Do proximal hip geometry, trabecular microarchitecture, and prevalent vertebral fractures differ in postmenopausal women with type 2 diabetes mellitus? A cross-sectional study from a teaching hospital in southern India.

This study from southern India showed that the trabecular microarchitecture and proximal hip geometry were significantly impaired in postmenopausal women with diabetes as compared to age and BMI matched non-diabetic controls. This is despite there being no significant difference in bone mineral density at the femoral neck and hip not between both groups. One-third of the study subjects with type 2 diabetes had prevalent vertebral fractures. Bone mineral density assessment as a standalone tool may not adequately reflect bone health in subjects with diabetes. INTRODUCTION: There is limited information with regard to bone health in Indian postmenopausal women with type 2 diabetes. We studied the bone mineral density (BMD), trabecular bone score (TBS), prevalent vertebral fractures (VF), proximal hip geometry, and bone mineral biochemistry in ambulatory postmenopausal women with and without type 2 diabetes mellitus (T2DM). METHODS: This was a cross-sectional study conducted at a tertiary care center. BMD, TBS, prevalent vertebral fractures, and hip structural analysis (HSA) were assessed using a dual-energy X-ray absorptiometry (DXA) scanner. Bone mineral biochemical profiles were also studied. RESULTS: A total of 202 ambulatory postmenopausal women known to have type 2 diabetes mellitus with mean (SD) age of 65.6 (5.2) years and 200 age and BMI matched non-diabetic controls with mean (SD) age of 64.9 (4.7) years were recruited from the local community. Although the prevalence of lumbar spine osteoporosis was significantly lower among cases (30.7%) as compared to controls (42.9%), the prevalence of degraded bone microarchitecture (TBS < 1.200) was significantly higher among cases (51%) than in controls (23.5%); P < 0.001. Prevalent vertebral fractures were not significantly different in cases and controls. The various geometric indices of the proximal hip were significantly impaired in subjects with diabetes as compared to controls. CONCLUSION: This study may highlight the utility of the trabecular bone score and hip structural analysis in subjects with diabetes, where the bone mineral density tends to be paradoxically high, and may not adequately predict fracture risk.

Vitamin D assessment and precision of clinical referrals: Insights gained from a teaching hospital in southern India.

OBJECTIVE: Vitamin D deficiency is widely prevalent worldwide. This has led to a significant surge in referrals for vitamin D assessment in recent years. The cost-effectiveness and rationalization of this practice is uncertain. This study aimed to evaluate the referral pattern for vitamin D testing from a tertiary center in southern India. MATERIALS AND METHODS: This was a cross-sectional study done over a period of one year (2017). A total of 95,750 individuals, referred for vitamin D screening were included in this study. Details regarding referring departments and indications for referral were obtained from the computerized hospital information processing system (CHIPS). RESULTS: The study population exhibited a female preponderance (54.1%) with mean (SD) age of 40.3 (18.5) years. Overall, 44% were found to have vitamin D deficiency. Most of the referrals were from nephrology (15.4%), neurology (10.1%), and orthopedics (9.1%). Nevertheless, dermatology, the staff-clinic, and hematology which contributed to 3.3%, 1.7%, and 1.7% of referrals, had a higher proportion of vitamin D deficiency of 59.1%, 57.7%, and 64.6%, respectively. Although the most common indications for referral were generalized body aches (20.5%) and degenerative bone disorders (20.1%), the proportion of subjects with vitamin D deficiency referred for these indications were 46.1% and 41.6%, respectively. In contrast, chronic steroid use that accounted for 3.3% of the referrals had 59.1% of subjects who were deficient in vitamin D. CONCLUSION: To ensure a rational approach to vitamin D testing, clinicians ought to use their discretion to screen those truly at risk for vitamin D deficiency on a case to case basis and avoid indiscriminate testing of the same.

Hypophosphataemic osteomalacia due to cadmium exposure in the silver industry.

Chronic heavy metal exposure and the health hazards that ensue are important public-health problems. We highlight the occurrence of hypophosphataemic osteomalacia due to chronic cadmium exposure in the silver industry in India. Three silversmiths presented similarly with clinical, biochemical and radiological evidence of hypophosphataemic osteomalacia. Considering their occupation, their blood samples were screened for heavy metals and were found to have toxic levels of cadmium. They were initiated on neutral phosphate and calcitriol. On follow-up, they reported significant reduction in severity of symptoms. It is essential to maintain a high index of suspicion in diagnosing this condition. A thorough knowledge of the occupational background of patients, as well as ambient conditions at the workplace is of utmost importance in contemplating the possibility of such rare occurrences. Moreover, regulatory agencies and policy makers ought to survey the silver industry and ensure that the metals used are within permissible safe limits of exposure.

Can ARFI elastography be used to differentiate parathyroid from thyroid lesions?

OBJECTIVES: To assess if elasticity score (ES) and shear wave velocity (SWV) measurement obtained using ARFI elastography can differentiate between parathyroid lesions and thyroid nodules. MATERIALS AND METHODS: ARFI elastography was performed on patients with primary hyperparathyroidism or solid thyroid nodules who were being considered for surgery using virtual touch quantification and virtual touch imaging (VTI) software. Only patients with surgical histopathology (47 parathyroid lesions, 38 benign thyroid nodules and 55 malignant thyroid nodules) were included for final analysis. SWV and ES of the parathyroid and thyroid nodules were compared and their ability to differentiate between parathyroid and thyroid was analyzed using receiver operating characteristic curve analysis. RESULTS: There were 39 solitary adenomas, 2 double adenomas and 4 parathyroid hyperplasias with mean size of 19.6 ± 9.7 mm in 44 patients (21 male, 23 females) with primary hyperparathyroidism. The mean SWV of the parathyroid lesion (1.6 ± 0.78 m/s) was significantly different from benign (2.11 ± 0.8 m/s) and malignant (4.3 ± 2.71 m/s) thyroid nodules, p < 0.05; so was the ES, Chi square = 51.6, p < 0.001. The majority of parathyroid lesions (n = 37, 78.7%) had ES of 2 with speckled (n = 42, 89.3%) appearance, and none showed ES of 4. The diagnostic performance of speckled appearance on VTI, elasticity score and SWV measurements was 0.901, 0.724 and 0.797, respectively, to differentiate between parathyroid and thyroid lesions. CONCLUSIONS: Parathyroid lesions are softer than thyroid nodules. A shear wave velocity of 1.72 m/s can differentiate between parathyroid lesions and thyroid nodules.

Anthropometric measurements for the prediction of the metabolic syndrome: a cross-sectional study on adolescents and young adults from southern india.

OBJECTIVES: To determine which anthropometric measurement correlates best with the metabolic abnormalities associated with the metabolic syndrome in adolescents and young adults. DESIGN: Cross-sectional study. SETTING: Schools, high schools and universities. PARTICIPANTS: 1359 adolescents and young adults aged 14-25 years. MAIN OUTCOME MEASURES: Anthropometric predictors of metabolic abnormalities as classified by International Diabetes Federation definition. RESULTS: The waist circumference (OR 1.56, 95% CI 1.0 to 2.43: p≤0.01) and the abdominal skin fold thickness (OR 1.44, 95% CI 1.02 to 2.04, p≤0.01) above the third quintile cut-offs were found to be significantly associated with metabolic abnormalities. The sensitivity of either one of these measurements in predicting metabolic abnormalities was 66.1% with a negative predictive value of 82.8%. Hyperglycaemia was significantly associated with an abdominal skin fold thickness over the fourth quintile alone (OR 1.63, 95% CI 1.24 to 2.1). All the anthropometric measurements correlated well with elevated triglycerides and hypertension. CONCLUSIONS: In a large community-based cross-sectional survey of subjects aged 14-25 years, the waist circumference and the abdominal skin fold thickness are important predictors of the metabolic abnormalities associated with metabolic syndrome. This simple clinical tool may help in a primary care setting to identify subjects who require a further biochemical evaluation and would considerably reduce the cost of unwarranted testing.

Klinefelter's syndrome with renal tubular acidosis: impact on height.

A 19-year-old Indian man presented with a history of proximal muscle weakness, knock knees and gynaecomastia. On examination he had features of rickets and bilateral small testes. Karyotyping revealed a chromosomal pattern of 47,XXX, confirming the diagnosis of Klinefelter's syndrome. He was also found to have hyperchloraemic metabolic acidosis with hypokalaemia, hypophosphataemia, phosphaturia and glycosuria, which favoured a diagnosis of proximal renal tubular acidosis. Patients with Klinefelter's syndrome typically have a tall stature due to androgen deficiency, resulting in unfused epiphyses and an additional X chromosome. However, this patient had a short stature due to associated proximal renal tubular acidosis. To the best of our knowledge, this is the second case of Klinefelter's syndrome with short stature due to associated renal tubular acidosis reported in the literature. This report highlights the need to consider other causes when patients with Klinefelter's syndrome present with a short stature.

Slipped upper femoral epiphysis in Hashimoto's thyroiditis in a 29-year-old man.

Slipped upper femoral epiphysis (SUFE) with an open physis is rare in an adult and the condition may present without prior diagnosis of an underlying medical condition. We have treated a 29-year-old man with bilateral SUFE associated with autoimmune hypothyroidism. The management was delayed and complicated by co-existing autoimmune chronic active hepatitis. He underwent thyroxine therapy and bilateral pinning in situ with a single ASNIS screw. Closure of the physis occurred after five months on the right side. The left side required a further corrective intertrochanteric osteotomy, and it was only after 13 months that complete fusion of this physis was seen. The case highlights the need to consider endocrine and metabolic conditions in atypical presentation of SUFE.

Pheochromocytoma and haemophilia: an unusual combination.

We report pheochromocytoma and haemophilia occurring in a 19-year-old South Indian man. To the best of our knowledge, this case is the first of its kind to be reported in the medical literature. The patient had bilateral adrenal pheochromocytomas with an extradrenal pheochromocytoma on the left side, and was successfully operated on after optimal preoperative blood pressure control and factor VIII support.

Foreign body aspiration in a boy with Prader-Willi Syndrome.

A five-year-old boy presented with progressive weight gain with effort intolerance and nocturnal symptoms suggesting obstructive sleep apnoea. A clinical diagnosis of Prader-Willi Syndrome was made. As the initial radiography and computed tomography suggested a foreign body, bronchoscopy was done under general anaesthesia and impacted peanuts were removed from the left main bronchus. His symptoms resolved instantly and the patient was asymptomatic at six months follow-up. This report highlights the need to consider foreign body aspiration as a cause for dyspnoea in children with Prader-Willi Syndrome. The report also focuses on the need to adopt strategies that prevent foreign body aspiration and choking in patients with Prader- Willi Syndrome.

Hyperostosis and hyperphosphataemia syndrome: a diagnostic dilemma.

The syndrome of hyperostosis and hyperphosphataemia (HHS) is very rare. It can mimic bone infections and tumours. A nine-year-old girl presented with pain in her left lower leg. Radiographs showed patchy sclerosis in the tibial diaphysis. Investigations were normal except for hyperphosphataemia. Open biopsy showed chronic inflammation. Bacterial cultures were negative. Four months later, she had pain in the other leg. On evaluation for hyperphosphataemia, there was increased renal reabsorption of phosphates. She responded to analgesics. In patients between six and 16 years of age, HHS must be considered when there is painful diaphyseal swelling of long bones associated with isolated hyperphosphataemia. The painful episodes can recur. Surgical decompression can be considered if conservative treatment methods are ineffective.

Antinociceptive and anti-inflammatory effects of the ethyl acetate stem bark extract of Bridelia scleroneura (Euphorbiaceae).

Bridelia scleroneura is a member of the Euphorbiaceae family. In folk medicine in Cameroon, the stem bark of this plant is used for relieving abdominal pain, contortion, arthritis and inflammation. In this study, the antinociceptive and anti-inflammatory activities of the ethyl acetate stem bark extract have been evaluated. The putative analgesic effect of the plant extract was examined in abdominal constriction, hot plate, formalin and on pain using tail immersion mouse models and in carrageenan-induced paw edema in rats. The extract (150-600 mg/kg) exhibited a dose-dependent analgesic effect (46.27-78.97%) in acetic acid-induced abdominal constriction in mice. B. scleroneura extract increased the pain latency of nociceptive response to thermal stimuli at the higher dose of 600 mg/kg. B. scleroneuna induced significant dose-dependent reduction of the nociception in both early and late phases of the formalin test. The extract at the dose of 300 mg/kg, increased significantly, by 63.70% and 52.01% the tail-immersion latency time, 1 and 2 h post-dosing. In the carrageenan test, B. scleroneura (150-600 mg/kg, p.o) had dose-dependent and significant effects at different time intervals. This behaviour was similar to indometacin (10 mg/kg) used as a standard drug. These results show that the ethyl acetate stem bark extract of B. scleroneura possesses peripheral and central analgesic properties as well as anti-inflammatory activity against acute inflammation processes, in support of the folk medicinal use of the plant.