Ameya Joshi

A Study of Bone Mineral Density and Its Determinants in Type 1 Diabetes Mellitus

Type 1 diabetes mellitus (T1DM) has been inconsistently associated with low bone mineral density (BMD) and increased fracture risk. 86 consecutive T1DM cases and 140 unrelated age and sex matched healthy nondiabetic controls were included in the study. After history and examination, BMD and body composition were assessed by dual energy X-ray absorptiometry (DXA). Serum samples were analyzed for calcium, phosphorus, albumin, creatinine, alkaline phosphatase, 25 (OH) vitamin D3, intact parathormone (PTH) levels (both cases and controls) and HbA1c, antimicrosomal and IgA tissue transglutaminase (IgA TTG) antibodies, cortisol, follicle stimulating hormone (FSH), testosterone, sex hormone binding globulin (SHBG), tetraiodothyronine (T4), thyroid stimulating hormone (TSH), growth hormone (GH), insulin-like growth factor-1 (IGF-1), and insulin-like growth factor binding protein 3 (IGFBP3) (cases only). T1DM cases had a lower BMD as compared to controls at both total body (TB) and lumbar spine (LS) (P < 0.05). Patients with celiac autoimmunity (CA) had significantly, lower BMD as compared to age, sex, and body mass index (BMI) matched T1DM controls. Linear regression analysis showed that low BMD in T1DM patients was associated with poor glycaemic control, lower IGF-1 levels, less physical activity (in total population as well as in male and female subgroups), and lower body fat percentage (in females) and higher alkaline phosphatase level (in males) (P < 0.05).

Coeliac autoimmunity in type I diabetes mellitus.

BACKGROUND AND STUDY AIMS Coeliac autoimmunity (CA) has a known association with type 1 diabetes mellitus (T1DM) for which screening is routinely recommended but less frequently followed. The impact of CA in T1DM has been variably reported. The aims of this study are as follows: (1) to study the prevalence of CA in patients with T1DM and (2) to study the impact of CA not only on nutritional parameters but also on glycaemic control, endocrine axes and bone health. PATIENTS AND METHODS Eighty-six consecutive patients with T1DM were screened for CA using immunoglobulin A (IgA) tissue transglutaminase as a marker (TTG; IgG anti-gliadin in IgA-deficient case). CA positive (CA+) cases were compared with age-matched and sex-matched CA negative (CA-) T1DM cases for anthropometry, glycaemic control (assessed by glycated haemoglobin (HbA1c) and hypoglycaemic/hyperglycaemic episodes), endocrine (thyroid function, cortisol, growth hormone (GH) axis, gonadal axes), haematological (haemoglobin, iron profile and vitamin B12 status) and calcium metabolism parameters and bone densitometry (by dual-energy X-ray absorptiometry (DXA)). Consenting patients with CA also underwent upper gastrointestinal (GI) endoscopy with duodenal biopsy. RESULTS Out of 86 patients, 11 (12.75%) screened positive for CA (seven patients underwent duodenal biopsies which were suggestive of Marsh grade III(2), II(3) and I(2) disease). The CA+ T1DM patients were comparable with CA- T1DM in terms of anthropometry. CA+ patients had higher HbA1c (10.7±1.8 vs. 8.4±1.0 (93±19 vs. 68±11 mmol/mol); p<0.01), more hypoglycaemic episodes (five vs. two; p<0.05), higher prevalence of iron and vitamin B12 deficiency, lower insulin-like growth factor-1 (IGF-1) levels and lower bone mineral density (BMD) z-score at total body (-1.91±1.05 vs. -0.63±0.73; p<0.05) and lumbar spine (-1.69±0.92 vs. -0.36±0.93; p<0.05). The incidence of fractures in the past 3years was also more in CA+ patients than in CA- patients (four vs. one; p<0.05). CONCLUSION CA has an important autoimmune association with T1DM. The concomitant presence of CA adversely affects stature, bone health, glycaemic control and iron and B12 levels in T1DM. IgA sufficiency should be ensured before using an IgA-based screening test for CA.

Osteoporosis treatment in India: Call for action

441 A 65‐year‐old female at a district place with aches, pains and weakness of a couple of hour’s duration visits an outpatient clinic. A few investigations of calcium and vitamin D are advised in addition to blood glucose levels and thyroid function test, and she is advised to do a dual energy X‐ray absorptiometry (DXA) scan, which she didn’t manage for next few months as the same is available in a bigger city, which is 3 h travel and ultimately lands up with a hip fracture. The same is treated, and she is discharged with advice to get a DXA scan and treatment of osteoporosis is deferred for same. In the same place is a 26‐year healthy girl who is prescribed once a month ibandronate at basic medical practitioner level because calcaneal bone density T‐score is ‐2.8, the test being done as a door to door screening. The two cases represent a paradox of inappropriate omission and commission, respectively.

Pituitary dysfunction in traumatic brain injury: Is evaluation in the acute phase worthwhile?

Introduction: Traumatic brain injury (TBI) is an under-recognized cause of hypopituitarism. According to recent data, it could be more frequent than previously known. However, there is a scarcity of data in Indian population. Aims: The main aim of the study was to determine the prevalence of pituitary hormone deficiencies in the acute phase of TBI. The secondary objectives were to correlate the severity of trauma with basal hormone levels and to determine whether initial hormone deficiencies predict mortality. Subjects and Methods: Forty-nine TBI patients (41 men and 8 women) were included in this study. Pituitary functions were evaluated within 24 h of admission. Results: Gonadotropin deficiency was found in 65.3% patient while 46.9% had low insulin-like growth factor-1, 12.24% had cortisol level <7 mcg/dl. Cortisol and prolactin level were positively correlated with the severity of TBI suggestive of stress response. Free triiodothyronine (fT3) and free thyroxine were significantly lower in patients with increasing severity of tuberculosis. Logistic regression analysis revealed that mortality after TBI was unrelated to the basal pituitary hormone levels except low T3 level, which was found to be positively related to mortality. Conclusions: Pituitary dysfunction is common after TBI and the most commonly affected axes are growth hormone and gonadotropin axis. Low fT3 correlates best with mortality. During the acute phase of TBI, at least an assessment of cortisol is vital as undetected cortisol deficiency can be life-threatening

Uncontrolled hyperglycaemia: a reversible cause of hemichorea–hemiballismus

Hyperosmolar hyperglycaemic state (HHS) an acute complication of diabetes mellitus, can be associated with neurological involvement ranging from seizures, involuntary movements to reversible focal neurological deficits without any structural lesions. We report a 71-year-old woman, a known case of type 2 diabetes mellitus who presented with the sudden onset of hemichorea–hemiballismus. On investigations she had hyperglycaemia and urinary tract infection. Achievement of euglycemia with insulin therapy resolved the involuntary movements completely. This highlights the fact that HHS is an uncommon but easily treatable cause of recent onset unilateral hemichorea–hemiballismus.

Bhagavad gita for the physician

This communication presents verses from the Bhagavad Gita which help define a good clinicians skills and behavior. Using the teachings of Lord Krishna, these curated verses suggest three essential skills that a physician must possess: Excellent knowledge, equanimity, and emotional attributes. Three good behaviors are listed (Pro-work ethics, Patient-centered care, and Preceptive leadership) and supported by thoughts written in the Gita.

Celiac autoimmunity in autoimmune thyroid disease is highly prevalent with a questionable impact.

Introduction: The prevalence of autoimmune thyroid disease (AITD) is 10–12% in the general population worldwide. Among various disorders co-existing with AITD, the concomitance of celiac disease (CD) with AITD results in poor absorption of thyroid medications and results in higher doses of the same. Institution of gluten-free diet (GFD) in this cohort helps reduce medication doses. Aim: To screen patients with AITD for the presence of celiac autoimmunity (CA). Materials and Methods: A total of 280 consecutive patients with AITD attending the thyroid Out-patient Department of a tertiary care hospital were screened for the presence of tissue transglutaminase antibodies (immunoglobulin A tissue transglutaminase). Those with a positive titer (but < 10 times the upper limit of normal) underwent upper gastrointestinal endoscopy and duodenal mucosal biopsy for the diagnosis of CD, followed by institution of GFD in confirmed cases. Results: Of a total of 280 (182 females and 98 males) patients with AITD screened, 24 (8.6%) turned out to be positive for CA. Of 24 (8.6%), 15 (8.24%) females and 9 (9.18%) males were positive for CA. There was no statistically significant difference in the thyroxine doses required for normalization of thyroid function and the weight of the patients in CA positive and CA negative patients. Conclusions: The prevalence of CD in patients with AITD is much greater than in the general population. This forms the basis for screening patients with AITD for presence of CD.

Vitamin D deficiency is associated with increased mortality in critically ill patients especially in those requiring ventilatory support

Introduction: Vitamin D (VitD) classically recognized for its role in the musculoskeletal system, has been implicated in myriad of conditions such as diabetes, immune dysfunction, cancers, heart disease, metabolic syndrome, etc. We studied the role of VitD in acute care setting and its correlation with mortality. Materials and Methods: A total of 85 consecutive consenting patients admitted in medical intensive care unit of tertiary care hospital who fulfilled the inclusion criteria were included. All patients were evaluated clinically, and blood samples were collected for hemogram, biochemical investigations including serum calcium, phosphorus, alkaline phosphatase, magnesium, along with 25(OH) VitD, 1,25(OH) VitD and intact parathormone levels. Simplified acute physiology score (SAPS II) was calculated for all patients. Results: VitD was deficient (<30 ng/ml) in 27 patients (32%). The overall mortality was more in VitD deficient group as compared to VitD sufficient group (74 vs. 41%; P < 0.05). The actual mortality in VitD deficient group was higher than the mortality predicted by SAPS II score (50 vs. 74%; P < 0.0507). VitD deficiency was also associated with more mortality among those requiring ventilator support (95% vs. 40%; P < 0.05) as well as with higher blood glucose (124.5 ± 29.7 vs. 94.8 ± 19.8: P < 0.01) levels. Conclusion: VitD deficiency was associated with increased mortality, poor ventilator outcomes, and increased blood glucose in critically ill patients.

Indeterminate thyroid nodule: Mystery continues despite recent advances

Sir, We read with great interest the article “A pragmatic approach to an indeterminate thyroid nodule.” It was interesting to go through the meticulous thought process for decision-making in an indeterminate nodule, and the approach designed will definitely help in clinical practice. Equally realistic is the author’s admission that cost of molecular studies in fine-needle aspiration cytology (FNAC) sample may be equal to the cost of surgery itself in our Indian setting.[1]

Fasts, feasts, and festivals in diabetes: Glycemic management during Parsi rituals

The article is one in the series of articles related to glycaemic management in festivals across all religions in India. The article discusses issues in glycaemic management among Parsi culture, which represent a small but ever important group of Indian population