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.

The good, the bad, and the ugly facets of insulin resistance.

Insulin is a potent anabolic hormone, and binding to its receptor activates downstream intracellular signaling pathways that regulate the nutrient metabolism, fluid homeostasis, growth, ionic transport, maintenance of vascular tone, and other functions. Insulin resistance (IR) is a condition characterized by subnormal cellular response to physiological levels of insulin. The IR is divided into three types (prereceptor, receptor, and postreceptor) based on the site of pathology. Beta cells attempt to overcome the IR by increasing the release of insulin, leading to hyperinsulinemia. IR is the predisposing factor for many metabolic and cardiovascular disorders. From the evolutionary perspective, the presence of IR offers a survival advantage in the face of starvation or stress. In this brief review, we discuss the different facets of insulin resistance and appraise the readers about the hitherto neglected beneficial advantages.

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.

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.

Caput medusae in alcoholic liver disease.

Caput medusae and palmar erythema are cardinal signs in cirrhosis of liver with portal hypertension. Palmar erythema is described more often as a marker for alcoholic etiology of chronic liver disease. The peripheral stigmata of chronic liver disease are not routinely seen now a days due to early diagnosis and better therapy. We recently encountered an interesting patient of alcoholic liver disease with two classical signs of the disease and report the same for this unusual presentation.

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.

Evaluation of thyrotoxicosis during pregnancy with color flow Doppler sonography.

OBJECTIVE: To determine whether color flow Doppler sonography (CFDS) is useful in differentiating Graves vs non-Graves thyrotoxicosis during pregnancy, when nuclear imaging is contraindicated. METHODS: Ten pregnant women with thyrotoxicosis were divided into Graves, and non-Graves, disease groups and were evaluated by CFDS for thyroid volume, vascularity, and inferior thyroid artery (ITA) flow velocity. Each patient was matched with a euthyroid woman of the same pregnancy duration. RESULTS: Of the 10 patients, 3 were diagnosed with Graves disease, 4 with gestational toxicosis, and 3 with destructive thyroiditis. Those in the Graves disease group had a greater thyroid gland volume (18.9+/-1.5 cm3 vs 12.1+/-2.4 cm3; P<0.05), greater thyroid vascularity, and greater ITA flow velocity than those in the non-Graves disease group (92+/-13 cm/s vs 20.4+/-2.4 cm/s; P<0.05). There was no significant difference in the corresponding values between the patients with gestational toxicosis and those with destructive thyroiditis or between them and their healthy controls. CONCLUSION: Thyroid evaluation by CFDS is useful for the differential diagnosis of thyrotoxicosis in pregnant women.

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.

A Prospective, Observational Study of Osteoporosis in Men.

CONTEXT: The number of men afflicted with osteoporosis is unknown. AIMS: This study aims to determine the prevalence of osteoporosis in men. SETTINGS AND DESIGN: This was a prospective, observational study. SUBJECTS AND METHODS: A total of 200 male attendants of patients attending endocrine outpatient department and who were >55 years were recruited for the study. All the patients with osteopenia and osteoporosis were advised lifestyle interventions, supplementation with calcium carbonate (1000-1500 mg/day) and 25-hydroxyl-Vitamin D (400-600 IU/day) and bisphosphonates if indicated. Vitamin D3 60,000 IU once a week for 8 weeks and once a month thereafter was prescribed to Vitamin D-deficient patients. Androgen-deficient patients were given replacements of either injectable testosterone or oral testosterone undecanoate. STATISTICAL ANALYSIS USED: Two sample t-test and paired t-test were used to compare pre- and post-test parameters. RESULTS: Overall 80 (40%) subjects had low bone mass, 93 (43.5%) had Vitamin D deficiency/insufficiency, and 39 (19.5%) had androgen deficiency. Osteoporosis was found in 8.5% patients. All patients were above 70 years (Mean age: 73.82 ± 2.79 years). Seventy percentage of these patients had low serum testosterone and 70% of patients had Vitamin D deficiency/insufficiency. About 31.5% of patients had osteopenia (mean age of 67.47 ± 6.35 years). Thirty-five percentage of these patients were androgen deficient and 25% were Vitamin D-deficient/insufficient. Age >70 years, serum testosterone <3 ng/ml, Vitamin D <30 ng/ml were strong risk factors for osteoporosis. Vitamin D supplementation, androgen replacement, and bisphosphonate therapy had beneficial effect on bone mineral density (BMD). CONCLUSIONS: Low bone mass was common (40%) in males over 55 years of age. Age >70 years, low androgen (<3 ng/ml), steroid use, and low Vitamin D (<20 ng/ml) were independent risk factors of male osteoporosis. Calcium and Vitamin D are effective in improving BMD. Androgen replacement has beneficial effect on BMD in hypogonadism patients.

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 22,000ft 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.

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 ß-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 ß-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.

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.