Prevalence of Coronary Artery Disease in Asymptomatic type 2 Diabetes Mellitus Patients with Invasive Correlation in North India.

Introduction: Type 2 diabetes mellitus (T2DM) is the risk factor for coronary artery disease (CAD). Material and Methods: In this study, we assessed the prevalence of CAD in asymptomatic T2DM patients and its correlation with invasive testing in treadmill testing (TMT)-positive cases. A total of 90 patients with asymptomatic T2DM were recruited and subjected to TMT TMT-positive patients were subjected to coronary angiography (CAG). Results: At baseline, the mean duration of T2DM (years) was 4.87 ± 4.04 with mean levels of HbA1c (%) of 7.96 ± 1.02. TMT was positive in 28 patients (31.1%) for reversible myocardial ischaemia (RMI), and among them, 16 patients consented to CAG, of which 14 required coronary angioplasty and the remaining two (7.1%) had to undergo coronary artery bypass grafting (CABG). The remaining 12 TMT positives (42.9%) were managed medically. Conclusion: To conclude, there is a high prevalence of silent CAD in T2DM. They need regular screening to detect the same and prevent the morbidity and mortality associated with overt CAD. Hence, it is important to screen people with type 2 diabetes, to prevent the morbidity and mortality associated with overt CAD.

Hungry bone syndrome like presentation following single-dose denosumab for hypercalcaemia secondary to sarcoidosis with IgA nephropathy.

A woman in her mid-50s with IgA nephropathy, sarcoidosis and steroid-induced diabetes mellitus presented with generalised paraesthesia and spontaneous tetany. She had received denosumab 60 mg subcutaneously 8 weeks previously for parathyroid hormone independent hypercalcaemia.At admission, she had severe hypocalcaemia (5 mg/dL), hypophosphataemia (1.9 mg/dL), hypomagnesaemia (1.4 mg/dL) and elevated serum creatinine (1.48 mg/dL) with prolonged QTc (corrected QT interval) on electrocardiograph. She initially received intravenous calcium and magnesium followed by oral calcium carbonate and calcitriol. Her prednisolone dose was tapered to 5 mg/day. Evaluation showed secondary hyperparathyroidism (1474 pg/mL) and elevated 1,25-dihydroxy vitamin D (195 pg/mL). After 1 week of oral calcium carbonate (3000 mg/day) and calcitriol (1.5 µg/day), she achieved normocalcaemia (8.1 mg/dL).To conclude, denosumab for hypercalcaemia with renal insufficiency causes prolonged severe symptomatic hypocalcaemia and hypophosphataemia mimicking hungry bone syndrome. It is important to periodically monitor for hypocalcaemia after denosumab.

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.

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.

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.

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.