Muthuswamy Ravikiran

Utility of Glycated Hemoglobin in Diagnosing Type 2 Diabetes Mellitus: A Community-Based Study

CONTEXT Although glycated hemoglobin (HbA1c) has recently been incorporated as a diagnostic test by the American Diabetes Association, its validity needs to be established in Asian Indians in a community setting. OBJECTIVE The objective of the study was to assess the validity of HbA1c as a screening and diagnostic test in individuals with newly detected diabetes mellitus. DESIGN AND SETTING Community based randomized cross sectional study in urban Chandigarh, a city in north India, from April 2008 to August 2009. SUBJECTS Subjects included 1972 subjects aged 20 yr or older. INTERVENTION Intervention included an oral glucose tolerance test and glycated hemoglobin in all the subjects. MAIN OUTCOME MEASURES Utility of HbA1c as a diagnostic method in newly detected diabetes mellitus subjects was evaluated. RESULTS Using World Health Organization criteria for diagnosis of diabetes mellitus, 134 (6.7%) had newly detected diabetes mellitus, 192 (9.7%) known diabetes mellitus, 329 (16.6%) prediabetes, and 1317 (69.4%) were normal of 1972 people screened. Using only the ADA criteria, 38% people were underdiagnosed. An HbA1c level of 6.1% had an optimal sensitivity and specificity of 81% for diagnosing diabetes. A HbA1c level of 6.5% (+/-2 SD) and 7% (+/-2.7 SD) had sensitivity and specificity of 65 and 88% and 42 and 92%, respectively, with corresponding positive predictive value and negative predictive value of 75.2 and 96.5% and 90.4 and 94.4%, respectively, for diagnosis of newly detected diabetes mellitus. CONCLUSION A HbA1c cut point of 6.1% has an optimal sensitivity and specificity of 81% and can be used as a screening test, and a cut point of 6.5% has optimal specificity of 88% for diagnosis of diabetes.

Prevalence and risk factors of metabolic syndrome among Asian Indians: A community survey

AIM To determine the prevalence of and risk factors for metabolic syndrome (MS) among urban Asian Indian adults. METHODS 2225 subjects aged > or =20 years were studied in a population based cross-sectional survey in Chandigarh, a city in north India. Anthropometric measurements, estimation of capillary plasma glucose, HDL cholesterol and triglycerides were done. Metabolic syndrome prevalence was estimated using National Cholesterol Education Program-Adult Treatment Panel III (NCEP ATP III), modified NCEP ATP III and International Diabetes Federation (IDF) criteria. Multiple logistic regression analysis was done to find out risk factors for metabolic syndrome. RESULTS The prevalence rates of metabolic syndrome were 35.8% (NCEP ATP III), 45.3% (modified NCEP ATP III) and 39.5% (IDF criteria). As per modified NCEP ATP III criteria, central obesity was the commonest abnormality among females and elevated blood pressure among males. Risk factors for MS were increasing age, female gender, sedentary lifestyle and diabetes in parents. CONCLUSIONS Our study showed a high prevalence of metabolic syndrome and its individual components. Independent risk factors for metabolic syndrome included increasing age, female gender, sedentary lifestyle and diabetes mellitus in parents.

Prevalence and risk factors of diabetes in a community-based study in North India: The Chandigarh Urban Diabetes Study (CUDS)

AIMS As there have been few studies in North India of the prevalence of diabetes within the past decade, this study aimed to assess the prevalence and risk factors associated with diabetes in the North Indian city of Chandigarh. METHODS This cross-sectional survey of 2227 subjects (response rate: 94%), aged ≥20 years and representative of the urban Chandigarh population, was conducted from April 2008 to June 2009. Fasting plasma glucose (FPG) and 2-h plasma glucose (2hPG) following ingestion of 75 g of an anhydrous glucose equivalent were estimated by glucometer in all subjects except those with known diabetes, in whom only FPG was measured. Diagnosis of diabetes was based on 1999 WHO criteria. The collected prevalence data was age-standardized for the Chandigarh population, and multivariate logistic-regression analysis was used to correlate risk factors with the presence of diabetes. RESULTS A total of 349 subjects (15.7%, 95% CI: 13.9-16.9) were diabetic, comprising 210 (9.4%) with known diabetes and 139 (6.2%) with newly diagnosed diabetes, and 344 (15.4%, 95% CI: 14.3-17.1) subjects were prediabetic. The age-standardized prevalence of diabetes and prediabetes were 11.1% (95% CI: 9.7-12.4) and 13.2% (95% CI: 11.8-14.6), respectively. Age ≥50 years, a family history of diabetes, BMI ≥23 kg/m(2), abdominal obesity and hypertension were significantly and positively associated with the presence of diabetes, whereas educational status was negatively associated with diabetes (P<0.001 for all). CONCLUSION The age-standardized prevalence of diabetes and prediabetes were 11.1% and 13.2%, respectively. Older age, family history of diabetes, obesity and hypertension were positively related, while educational status was negatively related, to the presence of diabetes.

High prevalence of cholelithiasis in primary hyperparathyroidism: a retrospective analysis of 120 cases

Primary hyperparathyroidism (PHPT) due to parathyroid adenoma is the most common cause of hypercalcemia, which is characterized by high parathyroid hormone (PTH) level despite elevated serum calcium levels [1]. With the advent of autoanalyzer and serum calcium is a part of routine screening in West. The presentation of PHPT is asymptomatic and hence, attention has been diverted to the features like hypertension, mental changes, peptic ulcer disease and gallstone disease [2, 3]. Few studies have shown the association of cholelithiasis with PHPT [4, 5]. Hypercalcemia and elevated PTH have been implicated as a cause for cholelithiasis in patients with PHPT. This retrospective study was conducted by the Endocrinology department at our institution. PHPT was diagnosed based on elevated calcium and PTH levels. Patients with hyperparathyroidism due to secondary and tertiary causes were excluded. Cholelithiasis was diagnosed by either ultrasonographic evidence of gallstone(s) and/or history of cholecystectomy. Prevalence of cholelithiasis in PHPT patients was compared with that in the normal north Indian population using a study [6] conducted by the Gastroenterology and Hepatology department of our institution. Serum calcium (reference range [RR]: 8.5–10.2 mg/dL), phosphate (RR: 3.5–5 mg/dL), alkaline phosphatase (RR 28–129 IU/L), and creatinine (RR: 0.5–1.4) were measured by standard methods. Serum iPTH (RR: 15–65 pg/mL) was measured by chemiluminescence assay and vitamin D (RR: 9–37 ng/mL) by radioimmunoassay (RIA) using commercially available kits. SPSS 10® software was used to analyze the data. Continuous variables were described as mean (SD) and categorical data were expressed in n (%). Correlation analysis was used to correlate two variables. P<0.05 was considered as statistically significant. One hundred and twenty patients (mean [SD] age 39 [14] years, 80 women) with PHPT were studied. Eightythree patients were below 50 years of age. Their mean weight was 55.1 (14.6) kg and mean BMI 20.8 (4.7) kg/m. All PHPT patients were symptomatic with the most common presenting symptom being bone pain (n=68, 56.7%). Fiftyfour (45.4%) patients had renal stones. The mean serum calcium level was 11.5 (1.8) mg/dL, phosphorus 2.9 (0.8) mg/dL, alkaline phosphatase 217.0 (489.4) IU/L (median 316), vitamin D 25.8 (27.8) (median 15.2) ng/mL and iPTH 819 (700) pg/mL (median 818). Thirty-one patients had cholelithiasis (25.8%). Cholelithiasis was more frequent in women (26 vs. 5) as compared to men; the prevalence in women increased with advancing age (Table 1). Overall the prevalence of gallstones in the reference published study [6] was 3.1% in healthy northern Indian population, and was higher among women (4.2%). After standardization of rates of gallstones for gender, the proportion of gallstones was 2.89% in the reference study, and was 21.24%. (p<0.04) in the present study. No correlation between preoperative serum calcium (r=0.042, p=0.66), phosphate (r=−0.07, p=0.42) and PTH (r=0.03, p=0.7) was seen with cholelithiasis. Using unconditional logistic regression analysis, the only factor that predicted development of gallstone was age (odds ratio −1.05, 95% CI −0.99–1.11, p=0.02). This study showed high prevalence of cholelithiasis in PHPT (25.8%) compared to the general population (3.1%) S. K. Bhadada (*) :A. Bhansali :V. N. Shah :M. Ravikiran : R. Santosh Department of Endocrinology, Postgraduate Institute of Medical Education and Research, Chandigarh 160 012, India e-mail: bhadadask@gmail.com

Predictors of pilosebaceous unit responsiveness to testosterone therapy in patients with hypogonadotrophic hypogonadism.

Testosterone replacement therapy is the mainstay of treatment in male patients with isolated hypogonadotrophic hypogonadism (HH) to achieve virilisation. However, responsiveness of pilosebaceous unit (PSU) to testosterone replacement therapy in these patients is quite variable. Androgen action is inversely proportional to the number of CAG repeats in exon 1 of androgen receptor gene; therefore, we hypothesised that CAG repeat length contributes to testosterone responsiveness in patients with HH. The CAG repeat length in 21 well‐virilised men (hair score > 30, responders) and 25 poorly virilised men (hair score ≤ 30, non‐responders) with HH on optimal testosterone replacement therapy at least for a period of 1 year was analysed. Serum LH, FSH, testosterone and 17 β oestradiol were estimated. Polymerase chain reaction (PCR) amplification of exon 1 of androgen receptor gene was performed from genomic DNA, and these PCR‐amplified products were sequenced for the number of CAG repeats. The difference between number of CAG repeats in responders and non‐responders was statistically significant (19.19 ± 3.25 and 22.24 ± 2.65, P = 0.001) and showed a strong negative correlation with total body hair score (r = −0.538 and P = 0.0001). In conclusion, these results suggest that the number of CAG repeats influences the responsiveness of PSU to testosterone treatment in patients with HH.

Images In...: Giant somatotropinoma

A 28-year-old man presented with fatigue and pronounced weakness. He had a history of headache, coarsening of facial features and progressive decline in vision for the previous 4 years. He also complained of cold intolerance, decreased libido, arthralgia in both knees, and proximal muscle weakness for the last 6 months. On examination, he had features suggestive of active acromegaly. On investigation, he was found to be hypothyroid (thyroxine (T4) 50 nmol/l, normal range (NR) 62–163 nmol/l; thyroid stimulating hormone (TSH) 0.2 uU/ml, NR 0.27–4.2 uU/ml), hypocortisolic (serum cortisol 12.8 nmol/l, NR, 171–536 nmol/l), and hypogonadal (serum testosterone 0.88 nmol/l, NR 9–27 nmol/l). His serum basal growth hormone (GH) was 142 ng/ml (normal <0.4 ng/ml), and it was non-suppressible after glucose load (155 ng/ml, normal <1 ng/ml). Serum IGF-1 concentration was 792 ng/ml (NR 117–329 ng/ml), and serum prolactin was 38.4 ng/ml (NR 5–20 ng/ml). Brain magnetic resonance imaging (MRI) showed sellar mass with huge lobulated suprasellar component (70×62×60 mm) with cystic changes and frontal lobe extension (fig 1). The patient underwent transsphenoidal followed by transfrontal subtotal excision of the tumour. Histopathology of the tumour showed pituitary adenoma with positive immunostaining for growth hormone. Currently, the patient is on hydrocortisone, L-thyroxine, and testosterone replacement, and treatment with radiotherapy is planned. Figure 1 Coronal (A) and sagittal (B) post-contrast magnetic resonance image T1 weighted sections showing a large intrasellar tumour with suprasellar component. Suprasellar solid component shows a lobulated margin with peripheral non-enhancing cystic areas (margins ...