Oxidative stress in hypothyroid patients and the role of antioxidant supplementation.

CONTEXT: The available data concerning oxidant stress and antioxidant capacity in hypothyroidism are scanty and inconclusive. While some authors suggest that tissues may be protected from oxidant damage because of a hypometabolic state in hypothyroidism, others report increased oxidative stress in hypothyroidism. Selenium acts as a cofactor for the thyroid hormone (TH) deiodinases that activate and then deactivate various THs and their metabolites. Selenium may inhibit thyroid autoimmunity. AIMS: The study was designed, first, to study the impact of oxidative stress in patients of primary hypothyroidism due to autoimmune thyroiditis, by estimation of serum malondialdehyde (MDA) as a biomarker of oxidative stress. Second, to study the change in MDA level pre- and post-L-thyroxine treatment. Finally, to look into the possible role of selenium supplementation on oxidative stress in autoimmune hypothyroidism. SUBJECTS AND METHODS: Patients attending endocrine outpatient department (OPD) services of IPGMER and SSKM hospital were considered for the study. Sixty treatment-naive adult patients (age > 18 years) with hypothyroidism were included in the study. The patients were divided into two groups, each comprised thirty patients. One group was treated with L-thyroxine and placebo (Group A). The other group received L-thyroxine replacement along with selenium (100 mcg twice a day) as antioxidant supplementation (Group B). The patients were blinded about selenium and placebo. The study duration for both groups was 6 months. The starting dose of L-thyroxine was 1.6 mcg/kg body weight free thyroxine (FT4), and thyroid-stimulating hormone (TSH) was repeated after 12 weeks. L-thyroxine dose adjustments were done if needed. MDA was assessed at the beginning and at the end of the study, i.e., after 6 months of treatment. The control cohort was composed of thirty healthy adults. Only overt hypothyroidism (OH) cases were included in the study. STATISTICAL ANALYSIS USED: Normality of data was determined using Anderson-Darling test, Shapiro-Wilk test, and QQ plot. P values were calculated using ANOVA and post hoc Bonferroni tests for normally distributed data. Correlation analysis was carried out using Pearson correlation test. P < 0.05 considered to be statistically significant. RESULTS: After treatment in Group A patients, FT4 showed a significant increment while TSH value decreased. MDA level reduced after treatment, (P < 0.001). After treatment in Group B patients, FT4 showed increment while TSH value decreased (P < 0.05). After treatment, there was a drop in estimated MDA level (P < 0.001). MDA level shows a significant drop in both groups after treatment. In Group B, there is more decline in the MDA percentage but did not reach statistical significance. By performing repeated measure MANOVA, no significant difference was found in the MDA levels between the two groups. MDA reduction when expressed as percentage showed reduction of 39.5% in patients of Group A. Similarly, Group B patients showed a percentage reduction of 45.4%. CONCLUSIONS: Oxidative stress compounds hypothyroidism. Hypothyroidism is a state of increased oxidative stress. In this study, biomarker, MDA level is high in treatment-naive primary hypothyroid patients. After treatment with L-thyroxine, the stress marker is reduced to a significant extent. MDA can be used as a useful biomarker to measure and monitor oxidative stress. The role of the addition of antioxidant in the form of selenium remained inconclusive.

Profile of liver enzymes in non-alcoholic fatty liver disease in patients with impaired glucose tolerance and newly detected untreated type 2 diabetes.

CONTEXT: The perception of non-alcoholic fatty liver disease (NAFLD) as an uncommon and benign condition is rapidly changing. Approximately, 70% type 2 diabetes mellitus (T2DM) patients have a fatty liver, which may follow an aggressive course with necroinflammation and fibrosis. AIMS: To assess the profile of liver enzymes in subjects with impaired glucose tolerance (IGT), new onset treatment naive T2DM and normal glucose tolerance (NGT) with and without NAFLD. SETTINGS AND DESIGN: Cross-sectional clinic-based study. SUBJECTS AND METHODS: 152 IGT and 158 recently detected T2DM subjects aged between 30 and 69 years, along with 160 age and gender matched controls with NGT. An ultrasonography scan of the upper abdomen was done in all patients in order to examine presence of fatty liver. Anthropometry, lipid profile, liver enzymes were also analyzed in all patients. STATISTICAL ANALYSIS USED: Unpaired t-test, Chi-square/Fisher Exact test (for categorical variables), Pearson/Spearmen correlation test to find significant difference, association and correlation between two or more groups respectively. RESULTS: NAFLD was significantly associated with higher alanine aminotransferase (ALT) and gamma-glutamyl transferase (GGT) but not ALP levels in IGT and T2DM patients. ALT, GGT significant correlated with waist circumference, body mass index, fasting insulin, homeostatic model assessment- insulin resistance, fasting blood glucose, high density lipoprotein cholesterol, triglyceride. 57% of NAFLD patients had normal ALT between 25 and 40 U/L, 53% of NAFLD subjects had normal GGT between 15 and 30 U/L. ALT <25 U/L and GGT <15 U/L had highest negative predictivity whereas ALT >40 U/L and GGT > 30 U/L had highest positive predictivity for presence of NAFLD in our study sample. CONCLUSIONS: Mild elevations of liver enzymes in the upper normal range are associated with features of metabolic syndrome and NAFLD even in IGT and recently detected T2DM patients. Novel cut-offs for liver enzymes are warranted in order to prevent unnecessary diagnostic work-ups and early detection of NAFLD to reduce the risk of cirrhosis, hepatocellular carcinoma and classical cardiovascular disease in T2DM and IGT patients.

Role of NF-κB activation and VEGF gene polymorphisms in VEGF up regulation in non-proliferative and proliferative diabetic retinopathy.

The present study was aimed to investigate the relation between nuclear factor kappa beta (NFκB) activation and downstream up-regulation of vascular endothelial growth factor (VEGF) in diabetic retinopathy (DR). Moreover the study was intended to evaluate the role of VEGF gene single nucleotide polymorphisms (SNPs) in DR occurrence and to investigate the functional relevance of VEGF gene SNPs in terms of VEGF expression in DR. Serum level of VEGF, VEGF R1 (receptor 1), VEGF R 2 (receptor 2) and NFκB (p50/65) activity was measured by enzyme linked immune sorbent assay. Genotyping and allelic composition of different SNPs i.e., rs2010963, rs3025039, rs1570360 and rs 2071559 were investigated by Taqman SNP genotyping assay. VEGF, NFκB p50/p65, and VEGF R1 & R2 gene expressions were quantified by real time quantitative polymerase chain reaction. Increased NFκB p50/p65 activity and expressions were observed in non proliferative diabetic retinopathy (NPDR) and proliferative diabetic retinopathy (PDR) subjects compared to type 2 diabetes mellitus without retinopathy (DNR) group. Significantly elevated levels of serum VEGF and highest VEGF expression were found among PDR subjects compared to DNR or NPDR subjects. CC genotype and C allele of rs2010963 and TT genotype and T allele of rs3025039 were significantly over represented among PDR subjects compared to DNR group. Increased activation of NFκß in NPDR and PDR subjects might involve increased up regulation of VEGF. VEGF SNPs i.e., rs2010963 C allele and rs3025039 T allele might be associated with PDR occurrence and in turn regulates VEGF expression among PDR subjects.

Urinary albumin : creatinine ratio predicts prediabetes progression to diabetes and reversal to normoglycemia: role of associated insulin resistance, inflammatory cytokines and low vitamin D.

BACKGROUND: The relationship between albumin : creatinine ratio (ACR), insulin resistance (IR), cytokines, dyslipidemia, and 25-hydroxy vitamin D (25-OHD) in individuals with prediabetes (IPD) was investigated to evaluate their role in predicting future risk of progression to diabetes. METHODS: The aforementioned parameters were evaluated in 147 IPD with persistent impaired fasting glucose and/or impaired glucose tolerance over two oral glucose tolerance tests, who were then followed up at 3-monthly intervals for progression to diabetes or reversal to normoglycemia. RESULTS: Data were analyzed for 137 IPD with at least 1-year follow-up. Forty-three IPD reversed to normoglycemia (Group I), 69 continued with prediabetes (Group II), and 25 progressed to diabetes (Group III) over a mean follow-up period of 28.36 ± 8.19 months. Baseline fasting blood glucose levels (BGLs), 2-h post-glucose BGLs, and ACR were lowest in Group I and highest in Group III. Of the 137 IPD, 54.75% (n = 75) had microalbuminuria. The IPD in the lowest ACR quartile had the highest reversal to normoglycemia. Cox regression revealed that baseline IL-6 was predictive of progression to diabetes (P = 0.03) and ACR was an independent predictor of reversal to normoglycemia (P = 0.007). Kaplan-Meier analysis showed higher reversal to normoglycemia in IPD without microalbuminuria (P < 0.001). CONCLUSION: An increased ACR is associated with higher creatinine, IR, and cytokine levels and lower 25-OHD levels in IPD. Microalbuminuria is associated with decreased reversal to normoglycemia and increased progression to diabetes. Low 25-OHD may be associated with increased progression to diabetes, perhaps via modulation of the ACR.

Can a faulty injection technique lead to a localized insulin allergy?

Insulin allergy is a rare occurrence which can present diagnostic and management dilemmas for the clinician. Three types of reaction have been reported: Localized, generalized (systemic), and insulin resistance. All need to be considered in cases of suspected insulin allergy. Adverse reactions to insulin have significantly decreased since the introduction of recombinant human insulin preparations. However, cases with insulin allergy continues to present in the clinic. Symptoms range from local injection site reactions to severe generalized anaphylactic reactions. The case study presented here describes an event of suspected insulin allergy arising out of faulty insulin injection technique.

Dyslipidemia, metabolic syndrome, and liver enzymes in impaired glucose tolerance and new onset untreated, type 2 diabetes Indian subjects.

UNLABELLED: This cross-sectional clinic-based study assessed and compared lipid profile, presence of metabolic syndrome (MetS), and liver enzymes in subjects with IGT, new onset treatment naïve T2DM, and normal glucose tolerance (NGT). INTRODUCTION: Type 2 diabetes (T2D) and IGT patients have increased dyslipidemia, MetS, and alterations in liver enzymes. AIMS AND OBJECTIVES: To assess and compare lipid profile, presence of MetS, and liver enzymes in subjects with IGT, new onset treatment naïve T2DM, and NGT. MATERIALS AND METHODS: This cross-sectional clinic-based study examined 152 IGT and 158 recently detected T2D subjects aged between 30 and 69 years, never treated with any anti-hyperglycemic, anti-hypertensive, and lipid lowering drugs. One hundred and sixty age- and gender-matched controls with NGT were also selected. Anthropometry, lipid profile, dyslipidemia (ADA criteria), presence of MetS (NCEP, IDF), liver enzymes, insulin resistance (HOMA-IR and QUICKI), and ß-cell function (HOMA ß) were analyzed in all subjects. RESULTS: T2D and IGT subjects had significantly higher BMI, waist circumference, blood pressure (BP), HOMA-IR, QUICKI, fasting insulin, HOMA-ß, MetS, triglyceride, LDL-C, SGPT, GGT, and lower HDL-C compared to NGT (control). High LDL-C (>100 mg/dl) was the commonest dyslipidemia followed by low HDL-C and hypertriglyceridemia in IGT and T2D. We found no significant differences in BMI, waist circumference, insulin resistance, total/LDL-C/HDL-C, and presence of MetS between T2D and IGT subjects. Diabetics exhibited significantly higher BP, triglyceride, SGPT, GGT, lower fasting insulin, and HOMA-ß-cell function compared to IGT. CONCLUSIONS: IGT and recent onset T2D individuals had similar increased cardiovascular risk markers, liver enzymes, and prevalence of MetS. High LDL-C was the commonest dyslipidemia in IGT and T2D. T2D subjects had higher triglyceride, BP, SGPT, GGT compared to IGT.

Evaluation of diabetic polyneuropathy in Type 2 diabetes mellitus by nerve conduction study and association of severity of neuropathy with serum sFasL level.

INTRODUCTION: Diabetes mellitus (DM), a growing health problem globally, has reached epidemic proportions in India. Recently, Fas-mediated apoptosis has been proposed as a causative factor responsible for neuronal degeneration in diabetic polyneuropathy (DPN), but there are very few studies to show association of serum soluble Fas ligand (sFasL) level with severity of neuropathy. AIM AND OBJECTIVE: The aim of this study was to investigate whether serum sFasL, a transmembrane glycoprotein involved in apoptosis, has any association with severity of peripheral neuropathy in Type 2 DM. MATERIALS AND METHODS: The study was conducted in Department of Physiology in collaboration with Department of Endocrinology, IPGME&R. sFasL levels in serum were assessed using ELISA method in healthy individuals (n = 16), newly diagnosed diabetic controls (n = 16) without any complications, and in DPN cases (n = 33) with predominant neuropathy only. All subjects underwent both electrodiagnostic procedures and vibration perception threshold (VPT) for quantitative assessment of the severity of neuropathy. Using nerve conduction studies, amplitudes, velocities, and latencies of both sensory and motor nerves were recorded. RESULTS: In DPN patients, concentration of sFasL levels (87.53 ± 3.49) was significantly decreased (P < 0.0001) not only when compared with normal controls (225.30 ± 2.97) but also when compared with diabetic patients without any complication (161 ± 3.63). Moreover, the concentration of sFasL is significantly (P < 0.0001) associated with the severity of neuropathy both by VPT and nerve conduction velocity (NCV). CONCLUSION: Fas-mediated apoptosis is involved in Type 2 DM and might be associated with the severity of polyneuropathy.

De morseir syndrome presenting as ambiguous genitalia.

BACKGROUND: A 10-year-old boy presented with genital ambiguity, poor linear growth, and delayed milestones. The aim and to highlight that although rare but congenital, hypogonadotropic hypogonadism may rarely present as ambiguity. MATERIALS AND METHODS: The patient was found to have bilateral cryptorchidism with proximal penile hypospadias, microphallus with a proportionate dwarfism with mildly delayed bone age, and karyotype 46XY. Euthyroid with normal steroid axis, growth hormone insufficient as suggested by auxology, low IGF1, and poor response to clonidine stimulation. MRI brain shows hypoplastic corpus callosum, hypoplastic anterior pituitary, and ectopic posterior pituitary bright spot. RESULTS: The patient underwent laparoscopic removal of right intrabdominal testis and orchidoplexy was performed on the left one. Testicular biopsy revealed no malignancy and growth hormone replacement was initiated. The patient awaits definitive repair of hypospadias. CONCLUSION: As a provisional diagnosis of combined growth hormone and gonadotropin deficiency, most probable diagnosis is septo-optic dysplasia or de moseir syndrome leading to genital ambiguity.

Early treatment with low fixed dose (5 mCi) radioiodine therapy is effective in Indian subjects with Graves' disease.

There is little consensus regarding the most appropriate dosage regimen for radioiodine treatment in Graves' disease. The authors evaluated the efficacy of low fixed dose (5mCi) of radioiodine therapy, in terms of its cure rate and promptness of control, as well possible factors influencing the outcome. One hundred and twenty five consecutive patients with Graves' disease with persistent disease activity despite receiving carbimazole were treated with 5 mCi fixed dose of I131. Patients, who remained hyperthyroid at 1 year, received a second dose of 7.5 mCi of I113. After first dose 73.6% were cured (36.8% hypothyroid and 36.8% euthyroid), while 26.4% patients did not respond. Those who achieved cure had significantly lesser goiter size (84.6% with grade I goiter and 70.7% with grade II) and had received significantly shorter duration of prior carbimazole therapy (22 +/- 10 months versus 63 +/- 27 months) (p < 0.01). Age, sex, baseline T3, T4, 24 hour I131 uptake did not affect the cure rate. Mean time to response was 7 +/- 4 months. One hundred and three (82.4%) patients were cured after 2 doses while only 22 (17.6%) were nonresponsive. Hence, low fixed dose (5mCi) radio active iodine (RAI) therapy seems to be effective in Graves' disease particularly in patients with small sized goiter and short duration of pretherapy with thionamides.

Profile of hypopituitarism in a tertiary care hospital of eastern India--is quality of life different in patients with growth hormone deficiency?

Hypopituitarism is of diverse aetiology. Apart from pituitary adenoma and Sheehan's syndrome, snakebite is a common aetiology of hypopituitarism. A total of 82 patients of hypopituitarism were studied. Biochemical and radiological investigations were done in all the cases. A quality of life questionnaire was put among the patients. Scores were calculated from the answers of the questionnaire and they were assessed about quality of life. Though growth hormone deficiency is associated with poor quality of life there were no significant differences with patients with hypopituitarism without any growth hormone deficiency.

A comparative study between total contact casting and conventional dressings in the non-surgical management of diabetic plantar foot ulcers.

Of all non-traumatic amputations 50% occur in Diabetics, mostly as a final outcome of foot ulcers. A major biomechanical factor in the causation of foot ulcers in persons with diabetes mellitus is elevated peak plantar pressure. Offloading the ulcer area in the form of equalisation of pressure across the plantar surface can accelerate healing of the ulcer. Total contact casting is one such method of offloading, and this study attempts to investigate the advantages of the above method as compared to conventional dressings in the physiatric management of the depth--ischaemia grades 1A, 1B, 2A, 2B neuropathic plantar ulcers in a diabetic patient. The outcome measure was the time taken for complete resolution of the ulcers. Of the 29 patients in Category A treated with total contact casting involving a total of 39 foot ulcers, 36 healed, which was statistically significant (p < 0.05) as compared to 25 out of the 33 ulcers healing in Category B consisting of 26 patients treated by conventional dressings alone. Total contact casting is an effective, rapid, economical, ambulatory and outpatient--based method for the treatment of diabetic foot ulcers.

Atorvastatin improves arterial stiffness in normotensive normolipidaemic persons with type 2 diabetes.

Increased arterial stiffness is an independent predictor of cardiovascular disease and mortality in middle-aged and olderadults. We measured arterial stiffness by pulse wave velocity (PWV)in brachial-ankle segments by automated oscillometry in 71 normotensive and normolipidaemic subjects with type 2 diabetes (40 males and 31 females). 57 patients (whose baPWV was more than 1400 cm/second) were randomised into two groups, group A (n=29) were given 10 mg atorvastatin daily for 6 months and group B (n=28) were given placebo. After 6 months, atorvastatin group had significant improvement in brachial-ankle pulse wave velocity (baPWV) (1712.03 +/- 349.9 cm/second versus 1558.81 +/- 303.26 cm/ second, p< 0.05). Though the placebo group showed some improvement (1692.03 +/- 425.15 cm/second versus 1636.78 +/- 425.1 cm/second) it was not statistically significant. Despite correlation was noted between baPWV and systolic blood pressure (SBP), there was no significant correlation between the mean baPWV and duration of diabetes, body mass index (BMI), waist circumference, waist-hip ratio (WHR), waist to height ratio (WHtR), glycated haemoglobin (HbA1c), LDL, HDL cholesterol and spot urine albumin creatinine ratio (ACR) at the baseline. The decrement of LDL-cholesterol is correlated with the decrement of the baPWV in the atorvastatin group only (p<0.01).

Tachykinin family genes and their receptors are differentially expressed in the hypothyroid ovary and pituitary.

Plasma tachykinin levels are known to be altered with sexual acyclicity and loss of reproductive function. Ovulatory dysfunction, as seen in postmenopausal women, is also often encountered in hypothyroid patients. To know the involvement of different tachykinin genes in hypothyroidism-associated reproductive disorders, we performed DD-PCR with the pituitary RNA of control and hypothyroid rats to see the differentially expressed gene profile. Subsequently, we selected a few clones, tachykinin being one of them. Since its expression was up regulated in hypothyroidism as it does in the sexually acyclic females, we wanted to correlate these two phenomena with hypothyroidism associated reproductive disorders. We observed differential expression of tac2 along with other tk genes and their receptors in rat pituitary and ovary, which suggests that hypothyroidism affects the expression of these genes in these tissues. The experiments were repeated in ovarian tissue obtained at surgery from hypothyroid human patients, which showed similar expression pattern of TAC3 (equivalent to rat tac2) and their receptors as in rat ovary. Significant reduction of tac2 expression in reproductively less active rat ovary suggests the association of tac2 with reproductive senescence. Our results suggest that decline in reproductive function in hypothyroidism is associated with altered expression level of tac2 and its receptors. Further investigation in this area could elucidate the possible mechanism of tachykinins' involvement in loss of sexual cyclicity and other reproductive disorders associated with hypothyroidism.

Localization and thyroid hormone influenced expression of collagen II in ovarian tissue.

Collagen type II (Col II), one of the main components of the hyaline cartilage, is a member of the fibril-forming collagen family. Due to its amino acid composition, the extent of lysine hydroxylation of Col II is much higher than that of other fibril forming collagens. Since lysyl hydroxylase isoforms are less synthesized in hypothyroid ovarian tissue, Col II level is expected to be reduced here and contribute to the degradation of ovarian ECM in this condition. As there was no previous report, we have demonstrated Col II expression in rat ovary. Col2A1 mRNA shares significant part of the total collagens in ovary as shown by the relative expression of the major collagen genes present in this tissue. It has also been shown that Col II is down regulated in hypothyroid ovarian tissue and its expression is increased upon stimulation by thyroid hormone (T(3)). To know whether less Col II in hypothyroid ovarian tissue is due to less synthesis of the protein or its increased rate of degradation is also involved in it, we demonstrated the status of Collagen - degrading Matrix Metalloproteinases in this condition and found up regulation of MMP-1, -8 and -13 in hypothyroid rat ovary. The present study shows the reduced Col II expression in hypothyroid rat ovary, with the concomitant increase in Col II degradation. This information will be useful for further studies on reproductive disorders.

The thyroid nodule--evaluation and management.

Thyroid nodules are common; with the growing availability of sensitive TSH assays, fine needle aspiration biopsy (FNAB) and high resolution ultrasonography (HRUSG), thyroid nodules are being increasingly recognised, diagnosed and treated. The diagnosis of a thyroid nodule is associated with considerable anxiety for the patient; a systematic approach, by excluding the possibility of malignancy, helps allay such anxiety. Nodules are sometimes picked up on neck imaging for non-thyroid conditions; these so-called 'incidentalomas' also need evaluation to rule out malignancy. A sensitive TSH assay is usually the first investigation; a suppressed TSH level leading to a radionuclide scan and an FT4 level to detect toxic nodules that are best managed by radio-iodine or surgical ablation. Thyroid peroxidase antibody is estimated if the TSH level is high. Palpable nodules in euthyroid subjects are best evaluated by HRUSG followed by USG-guided FNA. For nodules <10 mm size, USG-guided FNA is recommended only if clinical or USG features are suspicious. While the benign nodules are kept under regular follow-up, all malignant nodules should be removed surgically. Cystic thyroid lesions are well managed by percutaneous ethanol ablation. Routine measurement of serum calcitonin and other sub cellular markers is not recommended.