Subhankar Chowdhury

Percutaneous ethanol ablation in managing predominantly cystic thyroid nodules: An eastern India perspective

Aims: Percutaneous aspiration and ethanol injection (PEI) is effective in managing predominantly cystic (>50% cystic) thyroid nodules with efficacy ranging from 38-85%. We aimed to evaluate efficacy, safety, and factors determining outcomes of PEI in managing simple cystic (purely cystic) vs. complex cystic (having both cystic and solid components) thyroid nodules. Materials and Methods: Predominantly cystic thyroid nodules, without any ultrasonography and/or fine needle aspiration, evidence of malignancy were aspirated ultrasonography guided. Sterile 100% ethanol (50-100% volume aspirated) was injected and reviewed monthly for 3 months and thereafter 3 monthly. Responders were defined as ≥ 50% reduction in nodule volume. Results: Sixty-five patients out of 152 considered underwent PEI. Sixty patients [simple cystic (42) and complex cystic (18)] with mean follow-up of 12.3 ± 2.88 months were analyzed. Response rate of PEI was 78.33% [simple cystic (92.86%) and complex cystic (44.44%) nodules; P < 0.001]. Also, 31.67% patients achieved remission at 1st month. And, 46.67% patients achieved remission between 1-6-months follow-up. Kaplan Meier analysis showed significantly improved outcomes in patients with simple cystic nodules (P < 0.001). Cox-regression revealed type of nodule (simple cystic vs. complex cystic) to be predictive of outcome (P = 0.034). Complex cystic nodules were 67.6% less likely to go into remission, compared to simple cystic nodules. Baseline nodule size, aspirate, or volume of ethanol injected did not predict outcome. Conclusions: PEI is safe and should be treatment of choice for simple cystic thyroid nodules. PEI for complex cystic thyroid nodules are associated with lower response, increased recurrence, and need for repeated PEI.

Primitive neuroectodermal tumor of adrenal: clinical presentation and outcomes.

Primitive neuroectodermal tumor (PNET) of adrenal is an extremely rare tumor of neural crest origin. A nonfunctional left adrenal mass (14.6 × 10.5 × 10.0 cm) on computed tomography (CT) was detected in a 40-year-old lady with abdominal pain, swelling, and left pleural effusion. She underwent left adrenalectomy and left nephrectomy with retroperitoneal resection. Histopathology revealed sheets and nest of oval tumor cells with hyperchromatic nuclei, prominent nucleoli, scanty cytoplasm, brisk mitotic activity, necrosis, lymphovascular invasion, capsular invasion, and extension to the surrounding muscles; staining positive for Mic-2 (CD-99 antigen), vimentin, synaptophysin, and Melan-A. Thoracocentesis, pleural fluid study, and pleural biopsy did not show metastasis. She responded well to vincristine, adriamycin, and cyclophosphamide followed by ifosfamide and etoposide (IE). This is the first report of adrenal peripheral PNET (pPNET) from India. This report intends to highlight that pPNET should be suspected in a patient presenting with huge nonfunctional adrenal mass which may be confused with adrenocortical carcinoma.

Practical approaches for self-monitoring of blood glucose: an Asia-Pacific perspective.

Abstract Comprehensive glycemic control is necessary to improve outcomes and avoid complications in individuals with diabetes. Self-monitoring of blood glucose (SMBG) is a key enabler of glycemic assessment, providing real-time information that complements HbA1c monitoring and supports treatment optimization. However, SMBG is under-utilized by patients and physicians within the Asia-Pacific region, because of barriers such as the cost of monitoring supplies, lack of diabetes self-management skills, or concerns about the reliability of blood glucose readings. Practice recommendations in international and regional guidelines vary widely, and may not be detailed or specific enough to guide SMBG use effectively. This contributes to uncertainty among patients and physicians about how best to utilize this tool: when and how often to test, and what action(s) to take in response to high or low readings. In developing a practical SMBG regimen, the first step is to determine the recommended SMBG frequency and intensity needed to support the chosen treatment regimen. If there are practical obstacles to monitoring, such as affordability or access, physicians should identify the most important aspects of glycemic control to target for individual patients, and modify monitoring patterns accordingly. This consensus paper proposes a selection of structured, flexible SMBG patterns that can be tailored to the clinical, educational, behavioral, and financial requirements of individuals with diabetes.

Conservative management of severe bilateral emphysematous pyelonephritis: Case series and review of literature

Emphysematous pyelonephritis (EPN) is a life-threatening condition most commonly observed in diabetes, with nephrectomy believed to be the treatment of choice. However, nephrectomy in EPN is associated with increased risk of complications secondary to associated hemodynamic instability and may result in lifelong hemodialysis in case of bilateral EPN. We present three patients of severe bilateral EPN and one patient of unilateral EPN with diabetic ketoacidosis (DKA) successfully managed conservatively. Patient 1 (severe bilateral EPN) and patient 4 (unilateral EPN with DKA) responded to aggressive broad spectrum antibiotics, whereas patients 2 and 3 (severe bilateral EPN) responded to broad spectrum antibiotics along with percutaneous catheter drainage (PCD). PCD resulted in initial drainage of 300 and 200 ml of pus, respectively. All patients had associated uncontrolled hyperglycemia, poor glycemic control (HbA1c >8.5%), prerenal and intrinsic renal failure, leukocytosis, and dyselectrolytemia which responded to aggressive supportive management and insulin. There are several reports of successful medical management of severe bilateral EPN. Nephrectomy might no longer be the preferred treatment of severe bilateral EPN and may be reserved for patients’ refractory to antibiotics and PCD. Urgent randomized controlled trials are warranted in EPN to optimize the treatment protocols.

Occurrence of osteoporosis & factors determining bone mineral loss in young adults with Graves' disease

Background & objectives: There is a paucity of data with conflicting reports regarding the extent and pattern of bone mineral (BM) loss in Graves’ disease (GD), especially in young adults. Also, interpretation of BM data in Indians is limited by use of T-score cut-offs derived from Caucasians. This study was aimed to evaluate the occurrence of osteoporosis in active treatment naive patients with GD and determine the factors predicting BM loss, using standard T-scores from Caucasians and compare with the cut-offs proposed by the Indian Council of Medical Research (ICMR) for diagnosing osteoporosis in Indians. Methods: Patients with GD, >20 yr age without any history of use of anti-thyroid drugs, and normal controls without fracture history, drugs use or co-morbidities underwent BM density (BMD) assessment at lumbar spine, hip and forearm, thyroid function and calcium profile assessment. Women with menopause or premature ovarian insufficiency and men with androgen deficiency were excluded. Results: Patients with GD (n=31) had significantly lower BMD at spine (1.01±0.10 vs. 1.13±0.16 g/cm2), hip (0.88±0.10 vs. 1.04±0.19 g/cm2) and forearm (0.46±0.04 vs. 0.59±0.09 g/cm2) compared with controls (n=30) (P<0.001). Nine (29%) and six (19.3%) patients with GD had osteoporosis as per T-score and ICMR criteria, respectively. None of GD patients had osteoporosis at hip or spine as per ICMR criteria. Serum T3 had strongest inverse correlation with BMD at spine, hip and femur. Step-wise linear regression analysis after adjusting for age, BMI and vitamin D showed T3 to be the best predictor of reduced BMD at spine, hip and forearm, followed by phosphate at forearm and 48 h I131 uptake for spine BMD in GD. Interpretation & conclusions: Osteoporosis at hip or spine is not a major problem in GD and more commonly involves forearm. Diagnostic criterion developed from Caucasians tends to overdiagnose osteoporosis in Indians. T3 elevation and phosphate are important predictors of BMD. Baseline I131 uptake may have some role in predicting BMD.

Efficacy and safety of low dose oral prednisolone as compared to pulse intravenous methylprednisolone in managing moderate severe Graves' orbitopathy: A randomized controlled trial.

Background: High dose oral prednisolone (100 mg/day) in Graves’ orbitopathy (GO) is limited by lesser response, and greater side-effects compared to intravenous (iv) methylprednisolone. Low dose oral prednisolone has not been evaluated in GO. This study aimed to evaluate the safety and efficacy of low dose oral prednisolone in GO. Materials and Methods: A total of 114 consecutive GO patients were screened of which 65 patients with previously untreated moderate-severe GO, clinical activity score (CAS) >2, without co-morbid states were randomized into treatment Group-A (iv methylprednisolone 0.5 g for 3 days/month for 4 months) and Group-B (oral prednisolone 1 mg/kg/day for 6 weeks then tapered stopped), and followed-up. Thirty-one patients in each group with at least 1-year follow-up were analyzed. Responders were defined as improvement in ≥ 1 major response criteria or ≥ 2 minor response criteria. The trial is registered at ctri.nic.in (CTRI/2013/12/004264). Results: At 1-year, 27/31 (87.10%) patients were responders in Group-A compared to 17/31 (54.84%) in Group-B (P = 0.005). There was a greater improvement in CAS score in patients of Group-A as compared to Group-B (P < 0.001). Responders (n = 44) had significantly higher baseline intra-ocular pressures and left eye proptosis as compared to nonresponders. Cox-regression revealed baseline T4 levels, diplopia, and smoking history were predictive of remission. Low dose prednisolone was well tolerated, and the occurrence of adverse events were comparable in both groups. Conclusions: Low dose oral prednisolone is inferior to iv pulse methylprednisolone in managing GO, having a comparable side-effect profile. It can be a safe second line alternative in patients intolerant to pulse iv methylprednisolone.

Huge bilateral ovarian cysts in adulthood as the presenting feature of Van Wyk Grumbach syndrome due to chronic uncontrolled juvenile hypothyroidism.

Juvenile primary hypothyroidism causing cystic ovaries and pseudoprecocious puberty (Van-Wyk Grumbach syndrome (VWGS)) is well documented in literature. There are only a few reports of primary hypothyroidism presenting as ovarian cysts in adults. Here we present a case of huge bilateral ovarian cysts in adulthood as the presenting feature of VWGS due to chronic uncontrolled juvenile hypothyroidism. Large uniloculor right ovarian cyst (119 × 81 × 90 mm) and a multicystic left ovary (55 × 45 × 49 mm) were detected in a 24 year lady with secondary amenorrhea, galactorrhea, and palpable abdominal mass with history of neonatal jaundice, delayed milestones, short stature, and precocious menarche at age of 7.5 years age. She had elevated levels of cancer antigen (CA)-125 which normalized post levothyroxine supplementation. Elevated CA-125 may lead to misdiagnosis of ovarian carcinoma and inadvertent treatment. Bilateral ovarian cysts in adults are a rare presentation of juvenile hypothyroidism. It is necessary to screen for primary hypothyroidism in patients presenting with bilateral ovarian cysts to prevent unnecessary evaluation and treatment.

Comment on: Besser et al. Lessons From the Mixed-Meal Tolerance Test: Use of 90-Minute and Fasting C-Peptide in Pediatric Diabetes. Diabetes Care 2013;36:195–201

It was extremely gratifying to read an interesting article in Diabetes Care by Besser et al. (1) that suggested that 90-min C-peptide is a highly sensitive and specific measure of area under curve and peak C-peptide in children and adolescents with type 1 diabetes and offers a practical alternative to a full mixed-meal tolerance test. The authors also suggested that C-peptide measured at diagnosis and age at diagnosis can be used to predict the time taken for patients to become insulin-deficient. The authors suggested that those with the lowest tertile of fasting C-peptide (<0.17 nmol/L) reached insulin deficiency quicker than those in the …