Delayed Sheehan's syndrome diagnosed during the evaluation of secondary infertility: A case report.

Sheehan's syndrome may present with postpartum lactation failure and amenorrhea or with features of isolated hypopituitarism to panhypopituitarism. A high index of suspicion is required in a relevant clinical setting of postpartum hemorrhage.

Transplant endocrinology.

Solid organ transplants and stem cell transplants are becoming more common but a significant proportion of patients are still on waiting lists, awaiting transplants. When endocrinologists treat transplant recipients who have underlying endocrine problems, which might include endocrine emergencies, there are special clinical care considerations to be aware of. The stage of the transplant (pre-transplant, early post-transplant, and chronic post-transplant) must be taken into account. Additionally, it's crucial to be knowledgeable about immunosuppressive medications, their typical adverse effects and drug interactions. The review article addresses a number of endocrine and metabolic abnormalities that are reported after transplantation.

Improved Pregnancy Outcomes and Endometrial Receptivity by Thawed Frozen Embryo Transfer in Mildly Stimulated Cycles with Letrozole Combined with Estrogen in Women with Unresponsive Thin Endometrium Compared to Standard Endometrial Preparation with Estrogen Alone: A Retrospective Study.

Context: Infertile women undergoing frozen embryo transfer (FET) cycles may not show optimal endometrial growth with estrogens alone. Aim: To evaluate clinical effect of mild stimulation with letrozole and estrogens on endometrial growth in comparison to standard endometrial preparation with oral and topical estrogens in infertile women with unresponsive thin endometrium undergoing FET. Settings and design: Retrospective observational case-control study. Material and methods: Forty women unresponsive to first AC-FET cycle were given mild stimulation with letrozole and estrogens as second LE-FET cycle for endometrial preparation (LE-FET study group) and compared with 40 historical controls who had received two cycles of AC-FET (AC-FET control group). Responses were assessed by optimal endometrial thickness (≥ 7 mm) and clinical pregnancy. Statistical analysis: Descriptive statistics were elaborated by mean ± SD and percentages. Results were expressed by mean ± SD, unpaired t test for difference in endometrial thickness, chi square and Fisher exact test to compare the difference in pregnancy among both groups. Results: Mean endometrial thickness was significantly increased in LE-FET study group (6.68 ± 2.09 mm) versus AC-FET control group (5.35 ± 1.90 mm). Higher clinical pregnancy rate was noted in study group as compared to control group (35% versus 12.5%). Conclusion: This study suggests that letrozole with estradiol (LE-FET) compared to estradiol alone (AC-FET) for second cycle significantly increased endometrial thickness and improved clinical pregnancy rates in women with unresponsive thin endometrium after first AC-FET cycle with estradiol alone. Addition of letrozole to estrogen upfront for FET cycles may enhance endometrial receptivity and might improve pregnancy outcomes.

Assessment of removal rate coefficient in vertical flow constructed wetland employing machine learning for low organic loaded systems.

Secondary datasets of 42 low organic loading Vertical flow constructed wetlands (LOLVFCWs) were assessed to optimize their area requirements for N and P (nutrients) removal. Significant variations in removal rate coefficients (k20) (0.002-0.464 md-1) indicated scope for optimization. Data classification based on nitrogen loading rate, temperature and depth could reduce the relative standard deviations of the k20 values only in some cases. As an alternative method of deriving k20 values, the effluent concentrations of the targeted pollutants were predicted using two machine learning approaches, MLR and SVR. The latter was found to perform better (R2 = 0.87-0.9; RMSE = 0.08-3.64) as validated using primary data of a lab-scale VFCW. The generated model equations for predicting effluent parameters and computing corresponding k20 values can assist in a customized design for nutrient removal employing minimal surface area for such systems for attaining the desired standards.

Epistaxis, paroxysmal anxiety episodes, and hypertension in a child with SDHB-associated paraganglioma: A case report.

A child presented with anxiety and weight gain which were overlooked until she had epistaxis. She was found to have hypertension secondary to paraganglioma. She was managed with curative surgery involving multidisciplinary care. The tumor removal led to the amelioration of symptoms and marked control of hypertension.

Symptomatic hypoglycemia in a nondiabetic adult female recovering from mild COVID-19 infection: A case report.

A 38-year-old lady, recently recovered from SARS-CoV-2 infection and taking grape seed extract, suffered multiple episodes of severe postprandial hyperinsulinemic hypoglycemia. A careful evaluation ruled out the common etiologies of hypoglycemia and identified grape seed extract consumption as a possible cause. She recovered after stopping the nutritional supplements. In her, hypoglycemia could have resulted from transient beta cell dysfunction associated with SARS-CoV-2 infection or proanthocyanidins in the grape seed extract.

A prospective observational study to evaluate the change in inhibin-B as a marker of sertoli cell function in children subjected to surgical correction for undescended testes.

Background and Objectives: Undescended testes (UDT) or cryptorchidism is a common congenital disability characterised by the absence of at least one testicle from the scrotum. The primary aim of surgical correction is to preserve fertility potential and prevent complications including trauma, malignancy, hernia and torsion. Often, children, especially in developing countries, present late with UDT. The effect of surgical correction in the recovery of Sertoli cell function in children aged more than 2 years is not apparent. The present study was conducted to study the change in inhibin-B level as a marker of Sertoli cell function in surgically corrected UDT in a heterogeneous population. Materials and Methods: A prospective observational study conducted over a 3-year period at a tertiary care paediatric surgery centre recruited 76 children with UDT undergoing surgical correction. Inhibin-B as a marker for Sertoli cell function was studied preoperatively and postoperatively. Continuous variables were summarised by calculating mean, standard deviation, median and interquartile range (IQR). Quantile versus quantile plotting was done to assess the distribution of the data. Data were analysed in two groups, with participants aged <2 years (Group A) and more than 2 years (Group B). Wilcoxon signed-rank test was used to compare the pre-operative and post-operative value. Results: In Group A (n = 39), the median (IQR) of pre-operative inhibin-B was 181 pg/ml (148-254) and post-operative inhibin-B was 230 pg/ml (176-296). In Group B, the median (IQR) of pre-operative inhibin was 70 pg/ml (44-104) and post-operative inhibin was 102 pg/ml (46-176). There was a significant increase in post-operative inhibin when compared to the pre-operative inhibin (P = 0.015 and 0.012, respectively, in Group A and B). Luteinizing hormone (LH) showed a significant decrease (P = 0.002) in Group A following surgery but bordering on significance in Group B (P = 0.43). On the other hand, follicle-stimulating hormone showed a significant decrease (P < 0.01) in Group B following surgery but not in Group A (P = 0.87). Conclusion: The mean post-operative inhibin-B levels were increased significantly as compared to the pre-operative levels indicating either a successful orchiopexy/adequate germ cell number or both. The benefit of orchiopexy may extend even to children presenting late for evaluation.

Strategies for enhancing phosphorous removal in Vertical Flow Constructed Wetlands.

Constructed wetlands (CWs) are among the fastest emerging treatment methods for wastewater treatment. Unlike their organics and nitrogen removal capacities, the potential of CWs as a sink for phosphorous is still debatable. In this study, the secondary data from several CWs treating domestic sewage were compiled and assessed. Curves were plotted between orthophosphate-phosphorous (PO43--P) loading and the corresponding removal rates. Other factors affecting PO43--P removal like depth of the CW, surface area, organic loading rate etc. Were also analyzed. Removal rates of PO43--P were conforming to a linear positive relation with the loading rates. Pea gravel as a CW medium performed consistently well (60-80% removal) for a wide range of influent PO43--P loading (0.5-1.5 g/m3-d). The increased depth of the wetland appears to favor phosphate removal. PO43--P removal was found to be correlated with outlet dissolved oxygen, total Kjeldahl nitrogen removal and effluent nitrate. The study suggests that proper design, optimal organic loading and suitable pre-treatment may increase the applicability of CWs for phosphate removal from domestic wastewater. Larger area requirements can also be avoided by increasing their depth while keeping the volume of the filter media the same.

Designing the vertical flow constructed wetland based on targeted limiting pollutant.

The requirement of large land area limits the adoption of constructed wetlands (CWs) in urban settings with limited land availability. The area calculations for CW design are commonly carried out following Kikuth approach where the removal rate constant (K) is derived from literature. Investigation of secondary data of 82 vertical flow CWs, performed in this study, yielded wide variations (0.0003 - 0.822 md-1) in the calculated K values for different pollutants under different environmental and operational conditions indicating that it is important to incorporate the desired levels of pollutant removal to arrive at customized design of CWs. The results indicated that the relative standard deviation of K values could be narrowed by classifying the datasets based on design parameters like depth, hydraulic loading rates and substrate loading rates. These calculations can help arrive at more scientific design of CW to achieve the prevailing standards for the discharge or reuse of sewage.

Olfactory Dysfunction Among Asymptomatic Patients with SARS CoV2 Infection: A Case-Control Study.

Olfactory dysfunction (hyposmia, anosmia) is a well-recognized symptom in patients with coronavirus disease-19 (COVID-19). Studies of olfactory dysfunction in asymptomatic patients have not been reported. We conducted a study looking for the presence of olfactory dysfunction with an objective assessment tool in asymptomatic Covid 19 and compared it with patients with mild COVID-19 and age-matched controls. We recruited 57 male patients each of Mild COVID-19, asymptomatic Covid 19, and healthy controls for the study. All participants underwent evaluation of smell threshold by Butanol Threshold test (BTT) and ability to distinguish common odors by Smell identification test. The scores of each test were recorded on a numerical scale. The participants in all three arms were matched for age, history of smoking, and pre-existing medical conditions. The mean scores of the Butanol Threshold test in Mild COVID-19, asymptomatic Covid 19 and controls were 2.95 ± 2.25 (0-7.5), 3.42 ± 2.23 (0-7.5), and 4.82 ± 1.86 (0-8), respectively. A one-way ANOVA showed a significant difference between groups (df 2, MS 53.78, F 11.94, p < 0.005). Intergroup differences using the student T-test showed significantly low BTT scores in Mild COVID-19 (p < 0.005) and asymptomatic (p < 0.005) as compared to control. BTT scores could not distinguish between asymptomatic patients and control. The smell threshold was impaired in asymptomatic Covid 19 and Mild COVID-19. Butanol Threshold Test score could not differentiate between asymptomatic Covid 19 and controls.

Clinical manifestation and images of a patient having cardiovascular involvement in myxoedema coma.

Myxoedema coma is an endocrine emergency characterised by diminished sensorium associated with features of severe hypothyroidism. The disease carries a high mortality of 30%-60 %. The cardiac manifestation of the disease consists of bradycardia, hypotension, pericardial effusion and certain echocardiographic changes such as heart block and features of hypothermia. Here, we report a case of myxoedema coma with characteristic cardiac manifestations. These manifestations revert promptly on starting treatment, and achieving a eumetabolic status as was demonstrated in this patient.

Prevalence of Testosterone Deficiency in Elderly Male and its Association with Frailty and Mobility at a Tertiary Care Centre.

BACKGROUND AND OBJECTIVES: Several cross-sectional and prospective longitudinal studies have shown a progressive decline in Serum (S) Testosterone levels with an increase in age. The clinical consequence of this decline in S Testosterone is not clear from the prevailing data. Several ageing features like decreased libido, Osteo-sarcopenia, anemia, and depressed mood may be associated with reduced androgen levels in elderly males. This study was aimed to study the prevalence of androgen deficiency in elderly males more than 60 years of age presenting to the outpatient department of a tertiary care hospital and its association with frailty and mobility. METHODS: A cross-sectional observational study was conducted over two years at a tertiary care hospital in Pune, India. The participants underwent a detailed history and physical examination. Biochemical tests and S total testosterone estimation was done. Mobility was estimated by calculating the time taken to perform the Timed Up and Go test (TUGT). Frailty was calculated by Fried's frailty index. Data are presented as mean ± standard deviation, and a comparison between the groups was made using Mann-Whitney U-test. The categorical variables are presented in frequencies along with respective percentages and were compared using the Chi-square or Fisher's exact test. The data was analyzed using SPSS version 22. A P <.05 was considered statistically significant in all the tests. RESULTS: The mean age of the study participants was 68.37 ± 6.3 years, with a range of 60-88 years. The mean S total testosterone levels were 3.95 ± 2.06 ng/ml with a range of 0.04-25.36 ng/ml. As per the study definition, Ninety-two (21.67%) participants had testosterone deficiency. Three hundred and thirty-three (78.5%) participants had impaired motility represented by a TUGT time of more than 12 seconds. The Frailty index calculated revealed 94 (22.2%) of the study participants to be normal, 263 (62%) to be vulnerable, and 67 (15.8%) of the patients to be frail. CONCLUSION: The prevalence of testosterone deficiency in the elderly male population was 21.67%. However, there was no association of testosterone deficiency with frailty or impaired mobility. Furthermore, testosterone deficiency was not associated with BMI and hemoglobin levels. In the elderly, testosterone deficiency is associated with low bone mass and therefore imply an increased risk of osteoporotic fractures.

A Case Report of Pycnodysostosis Associated with Multiple Pituitary Hormone Deficiencies and Response to Treatment

Pycnodysostosis is a rare autosomal recessive osteosclerotic bone disorder associated with short stature and multiple bony abnormalities. Growth hormone (GH) deficiency may contribute to short stature in about 50% of patients. Available literature has rarely reported other pituitary hormone deficiencies in pyknodysostosis. Though the management remains conservative, recombinant human GH (rhGH) has been tried in selected patients. Here we present a case of pycnodysostosis which was evaluated for associated co-morbidities and found to have multiple pituitary hormone deficiencies. A 7-year-old girl was referred to our centre for evaluation of short stature. On examination, she had frontal and occipital bossing, limited mouth opening, hyperdontia with multiple carries, short and stubby digits and short stature. Investigation revealed dense sclerotic bones with frontal and occipital bossing, non-fusion of sutures with obtuse mandibular angle, non-pneumatised sinuses, small 'J' shaped sella turcica, acro-osteolysis of digits and absent medullary cavities. Cathepsin-K gene mutation analysis confirmed the diagnosis of pycnodysostosis. She was screened for associated co-morbidities and was found to have concomitant GH deficiency. Treatment with rhGH brought about an increase of 1 standard deviation score in height over 2 years and also unmasked central hypothyroidism at three months necessitating thyroxine replacement.

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.

Giant Intramuscular Myxoma of Thigh- A Rare Case Report.

INTRODUCTION: Myxoid soft tissue tumors consist of a heterogeneous group of mesenchymal neoplasms with a hallmark of the abundant extracellular myxoid matrix. Intramuscular myxomas are rare benign tumor affecting the musculoskeletal system. The common sites include the thigh, upper arm, calf, and the buttocks. Magnetic resonance imaging is the radiological modality of choice in diagnosing these cases, while tissue biopsy is the gold standard. CASE PRESENTATION: A 70-year-old male presented to orthopedics out-patient department with complaints of a humongous swelling engulfing his right thigh all around. The gradual and progressive appearance of burning sensations and rest pain around the affected area with difficulty in bearing weight, over the past 6-7 months forced him to seek medical attention. Biopsy and imaging were performed followed by final excision. The tumor was removed En-bloc and post-operative period was uneventful. The patient did not show any signs recurrence and was asymptomatic until the final followup of 26 months. CONCLUSION: Myxomatous swelling mimics an intramuscular lipoma, sarcoma, hematoma, or a hemangioma and must be carefully evaluated. En-bloc excision without spillage is the treatment of choice which ensures long and lasting recovery.

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.

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.