical history, physical examination and biochemical and hormonal assays (which changed with availability of tests and changing views). Assays for plasma adrenocorticotropic hormone (ACTH) (late 90s), salivary cortisol estimation, IJV sampling for ACTH and corticotrophin releasing hormone stimulation tests were added on later. Imaging included computed tomography (CT), magnetic resonance imaging (since the late 80's) and (68)Ga DOTA-TOC/FDG PET-CT (2008). RESULTS: Three hundred sixty-four patients (250 females, 114 males, age 6 months to 65 years, mean 28 years + 12 years) were diagnosed to have CS during this period. Two hundred and ninety-three patients (80.5%) were ACTH dependent (CD 215, ectopic ACTH syndrome 22, occult ACTH source 56) while 71 (19.5%) were ACTH independent (adrenal carcinoma 36, adenoma 30, primary pigmented nodular adrenal disease 4, AIMAH 1). Pituitary macro adenoma was seen in 14% of the CD cases. The most common presenting complaints were hypertension and diabetes mellitus. A total of 63% patients complained of weight gain while 15% had lost weight. Myopathy, infections, skeletal fractures and psychiatric problems were the other common observations in our patients. CONCLUSION: The clinical spectrum was broad. CD was the most common cause for CS.

Internal jugular vein: Peripheral vein adrenocorticotropic hormone ratio in patients with adrenocorticotropic hormone-dependent Cushing's syndrome: Ratio calculated from one adrenocorticotropic hormone sample each from right and left internal jugular vein during corticotrophin releasing hormone stimulation test.

BACKGROUND: DEMONSTRATION OF CENTRAL: Peripheral adrenocorticotropic hormone (ACTH) gradient is important for diagnosis of Cushing's disease. AIM: THE AIM WAS TO ASSESS THE UTILITY OF INTERNAL JUGULAR VEIN (IJV): Peripheral vein ACTH ratio for diagnosis of Cushing's disease. MATERIALS AND METHODS: Patients with ACTH-dependent Cushing's syndrome (CS) patients were the subjects for this study. One blood sample each was collected from right and left IJV following intravenous hCRH at 3 and 5 min, respectively. A simultaneous peripheral vein sample was also collected with each IJV sample for calculation of IJV: Peripheral vein ACTH ratio. IJV sample collection was done under ultrasound guidance. ACTH was assayed using electrochemiluminescence immunoassay (ECLIA). RESULTS: Thirty-two patients participated in this study. The IJV: Peripheral vein ACTH ratio ranged from 1.07 to 6.99 (n = 32). It was more than 1.6 in 23 patients. Cushing's disease could be confirmed in 20 of the 23 cases with IJV: Peripheral vein ratio more than 1.6. Four patients with Cushing's disease and 2 patients with ectopic ACTH syndrome had IJV: Peripheral vein ACTH ratio less than 1.6. Six cases with unknown ACTH source were excluded for calculation of sensitivity and specificity of the test. CONCLUSION: IJV: Peripheral vein ACTH ratio calculated from a single sample from each IJV obtained after hCRH had 83% sensitivity and 100% specificity for diagnosis of CD.