Acanthosis nigricans: a dermatologic marker of metabolic disease.

Most patients with acanthosis nigricans have either clinical or subclinical insulin resistance. We undertook a study to estimate the insulin sensitivity of a group of patients referred from the dermatologist with biopsy proven acanthosis nigricans. Thirty-six patients were evaluated in the Endocrinology clinic. Plasma glucose and serum Insulin levels were estimated after a 75 gms oral glucose load (OGTT). An intravenous Insulin Tolerance Test (ITT) was performed with measurement of Glucose Disposal Rate (GDR). There were 28 females and 8 males (M:F--3.5:1; mean age 26.3+/-1.7 years) in the study. 25/36 patients were morbidly obese (BMI--36.0 +/- 1.2 Kg/m2) with an abnormal body fat distribution (WH ratio--0.9 +/ - 0.02). One patient had generalized lipoatrophy. 16/36 patients with acanthosis nigricans had IGT or overt diabetes and all had highly significant hyperinsulinemia (AUCI = 20825 +/ 1287.7 vs. 6340.0 +/- 984.2 mIU/ml/hr in controls, p < 0.0005). The GDR in patients with acanthosis nigricans was reduced (-0.66 +/- 0.07) compared to controls (-0.39 +/- 0.08; p < 0.01). There was a significant positive correlation between indices of adiposity and insulin resistance in subjects with impaired tolerance.

A study of insulin resistance in subjects with acanthosis nigricans.

AIM: To study the prevalence of insulin resistance (IR) and its sequelae in patients with acanthosis. METHODOLOGY: Thirty six patients (28 females; eight males) with biopsy proven acanthosis nigricans and eight controls were evaluated for insulin sensitivity (IS) by estimating (a) the glucose and insulin responses to a 75 gm glucose load (Oral glucose tolerance test-OGTT), (b) the glucose disposal rate (GDR) during an intravenous insulin tolerance test (ITT). Serum androgen levels (testosterone--Te, androstenedione--ASD, Dehydro-epiandrosterone sulphate--DHEAS) were estimated in the basal state and 60 min after a bolus of insulin. Thyroid function tests (tri-iodo-thyronine--T3, thyroxine--T4, thyroid stimulating hormone--TSH) were performed in all subjects. RESULTS: The acanthotic population, overall had insignificant hyperglycemia (Area under curve of glucose--AUC-G : 17,745.5 +/- 847.5 v/s 11,051.3 +/- 274.5 mg/dl/min) and hyperinsulinemia (Area under curve of insulin -AUC-I: 20,825.2 +/- 1,287.7 v/s 6,340.1 +/- 984.2 microlU/ml/min) compared to controls during OGTT. Eight patients with acanthosis nigricans had impaired glucose tolerance and eight had overt diabetes using WHO criteria. 69.4% of the acanthotic subjects were obese and 13.9% (5/36) were hypertensive. Thyroid dysfunction was present in three (one had hypothyroidism and two had thyrotoxicosis). Reproductive disorders--menstrual irregularity (46.5%), amenorrhea (21.4%), hirsuitism (21.4%) and infertility (3.6%) was encountered in a significant number of acanthotics. Acanthotics overall had statistically higher levels of androgens; Te (females)--0.74 +/- 0.09 v/s 0.27 +/- 0.09 ng/ml (p < 0.005), ASD--1.8 +/- 0.21 v/s 0.94 +/- 0.2 ng/ml (p < 0.005) and DHEAS--1,880.8 +/- 216.3 v/s 772.8 +/- 210.4 ng/ml (p < 0.005). An elevated DHEAS correlated positively to body mass index (BMI) and android obesity. Serum Te levels correlated positively with GDR. Serum insulin levels increased progressively with obesity and acanthosis. Serum insulin was associated with progressive worsening of hyperandrogenism (as seen in non-obese controls, non-obese and obese acanthotics). CONCLUSIONS: Subjects with acanthosis nigricans should be screened for insulin resistance and its clinical and metabolic sequelae. Thyroid dysfunction should be sought in these subjects as it can be easily treated.

Microalbuminuria in insulin dependent diabetes mellitus.

This study aimed to evaluate the prevalence of microalbuminuria (MAU) and albumin excretion rate (AER) in a timed overnight (12 hours) urine sample, in 72 insulin-dependent-diabetic (IDD) patients and to correlate the same to the clinical profile, glycemic control and to diabetic complications. Nine IDD patients (prevalence--12.5%) were detected to be microalbuminuric. Males had significantly higher prevalence of MAU (17.4%) than females (3.8%; p < 0.05). The prevalence of MAU was 4% in the third decade of age, 15% each in the fourth and fifth and 28.6% and 60% in the sixth decade and above (p < 0.05%). Prevalence of MAU also increased progressively with duration of diabetes. It increased from 8.3% (< 5 yrs) to 12.5% (6-10 yrs) and 33.3% (> 15 yrs). High AER in obese patients--33.1 +/- 23.2 v/s 11.4 +/- 3.4 micrograms/min in lean patients supports an association of obesity with albuminuria. Higher prevalences of MAU (62.5%; p < 0.001) was observed in hypertensive IDD patients in comparison to normotensive patients (3.6%). AER in patients with borderline hypertension (21.0 +/- 14.5 micrograms/min; p < 0.05) and in overt hypertensives (49.1 +/- 19.2 micrograms/min; p < 0.0005) were significantly higher compared to normotensive IDD-patients (6.2 +/- 2.4 micrograms/min). Prevalence of MAU and AER increased progressively with the deterioration of glycemic control. Well controlled subjects were normoalbuminuric. The incidence of MAU increased from 11.1% in fairly controlled (NS) and 21.1% in poorly controlled (p < 0.01) subjects. Also AER increased significantly from 2.4 +/- 0.5 micrograms/min. to 9.8 +/- 6.7 and 23.1 +/- 7.3 micrograms/min with the deterioration of glycemic control. Glycemic control in terms of glycated hemoglobin (GHb) did not show much agreement with the prevalence of MAU and AER, though they worsened with deteriorating control. The prevalences of peripheral neuropathy (PN) (34.4% v/s 33.3%) and diabetic retinopathy (DR) (9.8% v/s 11.1%) were similar in normo- and microalbuminuric patients. Patients with PN had high AER (15.2 +/- 6.3 micrograms/min). Also, AER was significantly high in patients with DR (27.7 +/- 23.5 micrograms/min; p < 0.05). High prevalences of cardio-vascular disease (CVD) (33.3%; p < 0.05) were observed in microalbuminuric compared to normoalbuminuric (1.6%) patients. Also AER was significantly high in association with CVD (53.9 +/- 21.9 micrograms/min; p < 0.0005). It can be concluded that, in IDD patients, MAU is common in males, older individuals and subjects with longer duration of diabetes. Raised blood pressure and hyperglycemia were identified as risk factors for the development of MAU.

Microalbuminuria in non-insulin dependent diabetes mellitus.

Non-insulin-dependent diabetes mellitus (NIDDM) is the commonest form of diabetes. The aim of this study was to evaluate the nature and prevalence of microalbuminuria (MAU) in NIDDM. One hundred and twenty-eight NIDDM patients participated in this study on the prevalence of microalbuminuria and albumin excretion rate (AER). An attempt was made to correlate them to the clinical profile, glycemic control and to diabetic complications. Eighteen patients had MAU with 14.1% prevalence (males--17.5% v/s females--10.8%; NS). Prevalence of MAU was higher in the third and fourth decades of age (28.6%) with a decrease in the fifth decade (12.5%). Prevalence of MAU also increased progressively with duration of diabetes--13 to 14% (< 10 yrs) to 25% (> 10 yrs). High AER in obese patients (13.4 +/- 5.5 v/s 7.9 +/- 1.4 micrograms/min) supports an association of obesity with albuminuria. The prevalence of MAU in patients with borderline and overt hypertension was not statistically different from that in normotensive NIDDM patients. However, NIDDM with borderline hypertension showed high AER 16.2 +/- 5.6 micrograms/min compared to 7.8 +/- 1.3 micrograms/min in normotensives. Prevalence to MAU and AER increased progressively with the deterioration of glycemic control--from 3.3% in well controlled to 18.9% in fairly controlled (P < 0.5) and 31% in poor controlled patients (P < 0.01). Also AER increased significantly from 3.9 +/- 0.8 to 12.3 +/- 4.1 and 18.4 +/- 4.6 micrograms/min, in patients with well to fairly and poorly controlled glycemia respectively. The prevalence of MAU and AER did not correlate with glycated hemoglobin (GHb) levels. The prevalences of peripheral neuropathy (PN) (42.6% v/s 55.6%) were similar in normo- and microalbuminuric patients. Patients with PN had high AER 11.9 +/- 2.7 micrograms/min. Diabetic retinopathy (DR) was equally prevalent in normo- and microalbuminuric NIDDM patients of (20.4% v/s 22.2), and AER was not significantly higher (12.1 +/- 4.3 micrograms/min) in NIDDM with retinopathy. High prevalences of cardiovascular disease (CVD) in MAU-NIDDM (22.2%; NS) was observed compared to normoalbuminuric (9.3%) patients. Also AER was significantly high in NIDDM associated with CVD (21.9 +/- 10.9 micrograms/min; P < 0.025). It can be concluded that, MAU is more prevalent in third and fourth decades and with longer duration of diabetes. Poor glycemic control was identified as a risk factor as in IDDM for development of MAU. MAU was a marker of generalised vascular dysfunction.

Prevalence of islet cell antibodies and its correlation with glucose and insulin response to oral glucose tolerance test in 1st degree relatives of insulin dependent diabetes mellitus probands.

93 first degree relatives (1st DR) of insulin dependent diabetes mellitus (IDDM) patients were investigated for detection of islet cell antibodies (ICA) and beta cell functional status. ICA were detected in 26.9% Ist DR subjects (25/93), equally in parents, siblings and offspring. Normal (n = 16), impaired (n = 5) and diabetic (n = 4), glucose curves were seen in 1st DR. Low insulin levels were observed in parents and siblings with normal glucose tolerance test (N-GTT) at 90 min (p < 0.05), and (p < 0.0005) relatives with impaired glucose tolerance and diabetes. Insulin release to glucose (IRG-insulinogenic index) in control group was 352 +/- 42 mu U/mg. From the group of 25 ICA positive cases, 4 had mean IRG of 394 +/- 70 mu U/mg (group A) comparable to control, and had N-GTT; 12 had mean IRG of 107 +/- 15.9 mu U/mg (group B) significantly low (P < 0.005) compared to controls and group A and 9 showed IRG of 75 +/- 29.3 mu U/mg, lower than group B (NS) with abnormal response to glucose load. Loss of insulin secretory ability thus can precede hyperglycemia by years. The ICA positive relatives were grouped based on the immunological status with their probands. ICA status in probands does not give an idea about ICA status in their relatives. This indepth study leads to understand the correlation of genetic, metabolic and immunological parameters for early detection of IDDM in first degree relatives.

Prevalence of islet cell antibodies and B cell functional status in insulin dependent diabetes.

As autoimmunity is an important factor in the etiopathogenesis of IDDM, 85 ketosis prone i.e. insulin dependent diabetes (IDD) were evaluated for immunological and beta cell functional status. Islet cell antibodies (ICA) against purified islet cells used in Microwell ELISA Method, were detected in 27.1% of cases (23/85). There was a prevalence of 36.4% of ICA positivity in newly diagnosed cases and its prevalence declined with duration. The highest ICA positivity was observed in fourth decade of life. 17 of the 23 ICA positive cases (73.9%) had a mean duration of 2.1 years whereas the remaining 6/23 (26.1%) had a mean duration of 9 years. Females showed a younger age of onset of diabetes. Only one female with duration of 10 years tested positive for ICA.ICA positive males had later age of onset and longer duration of diabetes as compared to ICA positive females. Ten ICA positive cases studied were showing non-significant C-peptide (CP) release (after glucose load) in comparison to negative cases (14); p < 0.05, 8 of these cases were with < 3 months duration. Significantly low delta % C-peptide response implies a low residual beta-cell function and further loss of beta cell function earlier in ICA +ve cases. Thus this study leads to understand in depth the immune mechanism of IDDM.

C-peptide profiles in young diabetics.

Fifty-six patients who had been diagnosed diabetic prior to the age of 30 were evaluated to determine the C-peptide (CP) secretory response to a glucose load. These individuals were classified clinically as having insulin dependent (IDDM = 18); non-insulin dependent (NIDDM = 19) and insulin requiring diabetes (IRDM = 19). Insulin dependent diabetics had lower basal CP levels (0.44 +/- (SE) 0.1 ng/ml) which were not stimulated by hyperglycaemia (0.55 +/- 0.13 ng/ml) as compared to controls (basal CP = 1.6 +/- 0.2 and peak 6.2 +/- 0.8 ng/ml). Non-insulin dependent diabetics and insulin requiring diabetics could be divided broadly into two groups - one, a set of patients with low basal CP levels (NIDDM = 0.63 +/- 0.09 ng/ml) (IRDM = 0.38 +/- 0.08 ng/ml) and a blunted response to a glucose load (peak response NIDDM = 0.83 +/- 0.05 ng/ml, IRDM = 0.59 +/- 0.12 ng/ml) and a second group who had CP reserve evident in both fasting (NIDDM = 1.6 +/- 0.2 ng/ml; IRDM = 2.1 +/- 0.6) and post-glucose levels (Peak Response NIDDM = 4.6 +/- 0.4 ng/ml; IRDM = 3.0 +/- 0.6 ng/ml). Growth Hormone (GH) and cortisol levels were found to be high in patients with IDDM and IRDM with no insulin reserve and these did not suppress during the oral Glucose Tolerance Test. NIDDM patients with no insulin reserve had normal GH and high cortisol levels. It is emphasized from this study that insulin sensitivity is as important as the insulin secretory status in determining the presenting features of diabetes mellitus in the young.

Use of hCG stimulation test in women immunized with beta-hCG vaccine.

Eleven normally menstruating women, who had earlier been immunized with NII beta-hCG vaccine but had no detectable anti-hCG antibody titres, were selected as controls for the hCG challenge test using 1000/2000 I.U. The test was repeated in five of them after a booster immunization, which raised antibody titres to 18-450 ng/ml. Stimulation of serum progesterone secretion was used as an index of corpus luteum (CL) response to the I.V. hCG. In the control group, the progesterone (P) secretory response following hCG stimulus showed peak levels which were significantly higher than basal levels in all except 2 subjects. The non-responsiveness in 2 subjects cannot be easily explained but may be dose-related. No significant difference was noted between the two dose levels. Length of luteal phase was increased by 4-5 days in 6 out of 20 cycles studied. The results of this test in 5 women before and after the vaccine boosters were encouraging as peak P levels appeared higher than basal levels in controls, but not so in the immunized group. However, these results could not be confirmed statistically. Nonetheless, this study is suggestive that the antibodies generated by this vaccine were capable of intercepting the effect of exogenous hCG in the human female. Further studies with more subjects and higher dosage of hCG are called for.

Evaluation of endocrine parameters in clinical trials with beta-hCG vaccine.

This report presents data on various endocrine parameters with respect to pituitary-ovarian axis in-depth in control vs 18 subjects immunized with three beta-hCG based vaccine formulations. Hormonal parameters such as TSH, PRL, ACTH, progesterone, cortisol, T3 and T4 were measured by RIA in sera in control pre-vaccine cycles as well as at 3, 6, and 12 months after primary vaccine immunization. In 6 women urinary E1G, PdG, LH and FSH were measured by ELISA/RIA tests on early morning urine (EMU) samples collected throughout the menstrual cycle in control vs post-booster vaccine cycles. The results indicated that none of the beta-hCG vaccine formulations altered the pituitary peptide or steroid hormone levels in blood at any time during the period of study. Serum P concentration was adequate and indicative of ovulatory cycle in almost all the cycles during the study. The in-depth study on urinary excretion pattern and levels of gonadotropins and E1G and PdG throughout the control vs post-vaccine booster cycles conclusively showed that pituitary-ovarian axis was not adversely affected by the vaccine.

Hypothyroidism in children/adolescents. Clinical and hormonal profiles.

This paper describes the clinical, hormonal and radiologic profiles in 282 children evaluated for hypothyroidism. Short stature, mental retardation or puberal disturbances were often the presenting features in the older age group, whereas in the 1-5 years age group medical opinion was usually sought for symptomatology suggestive of thyroid hypofunction. Children in the 0-1 year group were suspected on the basis of psychomotor dysfunction. Skeletal immaturity was found in 93.0% of patients with overt hypothyroidism and in 36.6% cases with normal thyroid profiles but associated with malnutrition. High TSH levels were noted in 70.9% of the cases studied. 4.9% and 7.3% patients with normal TSH had low T3, and T4 levels respectively. FSH, testosterone and PRL levels were also affected in some patients with overt hypothyroidism. Therapeutic responses based on at least 1 year follow up were available in 170 cases. The results are discussed.

Clinical and immunological responses with Pr- beta-hCG-TT vaccine.

Six different batches of Pr-beta-hCG-TT vaccine have been evaluated in 23 women for the antibody response. The anti-sera formed against these conjugates were capable of reacting immunologically with the whole hCG in radioimmunoassays and also neutralized the biological activity of hCG in radioreceptor assays. The antibody titres attained peak levels 4-6 months after the first injection. The peak titres could not be sustained and most of the subjects showed a spiky pattern. One subject was considered as non-respective, two others had fairly low titres. Amongst the conjugates tested, batch 108 with SPLPS (sodium pthalate denatured with lipo-polysaccharides from S. entritides) seemed more promising, but the addition of the adjuvant was found to be pyrogenic and unlikely to be accepted clinically.

Use of plasma receptor test for HCG in fertility regulation.

PIP: A highly sensitive and specific pregnancy test, based on a radio-ligand assay system, is described; it was developed out of a need for more precision in pregnancy testing in a country which advocates menstrual regulation for pregnancy termination. The assay is based on identification of human chorionic gonadotropin by a plasma receptor and labeled antigen, and can be performed in about 60 minutes. Results of 428 serum samples collected from various clinical conditions were presented; these showed that the test had an accuracy of 99.7% in positive samples. Confirmation of these results was made by clinical follow-up, bioassays, histopathology, and radioimmunoassays. The only disadvantage to this test is the necessity for a radio-labeled isotope, and hence it can only be performed in areas and laboratories so equipped. The test's usefulness in cases of ectopic pregnancy, menstrual regulation, and threatened abortions is emphasized.^ieng

Metabolic and endocrine studies in women using norethindrone acetate implant.

Subcutaneously administered implant-D containing 40 mg of Norethindrone acetate in a single silastic implant was offered to 79 subjects who desired spacing of their family. The effect of constant release of steroid from this device on metabolic and endocrine functions was studied. Each subject in the pretreatment state served as her own control. The device was removed at 8 months initially and subsequently at 5-6 months. The clinical acceptability of this method was fairly high. The results reported in this study show that Norethindrone acetate administered in this way did not cause any adverse reactions on endocrine and metabolic functions as gauged by the parameters analysed.

Use of a radioreceptor test for HCG in women practicing contraception.

The importance of a simple, rapid and highly sensitive test for the diagnosis of early pregnancy cannot be overemphasized. In the present times when newer delivery systems of contraceptive agents and menstrual regulation procedures are increasingly used for fertility regulation, it is inevitable that confirmation of early pregnancy poses a severe problem. This radioreceptor test has been found to be very reliable even in early cases. A positive test was 100% accurate for pregnancy whereas the accuracy of a negative test was found to be 94.4%. Confirmation of these results was done by various other parameters like clinical, histological, radioimmunoassay for HCG and biological test for pregnancy.

PIP: An evaluation of a radioreceptor assay (RRA) for detection of early pregnancy is reported. Following delayed or irregular periods, 250 women were tested using the RRA. The test requires only .1 ml of plasma and the results are obtained within 2 hours. There were 179 positive tests, all of which were confirmed by other methods to be 100% accurate. The test was given to all but 7 of the patients within 2 weeks of the missed period. It is concluded that the RRA is more sensitive than most other immunological tests and less time-consuming than the radioimmunoassay.