bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract 136
Authors: Dahale Siddhant , Mehta Niragi , AasimMaldar  , Shah N. F. , Chadha Manoj , Chauhan Phulrenu
Published: February 2023

Introduction: Insulin autoimmune syndrome (Hirata’s disease) is a rare cause of hypoglycemia characterised by recurrent hypoglycemic episodes due to insulin autoantibodies, without any prior exposure to insulin.

Method: Retrospective review of patients with hyperinsulinemichypoglycemiawas done. 10 patients (8 females), aged between 7 to 60 years (mean 42.9 years), from year 2005 to 2021 were assessed.

Results: Four patients presented with fasting hypoglycemia, while all of them had post-absorptive hypoglycemic episodes. Four (40%) patients had evidence of other autoimmune conditions (three Hashimoto’s thyroiditis & one autoimmune cholangiopathy). Mean insulin was 2782uIU/mL (61-14,332), and mean C-peptide was 12.9 ng/dL (3.6-37.6). Mean anti insulin antibody level was 77.8% (13.6-98.82) in samples evaluated by RIA (till 2015), and 84.7 u/mL by ELISA (2016 onwards). Three (30%) patients had positive history of offending drug usage (clopidpgrel, torsemide and pantoprazole). One of the patients had history of Covid-19 infection three months prior. Treatment with low carbohydrate diet, alpha glucosidase inhibitor &/or prednisolone was effective in all symptomatically.

Conclusion: In hyperinsulinemichypoglycemia, when insulin is markedly elevated, but C-peptide is only moderately elevated, insulin autoimmune syndrome should be suspected and insulin in dilution and anti-insulin antibody should be checked. Also, history of other autoimmune conditions, and history of any offending drug usage should be diligently investigated in these patients.
Abstract 144
Authors: Shree Sanjay , Jatav Jitendra Kumar , Gupta Ritu
Published: February 2023

Background: In current scenario, burden of diabetes is increasing in India with time and along with its complications that are microvascular and macrovascular, one of which is stroke. There is an increased risk of stroke and its severity when a patient has diabetes with poor glycemic control. There are very few studies which compare the severity of stroke in patients of diabetes with good and poor glycemic control with non diabetic. Therefore, this study was conducted to assess the impact of diabetes on the pattern and severity of stroke (ischemic) with the help of glycosylated haemoglobin (HbA1C), which is easily accessible and affordable, so that various medical therapies should be implemented to prevent it.

Objectives: To know the glycemic status by estimating the HbA1c at the time of admission among all patients with acute ischemic stroke. To study the correlation of HbA1C on the severity of stroke at admission in diabetic patients. To compare the poor and good glycemic status patients among the diabetics with non-diabetic patients in acute ischemic stroke.

Material and Method: This is a Case control observational study in which the total sample size was 200, out of which 100 patients were cases (diabetic) and controls (non diabetic) respectively.

Results: In this study, cases were sub-categorized into good glycemic control- GGC (HbA1C < 7%) and poor glycemic control- PGC (HbA1C > 7%). Diabetes was more prevalent in male (58.5%) compared to female (41.5%) in which poor glycemic control was more common in males (55.8%) compared to females (44.2%). According to the TOAST Classification and NIHSS scoring systems, GGC has 16.7% of large artery occlusion and PGC has 36.5 percent of large artery occlusion. In the non diabetic group, 1% has large artery occlusion. In NIHSS score, 2% of patients have major stroke in the GGC group, 11.5% have severe stroke in the PGC group, and in the non diabetic group, 0.5% has severe stroke.

Conclusion: Sunanda et al. (2016) discovered that glycemic control has a significant association with the severity and outcome of diabetic ischemic stroke patients using HbA1c estimation. The severity of ischemic stroke patients during hospital stay was examined in this study with non-diabetics as a control, resulting in a study with a stronger association. Among the diabetic stroke patients, the severity of deranged glycemic status was found to have an influence on the stroke severity. Estimation of HbA1c levels at the time of admission might be a predictor of the severity of neurological impairment and functional outcome in patients with acute ischemic stroke.
Abstract 15
Authors: Archana M. P. , Jabbar P. K.
Published: February 2023

Background: Tumor-induced osteomalacia is a rare, acquired paraneoplastic syndrome, including hypophosphatemia, high serum alkaline phosphatase, reduced active vitamin D, suboptimal bone mineral density, bone pain, fragility fractures, and muscle weakness.

Case Description:

We present 6 patients who had hypophosphatemia and were diagnosed to have TIO [Table 1].

Discussion: In our case series, male: female ratio is 2:1. Mean age of the group was 39 years. Most of the patients were in forties and fifties (67%). One was a child. All patients had proximal myopathy of long duration at presentation. Mean duration of symptoms present were 4.1 years. The child had clinical and X-ray features suggestive of rickets. Other patients presented with fragility fractures. All patients had hypophosphatemia with a mean phosphorus of 1.24 mg/dl. All patients had low Tubular Maximum Reabsorption of Phosphate in relation to glomerular filtration rate (TMP/GFR) suggestive of renal phosphate wasting. FGF-23 wasnot done in all patients due to affordability issues. All patients underwent functional imaging (Ga-68DOTATATE PET) first followed by anatomical imaging (MRI/CT). Ga-68 DOTATATE scan revealed lesion in all patients. Lesions were located in Lower limbs (50%), head and neck region (33%) and in upper limb (16%). 4 patients underwent surgical excision of the lesions [Table 1]. 3rd patient had malignant TIO with metastatic lesions in the right lung and hypophosphatemia persisted despite surgical excision and subsequently underwent peptide receptor targeted radionuclide therapy (PRRT) with Lutetium following which hypophosphatemia improved. Patient remained asymptomatic for 6 years despite the poor survival rate associated with malignant TIO. Follow up scan of that patient after 8 years showed new lesions in lungs and he was initiated on Chemotherapy. Fourth patient was a known case of Hemophilia B, whose symptoms improved with phosphorus supplementation and in view of the surgical risk, surgery was deferred. 6th patient underwent bone curettage with grafting. But there was incomplete removal and she is currently on phosphate supplements. Other 3 patients were completely cured and is under follow up.

Conclusion: Although, Tumour induced Osteomalacia is a rare disease, we had 6 patients in 5 years. Serum phosphorus is a freely available investigation and can be used as a simple screening method for all patients with nonhealing fractures, bone pain and proximal muscle weakness. In the evaluation of TIO, functionalimaging, if possible, should be done first. If any lesion detected in imaging, surgical excision is mandatory. If lesion not localised or surgery not amenable, medical management modalities including PRRT should be consideredespecially in cases of malignant TIO along with phosphorus supplementation.
Abstract 154
Authors: Adhikary Pieu , Banerjee Mainak , Banerjee Sudipta , Chowdhury Subhankar
Published: February 2023

Background: Association of visceral adipose tissue (VAT) with high molecular weight (HMW) adiponectin and insulin resistance (IR) is known, whereas impact of subcutaneous adipose tissue (SCAT) is unclear. Our objective was to find out association of VAT and SCAT-derived HMW adiponectin with serum HMW adiponectin and explore their impact on HOMA-IR and type 2 diabetes (T2DM).

Methods: Among 51 subjects (Age- 30 to 57 years), 33 subjects (women = 20, men = 13) without T2DM and 18 subjects (women = 11, men = 7) with new onset diabetes (less than 1 year) were categorized as control and T2DM respectively according to American Diabetic Association (ADA) guideline, 2010. Adipocytes were isolated and cultured from adipose tissue biopsies obtained from these subjects during their abdominal surgery. Adiponectin mRNA expression was analysed by Real-Time PCR, and HMW adiponectin secretion were analysed by Enzyme-linked immunosorbent assay (ELISA).

Result: In both T2DM and control, no significant changes of adiponectin mRNA expression were found between SCAT and VAT; HMW adiponectin secretion from SCAT was significantly (p = 0.002) higher compared to VAT in both groups. In T2DM group adiponectin mRNA expression and tissue derived HMW adiponectin from SCAT and VAT significantly lower than that of control group. Serum HMW Adiponectin significantly decreased (p < 0.0001) in diabetic group. Spearman correlation analysis showed that, serum HMW adiponectin has stronger positive correlation with SCAT-derived HMW adiponectin (r = 0.51, p < 0.0001) than VAT-derived HMW adiponectin (r = 0.32, p < 0.05). HOMA-IR negatively correlated to serum HMW adiponectin (r = -0.41, p < 0.0001), and more strongly correlated to SCAT-derived HMW adiponectin (r = -0.55, p < 0.0001) than that of VAT (r = -0.42, p < 0.001).

Conclusion: HMW adiponectin predominantly secreted from SCAT may exert more impact on circulating HMW adiponectin, thereby leading to increased insulin resistance and risk of T2DM.
Abstract 159
Authors: Phadte Aditya , Memon Saba , Sarathi Vijaya , Patil Virendra , Lila Anurag , Bandgar Tushar
Published: February 2023

Background: side-chain cleavage deficiency (SCCD) patients present with primary adrenal insufficiency (PAI) with or without under virilized external genitalia. Distinction between classic and nonclassicalsteroidogenic acute regulatory protein (StAR) deficiency has been described, whereas in SCCD is unclear. The data on gonadal function and its correlation with SCCD genotype has not been studied.

Objectives: We describe our experience and perform a systematic review of genetically-proven SCCD patients to determine the distinct phenotypic and genotypic characteristics of 46XY SCCD patients with typical male external genitalia (SCCD-TMG) and atypical (SCCD-AG) external genitalia.

Methods: Retrospective review of three genetically proven SCCD patients from our center and per-patient data analysis from a systematic review of 52 probands was performed. SCCD-TMG (n = 19) was defined as external genitalia of Sinnecker score 1 with 46XY karyotype; the rest (Sinnecker 2-5) were classified as SCCD-AG (n = 15).

Results: We report two new Indian cases of SCCD with three novel likely-pathogenic variants and pubertal follow-up of a previously reported patient. In systematic review, age at diagnosis of primary adrenal insufficiency (PAI), and elevated renin were not different between 46XY SCCD-TMG (n = 19) and SCCD-AG (n = 15) whereas spontaneous puberty (9/9 vs 0/3, p = 0.0045), normal prepubertal (5/5 vs 6/6, p = 0.002), pubertal gonadotropins (2/9 vs 0/3, p = 1), and normal pubertal testosterone (9/11 vs 0/3, p = 0.027) were more common in SCCD-TMG. Testicular adrenal rest tumors were exclusive to SCCD-TMG (n = 4). SCCD-TMG was associated with four particular genotypes[monoallelic p.Glu314Lys with another deleterious variant on the second allele (p.Glu314Lys/X-CHS: X-compound heterozygous state), biallelic p.Arg451Trp, p.Phe215Ser/p.Arg232Ter, and monoallelic p.Val79Ile]. 46XX SCCD patients with p.Glu314Lys/X-CHS also had normal gonadotropins with spontaneous puberty.

Conclusion: SCCD-TMG is associated with four specific genotypes and distinct gonadal characteristics from SCCD-AG with overlapping features of PAI.
Abstract 184
Authors: Sharma Suresh Kumar
Published: February 2023

Introduction: Osteoporosis affects a substantial proportion of patients with chronic liver disease. Pathologic fracture in osteoporosis significantly affects quality of life and life expectancy. By some estimates, 40% of patients with chronic liver disease may experience osteoporotic fracture. In this study we review the pathogenesis, diagnosis and treatment of specific liver disease entities and their relation to osteoporosis

Method:

Inclusion criteria: All Chronic liver disease patients with Child A, Child B, Child C and within age group - Males and Females >21 years till menopause or 65 years.

Exclusion criteria: All patients with Haemodynamically Unstable; Age less than 21 years; Female with menopause (After cessation of menstruation >1 year); Patients with other medical disorders causing osteoporosis; Males and females age >65 years.

All patients included in the study were subjected to bone mineral density measurement of hip joint by dual energy X-ray absorptiometry (DEXA) (Osteopromax of M-tec company

Results:

Conclusion: We concluded that low BMD is highly prevalent in patients with CLD of variable aetiologies. Causes may be multifactorial. Early screening of osteoporosis in patients with liver cirrhosis will reduce the risk of morbidity and mortality.
Abstract 188
Authors: Manash Baruah , Ajay Aggarwal , Mathew John , Khan Pathan Muzammil , Manu Chandrappa , Jack Garcia Uranga , Singh KP
Published: February 2023

Aim: To evaluate the cost of control of insulin degludec/insulin aspart (IDegAsp) in people with T2DM from ARISE study as compared to previous therapy (OADs ± previous insulins ± GLP-1 RAs) based on Indian setting.

Methods: ARISE was a ~26 weeks open-label, non-interventional study (NCT04042441) including 1102 T2DM adults on any anti-hyperglycaemic treatment initiating or switching to IDegAsp based on investigator’s discretion as per local practice in 6 countries, with 185 patients from India. For this post-hoc analysis, a short-term cost of control model developed in Microsoft Excel was used to estimate the difference in yearly cost of control for IDegAsp versus other therapies from a patient payer perspective. Data from ARISE study was used with regards to the baseline cohort characteristics, treatment effects and for the proportion of patients achieving treatment targets. Drug acquisition costs based on maximum retail price in India as of October 2022 were taken into consideration, and the healthcare resource utilization costs were derived from other published literature.

Results: When assessing the Indian cohort, IDegAsp was associated with lower annual cost of control than all treatments towards achieving HbA1c <7% (by

JOURNAL/ijeam/04.03/02223308-202212008-00188/math_188MM1/v/2022-12-23T100831Z/r/image-tiff

9,86,738), and HbA1c less than pre-defined individual treatment target (by

JOURNAL/ijeam/04.03/02223308-202212008-00188/math_188MM2/v/2022-12-23T100831Z/r/image-tiff

16,75,108). The difference in yearly total costs including that of medication and healthcare resource use was lower with IDegAsp as compared to all treatment (by

JOURNAL/ijeam/04.03/02223308-202212008-00188/math_188MM3/v/2022-12-23T100831Z/r/image-tiff

2955.83). The number needed to treat to bring one patient to targets of HbA1c <7.0% and less than pre-defined individual treatment target was lower with IDegAsp than continuation of all baseline treatment options, 11.24 vs 23.26 & 10.53 vs 31.25, respectively.

Conclusion: Under Indian setting, IDegAsp was shown to be a cost-effective treatment for people with type 2 diabetes not achieving glycemic targets on other therapies in routine clinical practice.
Abstract 189
Authors: Nahid Eram , Mittal Madhukar , Ganakumar Vanishri , Garg M K
Published: February 2023

Background: 17-HSD-3 deficiency is autosomal recessive, rare cause of 46XY, DSD. The diagnosis is often missed in early childhood due to subtle features, and the usual presentation is at puberty with primary amenorrhea and features of virilisation. Herein we describe 34-year 46XY female who was never diagnosed and found to have compound heterozygous mutations in exon 1 and exon 9 in HSD17B3 gene by genetic testing.

Case Detail: Patient was first-born to a non-consanguineously married couple, term delivery with typical female external genitalia, and reared as female. There was history of right-sided inguinal hernia repair at 3 years of age. Breast development started at 15 years of age, along with deepening of voice and appearance of facial and body hair at 16-17 years. Initial evaluation by a Gynaecologist at 26 years of age for primary amenorrhea revealed a blind vagina, clitoromegaly, bilateral palpable gonads in inguinal region with 46XY karyotype. MRI revealed testes in inguinal canals and absence of Mullerian structures. No endocrine evaluation was done at this stage, and she underwent bilateral orchidectomy followed by estrogen supplementation. The patient first consulted us 8-years later, at 34 years of age. Since she had undergone bilateral orchidectomy, interpretation of hormonal evaluation including hCG-stimulation, was not feasible. Genetic sequencing revealed compound heterozygous mutations for c.128_131 del at exon 1 and c.644A>T novel mutation at exon 9 in HSD17B3 gene. The patient wanted to continue with the assigned female sex, and was continued on estrogen therapy along with genetic counselling.

Discussion: Mutation in HSD17B3 is rare cause of 46XYDSD. Usually reared as female, these patients come to medical attention because of inguinal hernia or labioscrotal swelling in childhood or primary amenorrhea along with variable degree of virilization in pubertal age group. Without specific endocrine evaluation, it may be overlooked as androgen insensitivity and 5-alpha-reductase deficiency due to clinical similarities. Basal and stimulated hormonal evaluation of hormonal precursors and metabolites can provide valuable information about the level of defect. Confirmatory molecular mutation analysis is often required, particularly in the setting of gonadectomy, as was the case in our patient. A total of 70 different mutation in the HSD17B3 gene has been reported to date The p.Phe43CysfsTer9 mutation at exon 1 identified in our patient has previously been reported, but p.Glu215Val mutation at exon 9 has not been previously reported and is a novel mutation.
Abstract 192
Authors: Kiran Kumar P , Gupta Yashdeep , Goyal Alpesh , Kandasamy Devasenathipathy , Seenu V , Kumar Rajeev , Pal Sujoy , Bal CS , Aggarwal Shipra , Tandon Nikhil
Published: February 2023

Background: Multiple endocrine neoplasia type 2 (MEN2) syndrome is a rare disorder with autosomal dominant inheritance, characterised by the presence of two of the following three endocrine manifestations: medullary thyroid carcinoma (MTC), pheochromocytoma (PCC) and primary hyperparathyroidism (PHPT). There is a paucity of data on clinical and genetic profile of MEN2 syndrome in the Indian subcontinent.

Objectives: We aimed to evaluate the clinical and genetic profile of index patients with MEN2 syndrome and perform screening for MTC among asymptomatic family members of such patients.

Materials and Methods: This was an ambispective study conducted in the department of Endocrinology at AIIMS New Delhi, involving diagnosed patients of MEN2 syndrome between January 2016 and November 2022. MTC screening was performed with measurement of serum calcitonin levels (normal: <10 pg/ml) among family members of index patients.

Results: We evaluated a total of 23 index patients with MEN2 syndrome (MEN2A, n=18; MEN2B, n=5). Data were derived retrospectively for 18 patients (MEN2A, n=14; MEN2B, n=4) and prospectively for 5 patients (MEN2A, n=4; MEN2B, n=1). Of the study patients, 16 (MEN2A, n=13; MEN2B, n=3) were females. The mean age at presentation in the two groups was 33 years and 22 years, respectively. Among patients with MEN2A syndrome, 11 (61%) presented with PCC and were synchronously detected to have MTC, while 7 (39%) presented with MTC, of whom 5 metachronously developed PCC. We noted PHPT in 3 (16%) patients with MEN2A syndrome. A total of 177 eligible family members of index patients with MEN2A syndrome were contacted, of whom 83 turned up for screening and 42 (50.6%) had elevated serum calcitonin levels (>10 pg/ml). Of the 5 patients with MEN2B syndrome, 4 (80%) presented with synchronous MTC and PCC and 1 (20%) presented with MTC alone. Of the 26 eligible family members of index patients with MEN2B syndrome, only 9 could be screened and all had normal serum calcitonin levels (<10 pg/ml). Metastatic MTC was noted in 3 (17%) patients with MEN2A syndrome and 3 (60%) patients with MEN2B syndrome Mutational analysis data are available for 7 index MEN2A and 4 MEN2B patients. The most common mutations in MEN2A and MEN2B groups were C634R (exon 11 of RET gene, n=5) and M918T (exon 16 of RET gene, n=4), respectively.

Conclusions: MEN2 syndrome should be suspected in patients with MTC and young-onset PCC and all first-degree relatives of index patients with this syndrome should be screened appropriately.
Abstract 2
Authors: Jethwani Parth , Mittal Madhukar , Shukla Ravindra , Garg MK
Published: February 2023

Background: The etiologies for ambiguous genitalia with palpable gonads include gonadal dysgenesis, congenital adrenal hyperplasia, androgen biosynthetic defects or androgen insensitivity. Klinefelter syndrome (1 in 500-1000 live male births) classically presents with hypergonadotropichypogonadism, infertility and neurocognitive deficits in adult men, and less frequently as isolated hypospadias and micropenis in infants. Klinefelter syndrome rarely can present with ambiguous genitalia. We detail a child with Klinefelter syndrome and associated androgen insensitivity presenting with genital ambiguity.

Case Details: 3 year 5 months old child (DOB: 6/5/19), reared as male, presented with complaints of ambiguous genitalia and small-sized penis since birth. He was passing urine from a normally located urethralopening. Although gonads were noticed in the scrotum since birth, there was bifid scrotum. There was no history of hypoglycemia, salt-wasting crises or hyperpigmentation. Child was born out of non-consanguineous marriage, by cesarean delivery, at term, with a birth weight of 2.6 kg. Child had attained developmental milestones appropriate for age. On examination, Ht:92 cm (-1.96 Z), Wt:13kg (-1.33 Z), BP: 85/54mmhg (SBP: 50th centile, DBP: 90th centile), MPH:162.5 cm, US:LS:0.7, Arm Span: 89 cm.

On examination, he had bilateral symmetric external genitalia with palpable gonads in the labio-scrotal folds. The labioscrotal folds were non-fused, but rugosity and pigmentation were present. Phallic length was 1.8 cm with a single urethral opening at the tip of phallus. EMS score was 6 and AG ratio was 0.5. Evaluation revealed Na:138, K:4.3, Cortisol:13.5 mcg/dl, LH: 0.862 mIU/ml, FSH:2.4 mIU/ml, Testosterone: 507 ng/dl. Post-hCG stimulation Testosterone/Dihydrotestosterone ratio was 12.43, while Testosterone/Androstenedione ratio was 22.96. Karyotype was 47,XXY. Genetic analysis revealed a pathogenic variant in the androgen receptor c.2495G>A (p.Arg832Gln), suggestive of androgen insensitivitysyndrome.

Discussion: There have been isolated case reports of genital ambiguity in Klinefelter syndrome with associated AIS. The mechanisms suggested to explain genital ambiguity in Klinefelter syndrome include parental origin of the X chromosome, skewed inactivation of the X chromosome, CAG repeat polymorphism, double dosage of DAX-1 gene and androgen insensitivity. Although rare, it remains paramount to recognize Klinefelter syndrome as a cause of genital ambiguity. Genotypic-phenotypic discordance in Klinefelter syndrome should especially alert the clinician to look for associated androgen insensitivity as one of the mechanisms.
Abstract 29
Authors: Mathews Anil , David Don , Dev Amal , Philip Rajeev
Published: February 2023

Introduction: The clinical spectrum in primary hyperparathyroidism (PHPT) though varied has undergone a striking change in developed countries with predominant asymptomatic PHPT detected during routine biochemical screening for other causes. Recent data from India showed that PHPT still presents with classic skeletal and renal manifestations. In this study we analyzed the clinical presentation, investigations, management, operative findings, and immediate post-operative course of patients with histologically proven PHPT at our centre.

Aim: To study the clinical and biochemical presentation of Hyperparathyroidism (HPT)

Materials and Methods: Patients diagnosed to have newly diagnosed primary hyperparathyroidism were studied. All patients underwent biochemical investigations including Calcium, Phosphorous, Alkaline Phosphatase, Albumin, 25-OH vitamin D, Parathyroid hormone, Creatinine, Urine calcium/creatinine ratio, BMD and Parathyroid scan. The period of the study was from September [2013] 2016 to June [2019] 2021.

Results: Out of the 40 patients studied 26 patients were female and 14 were male. 18 patients were incidentally detected during screening. The mean age was 42.7 ± 12.4. The mean calcium level was 11.5 ± 1.8 mg/dl, Phosphate was 2.8 ± 0.87 mg/dl. Mean PTH value was 206.4 ± 74.2 pg/ml. 2 Patients had brown tumor on skeletal survey. The mean BMD was -3.6 ± 0.8 (femur neck), -3.9 ± 0.86 (spine), -3.9 ± 0.7 (forearm). The cause of hyperparathyroidism included single adenoma in 22 patients, double adenoma in 8 patients, triple adenoma in 2 patients, ectopic adenoma (mediastinal) in 2 patients’ hyperplasia in 6 patients. 3 patients had MEN1 syndrome. 5 patients had familial HPT (3 MEN1 associated).

Conclusion: Hyperparathyroidism in Kerala resembles the disease trend seen in the developed countries, then the rest of India, with more cases being picked up incidentally in the asymptomatic stage. Renal calculi are a very common presentation of hyperparathyroidism in our study. Fracture of bones and brown tumors were rare in our study, probably due to the early diagnosis.
Abstract 43
Authors: Agrawal Mayur , Patwa Kavita , Gupta Priyanka
Published: February 2023

Introduction

For a long time it has been thought that Type 1 Diabetes Mellitus (T1DM) occurs in children and young people, though no strict cut-off of age. Usually, T1DM diagnosis is thought only for patients <20-25 years. Now with the increasing obesity pandemic we see Type 2 Diabetes mellitus (T2DM) in adolescents as well but diagnosing T1DM in adults is uncommon. Here we describe our patient of 55 years having T1DM.

Case history and examination

55 year post menopausal female presented with poorly controlled glycemia for 1 year. She was started on triple drug OHA combination as at diagnosis blood sugar was around 450 mg/dL. As blood sugars were not controlled other OHA was further added. Since the diagnosis, blood sugarwere uncontrolled so basal insulin was initiated. When she presented to us, glucometer reading was high with no ketosis and corresponding lab values was around 650 mg/dL. She was non-obese with BMI of 21.2 kg/m2 with no Acanthosis nigricans, no strie, no proximal muscle weakness and no h/o pancreatitis or steatorrhoea. She did not have any history of steroid abuse or any other alternate treatment. We ordered an Anti GAD antibody which came out to be very high > 600 IU/mL (N < 17).

Differential diagnosis

Diagnosis and treatment

T1DM occurs due to beta cell destruction by autoantibody leading to severe insulin deficiency. A basal or stimulated C peptide is used for estimating the insulinopenic status in T1DM but sometimes it is low in poorly controlled diabetes.[2] So it was not done in our case. We proceeded to Anti GAD antibody titre which was very high, thus confirming the diagnosis. Patient was started on basal bolus therapy after insulin and hypoglycemia education. She is doing fine with insulin dose titration.

Summary

This case emphasizes the role of measuring GAD antibodies and suspecting T1DM in adults too. Infact misdiagnosis occurs in nearly half of adults with new T1DM.[3] The notion that T1DM is limited to children is not true. Anti-GAD Ab is the most prevalent autoantibody in adult T1DM, though this varies with genetic make up and population studied.[4] Higher number of antibodies increases the probability of T1DM. Diagnosis is important so that these patients are informed for life long insulin and OHA should not be tried. They should be screened for other autoimmune conditions as well.
Abstract 54
Authors: Nadig Anusha , Fatema Zareen , Agarwal Sakshi , Honnatti Sharat , Basavaraj GS
Published: February 2023

Background: Diabetes Distress scale (DDS) is a self-reported questionnaire. It has 4 subscales (emotional burden, regimen distress, physician distress and interpersonal distress). DDS expresses the overall distress score of the PwD. A total score of >2.0 is considered clinically significant.

Aim: We looked at utility of the DDS in PwD enrolled on a lifestyle care program, complimented by an emotional wellness trained psychological counsellor. We also evaluated a change in the DDS after 3 months of program.

Methods: 104 patients who were enrolled ona 12-week virtual lifestyle care program of OneCare, were recruited for the study. Their demographic data and baselineglycaemic parameters were collected. DDS were administered at the beginning of the program and at the end of 3-month. Follow up glycaemic parameters were also documented for the study.

Results: Participants were on an average 44 (13.3) years. Mean duration of diabetes were 1.5 years and mean HbA1c of 9.2 (2.1) %. Mean DDS at the baseline were 1.9 (0.6) i.e., little distress. Participants were grouped based on the level of distress. 58% of the patient reported having no distress (<2.0), while 37% suffered from moderate distress (2.0-2.9). 5% patients were found to have high diabetes distress. There was a statistically significant improvement in total DDS score (d = 0.6) along with the emotional burden (d = 0.9) and regimen distress (d = 0.9) subscales of the DDS (p < 0.001) after the intervention. The mean reduction in overall DDS score was 0.49. Post diabeteslifestyle care program, 85% of the patient had no distress, 10%expressed having moderate distress respectively. Difference in the proportion of the patients in three categories of distress pre- and post-intervention were found to be statistically significant (p < .001). Post intervention HbA1c also significantly declined to 6.7 (1.0) % (p < .001).

Conclusion: Results of this study demonstrate the utility of DDS instrument as one of the important outcomes in assessing diabetes management and scope of providing better psychological care. Positive increments seen through the lifestyle care program seems to be promising way to address the often-neglected part of Diabetes management.
Abstract 57
Authors: Bhandiwad Chandrashekhar , Afzal Mohd. Abdul Mujeeb , Palle Sharmila , Paidipally Srinivasa Rao , Danda Vijay Sheker Reddy
Published: February 2023

Background: The circadian timing system consists of a central brain clock in the hypothalamic suprachiasmatic nucleus and peripheral clocks in tissues, including the liver, muscle, adipose tissue and pancreas. Misalignment between different components of the circadian timing system, daily rhythms of sleep–wake behavior and food intake might contribute to the development of insulin resistance and altered hormonal regulation. There are limited number of studies in India on the hormonal and metabolic changes in Night shift workers and there are no studies particularly in the vulnerable night shift workers in software Multinational companies (MNC) in India.

Objective: To Investigate the impact of Night shift work on Endocrine and metabolic Processes likeInsulin Resistance, Stress Response (Cortisol), Thyroid Axis and Gonadal Axis

Material and Methods: This is a Cross sectional observational study done on total 90 subjects with 45 “Night Shiftworkers” with More than 3 months Night Shift work in MNC and 45 “Day shift workers”. Night shift work was defined as Work in Night of more than 6-8 hours crossing mid night and more than or equal to 5 days a week work. Data was collected using a pretested questionnaire meeting the objectives of the study. Detailed history, physical examination including anthropometry and necessary investigations have been done.

Results and Discussion: Among Night shift workers statistically more number of subjects were having HOMA-IR > 2.5 (77.78% vs 62.23%) and more number of subjects qualified for subclinical hypothyroidism compared to day shift workers (22.22% vs 11.11%). The mean Triglycerides levels were elevated (212.42 md/dL vs 185.05 mg/dL) and HDL was low (35.4 mg/dL vs 39.8 mg/dL) among Night shift workers with significant P value. The mean 25 OH Vitamin D3 levels were low (9.95 ng/ml vs 15.09 ng/ml) among the night shift workers with significant P value. The Mean Serum 8 AM Cortisol in night shift workers are low (9.57 mcg/dL vs 11.11 mcg/dL) denoting reversal in cortisol rhythms compared to day shift workers. The Mean Estradiol levels in male night shift workers were higher (26.31 pg/ml vs 20.42 pg/ml) than the male day shift workers.

Conclusion: The Night shift work is associated with increased risk of metabolic syndrome with Insulin resistance and dyslipidemia, Vitamin D deficiency, Subclinical Hypothyroidism, and reversal in Cortisol levels. There is need for further focused study to confirm these findings in a large prospective study.
Abstract 70
Authors: Prasad Aravind
Published: February 2023

Introduction and Aims: Covid 19 can invade the testes directly by through the ACE2 receptors. It can also affect the hypothalamus and pituitary gland, thus disrupting the HPG axis. We aimed to assess the HPG axis in male survivors of Covid 19 about 3-5 months after recovery from Covid 19 infection.

Methods: This was a prospective study conducted at a tertiary centre in southern India. Adult male patients were enrolled for the study 3-5 months after recovery from Covid 19 infection. Hypogonadism was defined as low testosterone (total testosterone <241 ng/dl) or borderline low testosterone (total testosterone 241-317 ng/dl) with low free testosterone (<6.3 ng/dl). Primary hypogonadism was defined as hypogonadism with LH ³9.4 mIU/ml and secondary with LH <9.4 mIU/ml.

Results: We recruited a total of 85 subjects. The mean age of our study population was 49.50 ± 12.73 years. 24 (28.24%), 21 (24.71%), and 40 (47.06%) patients had mild, moderate and severe Covid 19 infection. Hypogonadism was seen in 21 (24.7%) study subjects. The predominant pattern of hypogonadism was secondary seen in 20 subjects (95%). Younger age, higher BMI and use of remdesivir were significantly associated with hypogonadism. The prevalence of hypogonadism was not associated with severity of illness, the extent of pulmonary involvement or the duration of hospitalisation.

Conclusion: We found a high prevalence of hypogonadism in male subjects 3-5 months after acute infection. Male Covid 19 patients should be followed after acute infection for symptoms suggestive of hypogonadism. Future studies are needed to improve our knowledge regarding the sexual dysfunction seen in post covid phase.
Abstract 84
Authors: Sourabh Sagar , Kalra Pramila
Published: February 2023

Background: Thyroid hormone deficiency may present with overt clinical symptoms or may have mild or no manifestations. Even in patients with overt biochemical hypothyroidism, symptoms and signs may be minimal or absent, especially in older persons. There is paucity of data in our country on serum levels of total testosterone, estradiol in primary hypothyroidism. The present study was done to assess sex hormone profile and sexual dysfunction, if any, in subjects with primary hypothyroidism. The study was done to measure serum levels of total testosterone in males and estradiol in females with primary hypothyroidism (overt and subclinical) and assess sexual function (erectile dysfunction in males and sexual arousal disorder in females) in the form of a questionnaire.

Methods: This study was conducted in Endocrinology OPD of a superspeciality centre in south India in subjects with primary hypothyroidism. A detailed history was taken, and a physical examination of participants was done. Anthropometric parameters like height, weight, and BMI were measured. Information regarding their sexual activity during the past four weeks was noted and the questionnaire was given to participants up to the age of 60 years. The questionnaires used were the female sexual function index for females and the international index of erectile function for males.

Results: A total of 49 subjects with newly diagnosed primary (subclinical and overt) hypothyroidism which included 37 females with TSH 16.34 ± 16.95 mIU/ml, estradiol 59.74 ± 51.84 pg/ml and FSFI score 24.1 ± 3.43 and 12 males with TSH 21.8 ± 15.7 mIU/ml, testosterone 399.67 ± 145.03 ng/dl and IIEF score 44.0 ± 9.802. Thirty seven percent of females and sixteen percent of males had subclinical hypothyroidism. Sexual dysfunction was present in 23 out of 37 females (62%) and 3 out of 12 (25%) males, and all three men had a low score in the erectile function domain of IIEF. The arousal domain was the most affected (68.7% scored less than 4), and satisfaction was least affected (28.6% scored less than 4) in females. Thyrotropin values didn’t show correlation with T in males and E2 in females. FSFI and IIEF scores did not correlate with TSH values.

Conclusion: The prevalence of sexual dysfunction in primary hypothyroidism was higher in females than males. The most affected domain was arousal in females and erectile function in males. Around thirty-seven percent of females in this study had subclinical hypothyroidism, and a higher prevalence of sexual dysfunction in females may be an indication to treat these patients with levothyroxine.
Abstract 92
Authors: Rashmi K G , Suryadevara Varun , Prasad Aravind , Naik Dhukhabandhu , Sahoo Jayaprakash , Kamalanathan Sadishkumar
Published: February 2023

Introduction: Coronavirus disease 2019 (COVID-19) mainly involves the lungs; it also affects the endocrine system including the hypothalamic-pituitary adrenal axis (HPA).

Aims: To assess and compare the changes in the HPA axis in survivors of SARS CoV-2 infection 3 months after recovery.

Methods: A cross-sectional, descriptive study was undertaken at JIPMER, including 69 patients ³18 years of age, after 3 months after the diagnosis of COVID-19. At baseline, a fasting sample was collected for basal cortisol, thyroid function, and biochemical investigations between 8.00-9.00 AM. A low dose Synacthen test (1 mg) was performed in all patient’s blood samples for serum cortisol collected after 30 and 60 minutes of intravenous administration.

Results: The mean age (SD) was 49.74 ± 12.05 years, 24 (34.78%) were female and 45 (65.2%) were male patients. 20 (28.98%) patients had mild, 10 (14.4%) had moderate and 39 (56.52%) patients had severe COVID-19 infection. 62 (89.85%) patients had post covid symptoms. Out of the sixty-nine patients with COVID-19, nine patients (9/69, 13.04%) had peak serum cortisol <18 mg/dL suggestive of secondary adrenal insufficiency. Peak serum cortisol did not differ according to disease severity [Mild, (13.03 ± 4.08 mg/dL) vs moderate, [(11.52 ± 2.40 mg/dL) vs severe, (13.70 ± 1.43 mg/dL), P = 0.67]. In addition, there was no difference in peak serum cortisol in patients with or without adrenal insufficiency [(12.99 ± 2.54 mg/dL) vs (22.44±5.52 mg/dL), P = 0.09 respectively.

Conclusion: HPA axis is affected in 13.04% of patients 3 months after presentation with COVID-19. These findings have important implications for the clinical care and long-term follow-up of patients after COVID-19.
Abstract 95
Authors: Nikith Siddu , Melkuntesanthiah Dhananjaya , L Sagar Reddy S , Sarathi Vijaya
Published: February 2023

Introduction: Markedly elevated thyroid stimulating hormone (TSH) in patient withsellar-suprasellar mass generally indicates pituitary hyperplasia but very rarely primary untreated hypothyroidism and pituitary adenoma may co-exist. It is crucial to differentiate these two conditions, because of significant difference in treatment modalities. Here, we report a caseseries of pituitary adenoma with markedly elevated TSH.

Methods: Case records of sella-suprasellar masses with elevated TSH (> 20 mIU/ml), registered between January 2021 and September 2022 were reviewed and those with the diagnosis of pituitary adenoma are included. The diagnosis of pituitary adenoma was based either on histopathology or radiological characteristics compatible with pituitary adenoma with no lesion size reduction with levothyroxine replacement.

Results: A total of five patients (4 males) presented at a median age of 37 (range: 23-62) years with headache (n = 4) and visual disturbances (n = 3) Median TSH level was 115.5 (range: 84-430) mIU/ml. Two patients had coexisting central hypocortisolism and hypogonadism. Magnetic resonance imaging revealed macroadenomas with heterogeneous enhancement in all patients. Optic chiasm compression and dome shaped elevation were seen in three patients each. None (n = 4) of the patients showed reduction in lesion size after 3 months of levothyroxine replacement. Three patients underwent surgery and histological confirmation as pituitary adenoma.

Conclusion: We report a unique series of pituitary macroadenomas with markedly elevated TSH due to coexisting primary hypothyroidism. This series cautions that all sellar masses with markedly elevated TSH are not pituitary hyperplasia. Baseline imaging characteristics and assessment of lesion size reduction after levothyroxine replacement help to differentiate pituitary adenoma from pituitary hyperplasia.
Gastrointestinal Bezoars in Paediatrics
Authors: Elghazeery Mohamed Ahmed , Hassan Alhassan Mohamed
Published: February 2023

Introduction:

Bezoars are indigestible lumps which are usually found in stomach. Types of bezoar include phytobezoar, trichobezoar, lithobezoar, pharmacobezoar, plasticobezoar, lactobezoar and metal bezoar. Trichobezoars mostly affect females in 20s and 30s with a rarity in paediatrics. Unexplained complaints with a palpable mass are commonly found in these patients. Treatment involves retrieval of mass with searching for others.Purpose:The purpose of this study was to present data and surgical management of cases with trichobezoars.

Materials and Methods:

We documented a retrospective review of trichobezoars done in our hospital between 2016 and 2022. All demographic data collected included gender and age of cases, composition and extent of bezoar, clinical presentation, imaging modalities, endoscopic trial, surgical approach and outcome.

Results:

Five cases of gastrointestinal tract (GIT) trichobezoars underwent surgery. All cases were females between (13 and 16 years). Trichobezoars were three gastric, one ileal and one of combined gastric and colonic. Complaints were abdominal pain, vomiting, weight loss and halitosis. Three cases had a palpable abdominal mass. Different radiological modalities were performed. Endoscopic retrieval was tried in one patient and the laparoscopic approach in another one, but the first route failed. Laparotomy followed by gastrotomy, enterotomy and colotomy was done without complications.

Conclusions:

Trichobezoars should be suspected in any child with unexplained abdominal complaints or with a palpable abdominal mass, especially in girls. Imaging can be done in different modalities for diagnosis. Endoscopic retrieval could be tried; however, its failure is common, necessitating laparotomy, which has an excellent outcome.
Type III Congenital Pulmonary Airway Malformation Associated with Oesophageal Atresia and Tracheoesophageal Fistula. A Case Report and Review of Literature
Authors: Fijasri Nurul Hafiez , Asri Nur Asmarina Muhammad , Shah Mohd Shahrulsalam Mohd , Samad Mohd Ridzuan Abd , Omar Norsuhana
Published: February 2023

Congenital pulmonary airway malformation (CPAM) together with oesophageal atresia and tracheoesophageal fistula (TOF) is a very rare condition in neonates. We presented a case of an infant with Gross type C oesophageal atresia with TOF coexisting with Stocker Type III CPAM in our centre. It is interesting to know that TOF associated with type III CPAM has never been reported in the literature. The child was delivered through caesarean section, and because of respiratory distress post-delivery, endotracheal intubation was carried out immediately. CPAM was diagnosed by a suspicious finding from the initial chest X-ray and the diagnosis was confirmed through computed tomography scan of the chest. The patient was initially stabilised in a neonatal intensive care unit (NICU), and after the successful ligation of fistula and surgical repair of TOF, lung recruitment was started by high flow oscillatory ventilation. The patient recovered well without complications and able to maintain good saturation without oxygen support through the stay in the neonatal unit. Early recognition of this rare association is essential for immediate transfer to NICU, the intervention of any early life-threatening complications, and for vigilant monitoring in the postoperative period.
Atypia of Undetermined Significance/Follicular Lesion of Undetermined Significance (Bethesda Category - III) in Thyroid Cytology
Authors: Das Prateek , Patnayak Rashmi , Bhola Rajesh , Jena Amitabh
Published: February 2023

Introduction:

Fine-needle aspiration (FNA) cytology is a reliable method to diagnose thyroid lesions. The Bethesda System for Reporting Thyroid Cytopathology (TBSRTC) is universally followed for thyroid cytology reporting. Out of the six categories described, Category III, atypia of undetermined significance/follicular lesion of undetermined significance (AUS/FLUS) is the most heterogeneous one.

Materials and Methods:

In this study conducted in a tertiary health care center in Eastern India over 2 ½-year period, 868 thyroid FNAs were performed and the cytology smears were interpreted using the TBSRTC. There were 32 FNAs in Category III. Histopathology report was available in nine cases.

Results:

The risk of malignancy (ROM) considering noninvasive follicular thyroid carcinoma with papillary nuclear features (NIFTP) as benign was 9.3% and by considering NIFTP as malignant was 21.8%.

Conclusion:

The ROM for AUS/FLUS in our study was within the revised ROM criteria. In Category III, surgery is preferable in nodules which harbor suspicious features either clinically or according to ultrasound findings.