Anupam Prakash

Polycystic ovary syndrome: Is obesity a sine qua non? A clinical, hormonal, and metabolic assessment in relation to body mass index.

Objective: To determine the proportion of polycystic ovarian syndrome (PCOS) patients who have normal body mass index (BMI) and to compare the clinical, hormonal, and metabolic profile between lean and overweight patients of PCOS. Materials and Methods: One hundred consecutive infertile women with PCOS were studied and divided into lean (BMI between 18.5 and 23) and overweight (BMI ≥ 23). Metabolic and hormonal profile (serum FSH, LH, testosterone, prolactin, TSH on days 2–3 of menstrual cycle; serum progesterone premenstrually; serum insulin—fasting and 2 hours postglucose, glucose tolerance test, and fasting serum lipid profile) was performed along with pelvic sonogropahy; and clinical features, viz. waist hip ratio, hirsutism, acne, acanthosis nigricans, and clitoromegaly were recorded. Results: 42% of the PCOS subjects had normal BMI. Average age, hirsutism (80.9% vs. 89.7%), irregular cycles (92.8% vs. 96.6%), acne (9.5% vs. 15.5%), clitoromegaly (2.3% vs. 3.4%), endometrial thickness >4 mm (9.5% vs. 15.5%), and hormonal profile were similar in the lean and overweight PCOS groups. Family history of diabetes (9.5% vs. 24.1%), abnormal glucose tolerance test (GTT) (4.7% vs. 10.3%), deranged lipid profile (14.2% vs. 31%), and 2-hour postprandial insulin levels were higher in the overweight PCOS (P < 0.05). Insulin resistance was observed in 83.3% of lean PCOS but was still lower than 93.1% seen in overweight PCOS (P < 0.05). Conclusion: 42% of the PCOS had normal BMI, but clinical and hormonal profile was similar to PCOS patients with elevated BMI (overweight/obese). However, insulin resistance is observed in 83.3% of lean PCOS. Family history of diabetes, impaired GTT, deranged lipid profile, and insulin resistance were more prevalent in overweight PCOS.

Efficacy of 2-hour post glucose insulin levels in predicting insulin resistance in polycystic ovarian syndrome with infertility

BACKGROUND: Insulin resistance (IR) is central to the pathogenesis of polycystic ovarian syndrome (PCOS), but tests for determining IR are elaborate, tedious and expensive. AIMS: To evaluate if “2-hour post-glucose insulin level” is an effective indicator of IR and can aid in diagnosing IR in infertile PCOS women. SETTINGS AND DESIGN: Observational study at infertility clinic of a tertiary care center. MATERIALS AND METHODS: 50 infertile women with PCOS and 20 females with tubal/male factor infertility were evaluated for the presence of IR, as defined by the fasting/2-hour post-glucose insulin levels cutoffs of >25/>41 μU/mL, respectively. The clinical, metabolic and endocrinologic profile was determined in both the groups. STATISTICAL ANALYSIS: Statistical analysis was performed using SPSS (Chicago, IL, USA). RESULTS: Body mass index, post load glucose, insulin, glucose/insulin ratio, area under curve (AUC) of glucose and insulin and insulinogenic index were significantly lower in the controls as compared to the PCOS group. “2-hour post-glucose insulin levels” were elevated in 88% of PCOS individuals but were normal in all females not suffering from PCOS. These levels significantly correlated with AUC of glucose and insulin, and insulinogenic index and inversely correlated with 2-hour glucose to insulin ratio (r=0.827, 0.749 and –0.732, respectively). CONCLUSIONS: “2-hour post-glucose insulin levels” appears to be a good indicator of IR. It can be a useful tool, especially in low resource setting where a single sample can confirm the diagnosis, thus reducing cost and repeat visits.

Thalassemia major in adults: Short stature, hyperpigmentation, inadequate chelation, and transfusion-transmitted infections are key features

Background: Effective transfusion and chelation have prolonged the quality and longevity of life in thalassemics, who now survive into adulthood. Hence, adult physicians need to be aware of their clinical and laboratory profile and the problems faced by them. Aim: The present study was aimed to evaluate the clinical profile of adult thalassemics. Materials and Methods: Adult (>18 years) thalassemia major patients (n=19) were evaluated clinically and fasting pretransfusion blood samples were analyzed for complete blood counts, kidney and liver function tests, plasma glucose, serum ferritin, and thyroid hormone levels. Results: Average age was 21.65±2.47 years (range 19–28 years), 42.1% had Body mass index (BMI) <18.5. Splenectomy had been performed in 47.4% before reaching adulthood, males significantly outnumbered females (72% vs. 12.5%). Hemoglobin levels <8 g/dl were observed in 31.6% and none had serum ferritin levels in the recommended range suggesting inadequacy of both transfusion and chelation. Indirect hyperbilirubinemia was observed in 21.1% patients although kidney functions, serum protein, and albumin were normal in all patients. Electrocardiographic abnormalities, diabetes mellitus or hypothyroidism were absent. Five patients (26.3%) had contracted transfusion-transmitted viral infections – 21.1% and 5.3% respectively had antibodies to hepatitis C virus and HIV, while 5.3% were positive for Australia antigen. All patients were receiving chelation therapy – deferiprone alone (78.9%) or along with desferrioxamine (21.1%). Average dose of deferiprone being used was 95±8 mg/kg. Conclusion: Adult thalassemia major patients present with a distinct clinical profile having low BMI, generalized hyperpigmentation, most are splenectomized, have low hemoglobin, inadequate chelation and harbor transfusion-transmitted infections. Adult physician needs to be aware of this profile.

Pregnancy outcome of women with gestational diabetes in a tertiary level hospital of north India.

Background: Women with gestational diabetes mellitus (GDM) pose an important public health problem because diabetes not only affects the maternal and fetal outcome, but these women and their fetuses are also at an increased risk of developing diabetes and related complications later in their life. Objectives: The study was conducted to determine the maternal and fetal outcomes of 50 diabetic vs 50 normoglycemic pregnancies. Materials and Methods: This was a retrospective analytical record-based study conducted in a tertiary level hospital. Detailed information regarding maternal, fetal, and labor outcome parameters was recorded in a prestructured proforma and compared in normoglycemic and diabetic pregnancies. Results: Patients with obesity, history of diabetes in the family, spontaneous abortions, and gestational diabetes in previous pregnancies had a greater incidence of GDM in current pregnancy (P<0.05 for all). Hypertension, polyhydramnios, macrosomia, fetopelvic disproportion, and cesarean sections were more (P<0.001) among diabetic pregnancies. Congenital anomalies, polycythemia, hypocalcemia, and hyperbilirubinemia were also observed to be more (P<0.05) in neonates born to diabetics, suggesting an adverse effect of hyperglycemia in utero. Conclusion: Diabetes during pregnancy is associated with higher maternal and fetal morbidity. Therefore, early screening, detection, close monitoring, and intervention is essential to reduce maternal and fetal short- and long-term adverse effects, especially in high-risk groups. Pregnancy provides an opportunity to the clinician to control the disease process and inculcate healthy lifestyle practices in these patients.

Effect of metformin therapy on 2-h post-glucose insulin levels in patients of polycystic ovarian syndrome.

AIMS: To evaluate if 2-h post glucose insulin level is an effective tool to monitor insulin resistance in response to metformin therapy, in infertile women with polycystic ovarian syndrome (PCOS). SETTINGS AND DESIGN: This prospective observational study was carried out in a tertiary care infertility clinic. MATERIALS AND METHODS: 40 women with PCOS were categorized as having insulin resistance if fasting or 2-h post glucose insulin levels were >25 or >41μU/ml respectively. Post glucose insulin was compared before and after six months of metformin therapy along with other clinical, hormonal and metabolic parameters by using McNemar and the Student’s t-test. RESULTS: Fasting insulin was elevated in 4 (10%) and post-load insulin in 34 (85%) patients; after metformin therapy respective values were 2 (5%) and 16 (40%). Metformin therapy reduced post glucose insulin levels (P<0.001), improved the regularity of periods (P<0.001) and resulted in reduction of LH levels (P<0.001), total testosterone (P<0.001) and mean Body mass index (BMI) (P=0.047). Metformin therapy did not alter waist-hip ratio and fasting insulin levels. CONCLUSION: 2-h post glucose insulin level is an effective tool to monitor insulin resistance in PCOS patients and improves significantly after metformin therapy, similar to improvements observed in clinical, hormonal and metabolic parameters.

Carbon Monoxide Poisoning

Carbon monoxide is a colourless, odourless and tasteless gas existing in a miniscule concentration in the atmosphere (

Thalassemia: An overview

This article provides an insight towards diagnosing and managing thalassemias. It begins by describing the structure of normal hemoglobin and elaborates on our understanding of the pathophysiology of thalassemia. An overview of transfusion therapy and its complications including endocrinopathies and cardiomyopathy has also been discussed.

Bilateral psoas abscess during pregnancy presenting as an acute abdomen: atypical presentation

Nearly half of skeletal tuberculosis patients have spinal tuberculosis, but psoas abscess develops in only 5% of spinal tuberculosis cases. However, bilateral psoas abscess is a rarity. Psoas abscess occurring in pregnancy could be a clinical dilemma and is hardly reported. We report an unusual presentation of bilateral psoas abscess in pregnancy presenting as an acute abdomen and adnexal mass.

Isolated distal cutaneous thrombosis: An unusual presentation and an interesting etiology

A middle-aged hypertensive male, with a fatty liver and chronic alcohol intake, relocated to a high altitude of 2100 m above sea level; in the first winter season, he developed bluish skin lesions over the tip of the nose, margins of both ear lobes, both knees, and subungual location. Systemic examination was unremarkable. Skin biopsy showed thrombi in dermal vessels without any evidence of vasculitis; immunofluorescence was negative. Investigations revealed mild elevation in plasma homocysteine levels, weakly positive antinuclear antibodies and elevated antiphospholipid antibodies, methylene tetrahydrofolate reductase C677T heterozygosity, and protein S deficiency. The patient received prednisolone for 2 weeks, aspirin and pentoxyphylline for 3 months, and continues to be on folic acid and vitamin B6. After 3 months, antiphospholipid antibodies and antinuclear antibody levels were normal. Isolated distal cutaneous thrombosis is an uncommon entity and precipitation by extreme cold in a hypertensive male with three thrombophilic states - one transient, one hereditary, and one acquired - is fascinating.

Premature Ovarian Failure – An Unusual Manifestation of Systemic Sclerosis

A 31-year-old woman presented with secondary amenorrhoea and inability to conceive, which was of 3 years duration. She had Raynaud’s phenomenon for 16 years, primary hypothyroidism for 5 years, digital ulcers for 4 years and skin tightening for 2 years. She had an expressionless face, with loss of wrinkles and restriction of the mouth opening along with flexion contractures of the hands and the terminal digit resorptions. Investigations showed Antinuclear antibodies (ANA) and anti-Scl 70 positivity confirming the presence of systemic sclerosis (SSc). The Follicle Stimulating Hormone (FSH) level was elevated, the ovarian follicles were absent, and the endometrial thickness was reduced confirming premature ovarian failure (POF). POF causing infertility and secondary amenorrhoea in SSc is an unusual manifestation; moreover, POF occured without the involvement of other internal organs.