Awareness regarding foot self-care practices among diabetic patients in Northeast part of India. Can primary care physician make a difference? A hospital based cross-sectional study.

Background: About 10% of patients with type 2 diabetes mellitus at the time of diagnosis have more than one risk factor for developing foot ulceration, and it increases to 15% in a lifetime. The risk of development of Diabetic foot ulcers/gangrene can be prevented by the patient's self-foot care practice at home. The present study aimed to determine the prevalence of awareness of self-foot care practice among diabetic patients in a rural setting. The study also aimed to identify the factors preventing dry or wet diabetic gangrene development and subsequent amputation. Methods: A hospital-based cross-sectional study was carried out among 1687 people with diabetes mellitus (DM) who attended orthopedic and diabetic OPD in a tertiary care hospital in Kamrup, Assam, India. An appropriate self-explanatory questionnaire about knowledge of self-foot care practice was given to all study participants. Foot examination was performed by authors participated in the study on all patients. The observations and results were categorized according to the International Diabetes Federation foot risk categories. Results: Of 1687 patients included in this study, 298 (17.7%) had foot ulcers of various grades, 164 (9.76%) had peripheral vascular disease, and 484 (28.7%), had peripheral neuropathy of different grades. After multivariate analysis, patients on insulin and combination therapy and peripheral neuropathy were significantly associated with the presence of foot ulcers. The mean knowledge score was as low as 9.7 ± 4.8 out of a total score of 23. Low awareness and knowledge were associated with low mean scores due to a lack of formal education (8.3 ± 6.1). Among the 1687 patients, only 381 (22.5%) are aware and have some knowledge about self-foot care, and 686 (40.6%) had their feet examined by a doctor only once since their initial diagnosis. The incidence of development of diabetic-related complications was significantly low in those who know about foot self-care as well as those whose feet had been inspected by a physician at least once. Conclusion: The incidence of development of diabetic-related complications was significantly low in those who know about foot self-care as well as those whose feet had been examined by a physician of family doctors at least once. There is a need to educate all patients of diabetes about self-foot care. It is prudent to establish an integrated foot care services within primary care centers and in the diabetic clinic to identify feet at risk, institute early preventive measures, and provide continuous foot care education through images videos on WhatsApp to patients and primary health care givers.

Analysis of relationship of hormonal, hematological and biochemical parameters in Indian alcoholics with severity of alcohol dependence.

Background: Alcohol dependence syndrome (ADS) is a major problem in India. ADS is known to be a systemic disorder involving almost all organ-systems. The evaluation of ADS patients' needs successive assessment of severity of clinical condition. In this study, we attempted to explore Severity of Alcohol Dependence Questionnaire (SADQ-C) as a severity measure by studying its association with laboratory parameters. Methods: During the two months study period 155 diagnosed ADS male patients who had been admitted to the Psychiatric Ward of two zonal level hospitals were enrolled for the study. The participants were examined by the Psychiatrist and the severity of alcoholism ascertained by the SADQ-C scoring. Based on SADQ-C scoring they were divided into three groups: severe alcohol dependence, moderate dependence and mild physical dependence. The patients' blood samples were collected and tested. Results: In our study, morning and evening level of serum cortisol showed positive correlation with increasing SADQ-C scoring. The differences in morning and evening cortisol level also augmented with increasing severity score (r=0.257; p=0.001). Hemoglobin, mean corpuscular volume (MCV) and serum level of LH, FSH and testosterone levels were not shown any statistically significant alterations amongst the studied groups. Serum LH, total bilirubin, direct bilirubin, AST, ALT and GGT level showed positive correlation with SADQ-C scoring but AST/ALT ratio showed negative correlation. Conclusion: This study elaborated relationship between SADQ-C scoring and laboratory parameters in Indian male ADS patients. It highlighted the requirement of incorporation of serum cortisol along with presently evaluated laboratory parameters for ADS severity evaluation.

Does parity and duration of lactation have any effect on the bone mineral density of the femur and lumbar spine in Indian women? A cross-sectional study from the Northeast region of India.

BACKGROUND: The effects of multiple pregnancies and period of lactation on bone density have not been studied till date and there is very less data available, especially from developing countries like India. Lumbar spine and femoral neck were used to measure BMD and results were recorded. OBJECTIVE: To find out the effect of parity and period of lactation on occurrence of osteoporosis in spine and femoral neck in women of the Northeast region of India. MATERIALS AND METHODS: The cross-sectional study included 294 perimenopausal and postmenopausal women aged 30-65 year old. Age, body mass index (BMI), parity, total lactation period, menopausal status, duration of menopause socioeconomic status, and nutritional history were noted. The dual-energy X-ray absorptiometry system was used to measure the BMD of lumbar and femoral neck BMD. Multiple regression analysis was done for finding out the association of parity and lactation with BMD. RESULTS: The parity was inversely related with BMD of lumbar spine (ß = -0.138, P = 0.00423) and BMD of femoral neck (ß = -0.142, P = 0.00487). This relation remained significant after adjusting for age, BMI, and duration of menopause. Period of lactation was also inversely correlated with BMD for lumbar spine (ß = -0.0812, P = 0.0012) and BMD of femoral neck (ß = -0.033, P = 0.0031). CONCLUSION: The number of parity and prolonged period of lactation have a negative effect on BMD in both regions especially in the lower socioeconomic strata with poor nutritional intake. Our data supports that parity and duration of lactation can be associated with future osteoporosis.

Post-mortem findings in Staphylococcus aureus acute infective endocarditis.

Infective endocarditis (IE) is a microbial infection of the heart valves or the mural endocardium that leads to the formation of vegetations composed of thrombotic debris and microorganisms often associated with the destruction of the cardiac tissues. Most of the infections are bacterial (bacterial endocarditis), although fungi and other microorganisms can be etiological agents. Causative organisms differ among the major high-risk groups. Virulent microorganisms like Staphylococcus aureus, commonly found on the skin, can infect normal or deformed valves and are responsible for 20-30% of all IE cases. Staphylococcus aureus is the major offender in IE among intravenous drug abusers. Acute infective endocarditis is typically caused by infection of a previously normal heart valve by a highly virulent organism (e.g., Staphylococcus aureus) that rapidly produces necrotizing and destructive lesions. These infections may be difficult to cure with antibiotics, and despite appropriate treatment, death can ensue within days to weeks. Here we present autopsy findings of a 31-year-old male patient who died of acute infective endocarditis caused by Staphylococcus aureus as the causative organism.

Can self-perceived easy fatigability be a predictor of vitamin D deficiency in young Indian women?

BACKGROUND: Easy fatigability is a common presenting complaint in Indian women who visited primary care hospitals. Many medical conditions like cancer, chronic bronchial asthma, prolonged use of glucocorticosteroid, renal disorder, and hypothyroidism have been associated with low levels of vitamin D. Correction of vitamin D level improves the symptom of fatigue. Whether low vitamin D causes fatigue in otherwise healthy women is the subject of research. AIM: This prospective nonrandomized and therapeutic study observed the prevalence of hypovitaminosis D in women with fatigue and the effect of correction of vitamin D level in fatigue-like symptoms. MATERIAL AND METHODS: One thousand two hundred adult women, who presented in our primary care hospital with complaints of easy fatigue, otherwise no associated medical illness were included. They completed the fatigue assessment questionnaire (FAQ). Patients with hypovitaminosis D received cholecalciferol (60000 IU) therapy for 5 weeks. Scores of pre- and post-treatment FAQs were noted and compared. RESULTS: The prevalence of low vitamin D was noted in 84.8% women who presented with main complaints of fatigue. After the correction of vitamin D level, fatigue symptom scores improved significantly (P < 0.001) in 82.6% of the women in all five-subscale categories of the FAQ. CONCLUSION: We observed a high prevalence of low serum vitamin D level in women who presents with fatigue with no medical illness. A significant improvement was noted in the severity of their fatigue symptoms after the correction of vitamin D levels with cholecalciferol therapy.

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.

Post-mortem findings in Staphylococcus aureus acute infective endocarditis

Infective endocarditis (IE) is a microbial infection of the heart valves or the mural endocardium that leads to the formation of vegetations composed of thrombotic debris and microorganisms often associated with the destruction of the cardiac tissues. Most of the infections are bacterial (bacterial endocarditis), although fungi and other microorganisms can be etiological agents. Causative organisms differ among the major high-risk groups. Virulent microorganisms like Staphylococcus aureus, commonly found on the skin, can infect normal or deformed valves and are responsible for 20-30% of all IE cases. Staphylococcus aureus is the major offender in IE among intravenous drug abusers. Acute infective endocarditis is typically caused by infection of a previously normal heart valve by a highly virulent organism (e.g., Staphylococcus aureus) that rapidly produces necrotizing and destructive lesions. These infections may be difficult to cure with antibiotics, and despite appropriate treatment, death can ensue within days to weeks. Here we present autopsy findings of a 31-year-old male patient who died of acute infective endocarditis caused by Staphylococcus aureus as the causative organism.

Is it necessary to screen patient with adhesive capsulitis of shoulder for diabetes mellitus?

BACKGROUND: Idiopathic adhesive capsulitis of shoulder is common cause of pain and restriction of shoulder motion between the ages of 30 and 65. The prevalence of adhesive capsulitis is as high as 10% to 22% in diabetes mellitus as compared normal population which is 02% and 04%. Therefore, the doubt arises whether patients developed adhesive capsulitis are at greater risk to develop diabetes mellitus and should be screen for diabetes so that it can be detected early. PURPOSE: To compare the prevalence of prediabeties and diabetes mellitus among patients with features of idiopathic adhesive capsulitis of shoulder who are otherwise healthy. METHODS: Patients between 30-65 years of age who attended Orthopaedics OPD with features of idiopathic adhesive capsulitis of shoulder were included. Participated underwent a 2 hour long oral glucose tolerance test and based on fasting and 2-hour plasma glucose levels, patients were diagnosed as normal glucose tolerance, prediabetic, or diabetic and the results were matched with previous published data. RESULTS: 135 patients as participated and completed the test. 21 (15.5%) patients with idiopathic adhesive capsulitis of shoulder were found to be prediabetic, and 37 (27.4%) patients were found to be diabetic. However, 31 patients had family history of diabetes. CONCLUSION: Based on our study, we can recommend that patients with features of idiopathic adhesive capsulitis of shoulder should be screened at least for fasting and post prandial blood sugar so that diabetes can be detected early.

Pancreatitis and hyperparathyroidism: Still a rare association!

BACKGROUND: Among the multitudinous etiologies of pancreatitis, primary hyperparathyroidism (PHPT) is rarely associated with pancreatitis. However, the cause and effect relationship between the two still evokes controversy. We aimed to study and characterize the nature of pancreatic disease in PHPT. METHODS: A retrospective single-center study was carried out in North India over a period of 1 year (June 2015 to May 2016). All patients with pancreatitis were included. In patients with high calcium levels, Intact Parathyroid Hormone (iPTH) by Radioimmunoassay (RIA) and an Technetium 99m Sestamibi scintigraphy (MIBI-Tc-99m) scan were performed. RESULTS: During the study period, 70 patients with pancreatitis were admitted to our hospital (53 with acute pancreatitis [AP] and 17 with chronic pancreatitis [CP]). Of them, 5 patients (9.4%) were detected to have PHPT. The mean age of patients was 30.4 years (20-49 years) with 3 males and 2 females, including 1 pregnant female (29th week of gestation). Contrast enhanced computed tomography (CECT) abdomen was performed in 4 cases (excluding 1 pregnant patient) with mean Computed tomography severity index (CTSI) of 4.7 (2-8). Four patients were detected to have increased uptake in one of the parathyroid glands, and the fifth patient had an ectopic parathyroid uptake in the mediastinum. All the resected samples were identified as parathyroid adenoma on histology. The patients were followed up for 1 year with no reported recurrence of symptoms. CONCLUSION: The data suggest an association between pancreatitis (both acute and chronic) and hypercalcemia due to PHPT. A high calcium value during AP or CP should always draw suspicion and warrants corresponding investigations in search of endocrine or malignant cause.

Effect of Glycemic Variability on Mortality in ICU Settings: A Prospective Observational Study.

BACKGROUND: Evidence suggests a role of glycemic variability in intensive care unit (ICU) mortality. OBJECTIVE: To assess effect of glycemic variability and ICU/in-hospital mortality. DESIGN: Prospective, observational study. SETTING: A 20-bedded medical/surgical ICU in a tertiary care hospital. PATIENTS: Critically ill patients requiring life-support measures admitted to the ICU between November 1, 2015 and December 30, 2016 with hyperglycemia [random blood sugar (RBS) ≥200 mg%] and sequential organ failure assessment (SOFA) scores ≤9. Patients were put on predefined insulin infusion protocol, multiple glucose values were obtained, and mean blood glucose level (MGL) was calculated as their simple arithmetic mean. Standard deviation (SD) of MGL and coefficient of variation (CV) of glucose (derived as a percentage of SD to mean blood glucose) were then calculated for each patient and analyzed for all-cause death during hospitalization period. RESULTS: A total of 123 patients having a mean age of 65.12 ± 16.27 years, mean SOFA score of 5.76 ± 1.76, and mean HbA1c of 6.22 ± 0.73% were included. MGL was 160.65 ± 24.19 mg/dl, SD 33.32 ± 15.08 mg/dl, and CV 20.74 ± 8.43. Deceased as compared to survivors had higher MGL (163.76 ± 24.85 vs 155.62 ± 22.43 mg/dl, P = 0.068) and higher glycemic variability (SD 38.92 ± 14.44 vs 25.06 ± 12.27 mg/dl; P < 0.001 and CV 23.69 ± 7.9 vs 15.98 ± 6.87; P < 0.001). Interestingly, more patients having higher CV at lower MGL (85.7%) died as compared to those having lower CV at higher MGL (55.6%). CONCLUSIONS: High glycemic variability is associated with increased ICU/in-hospital mortality. Outcome of patients having less glycemic variability even with slight hyperglycemia may be better than those having tight glycemic control but higher glycemic variability. Insulin protocols need to be in place for management of hyperglycemia in critical care setting aiming for adequate glycemic control as well as minimizing glycemic variability.

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 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 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.

Effect of oral vitamin D supplementation on glycemic control in patients with type 2 diabetes mellitus with coexisting hypovitaminosis D: A parellel group placebo controlled randomized controlled pilot study.

CONTEXT: Vitamin D supplementation in type 2 diabetes mellitus patients may lead to improved glycemic control by improving insulin secretion and decreasing insulin resistance. AIMS: To investigate effect of oral vitamin D supplementation on glycemic control, in patients with type 2 diabetes mellitus and coexisting hypovitaminosis D. SETTINGS AND DESIGN: Randomized, Parallel Group, Placebo Controlled Trial carried out in a tertiary care hospital of Indian Armed Forces. METHODS AND MATERIAL: Sixty patients with coexisting type 2 diabetes mellitus and hypovitaminosis D were randomized into cases and controls and were supplemented with oral Vitamin D and microcrystalline cellulose respectively for six months. Subjects' HbA1c and vitamin D levels were monitored at the beginning and end of the study, fasting plasma glucose (FPG) & post prandial plasma glucose (PPPG) during monthly OPD visits. STATISTICAL ANALYSIS USED: Intra-group comparison was made by paired t test & unpaired t test was used for inter-group (A v/s B) comparisons. Repeated measures ANOVA was undertaken to compare values over time. RESULTS: The two groups were comparable for all parameters at baseline. Case group showed significant decrease in mean HbA1c levels (7.29% to 7.02%; P = 0.01), mean FPG levels (131.4 to 102.6 mg/dl; P = 0.04) and mean PPPG levels (196.2 to 135.0 mg/dl; P < 0.001). Incidentally, significant improvement in systolic as well as diastolic blood pressure and total cholesterol was also noted in the cases, while for LDL cholesterol improvement tended towards significance (p = 0.05). CONCLUSIONS: We found that oral vitamin D supplementation was associated with improved glycemic control and other metabolic parameters in patients with type 2 diabetes mellitus. Supplementation to achieve normal levels of vitamin D can be a promising adjuvant therapy for T2DM patients & coexisting hypovitaminosis D.

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.

Efficacy of Teriparatide in Patients with Hypoparathyroidism: A Prospective, Open-label Study.

CONTEXT: Conventional treatment of hypoparathyroidism with calcium, Vitamin D analogs, and thiazide diuretics is often suboptimal, and these patients have poor quality of life. Teriparatide (parathyroid hormone 1-34 [PTH (1-34)]), an amide of PTH, is widely available for the use in osteoporosis; however, its use in hypoparathyroidism is limited. AIMS: The aim of this study is to evaluate the efficacy of PTH (1-34) in the treatment of patients with hypoparathyroidism. SETTINGS AND DESIGN: This was a prospective, open-label interventional study in a tertiary care hospital of Indian Armed Forces. SUBJECTS AND METHODS: All patients with hypoparathyroidism presented to the endocrinology outpatient department were included and were exhibited injection PTH (1-34) 20 µg twice daily that was gradually reduced to 10 µg twice daily along with calcium, active Vitamin D (alfacalcidol), and hydrochlorothiazide. Oral calcium and alfacalcidol doses were also reduced to maintain serum calcium within normal range. The quality of life (QOL) score was calculated using RAND 36 QOL questionnaire at baseline and termination of the study. STATISTICAL ANALYSIS USED: Paired t-test was used to calculate pre- and post-treatment variables. RESULTS: Eight patients (two males) were included in this study having mean age of 35.8 years. PTH (1-34) treatment led to the improvement in serum calcium (6.81-8.84 mg/dl), phosphorous (5.8-4.2 mg/dl), and 24 h urinary calcium excretion (416-203.6 mg). Parameters of QOL showed the improvement in overall QOL, physical performance, energy, and fatigue scores. No major adverse events were noted. CONCLUSIONS: Treatment of hypoparathyroidism with PTH (1-34) leads to improvement in calcium profile, reduction in hypercalciuria, and improvement in QOL, whereas it is safe and well tolerated.

An unusual case of hypercalcemia in a patient of concomitant hypoparathyroidism and celiac disease.

Milk alkali syndrome has shown resurgence with increase in use of (prescription or non prescription) calcium supplements. Cases of iatrogenic vitamin D intoxication has also increased due to increasing use of high doses of injectable vitamin D formulations by physicians, surgeons, orthopaedicians, gynecologists and other specialties inadvertently. Here, we present an unusual case of a 17-year-old boy who presented with iatrogenic hypercalcemia as a result of combination of milk alkali syndrome with vitamin D intoxication despite being a case of hypoparathyroidism and concomitantly suffering from celiac disease.