Journal of Clinical and Diagnostic Research, ISSN - 0973 - 709X

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On Sep 2018




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On Sep 2018




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"Journal of Clinical and Diagnostic Research is at present a well-known Indian originated scientific journal which started with a humble beginning. I have been associated with this journal since many years. I appreciate the Editor, Dr. Hemant Jain, for his constant effort in bringing up this journal to the present status right from the scratch. The journal is multidisciplinary. It encourages in publishing the scientific articles from postgraduates and also the beginners who start their career. At the same time the journal also caters for the high quality articles from specialty and super-specialty researchers. Hence it provides a platform for the scientist and researchers to publish. The other aspect of it is, the readers get the information regarding the most recent developments in science which can be used for teaching, research, treating patients and to some extent take preventive measures against certain diseases. The journal is contributing immensely to the society at national and international level."



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Lucknow
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On Aug 2018




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"Journal of Clinical and Diagnostic Research (JCDR) is a reputed peer reviewed journal and is constantly involved in publishing high quality research articles related to medicine. Its been a great pleasure to be associated with this esteemed journal as a reviewer and as an author for a couple of years. The editorial board consists of many dedicated and reputed experts as its members and they are doing an appreciable work in guiding budding researchers. JCDR is doing a commendable job in scientific research by promoting excellent quality research & review articles and case reports & series. The reviewers provide appropriate suggestions that improve the quality of articles. I strongly recommend my fraternity to encourage JCDR by contributing their valuable research work in this widely accepted, user friendly journal. I hope my collaboration with JCDR will continue for a long time".



Dr. Arundhathi. S
MBBS, MD (Pathology),
Sanjay Gandhi institute of trauma and orthopedics,
Bengaluru.
On Aug 2018




Dr. Mamta Gupta,
"It gives me great pleasure to be associated with JCDR, since last 2-3 years. Since then I have authored, co-authored and reviewed about 25 articles in JCDR. I thank JCDR for giving me an opportunity to improve my own skills as an author and a reviewer.
It 's a multispecialty journal, publishing high quality articles. It gives a platform to the authors to publish their research work which can be available for everyone across the globe to read. The best thing about JCDR is that the full articles of all medical specialties are available as pdf/html for reading free of cost or without institutional subscription, which is not there for other journals. For those who have problem in writing manuscript or do statistical work, JCDR comes for their rescue.
The journal has a monthly publication and the articles are published quite fast. In time compared to other journals. The on-line first publication is also a great advantage and facility to review one's own articles before going to print. The response to any query and permission if required, is quite fast; this is quite commendable. I have a very good experience about seeking quick permission for quoting a photograph (Fig.) from a JCDR article for my chapter authored in an E book. I never thought it would be so easy. No hassles.
Reviewing articles is no less a pain staking process and requires in depth perception, knowledge about the topic for review. It requires time and concentration, yet I enjoy doing it. The JCDR website especially for the reviewers is quite user friendly. My suggestions for improving the journal is, more strict review process, so that only high quality articles are published. I find a a good number of articles in Obst. Gynae, hence, a new journal for this specialty titled JCDR-OG can be started. May be a bimonthly or quarterly publication to begin with. Only selected articles should find a place in it.
An yearly reward for the best article authored can also incentivize the authors. Though the process of finding the best article will be not be very easy. I do not know how reviewing process can be improved. If an article is being reviewed by two reviewers, then opinion of one can be communicated to the other or the final opinion of the editor can be communicated to the reviewer if requested for. This will help one’s reviewing skills.
My best wishes to Dr. Hemant Jain and all the editorial staff of JCDR for their untiring efforts to bring out this journal. I strongly recommend medical fraternity to publish their valuable research work in this esteemed journal, JCDR".



Dr. Mamta Gupta
Consultant
(Ex HOD Obs &Gynae, Hindu Rao Hospital and associated NDMC Medical College, Delhi)
Aug 2018




Dr. Rajendra Kumar Ghritlaharey

"I wish to thank Dr. Hemant Jain, Editor-in-Chief Journal of Clinical and Diagnostic Research (JCDR), for asking me to write up few words.
Writing is the representation of language in a textual medium i e; into the words and sentences on paper. Quality medical manuscript writing in particular, demands not only a high-quality research, but also requires accurate and concise communication of findings and conclusions, with adherence to particular journal guidelines. In medical field whether working in teaching, private, or in corporate institution, everyone wants to excel in his / her own field and get recognised by making manuscripts publication.


Authors are the souls of any journal, and deserve much respect. To publish a journal manuscripts are needed from authors. Authors have a great responsibility for producing facts of their work in terms of number and results truthfully and an individual honesty is expected from authors in this regards. Both ways its true "No authors-No manuscripts-No journals" and "No journals–No manuscripts–No authors". Reviewing a manuscript is also a very responsible and important task of any peer-reviewed journal and to be taken seriously. It needs knowledge on the subject, sincerity, honesty and determination. Although the process of reviewing a manuscript is a time consuming task butit is expected to give one's best remarks within the time frame of the journal.
Salient features of the JCDR: It is a biomedical, multidisciplinary (including all medical and dental specialities), e-journal, with wide scope and extensive author support. At the same time, a free text of manuscript is available in HTML and PDF format. There is fast growing authorship and readership with JCDR as this can be judged by the number of articles published in it i e; in Feb 2007 of its first issue, it contained 5 articles only, and now in its recent volume published in April 2011, it contained 67 manuscripts. This e-journal is fulfilling the commitments and objectives sincerely, (as stated by Editor-in-chief in his preface to first edition) i e; to encourage physicians through the internet, especially from the developing countries who witness a spectrum of disease and acquire a wealth of knowledge to publish their experiences to benefit the medical community in patients care. I also feel that many of us have work of substance, newer ideas, adequate clinical materials but poor in medical writing and hesitation to submit the work and need help. JCDR provides authors help in this regards.
Timely publication of journal: Publication of manuscripts and bringing out the issue in time is one of the positive aspects of JCDR and is possible with strong support team in terms of peer reviewers, proof reading, language check, computer operators, etc. This is one of the great reasons for authors to submit their work with JCDR. Another best part of JCDR is "Online first Publications" facilities available for the authors. This facility not only provides the prompt publications of the manuscripts but at the same time also early availability of the manuscripts for the readers.
Indexation and online availability: Indexation transforms the journal in some sense from its local ownership to the worldwide professional community and to the public.JCDR is indexed with Embase & EMbiology, Google Scholar, Index Copernicus, Chemical Abstracts Service, Journal seek Database, Indian Science Abstracts, to name few of them. Manuscriptspublished in JCDR are available on major search engines ie; google, yahoo, msn.
In the era of fast growing newer technologies, and in computer and internet friendly environment the manuscripts preparation, submission, review, revision, etc and all can be done and checked with a click from all corer of the world, at any time. Of course there is always a scope for improvement in every field and none is perfect. To progress, one needs to identify the areas of one's weakness and to strengthen them.
It is well said that "happy beginning is half done" and it fits perfectly with JCDR. It has grown considerably and I feel it has already grown up from its infancy to adolescence, achieving the status of standard online e-journal form Indian continent since its inception in Feb 2007. This had been made possible due to the efforts and the hard work put in it. The way the JCDR is improving with every new volume, with good quality original manuscripts, makes it a quality journal for readers. I must thank and congratulate Dr Hemant Jain, Editor-in-Chief JCDR and his team for their sincere efforts, dedication, and determination for making JCDR a fast growing journal.
Every one of us: authors, reviewers, editors, and publisher are responsible for enhancing the stature of the journal. I wish for a great success for JCDR."



Thanking you
With sincere regards
Dr. Rajendra Kumar Ghritlaharey, M.S., M. Ch., FAIS
Associate Professor,
Department of Paediatric Surgery, Gandhi Medical College & Associated
Kamla Nehru & Hamidia Hospitals Bhopal, Madhya Pradesh 462 001 (India)
E-mail: drrajendrak1@rediffmail.com
On May 11,2011




Dr. Shankar P.R.

"On looking back through my Gmail archives after being requested by the journal to write a short editorial about my experiences of publishing with the Journal of Clinical and Diagnostic Research (JCDR), I came across an e-mail from Dr. Hemant Jain, Editor, in March 2007, which introduced the new electronic journal. The main features of the journal which were outlined in the e-mail were extensive author support, cash rewards, the peer review process, and other salient features of the journal.
Over a span of over four years, we (I and my colleagues) have published around 25 articles in the journal. In this editorial, I plan to briefly discuss my experiences of publishing with JCDR and the strengths of the journal and to finally address the areas for improvement.
My experiences of publishing with JCDR: Overall, my experiences of publishing withJCDR have been positive. The best point about the journal is that it responds to queries from the author. This may seem to be simple and not too much to ask for, but unfortunately, many journals in the subcontinent and from many developing countries do not respond or they respond with a long delay to the queries from the authors 1. The reasons could be many, including lack of optimal secretarial and other support. Another problem with many journals is the slowness of the review process. Editorial processing and peer review can take anywhere between a year to two years with some journals. Also, some journals do not keep the contributors informed about the progress of the review process. Due to the long review process, the articles can lose their relevance and topicality. A major benefit with JCDR is the timeliness and promptness of its response. In Dr Jain's e-mail which was sent to me in 2007, before the introduction of the Pre-publishing system, he had stated that he had received my submission and that he would get back to me within seven days and he did!
Most of the manuscripts are published within 3 to 4 months of their submission if they are found to be suitable after the review process. JCDR is published bimonthly and the accepted articles were usually published in the next issue. Recently, due to the increased volume of the submissions, the review process has become slower and it ?? Section can take from 4 to 6 months for the articles to be reviewed. The journal has an extensive author support system and it has recently introduced a paid expedited review process. The journal also mentions the average time for processing the manuscript under different submission systems - regular submission and expedited review.
Strengths of the journal: The journal has an online first facility in which the accepted manuscripts may be published on the website before being included in a regular issue of the journal. This cuts down the time between their acceptance and the publication. The journal is indexed in many databases, though not in PubMed. The editorial board should now take steps to index the journal in PubMed. The journal has a system of notifying readers through e-mail when a new issue is released. Also, the articles are available in both the HTML and the PDF formats. I especially like the new and colorful page format of the journal. Also, the access statistics of the articles are available. The prepublication and the manuscript tracking system are also helpful for the authors.
Areas for improvement: In certain cases, I felt that the peer review process of the manuscripts was not up to international standards and that it should be strengthened. Also, the number of manuscripts in an issue is high and it may be difficult for readers to go through all of them. The journal can consider tightening of the peer review process and increasing the quality standards for the acceptance of the manuscripts. I faced occasional problems with the online manuscript submission (Pre-publishing) system, which have to be addressed.
Overall, the publishing process with JCDR has been smooth, quick and relatively hassle free and I can recommend other authors to consider the journal as an outlet for their work."



Dr. P. Ravi Shankar
KIST Medical College, P.O. Box 14142, Kathmandu, Nepal.
E-mail: ravi.dr.shankar@gmail.com
On April 2011
Anuradha

Dear team JCDR, I would like to thank you for the very professional and polite service provided by everyone at JCDR. While i have been in the field of writing and editing for sometime, this has been my first attempt in publishing a scientific paper.Thank you for hand-holding me through the process.


Dr. Anuradha
E-mail: anuradha2nittur@gmail.com
On Jan 2020

Important Notice

Original article / research
Year : 2022 | Month : February | Volume : 16 | Issue : 2 | Page : OC14 - OC17 Full Version

Body Weight as a Major Determinant of Thyroxine Sodium Dosage in the Treatment of Primary Hypothyroidism


Published: February 1, 2022 | DOI: https://doi.org/10.7860/JCDR/2022/50989.15996
Surendra Kumar

1. Associate Professor, Department of Endocrinology, Patna Medical College, Patna, Bihar, India.

Correspondence Address :
Surendra Kumar,
Associate Professor, Department of Endocrinology, Patna Medical College,
Patna, Bihar, India.
E-mail: endodrsurendrakumar@gmail.com

Abstract

Introduction: Several formulae have been proposed for optimising the dosage prerequisites of levothyroxine (LT4), and body weight and Body Mass Index (BMI) have been suggested to be broadly dependent on the formulae range.

Aim: To evaluate the role of body weight as a determinant of LT4 dosage in the treatment of primary hypothyroidism.

Materials and Methods: The present study was a prospective observational study conducted at Outpatient Department (OPD) Endocrinology, Patna Medical College Hospital, Patna, Bihar, India, on 100 patients diagnosed with untreated primary hypothyroidism between February 2020 and January 2021. Demographic details, anthropometric measurements, vital signs, and details of types and dosage of treatment received were collected. LT4 dose requirement for each individual patient was then generated as mcg per kg/body weight per day. Estimation of serum Thyroid Stimulating Hormone (TSH), Free T4 (FT4), creatinine and thyroid peroxidase levels were carried out as per standard diagnostic protocols and the dosage adjustment was conducted based on target TSH levels. Population characteristics were expressed as mean±standard deviation. The Python version 3.4.5 with the package seaborn was used for statistical analyses and preparation of figures, distribution and correlation plots.

Results: The study enrolled 100 individuals (88 women and 12 men) with mean age of 40.69 years (age range 17 to 72 years). A significant positive correlation was noted between the LT4 dose and total body weight (p-value <0.001). The association was also significant when the LT4 dose was correlated with BMI (p-value <0.001) and FT4 (p-value <0.001). However, the correlation of Thyroid Peroxidase Antibodies (TPO Ab), TSH, height and age with the LT4 daily dose (p-value >0.05) was found to be statistically non significant.

Conclusion: There exist a significant positive correlation between LT4 dosage and body weight. Hence, body weight should be considered as a key determinant while prescribing LT4 therapy for the treatment primary hypothyroidism.

Keywords

Body mass index, Levothyroxine, Obesity

Hypothyroidism is one of the most common endocrine disorders worldwide with potentially devasting consequences on the patients’ well-being. The prevalence of hypothyroidism in iodine-deficient countries is estimated to be 1-2%. However, one-third of the world population lives in iodine-deficient regions and changes in diet and agricultural practices are the major causes for iodine deficiency (1). A multi-centre cross-sectional study conducted across eight major Indian cities has estimated the prevalence of hypothyroidism to be around 11%. The study also identified significant association of the disease with female gender and older age (2). However, there is a lack of data on the prevalence of primary hypothyroidism in Indian population. A 2019 study by Baruah MP et al., reported significantly high prevalence (33%) of primary hypothyroidism among adult population in Guwahati city (3). The complications associated with untreated hypothyroidism include cardiovascular disease, goitre, infertility in women, cognitive dysfunction, growth retardation in children and myxoedema coma (4). The effect of iodine deficiency on cognitive and neurological development of offspring has been well established (1).

Levothyroxine sodium (an isomer of T4, LT4) is the most commonly used thyroid replacement therapy. The optimisation of LT4 dosage remains critical for the well-being of patients. The dosage of LT4 depends on various factors namely age, gender, serum TSH level, and female menstrual and pregnancy status, the residual thyroid function retained by the patient, the body weight or lean body mass of the patient, and the target thyrotropin or TSH level to be achieved during therapy. Another important factor that affects LT4 dosage requirement is its absorption, which is influenced by certain medical conditions (e.g., Hashimoto’s thyroiditis), medications (e.g., thyrosine kinase inhibitors), food and beverages, and the timing of LT4 administration (5),(6),(7). According to American Thyroid Association’s recommendation, dose adjustments should be made when there are large changes in body weight, with aging, and pregnancy, based on the assessment of LT4 levels 4-6 weeks after any dosage change (8).

A randomised, double-blind trial by Roos A et al., has recommended a full dose of LT4 of 1.6 μg/kg for young and healthy adults and a dose of 25 to 50 μg/d for old and cardiac patients (9). Over the years, numerous researchers have proposed different formulae for optimising dosage prerequisites, and the formulae range is broadly dependent on the body weight and the Body Mass Index (BMI) of the patient (10),(11),(12). The present study is intended to evaluate the role of body weight as a determinant of LT4 dosage in primary hypothyroidism therapy, as validation of this association would help to develop clear consensus on customisation of LT4 dosage based on body weight.

Material and Methods

The one-year prospective observational study included patients with known hypothyroidism who visited the OPD section of Department of Endocrinology, Patna Medical College Hospital, Patna, Bihar, India, between February 2020 and January 2021. The study was conducted in accordance with the International Conference on Harmonisation (ICH-GCP) and regulations and guidelines of Helsinki declaration.

Inclusion criteria: Only those patients with first diagnosed, untreated primary hypothyroidism were included in the study and followed-up till nine months.

Exclusion criteria: Patients on medications that are known to interfere with LT4 absorption or adjust LT4 binding proteins and pregnant or lactating women were excluded from the study.

Study Procedure

A total sample of 100 patients was included in the study and were followed uptill nine months. The medical records of the patients were accessed for collecting demographic details (age, sex) anthropometric measurements (height, weight, BMI), vital signs (pulse, Blood Pressure (BP)), and details of types and amounts of medical treatments received by the patients. LT4 dose requirement for each individual patient was then generated as mcg per kg/body weight per day. Various studies have estimated the replacement dose of LT4 based on body weight in hypothyroid patients treated to achieve a normal TSH (13),(14). These estimates range from1.6 mcg to 1.8 mcg LT4 per kilogram of actual body weight. It is well established that the aetiology of patients hypothyroidism, which is closely linked to the amount of residual thyroid function that a patient has, affect the dose of LT4 that will normalise the patients TSH (15). Estimation of serum TSH, FT4, creatinine and TPO Ab levels was carried out as per standard diagnostic protocols of the institute’s laboratory and data of the same were collected during the four follow-up timepoints (baseline, 3rd, 6th and 9th month). The dosage adjustment was conducted based on target TSH levels (1 to 3 IU/mL).

Statistical Analysis

Characteristics of the study population were expressed as mean±standard deviation. The Python version 3.4.5 with the package seaborn and Excel 2103 (16.0.13901.20400) were used for statistical analysis and preparation of figures, distribution and correlation plots. Descriptive statistics of demographic and clinical data was calculated. Continuous variables were summarised as means and standard deviations, and categorical variables as counts. The effect of weight on LT4 doses was tested using a multiple linear regression model. The model was generated with LT4 dose as the dependent variables and with weight, height, TSH value, age, BMI, FT4, and TPO Ab included as independent variables. The p-value of <0.05 was considered significant and <0.01 was considered highly significant.

Results

The study enrolled 100 individuals (88 women and 12 men) meeting the inclusion and exclusion criteria. The mean age of the individuals was 40.69 years, with a range of 17 to 72 years. The demographic characteristics of the enrolled subjects are shown in (Table/Fig 1).

Co-morbidities were present in 31% of the subjects and the corresponding number of subjects noted with hypertension, diabetes, and both hypertension and diabetes were 9%, 8% and 14%, respectively. Comparison of changes in biochemical characteristics from baseline to nine months is depicted in (Table/Fig 2). A significant reduction in mean serum TSH level (p-value <0.0001) and increase in FT4 levels (p-value <0.0001) were noted in subjects following the treatment.

Heat-map was used for the visualisation of correlation matrix between the input and output data. High correlation was observed in the upper rows of (Table/Fig 3), indicating a correlation of dosage of LT4 with BMI (0.45), height (0.11) and body weight (0.48).

The distribution pair plot of three variables against the outcome variable is depicted in (Table/Fig 4). The scatter plot displayed the data set containing quantitative variables. The trendline in the figure has shown corresponding increase in dosage of LT4 with weight, height, and BMI.

The relationship between the total daily dose of LT4 and body weight was analysed using multiple linear regression, and a significant positive correlation between the LT4 dose and total body weight was noted (p-value <0.01, (Table/Fig 5)). The association was also significant when the LT4 dose was correlated with BMI (p-value <0.001) and FT4 (p-value <0.001). A statistically non significant correlation was observed for TPO Ab, height and age with the LT4 daily dose (p-value >0.05).

Discussion

Studies have reported that many elderly patients are being treated with a large dosage of T4 or inappropriate TSH goals (16),(17). Due to the age-related reduction in thyroxine degradation and in lean body mass, there is a gradual decrease in the LT4 requirement with age (18). Hence, several studies have agreed upon the need to consider the factors like patient weight and lean body mass for the determination of LT4 dose (19),(20). The present study has evaluated the effect of LT4 therapy in hypothyroid patients focusing on the body weight with regular intervention testing of TSH and FT4 levels. Various studies have estimated the replacement dose of LT4 based on body weight in hypothyroid patients treated to achieve a normal TSH.

The use of a serum TSH and body weight-based calculations of LT4 dose usually produces similar dose estimates. The dose of LT4 also depends on lean body mass, age, gender, de-iodinase polymorphism and pregnancy (21),(22). The current study has shown that the body weight, FT4 and BMI have a significant influence on LT4. In concurrence with the current findings, a study by Younis IR reported that it is important to consider body weight while prescribing LT4 and the recommended initial dose should be higher for patients with more weight (22). A 2021 comparative study has highlighted the need to adjust the LT4 dosage based on the body weight in patients with primary hypothyroidism, keeping in mind to monitor the TSH and FT4 levels at regular intervals (18).

Fletcher A and Weeman A have noted that hypothyroidism is often overlooked as a cause of hypertension and the restoration of euthyroid status assists in the reduction of both systolic and diastolic pressure (23). Gronich N et al., showed that the risk of developing diabetes mellitus is higher in patients with hypothyroidism. These findings concur with the present study results, that has reported diabetes and hypertension as the comorbidities noted in the study participants (24).

The present study has considered an average dosage requirement of 92.125 mcg daily of LT4 for both the genders with an approximate weight of 63 kg. However, Chandra AK and Kumar M have used 125 μg daily for an average man weighing 75 kg, separately and 100 μg daily for an average-sized woman weighing 60 kg (18). Literature review shows that most of the studies have reported 3-6 months as the period of normalisation of the clinical signs and symptoms and quality of life and this is in line with the present study timeline of 3-9 months (9).

The current study has found a statistically non significant correlation of TPO Ab, TSH, height and age with the LT4 daily dose (p-value >0.05). Sawin CT et al., have noted that individual LT4 dosage requirement is dependent on lean body mass. The study has shown that middle-aged elderly men have age-related decrease in the LT4 requirement, as opposed to the same age female counterparts (25). Another study has reported the age-related decrease in LT4 in older menopausal women not in premenopausal women (26). However, the present study did not categorise women into different groups based on age or menopausal status. A review by Athanassiou KI and Ntalles K, has noted that the daily LT4 dosing may depend on factors such as age, body weight, presence of coronary artery disease and cardiac arrhythmias. The recommended dosing in adult is about 1.8 μg/kg body weight and in the elderly, it is about 0.5 μg/kg body weight (27). An interventional audit of a large community database has highlighted poor compliance, drug impedance, parietal cell antibodies (as a marker of atrophic/autoimmune gastritis), and celiac disease as the causes requiring high-dose levothyroxine replacement in patients with hypothyroidism (28). Okuroglu N et al., have reported a positive association between LT4 and antibody titres in patients with autoimmune thyroiditis; in contrast, the present study has noted a non significant association (29). Another study by Bakker B et al., found that the plasma TSH and FT4 concentrations reached the age-related normal range within a few days after diagnosis in congenital hypothyroidism following the LT4 treatment (30). Although the current study has reported a non significant association between TSH and LT4 daily dose, it did not estimate the number of days required to normalise serum TSH and FT4 levels.

Prospective design and evaluation of biochemical characteristics in a standard clinical laboratory are the major strengths of the present study. The study corroborating body weight as a significant determiner of LT4 dosage, highlights the need to bring necessary consensus in daily practice to avoid undertreatment or overtreatment.

Limitation(s)

Smaller sample size and lesser number of men potentially limit the generalisation of the present results. In addition, the impact of gender on LT4 dosage requirement was not evaluated in the study.

Conclusion

A significant positive correlation was observed between LT4 dosage and body weight. The present study has corroborated the role of body weight as a key determinant while prescribing LT4 therapy. This is beneficial to shorten the time required to attain a stable dose, and to avoid undertreatment or overtreatment. Future research focusing on dosage adjustment based upon age and pregnancy status in a larger cohort is highly warranted.

References

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Taylor PN, Albrecht D, Scholz A, Gutierrez-Buey G, Lazarus JH, Dayan CM, et al. Global epidemiology of hyperthyroidism and hypothyroidism. Nat Rev Endocrinol. 2018;14(5):301-16. [crossref] [PubMed]
2.
Unnikrishnan AG, Kalra S, Sahay RK, Bantwal G, John M, Tewari N. Prevalence of hypothyroidism in adults: An epidemiological study in eight cities of India. Indian J Endocrinol Metab. 2013;17(4):647-52. [crossref] [PubMed]
3.
Baruah MP, Duttachoudhury S, Saikia M, Saikia UK, Bhuyan SB, Bhowmick A, et al. Guwahati thyroid epidemiology study: High prevalence of primary hypothyroidism among the adult population of Guwahati city. Thyroid Res Pract. 2019;16:12-19. [crossref]
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Kalra S, Das AK, Bajaj S, Saboo B, Khandelwal D, Tiwaskar M, et al. Diagnosis and management of hypothyroidism: Addressing the knowledge-action gaps. Adv Ther. 2018;35(10):1519-34. [crossref] [PubMed]
5.
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DOI and Others

DOI: 10.7860/JCDR/2022/50989.15996

Date of Submission: Jun 21, 2021
Date of Peer Review: Sep 17, 2021
Date of Acceptance: Nov 09, 2021
Date of Publishing: Feb 01, 2022

AUTHOR DECLARATION:
• Financial or Other Competing Interests: None
• Was Ethics Committee Approval obtained for this study? No
• Was informed consent obtained from the subjects involved in the study? No
• For any images presented appropriate consent has been obtained from the subjects. No

PLAGIARISM CHECKING METHODS:
• Plagiarism X-checker: Jun 26, 2021
• Manual Googling: Oct 26, 2021
• iThenticate Software: Jan 14, 2022 (10%)

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