Prandial Insulins: A Person-Centered Choice.

PURPOSE OF REVIEW: Postprandial hyperglycemia, or elevated blood glucose after meals, is associated with the development and progression of various diabetes-related complications. Prandial insulins are designed to replicate the natural insulin release after meals and are highly effective in managing post-meal glucose spikes. Currently, different types of prandial insulins are available such as human regular insulin, rapid-acting analogs, ultra-rapid-acting analogs, and inhaled insulins. Knowledge about diverse landscape of prandial insulin will optimize glycemic management. RECENT FINDINGS: Human regular insulin, identical to insulin produced by the human pancreas, has a slower onset and extended duration, potentially leading to post-meal hyperglycemia and later hypoglycemia. In contrast, rapid-acting analogs, such as lispro, aspart, and glulisine, are new insulin types with amino acid modifications that enhance their subcutaneous absorption, resulting in a faster onset and shorter action duration. Ultra-rapid analogs, like faster aspart and ultra-rapid lispro, offer even shorter onset of action, providing better meal-time flexibility. The Technosphere insulin offers an inhaled route for prandial insulin delivery. The prandial insulins can be incorporated into basal-bolus, basal plus, or prandial-only regimens or delivered through insulin pumps. Human regular insulin, aspart, lispro, and faster aspart are recommended for management of hyperglycemia during pregnancy. Ongoing research is focused on refining prandial insulin replacement and exploring newer delivery methods. The article provides a comprehensive overview of various prandial insulin options and their clinical applications in the management of diabetes.

Effect of exercise-based rehabilitation on functional capacity and renal function in type 2 diabetes mellitus with nephropathy: a randomized controlled trial.

INTRODUCTION: Diabetic nephropathy is a growing public health challenge with implications on health. Renal function decline impacts the functional ability and overall health and well-being of individuals with diabetic nephropathy due to development of several renal manifestations. The objective of the study was to determine the effect of an exercise-based rehabilitation program on functional capacity and renal function among individuals with type 2 diabetic nephropathy. METHODS: A total of 283 individuals were screened and 60 eligible participants aged 45-70 years with diabetic nephropathy were randomly allocated (n = 30 each) to the intervention group (IG) and control group (CG), respectively. The study outcome measures comprised of functional capacity (6-min walk test) and renal function assessed at baseline, 12th week and 24th week. Participants allocated to IG received 12 weeks of exercise based rehabilitation (comprising of supervised + home-based exercises) along with standard care and followed-up till 24th week. RESULTS: The repeated measures ANOVA with Greenhouse-Geisser correction indicated significant timepoint*group interaction effect for 6-min walk distance F (1.71, 90.59) = 619, p < 0.001, serum creatinine F (1.23, 65.14) = 174.8, p < 0.001, estimated glomerular filtration rate F (1.15, 60.88) = 105.2, p < 0.001, serum urea F (1.48, 78.45) = 261.4, p < 0.001 and urine protein F (1.13, 59.82) = 4.58, p < 0.328. CONCLUSION: The study found that exercise based rehabilitation improved both functional capacity and renal function among individuals with type 2 diabetic nephropathy.

Efficacy and safety of once-weekly insulin icodec in type 2 diabetes: A meta-analysis of ONWARDS phase 3 randomized controlled trials.

AIM: Insulin icodec is a novel ultra-long action basal insulin analogue designed for once-weekly administration. With the merit of once-a-week administration, it promises better adherence and greater treatment satisfaction because of reduced injection frequency. The purpose of this study was to ascertain the efficacy and safety of once-weekly insulin icodec in comparison with other basal insulin analogues in the management of type 2 diabetes. MATERIALS AND METHODS: The PRISMA guidelines were followed during the conduct of this study. For the eligible studies, five databases and ClinicalTrials.gov were screened until July 2023. All randomized controlled trials comparing the efficacy and safety of insulin icodec in type 2 diabetes versus other insulin analogues were included. The extracted data were then analysed for meta-analysis using RevMan 5.3 software. RESULTS: Five clinical trials with 3764 participants were included. The meta-analysis showed that once-weekly insulin icodec had higher glycated haemoglobin (HbA1c) reduction [mean difference -0.17%, 95% confidence interval (CI; -0.28 to -0.06), p = .003], with no significant difference in fasting plasma glucose compared with other insulin analogues. HbA1c achievement <7% [odds ratio 1.51, 95% CI (1.14-1.99), p = .004] and HbA1c achievement <7% without hypoglycaemia [odds ratio 1.45, 95% CI (1.26-1.67), p < .00001] were observed in higher proportions with insulin icodec compared with the comparator group. The percentage of time spent in the target glycaemic range was comparatively similar between insulin icodec and the comparator [mean difference 2.42%, 95% CI (0.01-4.84), p = .05]. There was a significantly higher incidence of level 1 hypoglycaemia with insulin icodec but no significant difference was seen for the incidence of levels 2, 3 and combined 2/3 hypoglycaemia. Any adverse events and adverse events related to basal insulin were comparably similar in insulin icodec and comparators. The subgroup analysis of once-weekly insulin icodec with individual insulin analogues (glargine U100 and degludec) showed that insulin icodec had similar efficacy with insulin glargine U100 but superior efficacy with higher HbA1c reduction with insulin icodec compared with insulin degludec. The safety profile was comparable between insulin icodec and glargine U100, whereas insulin icodec reported higher incidence of hypoglycaemia events and any adverse events when compared with degludec. CONCLUSION: Once-weekly insulin icodec showed a better HbA1c reduction with a higher proportion of patients achieving HbA1c targets in comparison with once-daily basal insulin analogues. They were no major safety concerns with respect to hypoglycaemia or adverse events.

Development and Testing of an Electronic Diabetes Diary Integrated With a Hospital Information System for Individuals With Type 2 Diabetes Mellitus: Protocol for a Mixed Methods Study.

BACKGROUND: Type 2 diabetes mellitus (T2DM) is one of the leading noncommunicable diseases that require diabetes self-management (DSM) practices. This study proposes to develop a customized mobile health (mHealth) app integrated with a hospital information system (HIS) to enable real-time, two-way transfer of information between the patient and physician. The captured information in the electronic health record will facilitate physicians to have a chronological account of the patient's diabetes history and enable tweaking of the treatment. OBJECTIVE: The objectives of the study are (1) to develop the HIS-integrated Electronic Diabetes Diary (EDDy) per the end-user expectations at a tertiary care hospital in a south Indian state with a high prevalence of T2DM and (2) to evaluate and test adherence to EDDy in the management of T2DM. METHODS: The study will be carried out in 3 phases. Phase 1 involved in-depth interviews with primary end users to gather information regarding their expectations from the hospital-based EDDy. Phase 2 will use this information to develop a customized mHealth app using an iterative model of software development. Phase 3 will involve a pre- and posttest design; the developed app will be tested among consenting patients, where physicians will receive the patients' data through the HIS-integrated mHealth app. The pre- and posttest values will be analyzed for adherence leading to improvement in patients' self-management of blood glucose, user experience, glycemic control, and clinical utility. RESULTS: Phase 1 was completed on November 28, 2023. Phase 2 commenced in December 2023 and will end in May 2025. Phase 3 will follow afterward. CONCLUSIONS: The proposed app will include a convenient and simple alert system that enables the patient to test glucose values at self-selected intervals, provide grading options to enter diabetic-related complications, enhance patients' knowledge of tracking and managing the complications of diabetes, and help in maintaining the visual representation of glucose values and complications. The simplicity and usability of the modules are its novelty, which may motivate the patients to keep track of their glucose values and help them attain better health outcomes. TRIAL REGISTRATION: Clinical Trial Registry India CTRI/2023/03/051077; http://tinyurl.com/4tau4ndb. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): PRR1-10.2196/50732.

Effectiveness of Photobiomodulation Therapy on Neuropathic Pain, Nerve Conduction and Plantar Pressure Distribution in Diabetic Peripheral Neuropathy - A Systematic Review.

BACKGROUND: Diabetic peripheral neuropathy is a severe complication of type 2 diabetes mellitus. The most common symptoms are neuropathic pain and altered sensorium due to damage to small nerve fibers. Altered plantar pressure distribution is also a major risk factor in diabetic peripheral neuropathy, leading to diabetic foot ulcers. OBJECTIVE: The objective of this systematic review was to analyze the various studies involving photobiomodulation therapy on neuropathic pain and plantar pressure distribution in diabetic peripheral neuropathy. METHODS: We conducted a systematic review (PubMed, Web of Science, CINAHL, and Cochrane) to summarise the evidence on photobiomodulation therapy for Diabetic Peripheral Neuropathy with type 2 diabetes mellitus. Randomized and non-randomized studies were included in the review. RESULTS: This systematic review included eight studies in which photobiomodulation therapy showed improvement in neuropathic pain and nerve conduction velocity. It also reduces plantar pressure distribution, which is a high risk for developing foot ulcers. CONCLUSION: We conclude that photobiomodulation therapy is an effective, non-invasive, and costefficient means to improve neuropathic pain and altered plantar pressure distribution in diabetic peripheral neuropathy.

Perspectives of patients and healthcare professionals on metabolic monitoring of adult prescribed second-generation antipsychotics for severe mental illness: A meta-synthesis.

OBJECTIVES: We conducted a meta-synthesis of qualitative studies to synthesize the views of psychiatric patients on second-generation antipsychotics (SGAs) and the healthcare providers about the metabolic monitoring of adult-prescribed SGAs. METHODS: A systematic search was conducted in four databases through SCOPUS, PubMed, EMBASE, and CINAHL to identify qualitative studies of patients' and healthcare professionals' perspectives on the metabolic monitoring of SGAs. Initially, titles and abstracts were screened to exclude articles that were not relevant followed by full-text reading. Study quality was assessed by using Critical Appraisal Skills Program (CASP) criteria. Themes were synthesized and presented as per the Interpretive data synthesis process (Evans D, 2002). RESULTS: A total of 15 studies met the inclusion criteria and were analyzed in meta-synthesis. Four themes were identified: 1. Barriers to metabolic monitoring; 2. Patient related concerns to metabolic monitoring; 3. Support system by mental health services to promote metabolic monitoring; and 4. Integrating physical health with mental health services. From the participants' perspectives, barriers to metabolic monitoring were accessibility of services, lack of education and awareness, time/resource constraints, financial hardship, lack of interest on metabolic monitoring, patient capacity and motivation to maintain physical health and role confusion and impact on communication. Education and training on monitoring practices as well as integrated mental health services for metabolic monitoring to promote quality and safe use of SGAs are the most likely approaches to promote adherence to best practices and minimize treatment-related metabolic syndrome in this highly vulnerable cohort. CONCLUSION: This meta-synthesis highlights key barriers from the perspectives of patients and healthcare professionals regarding the metabolic monitoring of SGAs. These barriers and suggested remedial strategies are important to pilot in the clinical setting and to assess the impact of the implementation of such strategies as a component of pharmacovigilance to promote the quality use of SGAs as well as to prevent and/or manage SGAs-induced metabolic syndrome in severe and complex mental health disorders.

Maternal Serum Zinc, Copper, Magnesium, and Iron in Spontaneous Abortions.

Twenty five percent of pregnant women have some degree of vaginal bleeding during the first trimester, and about 50% of those pregnancies end in spontaneous abortion (SA) because the fetus is not developing typically. As studies have reported that inadequacies of trace metals such as Copper (Cu), Zinc (Zn), Magnesium (Mg) can predispose to various adverse pregnancy outcomes (PO); multiple micronutrient (MMN) supplementations are given without justifying their deficiency and toxicities on the fetus. Earlier studies on effects of MMN supplementations during pregnancy have not considered the need, duration, dose, and time of initiation of supplementations leading to inconclusive results. So, there is a need to optimize this to prevent their abuse and side effects. This study can help in establishing critical cut-offs of these minerals in maternal serum that can forecast future pregnancy outcomes. Study measured the serum Zn, Cu, Mg, and Fe in pregnant women who presented with (n = 80) and without (n = 100) SA at 5-2 weeks of pregnancy using iron -ferrozine method, magnesium-calmagite method, zinc reaction with nitro-PAPS, copper reaction with Di-Br- PAESA methods, respectively. Data analyzed using the student t test and cutoff value was established using Receiver Operating Characteristic (ROC) by SPSS software. Maternal serum Cu, Mg, Fe, and Zn levels measured were significantly lower in SA as compared to that of controls (p < 0.005) (Fig. 1) and maternal age and Body mass index were not statistically significant different among study group. Maternal serum Cu, Mg, Zn and Iron (Fe) measured in 5-12 weeks of pregnancy has the potential to forecast future occurrence of SA. The study has been registered under "The Clinical Trials Registry- India (CTRI)," -REF/2020/01/030393.

Role and Clinical Significance of Monocarboxylate Transporter 8 (MCT8) During Pregnancy.

The review aims to summarize the available research focusing on the importance of monocarboxylate transporter (MCT8) in thyroid hormone trafficking across the placenta and fetal development. A systematic search was carried out in PubMed; studies available in English related to "monocarboxylate transporter", "adverse pregnancy", "fetal development," and "thyroid hormone" were identified and assessed. The references within the resulting articles were manually searched. MCT8 is a highly active and selective thyroid hormone transporter that facilitates the cellular uptake of triiodothyronine (T3), thyroxine (T4), reverse triiodothyronine (rT3), and diiodothyronine (T2) in different tissues. MCT8 is expressed in the placenta from the first trimester onwards, allowing the transport of thyroid hormone from mother to fetus. Mutations in MCT8 cause an X-linked disorder known as Allan-Herndon-Dudley syndrome (AHDS), characterized by severe psychomotor impairment and peripheral thyrotoxicosis. Hence, any maternal thyroid dysfunction may cause severe consequences for the fetus and newborn. Further research regarding MCT8 gene expression, polymorphic variation, and adverse pregnancy outcomes must be done to establish that MCT8 is a novel prognostic marker for the early detection of pregnancy-related complications.

Effectiveness of self-management applications in improving clinical health outcomes and adherence among diabetic individuals in low and middle-income countries: a systematic review.

INTRODUCTION: A variety of mobile health (mHealth) applications are available to monitor an individual's health or lifestyle to make it convenient to access healthcare facilities at home. The usability of mHealth applications in controlling HbA1c (estimated average blood glucose) levels is unclear despite their increasing use. The burden of type 2 diabetes mellitus (T2DM) is high in low and middle-income countries (LMICs), with the highest burden in the Indian population. Our objective is to identify the effectiveness of mHealth applications in managing blood glucose levels of individuals with T2DM and to assess the impact of using mHealth applications in managing T2DM concerning health-promoting behaviour among the LMICs in the context of India. METHODS AND ANALYSIS: The electronic databases included for search are PubMed, Ovid Medline, EBSCO, CINAHL, Scopus, Web of Science and the Cochrane Central Register of Controlled Trials; additional sources of the search will be grey literature available on diabetes management websites and reference lists of included studies. Studies published in the English language in indexed and peer-reviewed sources will be considered. Studies reporting the effectiveness of mobile applications in the management of T2D in LMICs will be eligible for inclusion. The Population-Intervention-Comparison-Outcomes framework and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement 2021 will be used for reporting. Data analysis will be carried out using narrative synthesis, and a meta-analysis may be conducted if we come across homogenous data for the outcome. ETHICS AND DISSEMINATION: As this study is a systematic review, we will not be recruiting any participants for the study and hence will not require ethical approval. The study summary will be disseminated at a conference. PROSPERO REGISTRATION NUMBER: CRD42021245517.

The Emptiness Within: A Case of Empty Sella Syndrome.

Empty Sella syndrome (ESS) is characterized by the sella turcica being filled with cerebrospinal fluid (CSF), leading to partial or total compression of the pituitary gland, often resulting in hormonal deficiencies. It can be primary or secondary. In patients presenting with complaints of generalized weakness and fatiguability, with multiple episodes of prior hospitalizations, a thorough history and evaluation can lead to a diagnosis. We report a case of a 50-year-old lady with recurrent admissions for hyponatremia. Based on biochemical parameters and brain imaging, she was diagnosed to have ESS. We report this case to highlight the various diagnostic challenges associated with panhypopituitarism and the importance of having a high clinical suspicion, as the treatment is simple and lifesaving.

Metabolic Bone Disease in Children With Transfusion-Dependent Thalassemia.

OBJECTIVE: This study aimed to detect metabolic bone disease and endocrinopathies in a cohort of patients with transfusion-dependent thalassemia (TDT). METHODS: This prospective study was conducted between March 2020 - August 2021. Children with TDT older than 5 years, receiving regular blood transfusion, underwent comprehensive endocrine and metabolic bone disease evaluation, which included screening for short stature, delayed puberty, diabetes mellitus, hypothyroidism, adrenal insufficiency and hypoparathyroidism. Children older than 10 years also underwent. X-ray of thoracolumbar spine, and dual energy X-ray absorptiometry (DXA) scanning. RESULTS: Out of 37 patients (19 males), with mean (SD) age 15 (6) years, hypogonadism was the commonest endocrine deficiency seen in 15 (62%), followed by short stature, abnormal glucose metabolism, subclinical adrenal insufficiency, hypothyroidism, and hypoparathyroidism. Vitamin D insufficiency/deficiency was seen in 12 (60%) and hypocalcemia in 2 patients. Low bone mass was seen in 8, and osteoporosis, as evidenced by vertebral fractures, in 4 patients. Of the four patients with vertebral fracture, three were aged ≤18 years, one was symptomatic, two each had grade 1 and grade 2 fractures, one had multiple vertebral fractures, and all four had hypogonadism and multiple endocrine deficiencies. CONCLUSION: Vertebral fractures occur even in the second decade among patients with TDT, and are often associated with endocrinopathies, most commonly hypogonadism. Early screening and prevention of vertebral fractures is necessary.

Sertoli-Leydig cell ovarian tumour: a rare cause of virilisation and androgenic alopecia.

Sertoli-Leydig cell tumours (SLCTs) represent a rare cause of hyperandrogenic state. SLCTs are sex cord ovarian neoplasms, accounting for <0.2% of all ovarian tumours. Most of the sex cord-stromal tumours have a benign clinical course, with 10%-20% of them at risk of aggressive course. We report a case of a woman in her 30s who presented with androgenic alopecia, virilisation and secondary amenorrhoea. The evaluation revealed an extremely high testosterone level. Imaging for the localisation of source of excess testosterone with contrast-enhanced CT of the abdomen revealed a right ovarian mass. Hence, a diagnosis of testosterone-secreting ovarian tumour was considered. The patient underwent right salphingo-oophorectomy, and histopathology was reported as Sertoli cell tumour. Postoperatively, there was normalisation of serum testosterone levels with decrease in virilisation and resumption of spontaneous menstrual cycles. The patient conceived spontaneously after 2 months of surgery.

A mysterious case of recurrent fracture: Tumour-induced osteomalacia.

We report a case of tumour-induced osteomalacia in a 59-year-old man who presented with a long-standing history of myalgia, bone pain and pathological fracture of the bilateral femur at different intervals in the past 4 years. A biochemical evaluation revealed hypophosphatemia secondary to phosphaturia. Localization study by Ga-68 DOTANOC PET-CT for adult-onset hypophosphatemic osteomalacia revealed a tumour in the right femoral head. Resection of the tumour resulted in clinical improvement as well as normalization of biochemical parameters.

Neonatal thyrotoxicosis with maternal hypothyroidism.

Neonatal Graves' is uncommon, but a potentially fatal condition caused by transplacental transfer of thyroid stimulating immunoglobulin (TSI). It is seen in 1%-5% of infants born to a mother with Graves' disease. Here, we report a unique case of transient neonatal thyrotoxicosis with positive TSI in a premature neonate born to the mother with primary hypothyroidism. A short course of antithyroid drug treatment leads to significant clinical and biochemical improvement followed by complete recovery.

Micronutrients in Adverse Pregnancy Outcomes.

About 10 to 20% of reported pregnancies have complications like spontaneous abortion (SA), preeclampsia (PE), preterm birth (PTB), and fetal growth restriction (FGR); 60% are attributed to maternal nutritional alterations. Multiple micronutrients (MMN) are supplemented in the antenatal period, but no proper validation/guidelines are available regarding dosing/time, the need for initiation, and the duration of supplementation. Studies have reported adverse pregnancy complications related to the overuse/unwanted use of multiple micronutrient supplementations during pregnancy. Identifying the exact population requiring supplementation is necessary to prevent its abuse. This article attempts to review the impacts of micronutrient deficiency/supplementation in cases of SA, FGR, and gestational diabetes mellitus (GDM), preterm delivery and PE. The study used a literature search using PubMed, Google Scholar, Mendeley, and Scopus Databases using search words pregnancy, spontaneous abortion, gestational diabetes mellitus (GDM), fetal growth restriction (FGR), preterm delivery, preeclampsia (PE) or "adverse pregnancy" associated with minerals, micronutrients, or supplementation. The review also considered in-house literature databases, a single-window search at Kasturba Medical College (KMC) Health sciences library, MAHE (Manipal Academy of Higher Education). The figures included in the study were created by Biorender.com. Micronutrients play multiple roles during pregnancy and fetoplacental growth stimulating growth hormone secretion, Lysyl oxidase (LOX), involved in the crosslinking between collagen and elastin in the amniotic membrane, downregulation of interleukin (IL)-1 alpha, IL-1 beta, IL-4, IL-6, Il-10, IL-12, tumor necrosis factor (TNF)-alpha and several chemokines involved in hypertension, immune-inflammatory pathways, attenuate insulin resistance, structural development of neurons and glia. Over-supplementation has led to complications such as spontaneous abortion and gestational diabetes mellitus. Since there is a lack of standardization concerning micronutrient supplementation during pregnancy, there is a need for systematic study related to the role of micronutrients during each trimester of pregnancy to optimize its supplementation and to prevent hazards associated with its abuse.

Allele-specific PCR and Next-generation sequencing based genetic screening for Congenital Adrenal Hyperplasia in India.

Genetic screening of Congenital Adrenal Hyperplasia (CAH) is known to be challenging due to the complexities in CYP21A2 genotyping and has not been the first-tier diagnostic tool in routine clinical practice. Also, with the advent of massive parallel sequencing technology, there is a need for investigating its utility in screening extended panel of genes implicated in CAH. In this study, we have established and utilized an Allele-Specific Polymerase Chain Reaction (ASPCR) based approach for screening eight common mutations in CYP21A2 gene followed by targeted Next Generation Sequencing (NGS) of CYP21A2, CYP11B1, CYP17A1, POR, and CYP19A1 genes in 72 clinically diagnosed CAH subjects from India. Through these investigations, 88.7% of the subjects with 21 hydroxylase deficiency were positive for eight CYP21A2 mutations with ASPCR. The targeted NGS assay was sensitive to pick up all the mutations identified by ASPCR. Utilizing NGS in subjects negative for ASPCR, five study subjects were homozygous positive for other CYP21A2 variants: one with a novel c.1274G>T, three with c.1451G>C and one with c.143A>G variant. One subject was compound heterozygous for c.955C>T and c.1042G>A variants identified using ASPCR and NGS. One subject suspected for a Simple Virilizing (SV) 21 hydroxylase deficiency was positive for a CYP19A1:c.1142A>T variant. CYP11B1 variants (c.1201-1G>A, c.1200+1del, c.412C>T, c.1024C>T, c.1012dup, c.623G>A) were identified in all six subjects suspected for 11 beta-hydroxylase deficiency. The overall mutation positivity was 97.2%. Our results suggest that ASPCR followed by targeted NGS is a cost-effective and comprehensive strategy for screening common CYP21A2 mutations and the CAH panel of genes in a clinical setting.

Brown tumour mimicking skeletal metastasis.

Brown tumours of bone are highly vascular osteolytic lesions that depict a reparative cellular process instead of a neoplastic process in hyperparathyroidism (HPT) patients. These tumours have the potential to be aggressive and destructive. We report a case of a 30-year-old woman who presented with left thigh and lower back pain. The radiological evaluation showed multiple bony lesions in the pelvis and the spine, which mimicked multiple metastatic tumours. However, on biochemistry evaluation, serum calcium, alkaline phosphatase, and parathyroid hormone were all high, while serum phosphate was low, indicating primary HPT (PHPT), which was confirmed by parathyroid scintigraphy showing left parathyroid adenoma. Hence, the bony lesions were diagnosed as brown tumours secondary to PHPT. The patient underwent parathyroidectomy and developed severe hungry bone syndrome requiring parenteral calcium infusion along with oral calcium and active vitamin D supplementation. The clinical symptoms of bone pain improved after surgery.

Quadriplegia and rhabdomyolysis as a presenting feature of Conn's syndrome.

Conn's syndrome is an important endocrine cause for secondary hypertension. Hypokalaemia paralysis and rhabdomyolysis with accelerated hypertension may be the presenting symptoms of Conn's syndrome. Here, we present one such case of a 38-year-old woman presenting with accelerated hypertension and acute onset quadriplegia. On biochemical evaluation, she was found to have severe hypokalaemia, metabolic alkalosis and elevated creatinine phosphokinase. Further evaluation revealed an elevated aldosterone renin ratio suggestive of primary hyperaldosteronism which was localised to left adrenal adenoma on contrast-enhanced CT. Patient's blood pressure and serum potassium levels normalised after resection of the adrenal adenoma.

DXA Measured Visceral Adipose Tissue, Total Fat, Anthropometric Indices and its Association With Cardiometabolic Risk Factors in Mother-Daughter Pairs From India.

Visceral fat is the pathogenic fat depot associated with diabetes, dyslipidemia, and cardiovascular diseases. Estimation of visceral adipose tissue (VAT) by dual energy-X-ray absorptiometry (DXA) is a newer technique with less radiation exposure, shorter scanning time, and lower cost. In this study, we attempted to look at relationship between cardiometabolic risk factors and VAT, total body fat percent (TBF%) and anthropometry. We also studied the changes in body composition and metabolic parameters with menopause. The familial resemblance of VAT and TBF% in mother-daughter pair was also compared. This was a cross sectional community study of 300 women (150 postmenopausal mothers and 150 premenopausal daughters). Body composition indices by DXA and metabolic parameters were assessed. The association between DXA-VAT, TBF%, anthropometric measures, and cardiometabolic risk factors were studied by correlation, receiver operating characteristics curves, and logistic regression analysis. VAT indices were significantly higher and lean indices lower in postmenopausal women as compared to premenopausal women. One fourth of postmenopausal women were categorized as metabolically obese normal weight. DXA-VAT was a better predictor of cardiometabolic risk factors as compared to waist circumference, body mass index, and TF% in postmenopausal women (AUC:0.68 vs 0.62, 0.60 & 0.5, respectively), whereas body mass index had a better prediction in premenopausal women(AUC:0.68). VAT area >100 cm² had a significant association with the presence of ≥2 cardiometabolic risk factors (p = 0.04, OR: 2.2, CI:1.0-4.7) in the postmenopausal women. Daughters of the mothers with higher TBF% were found to have a higher TBF% compared to daughters of mothers with normal TBF% (36.2 ± 4.2 vs 32.2 ± 4.4, p = 0.03), similar resemblance was not seen for VAT. The study showed that the VAT increases and lean mass decreases with age and menopause. DXA measured VAT is a better predictor of cardiometabolic risk in postmenopausal women but not in premenopausal women. Total body fat may have a familial resemblance, but not the VAT which is determined by age, menopause, and probable life style factors.

Insulin autoimmune syndrome: a rare cause of spontaneous hypoglycaemia in non-diabetic individuals.

Insulin autoimmune syndrome (IAS) is a rare cause of hypoglycaemia, characterised by recurrent hypoglycaemic episodes secondary to insulin autoantibodies in individuals who are not exposed to exogenous insulin. We are reporting a case of IAS in a 64-year-old gentleman, who presented with predominant postprandial hypoglycaemic episodes. On biochemical evaluation, he was found to have hyperinsulinemic hypoglycaemia. Localisation studies with MRI abdomen and endoscopic ultrasound (EUS) were negative for pancreatic tumour. Tests sent for insulin antibody levels were elevated. The patient was treated with frequent meals, acarbose and glucocorticoids. Patient condition improved and did not experience hypoglycaemia on follow-up.