J Muthukrishnan

Correlation between bone markers and bone mineral density in postmenopausal women with osteoporosis.

OBJECTIVE To study the relationship between bone markers and bone mineral density (BMD) in an effort to identify their utility in postmenopausal women with osteoporosis. METHODS Eighty-two consecutive postmenopausal women with untreated osteoporosis were included in the study. Forearm, spinal, and femoral BMD by dual-energy x-ray absorptiometry and markers of bone formation (serum osteocalcin and bone-specific alkaline phosphatase) and bone resorption (urinary free deoxypyridinoline) were measured in all patients. Patients with low serum vitamin D levels, secondary osteoporosis, or clinically significant systemic disease were excluded from the study. The patients were classified on the basis of BMD of the lumbar spine into the following 3 groups: mild (n = 23) (T score -2.5 through -3), moderate (n = 42) (T score -3.1 through -4), or severe (n = 17) (T score <or=-4.1) osteoporosis. One-way analysis of variance and Pearson correlation were used for statistical analysis, with a P value <.05 being considered significant. RESULTS Serum osteocalcin was significantly different among the 3 study groups (4.1 +/- 2.7, 4.5 +/- 3.1, and 6.7 +/- 5.6 ng/mL, respectively; P = .0349) and had a significant negative correlation with BMD (r2 = -0.0779; P = .0168). Other bone markers such as bone-specific alkaline phosphatase and urinary free deoxypyridinoline did not correlate with the underlying BMD. CONCLUSION In our study, osteocalcin was significantly correlated with BMD in postmenopausal women with osteoporosis. Other bone markers did not correlate with BMD. Further large-scale population data and analyses are needed to confirm these findings.

Evaluation of thyrotoxicosis during pregnancy with color flow Doppler sonography

Objective: To determine whether color flow Doppler sonography (CFDS) is useful in differentiating Graves vs non‐Graves thyrotoxicosis during pregnancy, when nuclear imaging is contraindicated. Methods: Ten pregnant women with thyrotoxicosis were divided into Graves, and non‐Graves, disease groups and were evaluated by CFDS for thyroid volume, vascularity, and inferior thyroid artery (ITA) flow velocity. Each patient was matched with a euthyroid woman of the same pregnancy duration. Results: Of the 10 patients, 3 were diagnosed with Graves disease, 4 with gestational toxicosis, and 3 with destructive thyroiditis. Those in the Graves disease group had a greater thyroid gland volume (18.9 ± 1.5 cm3 vs 12.1 ± 2.4 cm3; P < 0.05), greater thyroid vascularity, and greater ITA flow velocity than those in the non‐Graves disease group (92 ± 13 cm/s vs 20.4 ± 2.4 cm/s; P < 0.05). There was no significant difference in the corresponding values between the patients with gestational toxicosis and those with destructive thyroiditis or between them and their healthy controls. Conclusion: Thyroid evaluation by CFDS is useful for the differential diagnosis of thyrotoxicosis in pregnant women.

Obesity and thyrotropinemia.

ObjectiveTo study the relation between body mass index (BMI) and TSH in euthyroid and subclinical hypothyroid obese children and compared serum TSH level among obese and overweight children.MethodsFifty consecutive children (aged 2–18 yr) presenting for obesity were studied. All cases with TSH > 10, low T3/T4, organic and syndromic obesity were excluded. Patients were divided into Group 1: Overweight (n=20) (BMI between 85th to 95th centile) and Group 2: Obesity (n=30) (BMI > 95th centile). Fisher’s exact test, Mann-Whitney U test and Pearson’s correlation were used for statistical analysis. P value < 0.05 was considered significant.ResultsElevated TSH level (between 4.5–10 mIU/L) with normal T3, T4 was seen in 4/20 overweight and 9/30 of obese children (P=0.5219). The mean TSH was comparable in both the groups (3.22 ± 3.1 mIU/L vs. 3.63 ± 2.2 mIU/L, P=0.3491). Overall TSH showed no correlation with BMI (r= 0.0014, P=0.9924).ConclusionThe preliminary data did not show any relation between severity of obesity and TSH level. Further large scale data from population are required to confirm these findings.

DISTAL RENAL TUBULAR ACIDOSIS DUE TO PRIMARY HYPERPARATHYROIDISM

OBJECTIVE To present 4 cases of distal renal tubular acidosis (RTA) in patients with primary hyperparathyroidism (PHPT) and discuss their possible etiopathogenetic correlation. METHODS We diagnosed distal RTA in 4 patients with symptomatic primary PHPT on the basis of the baseline biochemical variables and the results of the ammonium chloride loading test. Complete resolution of distal RTA was documented after surgical cure of PHPT by removal of a parathyroid adenoma. RESULTS All our patients presented with symptomatic bone disease and metabolic myopathy. One patient presented with recurrent renal stones. Inappropriately alkaline fasting urine (pH >5.5) in association with a normal anion gap metabolic acidosis suggested the diagnosis of distal RTA. All cases were confirmed by an ammonium chloride loading test. Three patients responded to surgical cure of PHPT by normalization of the acid-base status. CONCLUSION Hypercalciuria in PHPT can lead to nephrocalcinosis and renal tubular dysfunction, which manifests as distal RTA. Cure of distal RTA after surgical treatment of PHPT establishes PHPT as the primary cause of distal RTA in these cases.

Risk factors for contrast-induced nephropathy after coronary angiography

Contrast-induced nephropathy (CIN) is of concern after the use of radiocontrast media for coronary angiography (CAG) and percutaneous coronary intervention (PCI). We studied the incidence of CIN and its risk factors in patients undergoing CAG. In this prospective study, we included all patients with normal renal parameters undergoing CAG with nonionic radiocontrast media. We excluded patients with known chronic kidney disease, baseline creatinine more than 1.5 mg/dL, significant hypotension, anemia, and patients with acute myocardial infarction undergoing emergency PCI. Serum creatinine was done at baseline and serially for seven days after the procedure. Appropriate statistical tests were used to analyze the results and P <0.05 was considered statistically significant. The study population (n = 500, 348 males and 152 females) had a mean age of 56.6 ± 12.5 years. Twelve patients (2.4%) developed CIN and were equally distributed irrespective of the age, diabetes, or PCI procedure. CIN was observed to be more common in patients with hypertension than in those without hypertension (P = 0.0158). The total volume of contrast administered to CIN group (175 ± 59.3) was not significant as compared to that of non-CIN (159.1 ± 56) group (P = 0.334). None of the patients in our study required renal replacement therapy, and there was no mortality. CIN is observed in 2.4% of patients undergoing CAG and had a self-limiting course. Hypertension is the only observed risk factor, and further large-scale studies are necessary to delineate the novel risk factors for CIN in the general population with normal kidney function.

Two cases describing the effects of hypothyroidism on puberty and growth

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Combined steroid and lignocaine injection in resistant cases of tennis elbow: A prospective, interventional study from India

Background: Tennis elbow or lateral epicondylitis is a chronic, painful condition and is often resistant to conventional therapy. We evaluated the benefits of a combined steroid and lignocaine injection in resistant cases of tennis elbow. Materials and Methods: In this prospective, interventional study, we included chronic lateral epicondylitis patients resistant to analgesics and physiotherapy. The pain was assessed by visual analog scale (VAS), and we included patients with a baseline VAS >4. All patients were given local infiltration at the painful site with methylprednisolone (1 ml) and lignocaine (1 ml) by the peppering technique. The primary outcome was the change in VAS from the baseline at the end of 7 and 28 days. The improvement is classified as good, moderate, or mild based on the reduction in VAS score by 3, 2, 1, respectively. Descriptive statistics and appropriate tests were used to analyze the results. Results: The study population (n = 63; male: female - 33:30) had a mean age of 36.2 ± 4.5 years and disease duration of 17.4 ± 5.8 weeks. After 1 week, 55 patients showed good improvement, three patients showed moderate improvement, two patients showed mild improvement, and three patients had no improvement. The improvement persisted till 28 days in all the patients and one patient who had not improved after 7 days did not report for 28 days follow-up. Conclusion: Local infiltration with steroids and lignocaine is a useful modality of therapy for tennis elbow, especially in patients where ultrasonic therapy and conservative measures have failed.