Changing Pattern of Hypercalcemia in a Hospital Setting – A Hospital Based Experience

Background: Hypercalcemia is a common metabolic abnormality of varying severity that can be adequately diagnosed and treated. Primary hyperparathyroidism and malignant neoplasms are responsible for >90% of all cases. Objectives: To study the clinical presentation and etiological profile of hypercalcemic patients at a district level hospital over a period of 24 months. The number of patients of hypercalcemia due to other rare cause like vitamin D intoxication have been increasing mainly due to over the counter supplementation. Methods: Forty patients, 22 males with a mean age of 50±10.2 and 18 females with mean age 45±7.6 with hypercalcemia were studied. The first step in evaluating hypercalcemia was confirming it first, with an initial evaluation including the measurement of intact parathyroid hormone , 25-hydroxy vitamin D levels and alongwith imaging wherever required. Results: Out of 40 patients studied, the most common clinical presentations were symptoms of aches and pains in 12 patients and incidental finding of hypercalcemia in 10 patients, altered sensorium in 6 patients. In etiological profile, the most common etiology was vitamin D intoxication in 10 patients followed by hyperparathyroidism in 9 patients and malignanacy in 7 patients respectively. Conclusion: In our study vitamin D intoxication (VDI) was the most common cause of hypercalcemia. as compared with multiple studies previously which showed malignancy and hyperparathyroidism as predominant causes. Inadvertent excessive use of pharmaceutical preparations is the most common etiology of exogenous vitamin D toxicity.

Etiologic Aspects of Hirsutism in Kashmiri Women Presenting to a District Hospital in Northern State of India

To assess the etiological aspects of hirsutism in Kashmiri women presenting to a district hospital in the northern state of India. Methods: Design: Prospective evaluation of hirsute patients referred to our endocrinology clinic. Setting: District-level primary care hospital. Patient(s): 150 consecutive women referred for hirsutism. Intervention(s): Assessment of body hair as per the Ferriman and Gallwey scoring system and an investi-gative protocol including detailed clinical assessment with endocrinologic workup including estimations of gonadotropins, PRL, T, and 17- hydroxyprogesterone and abdominopelvic ultrasound. Main Outcome Measure: Cause of hirsutism. Results: The etiology of hirsutism revealed idiopathic hirsutism in 35%, polycystic ovary syndrome (PCOS) in 35%, postmenopausal state in 12%, adrenal and ovarian tumors in 5 %, congenital adrenal hyperplasia in 2 %, and drug-induced hirsutism in 6 %. The cause remained undetermined in 5 % of patients for whom the available information was not adequate. Conclusion: Hirsutism is as common a problem in the Kashmir Valley (India) as elsewhere in the world. Idiopathic hirsutism (35 %), PCOS (35 %), and postmenopausal state ( 12 %) are common causes of hirsutism. Late-onset congenital adrenal hyperplasia is a relatively uncommon cause of hirsutism in the Kashmir Valley.

Traumatic Brain Injury and Pituitary Dysfunction: A Tertiary Care Hospital Based Study

Traumatic brain injury (TBI), often is associated with lasting functional disability and represents a significant public health problem worldwide.It is one of the leading causes of death in young people in industrialized countries, and patients who survive suffer important clinical consequences, such as long-term cognitive, behavioral, and social defects. Aims and objectives: 1) To determine the frequency of acute corticotrophin deficiency in head injury patients with one week of TBI. 2) To determine the incidence of permanent hypopituitarism, 6 months after TBI in Kashmiri population - a potentially high-risk group: SS prone population.3) To study the factors affecting the development of hypopituitarism after TBI in Kashmiri population. Methods: This observational study was jointly carried out by the Departments of Endocrinology and Neurosurgery at the Sher-i-Kashmir Institute of Medical Sciences Srinagar (SKIMS) in collaboration with the Department of Immunology & Molecular Medicine of our institution. After obtaining formal consent, history and examination and baseline investigations, a hormonal profile for evaluation of pituitary dysfunction was taken within one week of presentation and later after 6 months of trauma including stimulation with glucagon injection. Results: RTA and fall from height were two common causes of head injury. GCS of the study subjects ranged from 3 to 15 with a median of 11, with 19 subjects (23.5%) having GCS of 8 or less. GCS varied from mild 6.5% to moderate 10.3% and severe 18.3% in terms of APACHE scores. Sick euthyroid syndrome and hypogonadism was seen in 83% and 60.5 % of patients in acute phase which after 6 months period settled at 5.65 and 17.6 % respectively. 52.6 and 18.4 % had one and two axis involvement at time of presentation and 14.3% and 59.5% had one and two axis involvement at 6 months interval of trauma. Conclusion: we conclude that hypopituitarism is a clinical condition much more common than previously thought. Considering the epidemiology of TBI and percentage of related hypopituitarism, we are facing a disease that is far more common than perceived one.

Screening, Evaluation and Management of Monogenic Form of Diabetes: A Hospital Based Experience

Maternally inherited diabetes with deafness is rare diabetes caused by a mitochondrial DNA defect. 85% of cases are associated with m.3243A N G mutation. The phenotypic heterogeneity of MIDD may be the consequence of different levels of mutated mtDNA among mitochondria in a given tissue. It is important to diagnose this form of diabetes because of the unique management issues and associated comorbidities. A very strong family history of diabetes, deafness and presence of retinal dystrophy should prompt an investigation for MIDD. Microvascular complications out of keeping with duration of diabetes are another clue to the diagnosis. Retinal and renal manifestations of mitochondrial disease may be confused for diabetic complications. Glutamic acid decarboxylase (GAD) autoantibody negativity in a nonobese diabetic is another clue. Cardiac conduction defects and GDM may also raise suspicion as to the diagnosis. Recognizing this etiology of DM should promote family screening, genetic counseling, screening of associated comorbidities, avoidance of metformin, and cautious use of statins. Methods: We screened a total of 125 patients with diabetes and after careful history and examination, family history and screening, focused examination by ENT and an ophtho specialist and imaging of brain along with fundus photography, we found out a total of 7 patients with monogenic diabetes. Results: Out of 125 patients screened ,there were 5 females and 2 males.5 out of 7 patients were having maternal history and were diagnosed after 4 to 12 years of diabetes duaration.5 out of 7 patients had neurological involvement and 4 out of 7 patients had hearing impairment.5 out of 7 patients had retinal findings on fundus photography. Conclusion: Recognizing this etiology of DM should promote family screening, genetic counseling, screening of associated comorbidities, avoidance of metformin, and cautious use of statins.