High Malignancy Risk and Its Predictors in South Indian Patients With Bethesda II Thyroid Nodules.

BACKGROUND: Global data reports a low malignancy risk, whereas regional data report a variable risk of malignancy in Bethesda II thyroid nodules. The limited availability of surgical histopathology might have underestimated the risk of malignancy. Here, we report the prevalence of malignancy and its predictors in Bethesda II thyroid nodules for which the surgical histopathological diagnosis was available. METHODS:  This retrospective study was done at a tertiary healthcare center in South India between January 2008 and September 2015. Case records of adults with thyroid nodules who underwent surgery were collected. Patients with inadequate data were excluded from the study. The data was analyzed using SPSS version 21.0 and a p-value of < 0.05 was considered statistically significant. RESULTS:  A total of 563 patients were included in the study with a mean age of 36±12 years. Serum thyrotropin (TSH) was low in 87 (15.4%) patients whereas 362 (64.2%) patients had multinodular goiter (MNG). Sonographic evidence of suspicious cervical lymph node and microcalcification was seen in four (0.7%) and 48 (8.5%) patients, respectively. A total of 48 (8.5%) patients had thyroid carcinoma in the final histopathology. Of these, 42 (87.5%) had papillary thyroid carcinoma, five (10.4%) had follicular thyroid carcinoma and one (4.1%) had anaplastic carcinoma. Age, gender, and maximum nodule size were not associated with malignancy. Thyrotoxicosis was negatively associated with malignancy whereas multi-nodularity, thyroid calcification, or suspicious cervical lymph node on ultrasound and total thyroidectomy were positively associated with malignancy on univariate analysis. On binary logistic regression, only the former four, but not total thyroidectomy, were independent predictors of malignancy. CONCLUSIONS:  We report a high (8.5%) prevalence of malignancy among South Indian patients with Bethesda II thyroid nodules. Thyroid microcalcification, presence of suspicious cervical lymph node on ultrasound, and multinodularity were associated with high and suppressed TSH with low risk of malignancy. Further prospective studies are warranted to confirm the study observations.

Acton-Prolongatum Stimulated Blood Steroid Profile in Apparently Healthy Asian Indian Women of Reproductive-Age Group.

Blood steroid profile is a recently introduced test in India that is commercially available through a few diagnostic laboratories. In adult women, ACTH-stimulated steroid panel helps to differentiate polycystic ovary syndrome (PCOS) from nonclassical forms of CAH. However, the interpretation of ACTH-stimulated steroid panels is often impeded by the limited availability of reference ranges. Here, we report the adrenal steroid levels after stimulation with Acton Prolongatum in Asian Indian women of reproductive age. This prospective study was conducted at a tertiary health care center in the Southern part of India. Apparently healthy women in the reproductive age group with regular menstrual cycles (21-35 days) at least over the last 6 months were included. All participants received intramuscular Acton Prolongatum® (Pfizer) in the morning hours during the follicular phase and the steroid profile was analyzed by liquid chromatography-tandem mass spectrometry in a blood sample collected 60-min later. The study included 32 apparently healthy women. The mean age of the study population was 22.19 ± 4.36 years. None of the participants experienced any adverse events during the procedure. The median (range) serum cortisol, 17α-hydroxyprogesterone, 11-deoxycortisol, and corticosterone were 22.65 (14.3-37.21) µg/dl, 99.72 (47.21-344.71) ng/dl, 287.2 (74.41-530.61) ng/dl and 728.04 (118.74-1708.2) respectively. In conclusion, this is the first report of the response of adrenal steroids measured by LC-MS/MS at 60 min after Acton Prolongatum in Asian Indian women of the reproductive age group. However, further larger studies are warranted to establish more robust ACTH-stimulated reference ranges for steroid profile in Indian women.

Hyperamylasemia is not Associated with Dipeptidyl Peptidase 4 Inhibitors in South Indian Adults with Type 2 Diabetes Mellitus.

Introduction: Although not definitive, there is small increased risk of acute pancreatitis with the use of dipeptidyl peptidase 4 inhibitors (DPP4i). Hence, there is an interest in the elevation of pancreatic enzymes among type 2 diabetes mellitus (T2DM) patients using DPP4i. However, the studies regarding their association are limited and provide conflicting results. Moreover, there are no such studies among South Indian T2DM patients. Hence, we evaluated the prevalence of hyperamylasemia among South Indian T2DM patients and its association with DPP4i use. Methods: This cross-sectional study was conducted at a tertiary health care center from South India. Adult T2DM patients on stable doses of antidiabetic medications for at least previous 3 months were included in the study. Patients with other types of diabetes mellitus, gall stones, diabetic ketoacidosis, acute illness, chronic kidney disease and untreated hypothyroidism were excluded from the study. All participants were evaluated with glycemic parameters, serum creatinine and serum amylase. Hyperamylasemia was defined as serum amylase ≥220 U/L. Results: A total of 200 participants were included in the study among whom 93 patients were not on DPP4i whereas 107 were on DPP4i including 41 (38.32%) each on teneligliptin and sitagliptin. Baseline characteristics including glycemic measures were comparable between DPP4i users and nonusers. A total of 14 patients (7%) had hyperamylasemia but the prevalence of hyperamylasemia did not differ between DPP4i users and nonuser (6/107 vs. 8/93, P = 0.42). Conclusions: Asymptomatic hyperamylasemia is not uncommon in South Indian T2DM patients but is not associated with the use of DPP4i.

Effect of T12 Mislabeling as L1 on the Diagnosis of Low BMD at Lumbar Spine.

INTRODUCTION: Mislabeling of T12 vertebra as L1 has been shown to reduce L1-L4 bone mineral density (BMD). However, the effect of such mislabeling on the L1-L4 BMD and prevalence of osteoporosis and/or osteopenia in a clinical setting is not known. The study aimed to the effect of mislabelling of T12 as L1 on the L1-L4 BMD and diagnosis of osteoporosis and/or osteopenia. It is a retrospective study done at a tertiary health care center in South India. Database of dual X-ray absorptiometry machine at our center was reviewed and BMD data of men aged more than 50 years and postmenopausal women who underwent BMD during the last 3.5 years were included in the analysis. A total of 570 subjects had undergone BMD testing at the lumbar spine of whom images of the T12 and lower part of the T11 were available for 293 subjects. Six of these with ≤1 eligible vertebra for the calculation of L1-L4 BMD were further excluded from the analysis. The BMD data of the remaining 287 subjects were noted. Later T12 was labeled as L1 and a new set of BMD data was obtained. Using the WHO classification, BMD status was classified as normal BMD, osteopenia, and osteoporosis for both the analyses. L1-L4 BMD (0.916 ± 0.163 vs 0.937 ± 0.170, p < 0.0001) and T-scores of L1-L4 (-2.23 ± 1.37 vs -2.06 ± 1.43, p < 0.0001) with mislabeling were significantly lower than those measured with correct labeling. BMD status was misclassified by T12 mislabelling as L1 in a total of 30 (10.4%) individuals. Inter-rater agreement between the 2 scenarios for the diagnosis of osteoporosis, osteopenia, and normal BMD was substantial (weighted Kappa: 0.87 [95%CI: 0.83-0.91]). To conclude, mislabeling of T12 as L1 significantly reduces L1-L4 BMD. However, the diagnosis of BMD status by mislabeling has a substantial agreement with that obtained with correct labeling.

Thyroid dysfunction and its association with microvascular complications in patients with type 2 diabetes mellitus in south India.

BACKGROUND AND AIMS: To study the prevalence of thyroid disorders and their association with microvascular complications among adult type 2 diabetes mellitus (T2DM) patients from south-coastal Andhra Pradesh, India METHODS: This cross-sectional study included 500 subjects with T2DM and was conducted in a tertiary health care center from south-coastal Andhra Pradesh. Participants previously diagnosed with thyroid disorders were excluded from the study. RESULTS: Thyroid dysfunction was observed in 98 (19.6%) subjects of which subclinical hypothyroidism (n = 66, 13.2%) was the most common. Subclinical hypothyroidism (SCH) was more frequent in obese patients (16.2% vs 7.6%, p = 0.007) and metformin users (9.6% vs 18.7%, p = 0.0044). Diabetic retinopathy (27.3% vs 8.9%, p = 0.001) was significantly more frequent in SCH patients than euthyroid T2DM patients. CONCLUSION: Among T2DM patients from south-coastal Andhra Pradesh the prevalence of thyroid dysfunction, especially that of SCH was high; SCH was more frequent among obese and nonmetformin users and was associated was associated with increased risk of diabetic retinopathy.

Insulin resistance and hyperandrogenemia independently predict nonalcoholic fatty liver disease in women with polycystic ovary syndrome.

AIMS: To find the prevalence and predictors of nonalcoholic fatty liver disease (NAFLD) in Asian Indian polycystic ovary syndrome (PCOS) women. MATERIALS AND METHODS: This is a prospective, cross-sectional study conducted at a tertiary care hospital from South India. Sixty women fulfilling the Rotterdam (2003) criteria for PCOS were recruited for the study. All participants were evaluated with ultrasound abdomen for fatty liver and additional biochemical investigations including fasting plasma glucose, postprandial plasma glucose, serum insulin, lipid profile and liver function tests. RESULTS: The mean age of the study population was 24.06 ±â€¯5.9 (range: 15-39) years. Oligomenorrhea, hirsutism and acne were present in 58 (96.7%), 37 (61.7%) and 33 (55%) women. Mean BMI of the study population was 29.5 ±â€¯5.28 (range: 19.95 to 45.44) kg/m2. Fifty (83.3%) women were obese (BMI: ≥ 25 kg/m2). Twenty-three (38.3%) women with PCOS had NAFLD. Three women each had isolated elevation of alanine transaminase (ALT) and aspartate transaminases (AST) whereas three women had elevation of both. All women with elevated transaminases had NAFLD. By univariate analysis, factors associated with NAFLD were serum total cholesterol, serum insulin, HOMA-IR, hyperandrogenism, ALT and AST. On multiple regression analysis using linear regression, HOMA-IR and hyperandrogenemia were the only significant predictors of NAFLD. CONCLUSION: Our study reports NAFLD in more than one third of Asian Indian women with PCOS. In addition to insulin resistance (HOMA-IR), hyperandrogenemia is an independent predictor of NAFLD in women with PCOS.

Rhinocerebral Mucormycosis with Top of Basilar Artery Syndrome.

AIM: Our objective is to highlight the varied forms of vascular dissemination of rhinocerebral mucormycosis resulting in ischemic arterial syndromes, especially rare posterior ischemic circulatory strokes, through dissemination of mucormycosis from sphenoid bone to clivus by bony erosion and to the basilar artery, thus causing the top of basilar artery syndrome. MATERIALS AND METHODS: We have reported a case of rhinocerebral mucormycosis in an uncontrolled diabetic patient presented to the neurointensive care unit, department of neurology. FINDINGS: A 56-year-old male diabetic patient with poorly controlled glycemic levels presented with pansinusitis resulting in rhinocerebral mucormycosis with basilar artery erosion through clivus bone erosion from sphenoid sinus. Mucormycosis is caused by fungi. Mucormycosis is commonly reported in immunocompromised patients such as poorly controlled diabetes mellitus, blood dyscrasias, malnutrition, neutropenia, iron overload, organ transplant, and immunosuppressive therapy. Mucormycosis rises with an increase in incidence of diabetes mellitus and HIV infection leading to immunocompromised status of the patient. In our case, there is invasion to the sphenoid bone and to clivus by bony erosion and to the basilar artery, thus causing the top of basilar artery syndrome, which is very unusual. CONCLUSION: Mucormycosis has a very fatal rapid progression with varied forms of cerebral dissemination with high mortality; hence early recognition and aggressive treatment are needed to increase the survival rate.