Rv Jayakumar

Non-alcoholic Fatty Liver Disease and Metabolic Syndrome—Position Paper of the Indian National Association for the Study of the Liver, Endocrine Society of India, Indian College of Cardiology and Indian Society of Gastroenterology

Non-alcoholic fatty liver disease (NAFLD) is closely associated with metabolic syndrome. Prevalence of metabolic risk factors including diabetes mellitus, obesity, etc. is rapidly increasing in India putting this population at risk for NAFLD. Patients with NAFLD are at increased risk for liver-related morbidity and mortality and also cardiovascular disease risk and increased incidence of diabetes mellitus on long-term follow-up. Management of patients with NAFLD may require a multi-disciplinary approach involving not only the hepatologists but also the internists, cardiologists, and endocrinologists. This position paper which is a combined effort of the Indian National Association for Study of the Liver (INASL), Endocrine Society of India (ESI), Indian College of Cardiology (ICC) and the Indian Society of Gastroenterology (ISG) defines the spectrum of NAFLD and the association of NAFLD with insulin resistance and metabolic syndrome besides suggesting preferred approaches for the diagnosis and management of patients with NAFLD in the Indian context.

Type 1 diabetes versus type 2 diabetes with onset in persons younger than 20 years of age.

Type 1 diabetes (T1D) is the most common form of diabetes in children in Western countries. There have been no large studies of childhood diabetes from India. We undertook the MEDI study (Multicenter Survey of Early Onset Diabetes in India) to assess the proportion of various subtypes of diabetes among the young subjects presenting to the endocrinology divisions of seven large teaching hospitals in different regions of India. In addition, we compared the clinical features of T1D and type 2 diabetes (T2D) in Indian subjects. Patients with onset of disease at younger than 20 years of age were included in this study. Six hundred and three subjects (603) were studied of whom 535 subjects (89%) had T1D, 36 (6%) had T2D, 18 (3%) had diabetes related to tropical pancreatitis or other forms of chronic pancreatitis, while other subtypes accounted for the rest. Compared to those with T2D, subjects with T1D were younger, had a lower C‐peptide level, higher prevalence of ketosis, lower prevalence of acanthosis nigricans, and lower LDL and triglyceride levels. When compared with that of T2D, a higher proportion of patients with T1D were positive for GAD‐65 and IA‐2 antibodies, and this difference was statistically significant for GAD‐65 antibodies. Overall, this large multicenter study showed that T1D is the commonest form of diabetes in childhood. T2D is the next most common kind, while chronic pancreatitis‐related diabetes is uncommon.

Foot care practice – The key to prevent diabetic foot ulcers in India

BACKGROUND The magnitude of diabetic foot ulcers (DFUs) and the amputation rates due to DFUs remain high even in developing and developed countries. Yet, the influence of knowledge, attitude, and practice (KAP) of diabetic foot care (DFC) on DFU incidence is not studied much. OBJECTIVE To study causal relationship between knowledge, attitude and practice (KAP) on DFC between diabetic patients with and without DFUs; and the risk factors associated with DFUs. METHODS A consecutive of 203 diabetic patients (103 with DFU and 100 without DFU) were included in the study. Their demographic details, medical history, and personal habits were recorded. KAP on DFC was assessed using a questionnaire. Responses were recorded, scored, and analyzed. RESULTS Of the cohort, 67.5% were males, mean age: 59.9 ± 11.4 years. Patients without DFU had good knowledge on DFC compared to those with DFU (86% versus 69.9%) (p<0.001). Incidence of DFU was 9% and 39.8% (p<0.001) among patients who practiced and not practiced DFC respectively. 88% patients with and without DFUs; showed favorable attitude toward adopting DFC. Risk factors - diabetic peripheral neuropathy, peripheral vascular disease, retinopathy, nephropathy, smoking, tobacco chewing and alcohol consumption were significantly (p<0.001) associated with DFUs. CONCLUSIONS An inverse relationship between DFU and foot care knowledge as well as practice was observed. Apart from tight glycemic control, diabetic patients must be educated and motivated on proper foot care practice and life style modifications for preventing DFUs.

Turner syndrome and its variants

Case records of female patients with karyotype proven turner syndrome were analyzed. 11 patients had classic Turner karyotype (Group 1) and 13 patients had karyotype suggestive of one of the variants of Turner syndrome (Group 2). There was a median difference of 3 years between the age of presentation and the age of diagnosis in Group 2. Out of the thirteen patients in Group 2, 4 had no clinical stigmata of Turner Syndrome; the rest (n=9) had one or more of the typical clinical stigmata of Turner Syndrome. One patient with a complex mosaic karyotype also had an intracranial medulloblastoma. One patient in each group had coarctation of the aorta. 5 patients in Group 1 and 3 patients in Group 2 had primary hypothyroidism and received levothyroxine. The median Thyroid Stimulating Hormone levels were significantly higher among patients in group 1 than in group 2.

Geriatric thyroidology: An update.

Thyroid anatomy and physiology change in the elderly with age-related fibrosis and atrophy in the thyroid gland and changes in thyroid hormones. The incidence of thyroid nodules increases with age, making the thyroid more nodular. Hypothyroidism is common in the elderly and, if untreated, is associated with significant morbidity. Elderly patients are sensitive to iatrogenic hyperthyroidism, especially with preexisting cardiac disease. Hence, treatment of hypothyroidism should be individualized and should be started with low doses and titrated according to response. Hyperthyroidism, although less common in the elderly if present, is associated with significant cardiac morbidity and mortality. Radioiodine therapy is considered a safe primary treatment in the elderly with hyperthyroidism. Management of subclinical hypo- and hyperthyroidism is still controversial. The incidence of thyroid tumors increase with age. Thyroid malignancy in the elderly is considered as a more advanced disease compared with the young, and aggressive management is recommended.

Acanthosis Nigricans and insulin levels in a south Indian population—(ADEPS paper 2)

SUMMARY OBJECTIVE Aim of the study was to determine the prevalence of Acanthosis Nigricans (AN) in a central Kerala south Indian population and to evaluate its correlations with diabetes, obesity, insulin levels and other factors. METHODS A cross-sectional community survey including physical examination and biochemical evaluation was conducted among adults above the age of 18 years in central Kerala In the first phase of the study 3069 participants were surveyed using questionnaires regarding socioeconomic status and medical details. Among them 986 subjects were evaluated in the second phase of the study which included anthropometric measurements, examination for blood pressure and Acanthosis Nigricans, blood tests such as blood glucose, fasting lipids. Fasting serum insulin level was measured for all non-diabetic subjects. Statistical analysis was done using SPSS 11.0 version software. RESULTS RESULTS of the study showed that 16.1% of population had AN and it was significantly higher among females (19.6%) than males (11.4%). Prevalence of AN was highest in 30-40 year age group and it decreased with the age. Prevalence of AN correlated positively with female gender, obesity, high triglyceride levels and presence of diabetes. Presence of AN was significantly associated with higher fasting insulin levels. Males with AN had significantly higher insulin values than females with AN. CONCLUSION AN has stronger clinical relevance among males than females and it can be used as a marker of insulin resistance in south Indian population especially if obesity and family history of diabetes are also present.

Iodine status and its correlations with age, blood pressure, and thyroid volume in South Indian women above 35 years of age (Amrita Thyroid Survey)

Background: Thyroid disorders are more commonly seen among females and the prevalence increases with age. There is no population data from India focusing on iodine levels and their correlations with thyroid volume and other factors in adult women. Aim: This study was designed to establish the iodine status and its relation with various factors including thyroid volume measured by ultrasound among the females of Kerala. Materials and Methods: This was a cross sectional house to house survey among the females above 35 years of age in a randomly selected urban area in Cochin Corporation, Kerala State, India. Selected subjects were interviewed, examined and blood and urine tests were done. Thyroid volume was calculated using ultrasound. Results: Among the 508 subjects who participated in the checkup, 471 subjects were included for analysis. Mean age was 50.3 + 10.7 years and 53.2% were postmenopausal. A total of 98% of the subjects were using iodized salt and median urinary iodine excretion (UIE) was 162.6 mcg/l. UIE had negative correlation with age and systolic blood pressure (BP), but had no correlation with thyroid volume (TV), thyroid nodularity, free thyroxine 4 (FT4), thyroid stimulating hormone (TSH) or anti thyroid peroxidase (TPO) levels. Iodine deficiency was more commonly seen in subjects with hypertension and also among postmenopausal females. Conclusions: This study showed that females > 35 years were iodine sufficient, though one third of the subjects had UIE levels less than the recommended level. Iodine levels had significant negative correlation with age and systolic BP and no correlation with thyroid volume or biochemical parameters. Iodine deficiency was significantly higher in subjects with new and known hypertension and this relation merits further evaluation.

Hypoglycemia in type 2 diabetes: Standpoint of an experts′ committee (India hypoglycemia study group)

The epidemic of type 2 diabetes and the recognition that achieving specific glycemic goals can substantially reduce morbidity have made the effective treatment of hyperglycemia a top priority. Despite compelling evidence that tight glycemic control is crucial for delaying disease progression, increased risk of hypoglycemia associated with such control underscore the complexity of diabetes management. In most cases, hypoglycemia results from an excess of insulin, either absolute or relative to the available glucose substrate and the factors perhaps exacerbating the risk are pharmacokinetic imperfections, behavioral, co-morbidities etc. Additionally, many patients remain undiagnosed, and many diagnosed patients are not treated appropriately. In this article, the challenges of hypoglycemia, confronting health care providers and their patients with diabetes, are discussed for making treatment decisions that will help minimize risk of hypoglycemia and eventually overcome formidable barriers to optimal diabetes management. Strategies to treat and minimize the frequency and severity of hypoglycemia without compromising on glycemic goals are also presented.

A comparative study of zoledronic acid and once weekly Alendronate in the management of acute Charcot arthropathy of foot in patients with diabetes mellitus

Aim: The aim of this study was to assess and compare the response to two forms of treatment-immobilization with zoledronic acid injection and immobilization with oral weekly Alendronate, in patients with diabetes mellitus and acute Charcot arthropathy (CA) of foot in terms of clinical and radiological parameters. Material and Methods: Patients attending the endocrinology and podiatry clinic with history of diabetes mellitus and Acute CA were taken for study. The patients were randomized into two treatment groups. Group Z-zoledronic acid injection along with total contact cast (TCC). Group A-Tab. Alendronate 70 mg. once a week till the complete clinical resolution of acute CA along with TCC. Forty-five patients were randomized and 40 of them completed the study. The primary end point was complete clinical resolution of acute CA-defined as temperature difference between normal and affected foot <1°F. Results: Among the 40 patients, 30 (75%) had complete clinical resolution. The mean number of days taken for complete clinical resolution since the initiation of treatment (either Zoledronic acid or Alendronate) was approximately 122 days. There was no significant difference in a number of days required for complete clinical resolution, between the two forms of therapy. There was more than 50% reduction in the visual score between the baseline and the final scan. The target to non-target ratio in the skeletal phase also showed an average of 40% reduction from the baseline to the final skeletal scintigraphy. Conclusion: Both Intravenous Zoledronic acid and oral alendronate had comparable efficacy with respect to the time taken for attaining complete clinical resolution of acute CA of foot. However, Alendronate therapy was cost effective among the two. 99mTc MDP bone scan can be used as an adjuvant to the clinical parameters in assessing the response to therapy.

Prevalence of thyroid disorders is not different in type 2 diabetes mellitus compared to nondiabetics in South India

Studies on thyroid disorders in type 2 diabetes mellitus (DM) are fewer than those in type 1 diabetes, but data from different parts of the world have shown conflicting results. To look at the prevalence of thyroid disorders in type 2 DM and nondiabetic controls separately in a community cohort and a hospital cohort from the same locality in South India. Thyroid function tests and thyroid autoantibodies were done in 986 people in the community (258 diabetics and 634 nondiabetics). In the hospital cohort of 194 people (147 diabetics and 47 nondiabetics), an ultrasonography of the neck was done in addition. Thyroid dysfunction was more common in the community compared to the hospital cohort 15.9 vs 9.6% but there was no difference in the proportion of people with thyroid dysfunction in diabetics and nondiabetics in both the community and the hospital cohorts. (15.6 vs 16.2% in the community and 9.6 vs 6.3% in the hospital in diabetics and nondiabetics respectively). Clinical goiter and sonographically detected goiter were also similar in diabetics and nondiabetics in the community and the hospital cohorts respectively. Females had more prevalence of goiter irrespective of the presence of diabetes. Commonest thyroid dysfunction was hypothyroidism and subclinical hypothyroidism in both cohorts. This unique study conducted in a community and hospital cohort from the same locality showed that the prevalence of thyroid disorders is similar in type 2 diabetic and nondiabetic subjects in our population.