Deepak Khandelwal

Overt and Subclinical Hypothyroidism Who to Treat and How

Hypothyroidism denotes deficient production of thyroid hormone by the thyroid gland and can be primary (abnormality in thyroid gland itself) or secondary/central (as a result of hypothalamic or pituitary disease). The term ‘subclinical hypothyroidism’ is used to define that grade of primary hypothyroidism in which there is an elevated thyroid-stimulating hormone (TSH) concentration in the presence of normal serum free thyroxine (T4) and triiodothyronine (T3) concentrations. Subclinical hypothyroidism may progress to overt hypothyroidism in approximately 2–5% cases annually. All patients with overt hypothyroidism and subclinical hypothyroidism with TSH >10mIU/L should be treated. There is consensus on the need to treat subclinical hypothyroidism of any magnitude in pregnant women and women who are contemplating pregnancy, to decrease the risk of pregnancy complications and impaired cognitive development of the offspring. However, controversy remains regarding treatment of non-pregnant adult patients with subclinical hypothyroidism and serum TSH values ≤10mIU/L. In this subgroup, treatment should be considered in symptomatic patients, patients with infertility, and patients with goitre or positive anti-thyroid peroxidase (TPO) antibodies. Limited evidence suggests that treatment of subclinical hypothyroidism in patients with serum TSH of up to 10 mIU/L should probably be avoided in those aged >85 years. Other pituitary hormones should be evaluated in patients with central hypothyroidism, especially assessment of the hypothalamic-pituitary-adrenal axis, since hypocortisolism, if present, needs to be rectified prior to initiating thyroid hormone replacement.Levothyroxine (LT4) monotherapy remains the current standard for management of primary, as well as central, hypothyroidism. Treatment can be started with the full calculated dose for most young patients. However, treatment should be initiated at a low dose in elderly patients, patients with coronary artery disease and patients with long-standing severe hypothyroidism. In primary hypothyroidism, treatment is monitored with serum TSH, with a target of 0.5-2.0 mIU/L. In patients with central hypothyroidism, treatment is tailored according to free or total T4 levels, which should be maintained in the upper half of the normal range for age. In patients with persistently elevated TSH despite an apparently adequate replacement dose of LT4, poor compliance, malabsorption and the presence of drug interactions should be checked. Over-replacement is common in clinical practice and is associated with increased risk of atrial fibrillation and osteoporosis, and hence should be avoided.

The Effect of Puberty on Interaction between Vitamin D Status and Insulin Resistance in Obese Asian-Indian Children

To study the effect of puberty on the relationship between serum 25-hydroxyvitamin D (25(OH)D) and parameters of insulin kinetics in obese Asian-Indian children. Material and Methods. The study population included 62 obese Asian-Indian children and adolescents in the age group of 6–17 years. Blood glucose, serum insulin, and serum 25(OH)D were measured. Total body fat was measured by dual energy X-ray absorptiometry. Indices of insulin resistance (HOMA-IR, AUC for insulin) and sensitivity (WBISI) were calculated after oral glucose tolerance test. Result. A total of 62 subjects (35 boys; mean age = 13.0 ± 3 years; BMI = 29.3 ± 4.8 kg/sq M; 19 subjects in Tanner stage 1, 11 in stage 2, 6 in stage 3, 3 in stage 4, and 23 subjects in Tanner stage 5) were studied. All study subjects were vitamin D deficient with a mean serum 25(OH)D of 8.5 ± 4.2 ng/mL. No significant relationship was observed between serum 25(OH)D and parameters of insulin kinetics in prepubertal children. However, a significant inverse correlation was seen between serum 25(OH)D and HOMAIR (r = −0.41, P = 0.03) in postpubertal subjects. Conclusion. The relationship between vitamin D status and parameters of insulin kinetics are affected by puberty.

Metabolic bone disease as a presenting manifestation of primary Sjögren's syndrome: Three cases and review of literature

Primary Sjögrens syndrome (pSS) is a chronic autoimmune disease characterized by a progressive lymphocytic infiltration of the exocrine glands with varying degrees of systemic involvement. Chronic inflammation compromises the glands’ function that leads to dry symptoms in the mouth/eyes. Renal involvement is a well recognized extraglandular manifestation of pSS. Metabolic bone disease (MBD), however, rarely occurs as the primary manifestation of a renal tubule disorder due to pSS. To the best of our knowledge there are only 6 reported cases of metabolic bone disease as the primary manifestation of pSS to date. Four of these had distal renal tubular acidosis (RTA), and 2 had a combined picture of distal and proximal tubular dysfunction. We herein present our experience of 3 cases who presented to us with a clinical picture suggestive of MBD. While investigating these patients, we found evidence of RTA, which was found to be secondary to pSS.

Hypokalemic paralysis as a presenting manifestation of primary Sjögren's syndrome: A report of two cases.

Primary Sjögrens syndrome (pSS) is a chronic autoimmune disease characterized by a progressive lymphocytic infiltration of the exocrine glands with varying degrees of systemic involvement. Overt or latent renal tubular acidosis (RTA), caused by tubulointerstitial nephropathy, is a common extraglandular manifestation of pSS. Hypokalemic paralysis is a well known, albeit rare complication of severe distal RTA from any cause. Cases of pSS manifesting for the first time as hypokalemic paralysis caused by distal RTA have been rarely reported. We herein present our experience of two cases, who presented to us for evaluation of hypokalemic paralysis and on work up found evidence of distal RTA, which on further work up found to be secondary to pSS. A high index of suspicion for pSS should be kept in all patients with hypokalemic paralysis.

Sleep disorders in type 2 diabetes

Type 2 diabetes mellitus (T2DM) has shown to be associated with higher incidence of sleep disorders, which may be due to disease itself or because of secondary complications or associated comorbidities associated with diabetes. On the other hand, shorter sleep duration and erratic sleep behavior itself have been linked with higher incidence of obesity, metabolic syndrome, and T2DM. Assessment of sleep quality and sleep disorders as a part of the comprehensive medical evaluation is recommended based on emerging evidence suggesting a relationship between sleep quality and glycemic control in persons with T2DM. In this review, we attempt to summarize common sleep disorders associated with T2DM, their impacts on glycemic and other metabolic control, and various preventive and therapeutic strategies to tackle these problems.

Acromegaly with no pituitary adenoma and no evidence of ectopic source

More than 99% of patients with acromegaly harbor a growth hormone (GH) secreting pituitary adenoma. As the time from onset of signs/symptoms to diagnosis of acromegaly is long (symptom onset to diagnosis is often 4–10 years), pituitary adenomas that cause GH excess are often large and are nearly always visible on conventional magnetic resonance imaging (MRI). However, in rare circumstances, acromegalic patients without an ectopic source will not have imaging evidence of a pituitary adenoma. Management of these patients poses special challenge, and once ectopic source of GH/growth-hormone-releasing hormone (GHRH) is ruled out, an exploration of pituitary might be useful. We herein report a case of acromegaly with imaging evidence of sellar floor osteoma, but no pituitary adenoma, and negative work up for an ectopic source of GH/GHRH tumor, and on surgical exploration pituitary adenoma could be identified and removed and confirmed on histopathologic examination.

Patient-centered management of hypothyroidism

This communication from the National Indian Patient-centered Thyroid management group (InPACT) deals with a novel, yet essential, aspect of hypothyroidism management. The authors describe the role and scope of patient-centered care in this condition. They focus on the relevance of a patient-centered clinical approach, which will help decide appropriate targets, as well as techniques to achieve those targets. Means of helping persons with hypothyroidism live a healthy life, such as education about precaution in concomitant food and medications intake, as well as sick day management, are discussed.

Management of glycemia in acute febrile illness

With increasing the prevalence of diabetes and prediabetes across the globe, a large number of patients with acute febrile illness (AFI) are likely to have concomitant diabetes or stress hyperglycemia. Management of associated hyperglycemia in patients with AFI is of utmost importance for early recovery and to prevent complications. There is no published literature, detailing the strategies and targets for glycemic control in AFI specifically; however, guidelines do exist for the management of hyperglycemia in hospitalized or outpatients in general. This review attempts to provide pragmatic and practical suggestions to facilitate effective and safe management of hyperglycemia in patients with AFI.

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.

The rule of two-thirds in diabetes epidemiology

This communication hypothesises a rule of two thirds which seems to operate in Indian diabetes epidemiology. Two thirds of all persons with dysglycemia are prediabetic; two thirds of all persons with diabetes are diagnosed to have the condtion; and two thirds are diagnosed before the age of 50 years. Two thirds of people with diabetes have concomitant hypetension or dyslipidemia; two thirds do not get their HbA1c assessed; and two thirds of those who do, do not achiev target values. Yet, two thirds of people with diabetes report satisfactory psychosocial health and quality of life, and adherence to dietary therapy and medication. Only one thirds adhere to exercise and self monitoring advice, however. Two thirds of persons on oral glucose lowering drugs receive metformin; two thirds of those on insulin receive premixed insulin or twice daily isnuslin, and a similar proportion uses pens for delivery. Thus, the rule of two thirds, rather than of halves, operates in modern Indian diabetes practice.