[Show abstract][Hide abstract] ABSTRACT: Sheehan syndrome is a rare but potentially serious complication of postpartum haemorrhage. The diagnosis can often be delayed by many years as symptoms may be subtle. We report the case of a 45-year-old woman who presented to the medical emergency unit with acute onset altered sensorium. On further evaluation she was found to have severe hypoglycaemia which was corrected by giving intravenous dextrose. On detailed clinical evaluation, she had a history of agalactia and amenorrhoea following her last pregnancy which was 15 years ago. She had a history of excessive postpartum bleeding during her last delivery. MRI of the brain showed empty sella and hormonal evaluation revealed adenohypophyseal insufficiency as evident from decreased levels of cortisol, thyroid-stimulating hormone, triiodothyronine, free thyroxine, follicle-stimulating hormone, luteinising hormone and prolactin. Based on clinical, radiological and laboratory parameters her final diagnosis was Sheehan syndrome with hypoglycaemia.
[Show abstract][Hide abstract] ABSTRACT: Objective:
Comparison of efficacy and safety of two different regimens of vitamin D-600 000 IU as a single intramuscular dose, and 60 000IU orally once a week for 10 weeks-in treatment of nutritional rickets.
Children with nutritional rickets (age: 0.5-5 years, n = 61) were randomized to receive either 60 000IU vitamin D orally once a week for 10 weeks or 600 000IU single intramuscular injection. Serum calcium, phosphate, alkaline phosphatase, urinary calcium/creatinine ratio, serum 25 hydroxy vitamin D and radiological score were compared at 12-week follow-up.
No difference was found in efficacy of the two regimens on comparing biochemical and radiological parameters. Serum 25 hydroxy vitamin D >100 ng/ml was found in two children in the oral group and one child in the intramuscular group. No child developed hypercalcemia or hypercalciuria after starting treatment.
Staggered oral and one-time intramuscular administrations of 600 000IU vitamin D are equally effective and safe in treatment of nutritional rickets.
No preview · Article · Jan 2014 · Journal of Tropical Pediatrics
[Show abstract][Hide abstract] ABSTRACT: Given limited information available regarding associations between lung function and bone mineral density among healthy subjects, we undertook these analyses in the Hertfordshire Cohort Study. Forced expiratory volume in 1 s (FEV(1)), forced vital capacity (FVC) and FEV(1)/FVC were not associated with bone mineral density at any site; associations with bone mineral content were removed by adjustment for body size.
There is limited information available regarding the association between lung function and bone mineral density among healthy elderly subjects. We addressed this issue in the Hertfordshire Cohort Study.
From the above cohort, 985 subjects (496 men and 489 women) aged 60-72 years were recruited. All subjects underwent bone density measurements using dual energy X-ray absorptiometry and lung function tests using standardised spirometry. Chronic obstructive pulmonary disease (COPD) was defined as a FEV(1)/FVC ratio <lower limit of normal, calculated using separate equations for men and women.
Measures of lung function (FEV(1), FVC and FEV(1)/FVC) were not associated with bone mineral density at the lumbar spine, femoral neck and total hip in men or women; associations with bone mineral content and bone area were removed by adjustment for body size and lifestyle confounders. In this cohort, there were no associations observed between COPD and any measure of bone mass.
There was no association between lung function and bone mass in this community dwelling cohort after adjustment for body size and other confounders.
Full-text · Article · Dec 2013 · Archives of Osteoporosis
[Show abstract][Hide abstract] ABSTRACT: Hip fracture incidence is not known in India. This retrospective study was conducted to evaluate hip fracture incidence rates in Rohtak, a single district of North India. A total of 304 patients from this district with hip fracture were hospitalized during the calendar year 2009. The crude hip fracture rates were found to be 159 and 105 per 100,000, respectively, in women and men above the age of 50 years. Hip fracture is a significant health problem in North India.
This aims to study hip fracture incidence in Rohtak district of North India.
The study was conducted in Rohtak district, Haryana state, India located 80 km north of New Delhi. All patients having hip fracture admitted in Pandit B.D. Sharma Postgraduate Institute or one of the four orthopaedic centres located in Rohtak in year 2009 were included. Total population of Rohtak for the year 2009 was used to calculate age-specific hip fracture incidence.
A total of 541 patients with hip fracture were hospitalized in Rohtak district in year 2009. Out of these, 304 were from Rohtak district. Hip fracture crude incidence above the age of 50 years was 129 per 100,000. The corresponding figures were 105 and 159 per 100,000 among men and women, respectively. Hip fracture incidence was similar in both sexes till age of 55 years. From age of 55 onwards, the rates were significantly higher in women.
This is the first hip fracture incidence study from India. Hip fracture incidence rates in Rohtak district of India are intermediate between those in the industrialised world and Africa and similar to some of Asian countries such as China, Iran and South Korea. This study will help in formulating strategies for prevention of hip fracture in India.
No preview · Article · Dec 2013 · Archives of Osteoporosis
[Show abstract][Hide abstract] ABSTRACT: This case-control study was performed to evaluate 25-hydroxyvitamin D [25(OH)D] deficiency and its correlation with hand grip strength in 95 Indian hip fracture subjects and 95 controls. 25(OH)D deficiency was found in 88.4 % of hip fracture subjects that was significantly higher as compared to controls. Hand grip strength as measured by hand held dynamometer was significantly lower in patients, and there was a significant positive correlation between 25(OH)D and hand grip strength.
The present study was conducted to assess correlation between 25(OH) D and hand grip strength in hip fracture subjects residing in North India.
Ninety-five patients with hip fracture and similar number of controls were enrolled in the study. Fasting venous samples were analyzed for 25(OH)D, intact parathyroid hormone (PTH), alkaline phosphatase, calcium, and phosphate. Hand grip strength of study subjects was measured using Jamar dynamometer. Correlation between vitamin D levels and hand grip strength was analyzed in study population.
The mean age of hip fracture subjects was 61.4 ± 12.6 years which was comparable in men and women. Out of 95 subjects, 57 were men and 38 were women. Mean 25(OH)D levels were significantly lower whereas intact PTH levels were significantly higher in patient group compared controls (10.29 ± 6.53 vs 13.6 ± 4.01 ng/ml; 62.6 ± 59.3 vs 37.7 ± 28.8 pg/ml, respectively). The number of subjects with 25(OH)D deficiency and secondary hyperparathyroidism was significantly higher in hip fracture group. The mean hand grip strength among hip fracture subjects was significantly lower compared to that of controls (16.57 ± 5.74 vs 26.74 ± 5.23 kg). There was a significant positive correlation between 25(OH)D and hand grip strength ( r = 0.482, p value <0.01) in hip fracture population.
Majority of hip fracture patients in India have vitamin D deficiency, secondary hyperparathyroidism, and lower hand grip strength compared to controls. Further, there is significant positive correlation between 25(OH)D and hand grip strength.
No preview · Article · Dec 2013 · Archives of Osteoporosis
[Show abstract][Hide abstract] ABSTRACT: Low serum vitamin D and increased parathormone levels were found to be associated with depression and stress in a wintering expedition of 20 healthy male subjects over a period of 1 year in Antarctica. The continuous daylight during summer and the dark polar winter affect endogenous vitamin D production. Long-term effects on bone health need to be studied further.
Vitamin D plays a significant role in calcium and bone mineral metabolism and also affects cardiovascular, psychological, and cognitive functions. The ultraviolet B radiation component of sunlight, which shows marked seasonal variation in Antarctica, influences the synthesis of vitamin D. Depression and mood disorders are associated with this extreme photoperiod. In this study, we attempted to gauge the alteration of vitamin D homeostasis in Antarctica and its effect on bone mineral metabolism and mood over a period of 1 year.
Twenty male subjects who wintered over at India's Antarctic base Maitri (70°45'57″ S, 11°44'09″ E) from November 2010 to December 2011 were studied. Fasting serum samples were collected at baseline, 6 months, and 12 months for serum 25-hydroxyvitamin D, intact parathyroid hormone (PTH), total alkaline phosphatase (ALP), calcium, and phosphate. Beck Depression Inventory (BDI), Positive and Negative Affect Scale (PANAS X), and Perceived Stress Scale were used to measure depression, affect, and stress.
Mild vitamin D deficiency was present in two (10 %) subjects on arrival, which increased to seven (35 %) subjects during the polar winter at 6 months. The mean score on the BDI-II screen for depression was significantly higher during midwinter (4.8 ± 3.9) when compared with the baseline value (2.9 ± 2.1). Only 2/20 (10 %) of subjects met the criteria for minor depression. Higher PTH levels at 6 months correlated with a higher PANAS X score (p = 0.021). The mean values of calcium, inorganic phosphorus, and ALP were comparable during the course of the expedition.
Low light exposure during the dark polar winter, lower vitamin D, and increased intact PTH levels were found to be associated with depression during 1 year of Antarctic residence. The low dietary intake and decreased solar radiation exposure during the polar winter reduce serum vitamin D levels in otherwise healthy individuals, which suggests that supplementation may be necessary.
No preview · Article · Dec 2013 · Archives of Osteoporosis
[Show abstract][Hide abstract] ABSTRACT: A 38-year-old woman presented to our hospital emergency section in altered sensorium and with blood pressure of 80/60 mm Hg. She gave a history of recurrent episodes of loss of consciousness for 15-20 days, generalised body swelling and generalised weakness for the past 5-6 years. On further evaluation she was found to have severe hypoglycaemic episodes. In view of history of pregnancy and significant blood loss during surgery and long history of lethargy, asthaenia and generalised anasarca, the patient was evaluated for Sheehan's syndrome. Her serum cortisol levels were very low and she was found to have central hypothyroidism. MRI of the brain also revealed small sella turcica and small pituitary gland suggestive of hypopituitarism. The patient was started on high-concentration dextrose drips, steroids and thyroid hormone replacement. The patient showed a marked improvement within 1 week of treatment. And she was discharged with an advice to follow-up at our outpatient department.
[Show abstract][Hide abstract] ABSTRACT: We present the case of a 57-year-old male patient diagnosed with chronic lymphoid leukaemia (CLL) B-cell type along with moderate anaemia. On follow-up investigations the aetiology of anaemia turned out to be pure red cell aplasia (PRCA) on trephine bone biopsy with an elevated serum erythropoietin level. The patient received blood transfusion support. He showed remarkable improvement on oral corticosteroids (prednisolone 60 mg/daily dose) with no further requirement of blood transfusion over next 3 months. However, when the dose of steroid was tapered down to 10 mg/day, the anaemia reappeared. An increase in the dose of steroid brought the haemoglobin level back to normal. Anaemia in CLL can be due to many reasons, of which PRCA is an uncommon association occurring in only around 1% of patients with CLL and usually refractory to the conventional treatment with steroids. This PRCA secondary to CLL is considered to be immune in origin and a response to combination of immunosuppressive therapy such as steroids, cyclosporine, rituximab is anticipated. Our case responded completely to oral steroids alone.
[Show abstract][Hide abstract] ABSTRACT: A 21-year-old female patient recently diagnosed with severe hypothyroidism was found to have a large ovarian cyst. In view of the large ovarian cyst, she was advised to undergo elective laparotomy in the gynaecology department. She was further evaluated in our medical out-patient department (OPD), and elective surgery was withheld. She was started on thyroxine replacement therapy, and within a period of 4 months, the size of the cyst regressed significantly, thereby improving the condition of the patient significantly. This case report highlights the rare and often missed association between hypothyroidism and ovarian cysts. Although very rare, profound hypothyroidism that can cause ovarian cysts in an adult should always be kept in the differential diagnosis to avoid unnecessary ovarian surgery.
Hypothyroidism should be considered in the differential diagnosis of adult females presenting with multicystic ovarian tumours.Adequate thyroid hormone replacement therapy can prevent these patients from undergoing unnecessary and catastrophic ovarian resection.Surgical excision should be considered only when adequate thyroid replacement therapy fails to resolve ovarian enlargement.In younger women with ovarian cysts, it is also desirable to avoid unnecessary surgery so as to not compromise fertility in the future.
[Show abstract][Hide abstract] ABSTRACT: An 18-year-old girl presented to the emergency department with a history of noisy breathing and breathlessness progressively increasing for few days. The patient had stridor and tachypnoea. She was tall with a long thin face, wrist sign and high-arched palate suggestive of marfanoid features. X-ray of the neck revealed critical tracheal narrowing. Emergency tracheostomy was performed as a lifesaving procedure. Non-contrast CT neck revealed extratracheal compression by a mass surrounding it. Contrast-enhanced CT scan of the neck revealed heterogeneous mass arising from the right lobe of the thyroid and tracheal deviation with narrowing. Fine-needle aspiration cytology of the mass revealed medullary carcinoma of the thyroid, positive for calcitonin. Calcitonin levels were raised. Apart from the marfanoid features she had localised swellings over the lips, lower eyelid and the lateral aspects of the tongue, clinically suggestive of neuromas. A clinical diagnosis of multiple endocrine neoplasia type 2B syndrome was made. The patient underwent total thyroidectomy with central lymphnode dissection. This case highlights an unusual presentation of a rare disease.
[Show abstract][Hide abstract] ABSTRACT: Acute onset neuropsychiatric manifestations in hypopituitarism are uncommon. We report a case of a 60-year-old man who was a follow-up case of macroprolactinoma with hypopituitarism for the last 9 years. He was on medical treatment with cabergoline, thyroxine and depot testosterone. During the last 2 years he was non-adherent to medications especially cabergoline. He was hospitalised for 2 days through emergency services following acute onset psychosis. His pituitary hormone profile was suggestive of adrenal insufficiency, secondary hypothyroidism and hypogonadism. MRI of the hypothalamic pituitary region revealed a pituitary macroadenoma which was larger in size compared to the previous scan. Further, this lesion was compressing on the adjoining structures including optic chiasma. The patient was treated with intravenous fluids, hydrocortisone and thyroxine replacement therapy. With this treatment he completely recovered from psychosis within 48 h.
[Show abstract][Hide abstract] ABSTRACT: We describe a rare association of Cushing's disease causing avascular osteonecrosis of the femoral head in a patient with operated pituitary macroadenoma. Avascular necrosis of the femoral head (AVN) is not a common cause of musculoskeletal disability. Though AVN of the hip is a well-recognized complication of steroid treatment, it is rare in cases of endogenous hypercortisolism. To our knowledge, only 16 patients with AVN, associated with endogenous Cushing's syndrome (CS), have been documented in the medical literature. AVN associated with glucocorticoid use is more likely to manifest as bilateral disease than either idiopathic AVN or ethanol-associated AVN. We describe a 26-year-old woman who was diagnosed with Cushing's disease in 2007 and operated in the same year for an ACTH secreting pituitary adenoma, who was consequently given replacement dose steroid therapy for post operative panhypopituitarism. During follow up, she complained of bilateral hip pain and difficulty in ambulation. Magnetic resonance imaging showed multiple bony infarcts in the proximal femur and distal femur with femoral head collapse fractures bilaterally, consistent with AVN. She further underwent decompression surgery on bilateral hip joints. This case illustrates that AVN, an orthopaedic emergency, can be an alarming manifestation of Cushing's disease.
No preview · Article · Jun 2013 · The Journal of the Association of Physicians of India
[Show abstract][Hide abstract] ABSTRACT: Autonomic dysfunction may contribute to cardiovascular morbidity in subclinical hypothyroid patients. It is controversial whether the abnormality exists in sympathetic or the parasympathetic function. It is also not known whether the severity of autonomic dysfunction is related to the degree of thyroid deficiency.
Prospective case control.
Autonomic functions based on heart rate (HR) and blood pressure (BP) responses to various maneuvers were evaluated and scored in twenty two subclinical hypothyroid patients, 30-50 years and compared with twenty hypothyroid patients. Biochemical estimation of TSH, fT3, fT4, TPO antibody was done.
Sympathetic function abnormalities were seen in 82% subclinical hypothyroid patients and 85%hypothyroid patients when one test was abnormal. Parasympathetic dysfunction was also recorded in eight patients in both groups. When two abnormal tests were used as the selection criteria sympathetic function abnormality was observed in about 41% subclinical hypothyroid and 65% hypothyroid patients. There were no intergroup differences in autonomic functions, score and TPO levels. The TSH levels were not related to type or degree of autonomic dysfunction. Systolic BP in both groups and diastolic BP in hypothyroid patients were higher with lower thyroxine levels but the patients were normotensive.
Autonomic dysfunction of comparable degree was seen in subclinical hypothyroid and hypothyroid patients. Sympathetic function abnormality was more common although decreased parasympathetic function reactivity was also present. These abnormalities were unrelated to TSH levels.
[Show abstract][Hide abstract] ABSTRACT: Thyroid dysfunction is a common occurrence in pregnancy and affects both maternal and fetal outcomes. There are limited data on prevalence of hypothyroidism during pregnancy from India. Therefore, this study was designed to evaluate the prevalence of thyroid dysfunction especially hypothyroidism during first trimester in a large public hospital in North India.
All the consecutive first trimester pregnant women attending Lok Nayak and Kasturba Hospitals were enrolled in the study after institutional ethics approval and consent from the study subjects. The pregnant women with diagnosed thyroid disease and on thyroid medications were excluded from the study. Morning samples of study participants were analyzed for thyroid hormone profile which included free T3, free T4, TSH, and TPO Ab. In addition, all study participants were tested for CBC, LFT, KFT, and lipid profile.
A total of 1000 women were enrolled for this prospective observational study. The mean (SD) age of study subjects was 25.6 (11.1) years, and mean (SD) gestational age was 10.3 (3.4) weeks. One hundred and forty-three (14.3%) subjects had TSH values more than 4.5 mIU/L above the cutoff used for definition of hypothyroidism. Out of these, 135 had normal free T4 and therefore labeled as subclinical hypothyroidism and 7 had low free T4 suggestive of overt hypothyroidism. TPO Ab was positive in 68 (6.82%) of total, 25 (18.5%) of subclinical and 5 (71%) of overt hypothyroid patients.
Hypothyroidism, especially subclinical, is common in North Indian women during first trimester. Further countrywide studies are needed to evaluate the prevalence and etiology of hypothyroidism to prevent maternal and fetal adverse effects of hypothyroidism in India.
[Show abstract][Hide abstract] ABSTRACT: Background. Altered circadian cortisol and melatonin rhythms in healthy subjects exposed to an extreme polar photoperiod results in changes in mood and sleep, which can influence cognitive performance. Materials and Methods. We assessed the circadian rhythm of 20 subjects who wintered over at Maitri (S,
E), India’s permanent Antarctic station, from November 2010 to December 2011. Serum cortisol and melatonin levels were measured by radioimmunoassay at 8 am, 3 pm, 8 pm, and 2 am in a single day, once each during the polar summer and winter photoperiods. Conventional psychological tests, Depression, Anxiety, and Stress Scale (DASS-42), Epworth Sleepiness Scale (ESS), and a computerized neurocognitive test battery were used to measure mood, sleep, and cognitive performance. Results. The mean scores for DASS42 were higher during midwinter suggesting the presence of “overwintering.” Mean diurnal cortisol levels during summer and winter were comparable, but the levels of melatonin were markedly higher during winter. Higher 8 am melatonin levels were associated with better sleep quality, lower depression scores, and better performance in tasks like attention, visual memory, and arithmetic. Conclusion. Timing of artificial light exposure and usage of melatonin supplements in improving sleep and cognitive performance in expedition teams are of future research interest.