Quality of life in postmenopausal women and its association with sarcopenia.

OBJECTIVES: With the menopausal transition, there is a decline in estrogen concentration with potential health consequences affecting the quality of life. The loss of muscle mass, strength, and function, known as sarcopenia is common in postmenopausal women. The primary objective of this study is to assess the quality of life in postmenopausal women and its association with sarcopenia. METHODS: This was a cross-sectional study conducted in 106 postmenopausal women. Menopausal symptoms and risk of sarcopenia were assessed with Menopause Rating Scale (MRS) and Strength Assistance walking Rising from a chair Climbing stairs and Falls (SARC-F) questionnaires, respectively. Sarcopenia was defined and assessed according to the Asian Working Group for Sarcopenia guidelines 2019. RESULTS: The mean age was 59.34 ± 7.21 years and the mean age at menopause was 49.50 ± 2.67 years. The majority (80.2%) of the women had high MRS scores (≥9). The majority had mild somatic, moderate psychologic, and severe urogenital symptoms. SARC-F score was low in 85.8% of women. Most of the women (45.3%) had sarcopenia. Somatic symptoms were significant in women with sarcopenia. Urogenital symptoms were significant with greater menopausal duration. Appendicular skeletal muscle mass index was significantly less with greater menopausal duration. MRS score positively correlated with both SARC-F score and sarcopenia. Sarcopenia was significantly associated with greater menopausal duration. CONCLUSIONS: Most of the women had moderate to severe MRS scores suggestive of a poor quality of life. The majority of the women had sarcopenia. Most of the women felt they were strong (according to SARC-F score) despite sarcopenia. Although quality of life did not differ significantly with the duration of menopause, urogenital symptoms were significantly severe with greater menopausal duration. Despite no significant association between quality of life and sarcopenia in postmenopausal women, somatic symptoms were significant in women with sarcopenia. The greater menopausal duration was associated significantly with sarcopenia.

Bone Mineral Density and Bone Turnover Marker in a Subclinical Thyrotoxic State in Young Premenopausal Women.

BACKGROUND: Subclinical thyrotoxicosis (SCH) is characterized by normal serum thyroid hormone levels and low thyrotropin levels. The impact of this condition on the skeletal system may vary depending on its cause, yet the relationship is not fully comprehended in premenopausal women. Studies are scarce about its effects on bone health in our population. OBJECTIVES: This study aims to evaluate the bone mineral density (BMD) and bone turnover markers in premenopausal women with SCH and determine if any differences exist based on the condition's etiology. METHODS: A cross-sectional study was conducted at Ramaiah Medical College involving 36 participants for one year and six months after approval from the Ethics Committee. The carboxy-terminal telopeptide of type I collagen in blood and BMD were measured at the lumbar vertebrae (L1-L4) and femoral neck by dual-energy x-ray absorptiometry (Hologic v 2.0, Hologic, Massachusetts, U.S.). Statistical analysis was done using IBM SPSS Statistics for Windows, Version 20 (Released 2011; IBM Corp., Armonk, New York, United States).  Results: The mean age of the study population was 35.2 ± 7.2 years. The etiology was Graves' disease [n=11 (33.3%)], iatrogenic [n=14(38.8%)], toxic adenoma [n=6 (15.1%)], and multi-nodular goiter [n=5 (15.1%)]. The mean BMI was 23.5 ± 3.8 kg/m2, and the mean levels of corrected calcium, phosphorus, and 25 hydroxy-vitamin D were 9.12 ± 0.25 mg/dl, 2.95 ± 0.34 mg/dl, and 29.4 ± 6.4 ng/ml, respectively. The mean BMD at hip and spine was 0.81 ±0.16 g/cm2 and 0.92±0.08 g/cm2 respectively. The mean Z-score was (-0.02 ± 0.8) and (-0.92± 0.08) at the hip and spine. No significant difference was observed in the BMD at the hip (p = 0.14) or spine (p = 0.44) between the endogenous and exogenous subclinical thyrotoxic subgroups. At the same time, the carboxy-terminal telopeptide of type I collagen was significantly different between the two groups (p<0.05). CONCLUSION: In our cross-sectional study of premenopausal women with SCH, BMD at the hip or spine as measured by dual-energy X-ray absorptiometry did not reveal any significant reduction. The subclinical thyrotoxic state may not have an adverse effect on bone health in premenopausal females with sufficient levels of serum 25-hydroxy-vitamin D in the short term.

Communicative compathy and chronic care.

The concepts of sympathy and empathy are well entrenched in social and medical literature. In this article, we explore a relatively less explored construct, compathy. Compathy, defined as feelings that are shared with others, is a higher level of emotional maturity, which helps in achieving better quality care. We propose further discussion and debate on how to measure, attain, and maintain compathy in chronic care practice.

Bringing an end to diabetes stigma and discrimination: an international consensus statement on evidence and recommendations.

People with diabetes often encounter stigma (ie, negative social judgments, stereotypes, prejudice), which can adversely affect emotional, mental, and physical health; self-care, access to optimal health care; and social and professional opportunities. To accelerate an end to diabetes stigma and discrimination, an international multidisciplinary expert panel (n=51 members, from 18 countries) conducted rapid reviews and participated in a three-round Delphi survey process. We achieved consensus on 25 statements of evidence and 24 statements of recommendations. The consensus is that diabetes stigma is driven primarily by blame, perceptions of burden or sickness, invisibility, and fear or disgust. On average, four in five adults with diabetes experience diabetes stigma and one in five experience discrimination (ie, unfair and prejudicial treatment) due to diabetes, such as in health care, education, and employment. Diabetes stigma and discrimination are harmful, unacceptable, unethical, and counterproductive. Collective leadership is needed to proactively challenge, and bring an end to, diabetes stigma and discrimination. Consequently, we achieved unanimous consensus on a pledge to end diabetes stigma and discrimination.

Experiences and expectations of physician communication: A focus group discussion with Indian patients with type 2 diabetes mellitus.

OBJECTIVES: This pilot study aimed to: (a) understand the experiences of Indian patients with type 2 diabetes mellitus and their expectations of their physicians during a medical consultation, (b) serve as a preliminary study to inform the development of a larger project exploring and improving patients' communication experiences, and (c) assess whether the pilot study findings indicate the viability of using the Relationship: Establishment, Development, and Engagement model of communication as the conceptual framework for the larger project. METHODS: Using convenience sampling, 11 patients participated in a focus group discussion. Conventional content analysis was used. RESULTS: Two themes were generated: (a) A plethora of negative feelings: experiences of the physician's verbal and nonverbal communication styles, and (b) 'I know what I want': Expectations of communication by patients from their physician. CONCLUSIONS: The medical encounter with the physician elicited a range of negative experiences and clear expectations from the patients with type 2 diabetes mellitus. This pilot points to the need for (a) a mixed methods approach to comprehensively examine the communication needs of patients with type 2 diabetes mellitus from their physician, (b) understand physicians' communication practices, and (c) using these findings, culturally adapt and test the Relationship: Establishment, Development, and Engagement to improve physicians' communication skills in India.

Improving emotional and psychosexual well-being screening in women living with polycystic ovary syndrome: experiences from the United Kingdom and India.

With increasing evidence of emotional well-being disorders associated with polycystic ovary syndrome (PCOS), effective screening processes are of utmost importance. We studied the impact of using questionnaires to screen for emotional and psychosexual well-being across different models of care for PCOS. We analysed the data from the surveys to assess the difference in the prevalence of emotional and psychosexual ill-being across ethnicity and region. In this prospective cohort study, we invited all women attending consultations for PCOS in Birmingham, UK, and Bengaluru and Navi Mumbai, India. Those who consented to participate in the study were invited to complete a pre-clinic survey about socio-demographic data, Hospital Anxiety and Depression Scale (HADS), Body Image Concern Inventory (BICI), Beliefs about Obese Person scale (BAOP), and Female Sexual Function Index score (FSFI) and a post-clinic survey on clinic experience, lifestyle advice, and specialist referral. A total of 115 women were included in this study. The rate of questionnaire completion was 98.3% (113/115), 97.4% (112/115), 93.04% (107/115), and 84.3% (97/115) for HADS, BICI, BAOP, and FSFI, respectively. In the post-clinic survey, 28.8% reported they were screened for anxiety, 27.1% for depression, and 45.8% for body image concerns. The prevalence of anxiety, depression, and body dysmorphic disorder through pre-clinic survey was 56.5% (50.0% UK vs 59.5% India, P = 0.483), 16.5% (13.9% UK vs 17.7% India, P = 0.529), and 29.6% (36.1% UK vs 26.6% India, P = 0.208), respectively. Surveys with validated questionnaires can improve screening for emotional and psychosexual well-being associated with PCOS which may be missed by ad hoc screening during consultations.

Pheochromocytoma: Clinical Experience From a Single Tertiary Care Center in India.

INTRODUCTION: Pheochromocytoma is a catecholamine-secreting tumor arising from adrenomedullary chromaffin cells that has a varied clinical presentation. Identification of this tumor, which has episodic symptoms, is a diagnostic challenge for clinicians. Diagnosis at an appropriate time is important because it is associated with significant morbidity and mortality. This study aims to mitigate the limited availability of data in our geographical area. AIMS AND OBJECTIVES: To assess the clinical, biochemical, and radiological features and outcomes of patients diagnosed with pheochromocytoma at our center. MATERIALS AND METHODS: This is a retrospective study. Patients diagnosed with pheochromocytoma during 2015-2023 were included in the study. Clinical, biochemical, and radiological data were collected at presentation, post-surgery, discharge, and until the last follow-up; data were retrieved from hospital records. Statistical analysis was done using IBM Corp. Released 2011. IBM SPSS Statistics for Windows, Version 20.0. Armonk, NY: IBM Corp. RESULTS: This study included 19 patients, of whom 10 (52.6%) were female. The most common clinical presentation was a hypertensive crisis in patients with pre-existing hypertension (63.1%), followed by headache (47.3%). The classical triad of headache, palpitation, and sweating was seen in only three patients (15.7%). The mean tumor size was 5.01±2.06 cm, with a range of 2.5 to 12 cm. All patients underwent adrenalectomy; six patients (31.5%) had perioperative complications, with post-operative hypotension being the most common at 21% (n = 4), followed by an acute coronary event during alpha blockade in one patient (0.05%) and an intra-operative hypertensive crisis in one patient (5%). A biochemical remission rate post-surgery was achieved in 17 (89.47%) patients. CONCLUSIONS: Hypertensive crisis in patients with pre-existing hypertension was the predominant presenting feature in most of our patients. Female predominance was noted (52.3%) compared to males. Perioperative complications were observed in 31.5% of patients, with post-operative hypotension being the most common complication.

Fitterfly Diabetes CGM Digital Therapeutics Program for Glycemic Control and Weight Management in People With Type 2 Diabetes Mellitus: Real-world Effectiveness Evaluation.

BACKGROUND: Digital therapeutic platforms facilitate health care through patient-centered strategies based on multidisciplinary teams and shared decision-making. Such platforms can be used for developing a dynamic model of diabetes care delivery, which can help in improving glycemic control by promoting long-term behavior changes in people with diabetes. OBJECTIVE: This study aims to evaluate the real-world effectiveness of the Fitterfly Diabetes CGM digital therapeutics program for improving glycemic control in people with type 2 diabetes mellitus (T2DM) after the completion of 90 days in the program. METHODS: We analyzed deidentified data of 109 participants in the Fitterfly Diabetes CGM program. This program was delivered through the Fitterfly mobile app coupled with continuous glucose monitoring (CGM) technology. This program consists of 3 phases: the first phase is observation, wherein the patient's CGM readings are observed for 7 days (week 1); the second phase is the intervention; and the third phase aims at sustaining the lifestyle modification introduced during the second phase. The primary outcome of our study was the change in the participants' hemoglobin A1c (HbA1c) levels after program completion. We also evaluated the changes in participant weight and BMI after the program, changes in the CGM metrics in the initial 2 weeks of the program, and the effects of participant engagement in the program on improving their clinical outcomes. RESULTS: At the end of the 90 days of the program, the mean HbA1c levels, weight, and BMI of the participants were significantly reduced by 1.2% (SD 1.6%), 2.05 (SD 2.84) kg, and 0.74 (SD 1.02) kg/m2 from baseline values of 8.4% (SD 1.7%), 74.45 (SD 14.96) kg, and 27.44 (SD 4.69) kg/m2 in week 1, respectively (P<.001). The average blood glucose levels and time above range values showed a significant mean reduction by 16.44 (SD 32.05) mg/dL and 8.7% (SD 17.1%) in week 2 from week 1 baseline values of 152.90 (SD 51.63) mg/dL and 36.7% (SD 28.4%), respectively (P<.001 for both). Time in range values significantly improved by 7.1% (SD 16.7%) from a baseline value of 57.5% (SD 25%) in week 1 (P<.001). Of all the participants, 46.9% (50/109) showed HbA1c reduction ≥1% and 38.5% (42/109) showed weight loss ≥4%. The average number of times the mobile app was opened by each participant during the program was 108.80 (SD 127.91) times. CONCLUSIONS: Our study shows that participants in the Fitterfly Diabetes CGM program showed a significant improvement in their glycemic control and reduction in weight and BMI. They also showed a high level of engagement with the program. Weight reduction was significantly associated with higher participant engagement with the program. Thus, this digital therapeutic program can be considered as an effective tool for improving glycemic control in people with T2DM.

IDEA Group Consensus Statement on Medical Management of Adult Gender Incongruent Individuals Seeking Gender Affirmation as Male.

Gender-affirming hormone therapy (GAHT) is the most frequent treatment offered to gender-incongruent individuals, which reduces dysphoria. The goal of therapy among gender-incongruent individuals seeking gender affirmation as male is to change their secondary sex characteristics to affect masculine physical appearances. GAHT greatly improves mental health and quality of life among gender incongruent individuals. India-specific guideline for appropriate care for gender-incongruent individuals is almost absent. This document is intended to assist endocrinologists and other healthcare professionals interested in gender incongruity for individuals seeking gender affirmation as male. A safe and effective GAHT regimen aims to effect masculinising physical features without adverse effects. In this document, we offer suggestions based on an in-depth review of national and international guidelines, recently available evidence and collegial meetings with expert Indian clinicians working in this field. Clinicians represented in our expert panel have developed expertise due to the volume of gender incongruent individuals they manage. This consensus statement provides protocols for the hormone prescribing physicians relating to diagnosis, baseline evaluation and counselling, prescription planning for masculinising hormone therapy, choice of therapy, targets for monitoring masculinising hormone therapy, clinical and biochemical monitoring, recommending sex affirmation surgery and peri-operative hormone therapy. The recommendations made in this document are not rigid guidelines, and the hormone-prescribing physicians are encouraged to modify the suggested protocol to address emerging issues.

Emotional and psychosexual well-being is influenced by ethnicity and birthplace in women and individuals with polycystic ovary syndrome in the UK and India.

OBJECTIVE: To assess the association of ethnicity and birthplace on emotional and psychosexual well-being in women with polycystic ovary syndrome (PCOS). DESIGN: Cross-sectional study. SETTING: Community recruitment via social media campaigns. POPULATION: Women with PCOS completing an online questionnaire in September-October 2020 (UK) and May-June 2021 (India). METHODS: The survey has five components, with a baseline information and sociodemographic section followed by four validated questionnaires: Hospital Anxiety and Depression Scale (HADS); Body Image Concern Inventory (BICI); Beliefs About Obese Persons Scale (BAOP); and Female Sexual Function Index (FSFI). MAIN OUTCOME MEASURES: We used adjusted linear and logistic regression models, adjusting for age, education, marital status and parity, to evaluate the impact of ethnicity and birthplace on questionnaire scores and outcomes (anxiety and/or depression, HADS ≥ 11; body dysmorphic disorder (BDD), BICI ≥ 72). RESULTS: A total of 1008 women with PCOS were included. Women of non-white ethnicity (613/1008) reported higher rates of depression (OR 1.96, 95% CI 1.41-2.73) and lower BDD (OR 0.57, 95% CI 0.41-0.79) than white women (395/1008). Women born in India (453/1008) had higher anxiety (OR 1.57, 95% CI 1.00-2.46) and depression (OR 2.20, 95% CI 1.52-3.18) but lower BDD rates (OR 0.42, 95% CI 0.29-0.61) than women born in the UK (437/1008). All sexual domains, excluding desire, scored lower for non-white women and women born in India. CONCLUSIONS: Non-white women and women born in India reported higher emotional and sexual dysfunction, whereas white women and women born in the UK reported higher body image concerns and weight stigma. Ethnicity and birthplace need to be considered for tailored, multidisciplinary care.

Consensus on Current Landscape and Treatment Trends of Obesity in India for Primary Care Physicians.

Objectives: The objective of this consensus article was to form a list of expert recommendations and an easily adaptable algorithm for obesity management in India by primary care physicians (PCPs). Methods: A Delphi-based model was followed to form a list of the consensus recommendations. Consensus statements were created from the results of a literature review that were graded as per the Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) criteria. After being evaluated by an expert panel comprising diabetologists, endocrinologists, cardiologists, bariatric surgeons, and gynecologists, the statements were revised and reevaluated by a larger group of practitioners, including PCPs and diabetologists, to arrive at a consensus. Results: The panel opined that obesity is increasing in prevalence in India and is projected to rise in the coming years. Body mass index and waist circumference were both recommended for better identification of people at risk of obesity-related comorbidities than either of them alone. The Edmonton Obesity Staging System (EOSS) was suggested as being most suitable for the assessment (staging) of obesity. A multidisciplinary team was considered invaluable for assessing and managing patients with obesity. The use of once-a-week semaglutide (2.4 mg) via the subcutaneous route was suggested as the first-choice anti-obesity treatment when pharmacotherapy is deemed necessary. An algorithm considering all these aspects was proposed. Conclusion: Obesity needs to be recognized as a significant contributor to other comorbidities. The diagnosis and management of obesity should be comprehensive and consider patient psychology, the presence or absence of comorbidities, available pharmacologic agents, and long-term outcomes. The proposed algorithm could help clinicians in this aspect and improve the overall outcomes. How to cite this article: Deshpande NR, Kapoor N, Dalal JJ, et al. Consensus on Current Landscape and Treatment Trends of Obesity in India for Primary Care Physicians. J Assoc Physicians India 2023;71(10):69-77.

Indian physicians' attitudes and practice regarding menopause and its management: a focus group discussion.

OBJECTIVES: To explore Indian physicians' attitudes and practice toward menopause and its management. To contribute to the larger project aimed at developing communication skills and decision aids for Indian physicians and women. METHODS: Using a cross-sectional design, purposive sampling, and a qualitative methodology, 10 Indian physicians (female, 6; male, 4; mean age, 51.5 years) who were practicing either endocrinology or gynecology were recruited to participate in a virtual focus group discussion. Questions explored physicians' attitudes toward menopause and their approach toward addressing menopause and related concerns with their patients. The focus group was analyzed using qualitative content analysis. RESULTS: Three main themes emerged: (1) "The only way to get over it is to accept it": Attitudes toward menopause, (2) "More than menopausal hormone therapy, it is empathy that's required": Physiological and psychological symptom management and (3) Matching the empathic intent with skills: A need for training in the management of menopause. CONCLUSIONS: The study findings underscore the need to introduce Indian physicians to empathic communication skills training, involve, and educate physicians about the international and national clinical guidelines regarding menopausal hormone therapy and alternative therapies, and techniques for distress screening and early referrals. VIDEO SUMMARY: http://links.lww.com/MENO/B17 .

Management of Glucocorticoid-Induced Hyperglycemia.

Glucocorticoids are potent immunosuppressive and anti-inflammatory drugs used for various systemic and localized conditions. The use of glucocorticoids needs to be weighed against their adverse effect of aggravating hyperglycemia in persons with diabetes mellitus, unmask undiagnosed diabetes mellitus, or precipitate glucocorticoid-induced diabetes mellitus appearance. Hyperglycemia is associated with poor clinical outcomes, including infection, disability after hospital discharge, prolonged hospital stay, and death. Furthermore, clear guidelines for managing glucocorticoid-induced hyperglycemia are lacking. Therefore, this consensus document aims to develop guidance on the management of glucocorticoid-induced hyperglycemia. Twenty expert endocrinologists, in a virtual meeting, discussed the evidence and practical experience of real-life management of glucocorticoid-induced hyperglycemia. The expert group concluded that we should be proactive in terms of diagnosis, management, and post-steroid care. Since every patient has different severity of underlying disease, clinical stratification would help understand patient profiles and determine the treatment course. Patients at home with pre-existing diabetes who are already on oral or injectable therapy can continue the same as long as they are clinically stable and eating adequately. However, depending on the degree of hyperglycemia, modification of doses may be required. Initiating basal bolus with correction regimen is recommended for patients in non-intensive care unit settings. For patients in intensive care unit, variable rate intravenous insulin infusion could be temporarily used, but under supervision of diabetes inpatient team, and patients can be transitioned to subcutaneous insulin once stable baseline assessment and continual evaluation are crucial for day-to-day decisions concerning insulin doses. Glycemic variability should be carefully monitored, and interventions to treat patients should also aim at achieving and maintaining euglycemia. Rational use of glucose-lowering drugs is recommended and treatment regimen should ensure maximum safety for both patient and provider. Glucovigilance is required as the steroids taper during transition, and insulin dosage should be reduced subsequently. Increased clinical and economic burden resulting from corticosteroid-related adverse events highlights the need for effective management. Therefore, these recommendations would help successfully manage GC-induced hyperglycemia and judiciously allocate resources.

The Weight of Words: Indian Physicians' Perspectives on Patient Communication to Promote Diabetes Adherence.

Background: Effective communication by physicians can lead to improved patient adherence, resulting in better patient outcomes and increased patient satisfaction. This study: (i) examined communication with patients when they were non-adherent, (ii) examined attitudes toward common communication cues, and (iii) explored communication approaches to encourage diabetes adherence used by Indian physicians. Methods: Using a concurrent mixed methods approach, Indian physicians, specialized in diabetes and/or endocrinology were recruited, to complete a survey containing quantitative (n = 834) and qualitative (n = 648) questions. The questions included (i) whether physicians expressed disappointment and used scare tactics for non-adherent patients, (ii) to rate the importance of common communication cues when promoting adherence, and (iii) nested, qualitative questions to understand their communication approach to promote adherence. The data were analyzed using descriptive statistics and qualitative content analysis, respectively. Results: The quantitative study reported that the majority of the physicians sometimes showed their disappointment in their patient's progress (44.4%), sometimes used scare tactics to convey disease severity due to non-adherence (34.3%), and rated all communication cues as most important. The qualitative findings revealed that physicians used paternalistic (authoritative, educational, authoritarian) or collaborative (multistakeholder, patient-centered) approaches and the language cues of fear, blame, and threats to promote patient adherence. Conclusion: These findings highlight the need for communication skill training programs for Indian physicians focused on empathic, non-verbal, supportive, and inclusive techniques so as to promote patient adherence. Further, these trainings need to use role-playing, video recording, and peer feedback methods to show physicians how to implement these skills during patient interactions.

Intensification of Gla-100 with Prandial Insulin: A Stepwise Progression Toward Glycemic Control.

The inadequate control of postprandial glucose (PPG) excursions, are linked in some studies with cardiovascular disease. Even though basal insulins, such as insulin glargine 100 U/mL (Gla-100), maintain overall glycemic control, effective PPG control eventually requires intensification of therapy by adding prandial insulins. Compared to conventional basal-bolus or premixed approaches, a stepwise basal-plus or basal-prandial intensification regimen involving the addition of one, two, or three prandial insulins to basal therapy such as Gla-100, has received much attention in recent times. This intensification approach is comparable to other conventional approaches in terms of glycemic control, and offers the additional advantages of fewer hypoglycemic events, personalization of therapy, and a simple self-management algorithm for titration. Owing to such benefits, recent guidelines recommend its use over other approaches for initiating intensification. It is preferred by both physicians and patients and is a better alternative to immediately embarking on a full basal-bolus regimen or introducing premixed insulin preparations for intensification of therapy.

Challenges in Women with Diabetes During the COVID-19 Pandemic.

The coronavirus disease 2019 (COVID-19) pandemic has created significant challenges for healthcare systems across the world. The disease seems to infect men and women in equal numbers, though trends suggest that men have greater morbidity. This has been attributed to differences in immunological response, expression of angiotensin-converting enzyme 2 (ACE2), prevalence of comorbidities, and health-related behaviours, such as smoking. However, this cannot be taken to mean that women are somehow protected. Advanced age, smoking, diabetes, hypertension, cardiovascular disease and chronic obstructive pulmonary disease have emerged as the leading contributors to increased morbidity and mortality from the disease. Women with diabetes form a vulnerable group as they often receive suboptimal diabetes care and support, even though they have a high burden of comorbidities and complications. While there are challenges in healthcare delivery during the pandemic, cardiometabolic care cannot be compromised, which calls for exploring new avenues of healthcare delivery, such as telemedicine. Pregnant women with diabetes should continue to receive quality care for optimal outcomes, and the psychological health of women also needs special consideration. The management of hyperglycaemia during COVID-19 infection is important to reduce morbidity and mortality from the infection. The gendered impact of outbreaks and quarantine goes beyond biomedical and psychological aspects, and the socioeconomic impact of the pandemic is likely to affect the long-term care of women with diabetes, which creates an urgent need to create effective policies and interventions to promote optimal care in this vulnerable group.

Serum CCL 18 Levels in Women with Polycystic Ovarian Syndrome.

BACKGROUND: Polycystic ovarian syndrome (PCOS) is one of the most common metabolic disorders seen in women of the reproductive age group, with the majority of them having insulin resistance. There is a need to identify sensitive markers of insulin resistance. CC chemokine ligand 18 (CCL 18) secreted from white adipose tissue is upregulated in individuals with insulin resistance. OBJECTIVES: To study the correlation between serum CCL 18 levels and insulin resistance in PCOS. MATERIALS AND METHODS: This case-control study included 45 PCOS women and an equal number of age and body mass index (BMI) matched controls. Estimation of serum CCL 18, serum testosterone, fasting plasma glucose, fasting insulin, HbA1c, and ultrasonography of abdomen and pelvis was done and HOMA IR was calculated. RESULTS: Serum CCL 18 level was higher in women with PCOS when compared to controls. The mean level of serum CCL 18 (ng/mL) in the PCOS group and control group was 28.32 ± 4.17 and 11.90 ± 4.91, respectively (P < 0.001). Blood pressure, waist circumference, waist-hip ratio, modified Ferriman Gallway score (FG) score serum total testosterone, fasting serum insulin, and HOMA IR showed a relationship with serum CCL 18 levels. Serum CCL 18 was an independent predictor of PCOS (P < 0.05). A serum CCL 18 cutoff level of 18.84 ng/mL showed 93.3% sensitivity and 91.7% specificity in distinguishing PCOS subjects from healthy individuals. CONCLUSION: There is a significant correlation of serum CCL 18 level with insulin resistance in PCOS subjects and serum CCL levels can be considered as a marker of PCOS.

IDEA Group Consensus Statement on Medical Management of Adult Gender Incongruent Individuals Seeking Gender Reaffirmation as Female.

Cross sex hormone therapy (CSHT) is a strongly desired medical intervention for gender incongruent individuals. The goal is to change secondary sex characteristics to facilitate gender presentation that is consistent with the desired sex. When appropriately prescribed CSHT can greatly improve mental health and quality of life for gender incongruent individuals. Appropriate care for gender incongruent individuals in India is almost absent due to lack of country specific guideline and lack of training amongst the medical professionals. This document is intended to assist endocrinologists and physicians whose adult gender incongruent client is seeking gender reaffirmation as female (transfeminine). These individuals require a safe and effective CSHT regimen that will suppress endogenous male hormone secretion and maintain physiologic levels of female sex hormone. In this document, we offer suggestions based on an in-depth review of Guidelines of Endocrine Society, The World Professional Association for Transgender Health guidelines, the Sappho Good Practice Guide of India and collegial meetings with expert Indian clinicians working in this field. Clinicians represented in our expert panel are not gender specialists by training but have developed expertise due to the volume of gender incongruent individuals they manage. This consensus statement on medical management provides protocols for the prescribing clinician relating to diagnosis, baseline evaluation and counselling, prescription planning for feminizing hormone therapy and anti-androgen therapy, targets for monitoring hormone therapy, choice of therapy, clinical and biochemical monitoring, recommending sex reaffirmation surgery and peri-operative hormone therapy. The recommendations made in this document should not be perceived as a rigid set of guidelines and the treating clinicians are encouraged to modify our suggested protocols to address emerging issues.

Serum Fibroblast Growth Factor 21 Levels in Patients with Hyperthyroidism and its Association with Body Fat Percentage.

BACKGROUND: Most of the actions of thyroid hormone (TH) on body metabolisms like maintenance of basal metabolic rate (BMR) and body fat are similar to that of fibroblast growth factor 21 (FGF21). We hypothesized that in patients with hyperthyroidism, the pathological changes in the BMR, body fat are mediated by TH through FGF21. OBJECTIVES: To study the association of serum FGF21 levels with hyperthyroidism and correlate body fat percentage with serum FGF21 levels in hyperthyroid patients. STUDY DESIGN: Case-control prospective follow-up study. METHODOLOGY: A total of 68 hyperthyroid patients and age, sex-matched healthy controls who fulfilled the inclusion and exclusion criteria were studied. Among them, 45 cases were followed up at 3 to 6 months after the achievement of euthyroidism. Body fat percentage was calculated from Jackson and Pollock 3 site equation and Siri equation. BMR percentage was calculated by the Gale formula. RESULTS: The mean age in years in the cases was similar to that of controls (36.14 ± 10.01 vs. 36.57 ± 10.53, P = 0.81). The serum FGF21 levels at baseline were significantly elevated in patients with hyperthyroidism compared to controls [median 406.6 pg/ml (interquartile range, 262.9-655.6) vs. 252.3 (125.1-341) P < 0.001] and declined dramatically following treatment with anti-thyroid drugs [405 (275.5-680.4) vs. 203.6 (154.6-230.6) P < 0.001]. Serum FGF21 levels negatively correlated with body fat percentage (r = -0.268, P = 0.002). After adjusting to various confounding factors, serum FGF21 was independently associated with hyperthyroidism and was significant. (OR [95%CI] 3.78 (1.046-13.666) P = 0.043). CONCLUSION: Serum FGF21 levels were elevated in hyperthyroid patients and decreased following treatment with anti-thyroid drugs. It was independently associated with hyperthyroidism. There may be a future therapeutic role of FGF21 inhibition in the reversal of these changes in addition to anti-thyroid drugs in patients with hyperthyroidism.