Search

Background: Congenital hypothyroidism (CH) is the most common cause of preventable intellectual disability. Newborn screening (NBS) for CH has been in vogue in many parts of the world since 1970, but despite its well-known benefits, many developing countries including India have not been able to establish universal NBS for CH till date. Objective: The aim of this study was to review the clinical aspects of congenital hypothyroidism in a tertiary care university referral teaching hospital, focusing on aetiology of CH, predictors of permanence, optimal targeted dose strategies based on aetiology and the effect of newborn screening on the time to diagnosis. Material and Methods: The electronic medical records of 233 children with CH referred to our centre between January 2009 and December 2019 were analysed. A partial NBS was established in the state in 2012. Results: Dyshormonogenesis (57.5%) was the most common aetiology of CH. The incidence of transient CH in children with a gland in situ (GIS) was 35%. Levothyroxine (LT-4) dose of >2.75 μg/kg/day (sensitivity 76.5, specificity 72), >2.15 μg/kg/day (sensitivity 82.4, specificity 61.9) and >1.85 μg/kg/day (sensitivity 76.5, specificity 61.9) at years 1, 2 and 3, respectively, were predictors of permanent CH. An initial LT-4 dose ≥8 μg/kg was sufficient and very seldom led to undertreatment in children with dyshormonogenesis. On the contrary, even doses ≥13 mcg/kg/day led to frequent undertreatment in children with thyroid dysgenesis. After the introduction of newborn screening, the median age at diagnosis came down from 45 days (IQR 14–180 days) to ten days (IQR 3–12 days). Conclusion: Targeted dosing based on aetiology of CH may be more appropriate to optimise outcomes. The time to diagnosis of CH reduced significantly after the adoption of even a partial NBS program highlighting the urgent need for implementation of the same in resource poor settings. [ABSTRACT FROM AUTHOR]

Introduction: Differentiated thyroid carcinoma/cancer (DTC) burden in developing countries could be different from that of the developed nations. Aims and Objectives: To describe the clinicopathological characteristics in a cohort of DTC patients in a south Indian state of Kerala and to compare with the data from other centres. Materials and Methods: A retrospective analysis of the data collected on DTC patients, from January 2010 to August 2018, attending thyroid cancer clinic at a tertiary care centre. Results: Among the 944 patients (male 262; female 682; mean age 43.8 years; standard deviation, SD 13.8), types of tumour were as follows: classical papillary thyroid carcinoma (cPTC) 48.3%, follicular variants of PTC (FVPTC) 28.8%, follicular and hurthle cell carcinoma (FTC&HCC) 10.1%. Mean size of the tumour was 2.7 cm (SD 1.8) papillary thyroid micro carcinomas (PTMC) were seen in 113 patients (12%), which were detected incidentally. Metastases were present at diagnosis in 40.2% cases, most common site being cervical lymph nodes. Distant metastases were seen in 113 patients (14.5%) and commonest site was bone. The American Thyroid Association (ATA) risk stratification was possible only in 684 subjects and showed 31.3% low risk, 41.8% intermediate risk and 26.9% at high-risk category. Lymph node metastasis and distant metastasis were the commonest determining factors for intermediate and high-risk category, respectively. High-risk category was significantly higher in patients >55 years, tumour size >4 cm, FTC/HCC tumour type and extranodal extension (ENE) of lymph node metastasis. Radio active iodine ablation was given to 85.2% subjects. Conclusion: In our DTC population, FVPTC formed the second most common type and PTMC were all incidentalomas. Metastasis at diagnosis was higher suggesting delayed presentation. Old age, FTC/HCC, large size of the tumour, ENE were significantly higher in high-risk patients. Rest of the features of these cohort was comparable with the United States cohort of DTC patients. [ABSTRACT FROM AUTHOR]

Context: Medullary thyroid carcinoma (MTC), being an aggressive disease, requires meticulous follow-up and multidisciplinary management. The clinical presentation, management, outcome of MTC varies among different populations. Aims: An audit was conducted to evaluate the demography, clinical presentation, management, and outcome of MTC in a tertiary care center in South India. Settings and Design: A retrospective analysis was conducted of data from hospital records of patients with MTC treated at our center from 2004 to 2019. Statistical Analysis: All analyses were performed with SPSS software (version 16). Results: Among the 82 patients (M 42, F 40), mean age was 42.07 years (SD 14.5), 46 were operated at our center and 36, outside. Follow-up data were not available for all patients. Median duration of the disease was 36 months and median follow-up was 28 months. Lymphnode dissection was more common (37/46) in patients operated at our center than outside operated patients (17/36) (P < 0.01). At presentation, more than half of the patients had stage IV disease and 8 had distant metastases. Bone, lung, and liver were the common sites of metastases. Persistent hypercalcitoninemia >50 pg/mL was seen in 49.9%. Salvage surgeries of the neck were necessary in 29 patients (38.2%). Mean survival was 66 months and 10-year survival was 35%. Male gender (P = 0.008) and Stage IV disease at presentation (P = 0.038) were associated with poorer survival. Conclusion: MTC, in our population, presented at an advanced stage. Male gender and stage IV at presentation had poor survival. Early diagnosis, aggressive initial neck clearance, close follow-up with tumor markers, appropriate imaging, along with prompt surgical intervention will help to improve outcome. [ABSTRACT FROM AUTHOR]

Background and Aims: Liver transplantation has become an effective therapy for patients with end-stage liver disease. The risk of new-onset diabetes after transplantation (NODAT) and posttransplant metabolic syndrome (PTMS) is high among patients after liver transplantation. These are thought to be associated with increased risks of graft rejection, infection, cardiovascular disease, and death. Our study aimed to document the incidence of NODAT and PTMS and analyze pre and posttransplant predictive factors for their development in patients undergoing a liver transplant. Methods: This was a prospective comparative study on 51 patients who underwent live donor liver transplantation. They were evaluated at baseline, 3 and 6 months after transplantation with fasting glucose, lipids, serum insulin levels, C-peptide, and HbA1C. They were followed up at 5 years to document any cardiovascular events or rejection. Results: The incidence of preoperative diabetes mellitus (DM) in the study group was 25/51 (49%). The incidence of NODAT was 38.5% (10/26 patients) and PTMS 29% (10/35), respectively. Age (47.7 ± 5.4 vs 41.5 ± 12.7 years), HOMA2 -IR (2.3 ± 1.8 vs 2.1 ± 1.6), serum insulin (16.1 ± 12.0 vs 17.9 ± 14.5), and C-peptide (4.6 ± 0.5 vs 4.8 ± 0.7) were similar at baseline in the NODAT group compared to those who did not develop it. Mean tacrolimus levels were higher in PTMS group (6.8 ± 2.9 vs 5.0. ± 2.0 P value = 0.042). By the end of 5 years, 7 patients expired; 6 due to rejection and one due to cardiovascular disease. Moreover, 2 of these patients had preexisting DM and 2 had NODAT. Conclusions: None of the baseline metabolic factors in patients undergoing liver transplant were predictive of the development of NODAT or PTMS. Mean tacrolimus levels were significantly higher in the PTMS group. A 5-year follow-up showed no excess risk of cardiovascular events or rejection in those with preexisting DM or in those who developed NODAT. [ABSTRACT FROM AUTHOR]

Context: Insulin autoantibody syndrome (IAAS) is considered to be a rare cause of hyperinsulinaemic hypoglycaemia. Lack of familiarity with the varied clinical manifestations leads to underdiagnosis. Localization techniques aimed at insulin-secreting neoplasms and nesidioblastosis, which are expensive often are ordered when the correct diagnosis is not made. Aims: We describe the myriad of clinical manifestations associated with IAAS based on single centre experience. Settings and Design: Retrospective analysis of patients who got admitted with symptoms suggestive of hypoglycaemia and underwent mixed meal test and prolonged hypoglycaemic test from 2016 to 2019. Subjects and Methods: Retrospective data of 12 patients with IAAS who were diagnosed in the threeyear time period between 2016 and 2019 are included in this analysis. Clinical details, biochemical parameters and imaging modalities were analysed. Statistical Analysis: All analyses were performed with SPSS software (version 17). Results: Total of twelve patients 12 (5 male and 7 females) were identified as IAAS. Median age of presentation was 57 years. Median insulin levels and median C-peptide levels were 300 miu/ml and 18.5 ng/ml respectively. Only 3 (25%) patients had spontaneous resolution. Steroid induced remission occurred by 3 months in the remaining patients. Intermittent hyperglycaemia was seen in 9 (75%) patients. Implicatable drug use preceding the occurrence of the clinical symptoms was observed in five patients. Conclusion: IAAS is not uncommon in India. The diagnosis should be pursued in patients with hyperinsulinaemic hypoglycaemia especially when insulin levels are very high or when there is intermittent hyperglycaemia. [ABSTRACT FROM AUTHOR]

Atypia of undetermined significance or follicular lesion of undetermined significance (AUS/FLUS) of The Bethesda System for Reporting Thyroid Cytopathology (TBSRTC) has emerged as the most controversial category because of its heterogeneity and inconsistent reporting. There is a definite paucity in data available from the Indian subcontinent about the outcome of nodules carrying Bethesda category III or Bethesda category IV diagnoses. Aims and Objectives: The primary objective of our study was to determine the malignancy rate in Bethesda categories III and IV nodules. The secondary objectives were to determine predictive value of BRAFV600E mutation analysis on indeterminate thyroid nodules, predictive value of Thyroid image reporting and data system (TI-RADS) in malignancy prediction and to study the common histological variants in indeterminate nodules. Materials and Methods: This prospective study included 176 consecutive nodules of Bethesda categories III and IV, diagnosed over a period of 2 years from August 2015 to August 2017. A part of the fine needle aspirate was used to perform the BRAFV600E mutation analysis. The malignancy risk associated with these Fine needle aspiration Cytology categories were discussed with the patients. Those with Bethesda category IV diagnosis was advised surgery, whereas those with Bethesda category III were given the options of close follow-up with repeat FNA in 3 months or immediate surgery. Results: In our prospective study, there were 176 consecutive samples of categories III (140/79.5%) and IV (36/20.5%). Seventy-five (53.6%) category III nodules and 29 (80.6%) category IV nodules underwent immediate surgical excision. Fifty-five consecutive indeterminate cytology nodules were subjected for BRAFV600E. One of the samples was found to be positive for BRAF T1799A (V600E) mutation. The second sample harboured a missense mutation at position 1819 (TCC--GCC), wherein the codon 607 (TCC) coding for serine was substituted by alanine (GCC) which is a variant of unknown significance. In our study, the malignancy rate of Bethesda categories III and IV, which were triaged for immediate surgery were 54.6% and 72.4%, respectively. Conclusion: Malignancy rate in Category III at our center was much higher than that described by ATA and by other studies published from centers around the world, including the only two studies from India. In view of the strikingly high malignancy rate in these indeterminate nodules, strong consideration to surgery should be given to patients with FNA results suggesting these two categories. BRAFV600E mutation analysis in FNA specimen has limited utility in improving the preoperative diagnostic rate for malignancy. [ABSTRACT FROM AUTHOR]

Background: Klinefelter syndrome (KFS) is the commonest chromosomal abnormality, yet remains largely underdiagnosed due to its varied clinical presentation. This study was done to understand the clinical spectrum in our population. Aim: We intended to study the clinical characteristics of children and adults with KFS in our population. We also desired to identify any special features of Klinefelter variants. Methods: Forty-four patients with karyotype diagnosis of KFS during the time period 2007-2015 were included in this retrospective study. Clinical details and hormonal profile were obtained from hospital information system. Results: Our study population consisted of 17 (38.6%) participants in pediatric age group (age <18 years) and 27 (61.4%) adults. Clinical presentation prompting evaluation in the former group included cardiac anomalies (29.4%), dysmorphism (23.5%), hypogonadism (17.6%), developmental delay (11.8%), tall stature (11.8%), and cryptorchidism (5.9%). Among adults, 16 (59.2%) presented with hypogonadism and 9 (20.4%) had primary infertility. Six children (35.3%) had micropenis and four (three children, one adult) had unilateral undescended testis. Behavioral problems were detected in 19 (43.2%) subjects. Mean follicle stimulating hormone (FSH) and luteinizing hormone (LH) values were 38 IU/mL and 18 IU/mL, respectively. The classical 47 XXY karyotype was detected in 38 (86.4%) subjects and 6 (13.6%) had karyotype consistent with Klinefelter variants. Conclusion: KFS was diagnosed only after 18 years of age in two-thirds of patients. Developmental delay, cardiac anomalies, behavioral abnormalities, and intellectual disabilities were the common presentations in pediatric subjects. Adults predominantly presented with hypogonadism. Individuals with Klinefelter variant karyotype sought medical attention predominantly for non-gonadal concerns. [ABSTRACT FROM AUTHOR]

Context: The literature on outcomes of bilateral adrenalectomy (BADx) in Cushing's syndrome (CS) is scant. Aims: The aim of this study is to analyze the short- and long-term outcomes of patients who underwent BADx and to compare the outcomes among different etiologies of CS. Settings and Design: This is a retrospective analysis of patients who underwent BADx for CS at our center between 2005 and 2018. Materials and Methods: In all, 33 patients were studied for clinical outcomes, survival rates, and long-term complications. Statistical Analysis: All analyses were performed with SPSS software (version 21.0). Results: The mean age at surgery was 39.33 ± 15.67 years. The primary etiology for CS was Cushing's disease (CD) in 42.42%, ectopic source in 36.36%, primary pigmented nodular adrenocortical disease (PPNAD) in 12.12%, and adrenocorticotrophin hormone–independent macronodular adrenal hyperplasia (AIMAH) in 9.09% of patients. The median follow-up time was 72.77 months. Improvement in hypertension and diabetes status after surgery was seen in 78% and 76.19% of patients, respectively. Proximal myopathy improved in 68% of patients. Nelson's syndrome and adrenal crisis were seen in 21.4% of patients each on long-term follow-up. Total mortality after BADx was 33.3%. Mortality in the first 30 days after surgery was seen in five patients (15.15%). Higher cortisol levels at presentation and age more than 40 years were predictors of mortality. Among the Cushing's subtypes, PPNAD had the best prognosis followed by CD. Perioperative Infections were a major cause of mortality. Conclusion: BADx is an effective treatment for CS especially in patients with PPNAD and CD but carries a significant mortality rate too. [ABSTRACT FROM AUTHOR]

Background: Prediction of outcome in diabetic foot infection (DFI) remains difficult due to lack of active signs of infection, and apparently normal white blood cell (WBC) count. Erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) have been studied previously in this regard and were not useful. Hence, we evaluated procalcitonin (PCT) as a prognostic marker in this study. Objectives: We aimed to study the role of PCT, CRP, and ESR levels in predicting clinical outcome of acute DFI. Materials and Methods: A total of 250 subjects (197 men, 53 women) with acute DFI were enrolled. WBC count, ESR, CRP, and PCT were done for all subjects at admission after obtaining informed consent. Subjects were managed according to hospital protocol and followed up for 1 month. Clinical outcome was assessed based on mobility and morbidity status of the subject. Results: Old age, anemia, hyponatremia, hypoalbuminemia, and elevated serum creatinine were risk factors for poor outcome. Presence of cardiac failure, diabetic retinopathy, peripheral vascular disease, previous amputations, and positive bone culture had negative influence on clinical outcome. Elevated WBC count, ESR, CRP, and serum PCT were significantly associated with bad outcome. Elevated PCT (>2 ng/ml) [odds ratio (OR) (95% confidence interval (CI)), 2.03 (1.13–5.19), P < 0.001], gangrene [OR (95% CI), 2.2 (1.02–4.73), P = 0.04], and sepsis [OR (95% CI), 10.101 (4.34–23.25), P < 0.001] were good predictors of clinical outcome in acute DFI. Conclusion: PCT proved to be a reliable marker of acute DFI and good predictor of clinical outcome than existing markers WBC count, ESR, and CRP. Hence it should be useful for clinicians while managing acute DFI. [ABSTRACT FROM AUTHOR]

Background: Thyroid Imaging Reporting and Data System (TIRADS) scoring is used to assess the nature of nodules in the thyroid gland, especially with regards to the possibility to predict chances of malignancy of those nodules. The commonest used system worldwide is the one by the American College of Radiology (ACR-TIRADS). Majority of thyroid cancers are hard; hence the stiffness evaluation can become part of nodule characterization. Strain or stress elastography is the elastography technique in which the ultrasound probe is placed in front of the thyroid nodule with interposition gel. The beating of the carotid artery generates a sufficient deformation to create a qualitative map image in the region of interest. Addition of strain elastography to the TIRADS scoring can improve the sensitivity & specificity of the modalities in predicting the malignant potential of thyroid nodules. Methods: In this cross-sectional study, among the USG Thyroid cases done in Endocrinology Dept. of a tertiary care hospital in South India, the cases which showed Solitary Thyroid Nodule (STN) among them during 6-month study period were selected. All of them had undergone Strain Elastography (SE) also. The data with regards to the USG nature of those STNs including ACR-TIRADS scoring, & the SE nature of them including Rago scoring, were taken &analysed. Both TIRADS score &Rago score were analysed together. From among those STNs, only those nodules with either TIRADs score 5 or Rago score >2 was included in the detailed analysis because those would be the nodules with more chance of being malignant. All such nodules also underwent USG guided Fine Needle Aspiration Cytology (FNAC) & the report of FNAC was analysed to find whether they belonged to Bethesda Category less than III (benign) or belonged to Bethesda Category III or more (suspicious for malignancy). Results: Out of the total 91 STNs studied, 36 (40%), 40 (44%) & 15 (16%) were of Rago 3/4, Rago 2 &Rago 1 scoring respectively on SE. 10 out of the 91 STNs were of ACR-TIRADS 5 scoring. 2 out of the 7 Rago 3/4 with TIRADS 5 STNs had FNAC showing Bethesda Cat. III or more nature. 2 out of the 29 Rago 3/4 with TIRADS <5 STNs had FNAC showing Bethesda Cat. III or more nature. 1 out of the 3 Rago 1 or 2 with TIRADS 5 STNs had FNAC showing Bethesda Cat. III or more nature. 36 Rago 3/4 STNs on FNAC yielded Bethesda Cat III or more (4/36 = 11.1%). 55 STNs had Rago < 3 score & based on TIRADS criteria only, 18 of them underwent FNAC & Bethesda Cat. III or more was seen in 2 (2/18 = 11.1%). FNACs on the 10 TIRADS 5 nodules showed Bethesda Cat III or more nature was seen in 4 (4/10 = 25%). These results show that even though not needing FNAC study based on TIRADS criteria, those Rago 3, 4 nodules on FNAC have showed to have suspicious result in FNAC. This means that more stiff nodules as represented by Rago 3, 4 scores in SE could be suspicious for malignancy even when they were not suspected to be of so based on ACR TIRADS USG criteria alone. Conclusion: Sometimes when based on TIRADS criteria alone, some STNs with suspicious for malignant nature may be missed; but when Strain Elastography is also added to the same, the chance of detecting stiffer nodules increases, that could have malignant nature. Strain Elastography modality in USG machine needs to be used more along with conventional TIRADS scoring of thyroid nodules. [ABSTRACT FROM AUTHOR]

Context: Papillary thyroid carcinoma with tall cell histology (PTC-TCH) is an aggressive subtype in terms of clinicopathological features and outcome. Even 10% of tall cells can show aggressive features. Aims: The aim of this study is to investigate the behavior of PTC-TCH, to compare with classic PTC (cPTC), and evaluate the short-term outcome. Settings and Design: This is a retrospective analysis of patients with cPTC and those with TCH (PTC-TCH) seen from January 2010 to May 2017 seen in our Thyroid Cancer Clinic. Materials and Methods: A total of 40 patients with TCH were compared with 352 cPTC and evaluated for age, gender, tumor size, presence of multifocality, capsular, vascular invasion, extrathyroid extension, and appearance of metastases. Short-term response to therapy was assessed using the 2015 American Thyroid Association guidelines. Statistical Analysis: P < 0.05 was considered statistically significant. All analyses were performed with SPSS software (Version 21.0, Chicago, IL, USA). Results: PTC with TCH presented at a younger age, had larger tumors, and more extrathyroid extension. Seven out of 40 cases developed lung metastases, (17.5% vs. 4.5% in cPTC), within a year of diagnosis. Conclusion: PTC-TCH irrespective of percentage of tall cells showed aggressive features and early metastases. They should be recognized early as an aggressive subtype and treated intensively. Close follow-up must be instituted to look for metastases, especially to the lungs. [ABSTRACT FROM AUTHOR]

Introduction: The benefits of treating subclinical hypothyroidism are currently under debate, prevention of adverse cardiac events purporting to be one of the main benefits. The effect of subclinical hypothyroidism on the cardiovascular health of the Indian sub-population is largely unknown. This study was designed to examine these effects and to help guide treatment of this disorder. Methods: A cross-sectional adult population survey was carried out in urban coastal area of central Kerala. 986 volunteers underwent complete biochemical and physical examinations, 110 were found to have subclinical hypothyroidism (8.9%). The ten-year risk of an adverse cardiac event, was calculated using the Framingham score algorithm. Eligible subclinical hypothyroid subjects (N = 110) and a randomly selected, age and gender matched control group (N = 220) were compared. Results: This population was found to have high baseline levels of diabetes 19.5%, hypercholesterolemia 57.2% and systolic hypertension 24.6%. No association was found between subclinical hypothyroid status or rising TSH and Framingham 10-year risk. While no difference between groups was noted with respect to lipid profile, a rising TSH was found to be significantly correlated with mild worsening of the lipid profile. A significant positive correlation was found between skinfold thickness and TSH. Conclusions: Subclinical hypothyroidism is not a contributing factor to elevated Framingham risk in this population, and while a mild effect was observed on the lipid profile, its effect is unlikely to be clinically relevant. We hypothesize that in this population a genetic component may be responsible for the uniquely high rates of metabolic syndrome and other endocrine diseases. [ABSTRACT FROM AUTHOR]

Traditionally pharmacological Growth Hormone Stimulation Tests (GHSTs) have been used to distinguish true GHD from ISS and CDGP in pediatric endocrine clinics. However these tests are not physiological and subject the patients to unnecessary stress of multiple samplings and risk of hemodynamic instability. Various clinical and biochemical findings if studied appropriately can predict the need to perform GHSTs in such patients and minimize unnecessary testing. Aim: To study the role of IGF-1 levels as a predictor of and positive GHSTs in children and adolescents presenting with short stature (SS). Materials and Methods: Medical records of children and adolescents presenting with SS were retrieved and their demographic data, IGF-1 centiles and results of GHSTs were studied. A positive GHST was taken as peak GH level (<7 ng/ml). Correlation of IGF-1 centile for chronological age and bone age with GHST results was studied and ROC curves were drawn to study the sensitivity and specificity of IGF-1 centiles in predicting positive GHST. Results: Data of 199 patients presenting with growth failure from 1st January 2010 to 31st March 2021 was collected. 65 females and 134 males were included. Mean age of the cohort was 11 years 4months and mean IGF-1 level was 132.8ng/ml. 166 patients had IGF-1 levels < 30th centile for chronological age. The remainder 33 patients who had IGF-1 centiles > 30th centile for chronological age consistently had negative GHST thus indicating unnecessary pharmacological testing. Conclusion: GHSTs can thus be avoided in children who have IGF-1 centile >30th centile for chronological age and thus avoid unnecessary stress and risk to the patients. [ABSTRACT FROM AUTHOR]

Context: Most of the information on remission related factors in Grave's disease are derived from Western literature. It is likely that there may be additional prognostic factors and differences in the postdrug treatment course of Grave's disease in India. Aim: To study factors which predict remission/relapse in Grave's disease patients from South India. Also to establish if technetium (Tc) uptake has a role in predicting remission. Subjects and Methods: Records of 174 patients with clinical, biochemical, and scintigraphic criteria consistent with Grave's disease, seen in our Institution between January 2006 and 2014 were analyzed. Patient factors, drug-related factors, Tc-99m uptake and other clinical factors were compared between the remission and nonremission groups. Statistical Analysis Used: Mann-Whitney U-test and Chi-square tests were used when appropriate to compare the groups. Results: Fifty-seven (32.7%) patients attained remission after at least 1 year of thionamide therapy. Of these, 11 (19.2%) patients relapsed within 1 year. Age, gender, goiter, and presence of extrathyroidal manifestations were not associated with remission. Higher values of Tc uptake were positively associated with remission (P - 0.02). Time to achievement of normal thyroid function and composite dose: Time scores were significantly associated with remission (P - 0.05 and P - 0.01, respectively). Patients with lower FT4 at presentation had a higher chance of remission (P - 0.01). The relapse rates were lower than previously reported in the literature. A higher Tc uptake was found to be significantly associated with relapse also (P - 0.009). Conclusion: The prognostic factors associated with remission in Graves's disease in this South Indian study are not the same as that reported in Western literature. Tc scintigraphy may have an additional role in identifying people who are likely to undergo remission and thus predict the outcome of Grave's disease. [ABSTRACT FROM AUTHOR]

Background: There are recommendations regarding the total dose of hydrocortisone to be administered in the treatment of classical congenital adrenal hyperplasia (CAH) to achieve the twin objectives of glucocorticoid replacement and control of hyperandrogenism. However, there is evidence gap regarding the breakup, timing and type of the steroid regimen. Objectives: Efficacy of three different glucocorticoid regimens having the same total dose of steroid, differing in either the timing or type of evening steroid administered, in achieving biochemical control of the disease was assessed. Materials and Methods: The study was done in 13 prepubertal children with classical CAH over a 6-month period with 2 months devoted to each regimen. We used a prospective cross-over design using 10-15 mg/m² total dose of hydrocortisone. Two-fifths of the total dose of hydrocortisone was administered in the morning and one-fifth of the total dose was administered at noon in all the regimens. The regimens differed in the timing of the evening dose of hydrocortisone, 06.00-07.00 pm in regimen 1 and 09.00-10.00 pm in regimen 2. The third regimen had the evening dose of hydrocortisone replaced by an equivalent dose of prednisolone suspension which was administered at 10.00 pm. Serum 17-hydroxyprogesterone and testosterone levels were compared to assess the efficacy of treatment regimens. Results: The three different regimens were found to be similar in their ability to control 17-hydroxyprogesterone and testosterone levels. The percentage of patients with predefined criteria for biochemically controlled disease was similar in all the three regimens. However, there was a trend toward better control of 17-hydroxyprogesterone levels in patients receiving evening dose of prednisolone. Conclusions: There is no significant advantage in administering the hydrocortisone dose late at night in patients with classical CAH. [ABSTRACT FROM AUTHOR]

Aim: The aim of this study was to assess and compare the response to two forms of treatment-immobilization with zoledronic acid injection and immobilization with oral weekly Alendronate, in patients with diabetes mellitus and acute Charcot arthropathy (CA) of foot in terms of clinical and radiological parameters. Material and Methods: Patients attending the endocrinology and podiatry clinic with history of diabetes mellitus and Acute CA were taken for study. The patients were randomized into two treatment groups. Group Z-zoledronic acid injection along with total contact cast (TCC). Group A-Tab. Alendronate 70 mg. once a week till the complete clinical resolution of acute CA along with TCC. Forty-five patients were randomized and 40 of them completed the study. The primary end point was complete clinical resolution of acute CA-defined as temperature difference between normal and affected foot <1 °F. Results: Among the 40 patients, 30 (75%) had complete clinical resolution. The mean number of days taken for complete clinical resolution since the initiation of treatment (either Zoledronic acid or Alendronate) was approximately 122 days. There was no significant difference in a number of days required for complete clinical resolution, between the two forms of therapy. There was more than 50% reduction in the visual score between the baseline and the final scan. The target to non-target ratio in the skeletal phase also showed an average of 40% reduction from the baseline to the final skeletal scintigraphy. Conclusion: Both Intravenous Zoledronic acid and oral alendronate had comparable efficacy with respect to the time taken for attaining complete clinical resolution of acute CA of foot. However, Alendronate therapy was cost effective among the two. 99mTc MDP bone scan can be used as an adjuvant to the clinical parameters in assessing the response to therapy. [ABSTRACT FROM AUTHOR]

Background: Thyroid disorders are more commonly seen among females and the prevalence increases with age. There is no population data from India focusing on iodine levels and their correlations with thyroid volume and other factors in adult women. Aim: This study was designed to establish the iodine status and its relation with various factors including thyroid volume measured by ultrasound among the females of Kerala. Materials and Methods: This was a cross sectional house to house survey among the females above 35 years of age in a randomly selected urban area in Cochin Corporation, Kerala State, India. Selected subjects were interviewed, examined and blood and urine tests were done. Thyroid volume was calculated using ultrasound. Results: Among the 508 subjects who participated in the checkup, 471 subjects were included for analysis. Mean age was 50.3 + 10.7 years and 53.2% were postmenopausal. A total of 98% of the subjects were using iodized salt and median urinary iodine excretion (UIE) was 162.6 mcg/l. UIE had negative correlation with age and systolic blood pressure (BP), but had no correlation with thyroid volume (TV), thyroid nodularity, free thyroxine 4 (FT4), thyroid stimulating hormone (TSH) or anti thyroid peroxidase (TPO) levels. Iodine deficiency was more commonly seen in subjects with hypertension and also among postmenopausal females. Conclusions: This study showed that females > 35 years were iodine sufficient, though one third of the subjects had UIE levels less than the recommended level. Iodine levels had significant negative correlation with age and systolic BP and no correlation with thyroid volume or biochemical parameters. Iodine deficiency was significantly higher in subjects with new and known hypertension and this relation merits further evaluation. [ABSTRACT FROM AUTHOR]

Background: Hyperandrogenism has always been an indispensable arm of the clinicopathological entity described as Polycystic ovarian syndrome (PCOS). There are conflicting results regarding the androgenic steroid profile in PCOS. The relation between clinical manifestations like hirsutism, biochemical manifestations like insulin resistance and their relationship with testosterone, dehydroepiandrosterone sulphate (DHEAS) and dihydrotestosterone (DHT) has been debated. Aims and Objectives: (1) To study the differences in level of androgenic steroids (testosterone, DHT, DHEAS) in PCOS patients with and without hirsutism. (2) Elucidate the relationship between gonadal steroids and metabolic parameters like lipids and insulin resistance. Materials and Methods: Serum samples of 53 consecutive patients with PCOS diagnosed by the Rotterdam criteria were analysed for androgenic steroids (testosterone, dihydrotestosterone & DHEAS). Clinical parameters including hirsutism scoring, metabolic parameters (fasting glucose, fasting insulin, lipid profile & insulin resistance according to the homeostatic model assessment: HOMA-IR) and radiological parameter (USG measurement of ovarian volume) were assessed. Results: Among the study group 56% (30/53) of PCOS patients were found to have hirsutism. Patients with hirsutism had higher DHEAS (p = 0.02) and higher DHT levels (p = 0.001) than patients without hirsutism. Insulin resistance as measured by HOMA-IR >2 was found in 62% (33/53) of patients. There was no statistically significant difference in insulin resistance between the hirsute & non hirsute group. Subjects with higher testosterone levels had greater insulin resistance (p = 0.039). Neither DHT levels nor DHT/Testosterone ratio were found to correlate with Insulin resistance. High BMI (>25) was found in 35.8% (19/53) cases and higher BMI was associated with higher testosterone levels. Conclusions: These results underscore the importance of DHT in hirsutism in patients with PCOS. Testosterone levels are higher in the insulin resistant patient. The cause vs effect of these findings need to be discussed and studied further. [ABSTRACT FROM AUTHOR]

Introduction: The prevalence of medical complications such as hypertension, hyperlipidemia, weight gain and diabetes has been rising along with increased life expectancy after livertransplantation. These metabolic complications lead to cardiovascular complications and increased late morbidity and mortality. Post-transplant risk stratification and aggressive treatment of metabolic complications, including modification of risk factors is imperative to prevent serious complications. Methods: We retrospectively studied 180 consecutive liver transplant recipients at Amrita Institute of Medical Science, Kochi, Kerala. We gathered demographic and biochemical data, pre-transplant Model for End-Stage Liver Disease scores, etiology of liver disease, daily glucose kinetics, type of insulin, requirement for diabetes medications at 12 months, immunosuppression therapy (including steroids), was assessed. Results: Of the 180 patients identified, 121 had complete data and were included in the analysis. Male:Female ratio was 4:1.15% had pre-existing diabetes. Nearly, 14% developed post-transplant diabetes. Nearly, 30% of the post-transplant patients became normoglycemic at 6 months post-transplant. Diabetes, family history of diabetes and excess body weight at baseline were the risk factors for incidence of metabolic syndrome. Detailed analysis of the results will be discussed during the conference. Conclusion: New onset diabetes after transplantation and metabolic syndrome are associated with increased risks of graft rejection, infection, cardiovascular disease and death. Whilst the pathophysiology remains unclear, being vigilant for this important complication and starting hyperglycemic management in a timely fashion may reduce the incidence of and morbidity associated with these metabolic complications. [ABSTRACT FROM AUTHOR]