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

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Dr Bhanu K Bhakhri

"The Journal of Clinical and Diagnostic Research (JCDR) has been in operation since almost a decade. It has contributed a huge number of peer reviewed articles, across a spectrum of medical disciplines, to the medical literature.
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Super Speciality Paediatric Hospital and Post Graduate Teaching Institute, Noida
On Sep 2018




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On Sep 2018




Prof. Somashekhar Nimbalkar

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Prof. Somashekhar Nimbalkar
Head, Department of Pediatrics, Pramukhswami Medical College, Karamsad
Chairman, Research Group, Charutar Arogya Mandal, Karamsad
National Joint Coordinator - Advanced IAP NNF NRP Program
Ex-Member, Governing Body, National Neonatology Forum, New Delhi
Ex-President - National Neonatology Forum Gujarat State Chapter
Department of Pediatrics, Pramukhswami Medical College, Karamsad, Anand, Gujarat.
On Sep 2018




Dr. Kalyani R

"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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Sri Devaraj Urs Academy of Higher Education and Research , Kolar, Karnataka
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Professor and Head
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On Sep 2018




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Calcutta National Medical College & Hospital , Kolkata




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Best regards,
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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

Important Notice

Original article / research
Year : 2011 | Month : April | Volume : 5 | Issue : 2 | Page : 254 - 256

Evaluation of the Thyriod Status, Oxidant Stress and Antioxidant Status in patients with Type - 2 Diabetes Mellitus

KEDARI G S R

Dept of Biochemistry, Saveetha Medical College & Hospital, Saveetha University, Saveetha Nagar, Thandalam, Chennai – 602 105, Tamilnadu, India.

Correspondence Address :
Kedari G S R, Assistant Professor, Dept of Biochemistry, Saveetha
Medical College & Hospital, Saveetha University, Saveetha Nagar,
Thandalam, Chennai – 602 105, Tamilnadu, India.
Email: kedari.gsr@gmail.com

Abstract

Diabetes mellitus is the world’s most common endocrine disorder and the aim of the present study was to evaluate the role of the thyroid hormone status in type-2 diabetes cases by measuring serum free 3, 5, 3’-tri-iodothyronine (FT3), free tetra-iodothyronine (FT4) and thyroid stimulating hormone (TSH) levels, the role of oxidative stress by assessing plasma malondialdehyde (MDA) levels, as well as the status of antioxidants like ascorbic acid and reduced glutathione (GSH) in blood. For this, 30 casesof diabetes mellitus were included .The findings were compared with 30 age matched healthy controls, irrespective of sex. A significant increase in the levels of MDA was observed in the cases as compared to the controls. A significant decrease in the levels of serum FT3, vitamin-C, and GSH was also noticed in the cases as compared to the controls. There was no significant difference in the levels of serum FT4 and Serum TSH.

Keywords

Serum FT3, Serum FT4, Serum TSH, Oxidative stress and antioxidants

How to cite this article :

KEDARI G S R. EVALUATION OF THE THYRIOD STATUS, OXIDANT STRESS AND ANTIOXIDANT STATUS IN PATIENTS WITH TYPE - 2 DIABETES MELLITUS. Journal of Clinical and Diagnostic Research [serial online] 2011 April [cited: 2018 Nov 15 ]; 5:254-256. Available from
http://www.jcdr.net/back_issues.asp?issn=0973-709x&year=2011&month=April&volume=5&issue=2&page=254-256&id=1266

Diabetes mellitus is the most common endocrine metabolic disorder, affecting about 170 million people worldwide (1). The diseases of the thyroid gland are amongst the most abundant endocrine disorders in the world which are second only to diabetes. Thyroid diseases affect approximately 10-15% of the patients with diabetes, whereas in non-diabetics, the prevalence is approximately 6%. The mode of association between diabetes and thyroid diseases is more complex and is largely unclear. Neither diabetes nor thyroid diseases present a homogenous, nosological unit; the pathogenesis of the different types of diabetes as well as thyroid diseases is diverse. Therefore, even the correlations between them are different (2).

The metabolic dysregulation which is associated with diabetes mellitus causes secondary pathophysiological changes in multiple organs due to hyperglycaemia. Prolonged exposure to elevated glucose induces both repeated acute changes in intracellular metabolism and cumulative long-term changes in the structure and function of the macromolecules (3). In a normal cell, there is an appropriate pro-oxidant- antioxidant balance. This balance is shifted towards pro-oxidants when the production of the oxygen species is increased or the levels of the antioxidants are decreased and this state is called as ‘oxidative stress’. Oxidative stress is implicated in the pathogenesis of a variety of human diseases (4).Oxidative damage occurs to biomolecules like lipids, proteins, carbohydrates and nucleic acids and other extracellular components like collagen and hyaluronic acid which are very deleterious (5).The formation of lipid peroxides by the action of the free radicals on unsaturated fatty acids has been implicated in the pathogenesis of atherosclerosis and vascular diseases (6).Increased levels of the products of oxidative damage to lipids have been detected in the sera of diabetic patients and their presence correlates with the development of complications (7). The body’s defense mechanisms play an important role in the form of antioxidants that help to minimize the damages which are caused by oxidative stress. Antioxidants are compounds that dispose, scavenge and suppress the formation of free radicals or oppose their actions (8). Hence, the present study was undertaken to assess the thyroid hormone status, the extent of lipid peroxidation and the status of the antioxidant defense mechanisms in patients with diabetes.

Material and Methods

The present study was conducted in the Department of Biochemistry, PES Medical College, Kuppam. Thirty diagnosed cases of type- 2 diabetes mellitus were chosen for the study, which belonged to the age-group of 35-60 years. None of them had a previous history of thyroid diseases. Thirty age-matched subjects without diabetes were taken as the controls. Informed consent was obtained from all of them. Ten milliliters of fasting blood samples were collected by venipuncture and for the separation of sera, 5 ml of blood was centrifuged at 3000rpm for 5min and the remaining 5ml of blood was taken into a plain vial containing EDTA and was centrifuged at 3000rpm for 10min for the separation of plasma. The separated serum was used to estimate Serum TSH, FT3 and FT4 by the ELISA method (9), (10). The plasma MDA levels were estimated by using thiobarbituric acid reacting substances (TBARS) by the method of Yagi (11) and Sinnhuber et al (12). Reduced glutathione was determined by the method of Beutler et al (13) and ascorbic acid was determined by the method of Tietz (14). All the results were expressed as mean ±SD and statistical comparsions were done. Due permission was obtained from the Institutional Ethics Committee prior to the starting of the work.

Results

There was a significant decrease in the values of serum FT3 in type- 2 diabetics as compared to the controls. There was no statistically significant difference in the values of serum FT4 and TSH between the type-2 diabetics and the control groups (Table/Fig 1). There was a significant increase in the values of MDA in diabetes mellitus patients as compared to the controls, whereas, there were significantly decreased levels of Vit-C and reduced glutathione in the diabetes mellitus cases as compared to the controls (Table/Fig 2).

Discussion

Diabetes mellitus comprises a group of common metabolic disorders that share the phenotype of hyperglycaemia. Several distinct types of diabetes mellitus exist and these are caused by a complex interaction between the genetic factors (15).In the present study; there was no statistically significant difference in the levels of serum FT4 and serum TSH. The decreased serum level of FT3 may be due to the impairment of the 5-monodeiodinase enzyme activity which controls the peripheral conversion of T4 into T3 (16).Suzuki et al (17) attributed the abnormal thyroid hormone levels which are found in diabetes to the presence of the thyroid hormone binding inhibitor (THBI), which is an inhibitor of the extra thyroidal conversion enzyme which converts T4 to T3 and to the dysfunction of hypothalamo- hypophyseal-thyroid axis. These situations may prevail in diabetics and would be aggravated in poorly controlled diabetics. Stress, when associated with diabetes, may also cause changes in the hypothalamo anterior-pituitary axis. It appears that sub-clinical hypothyroidism and hyperthyroidism may result from the hypothalamo- hypophyseal-thyroid axis disorders, as suggested by Celani et al (18). A suggestion was made that the finding of definite hypothyroidism or hyperthyroidism should be given adequate attention and that the treatment of the thyroid disorder should be appropriately undertaken (19).

The significant rise in the MDA levels in diabetes confirms that it is associated with an increased production of reactive oxygen species (ROS) and free radicals. Lipid peroxidation is a chain reaction which provides a continuous supply of free radicals that initiate further peroxidation (20). Insulin secretion is associated with peroxide production. We also observed a significant decrease in the levels of reduced glutathione in the cases as compared to the controls. The intracellular depletion of reduced glutathione (GSH) can be either due to the formation of a direct complex with an electrophilic agent or due to the inhibition of synthesis or due to the subjection of the cell to oxidative stress (21). When a cell is subjected to oxidative stress, there is increased utilization of glutathione, thus leading to its depletion. Many enzymes are GSH dependent and their activity may be regulated by the thiol disulphide exchange. They are thus dependent on the GSH status. Glutathione-S-transferase (GST) is reduced in diabetics which are dimeric, mainly cytosolic enzymes that have extensive ligand binding properties in addition to their catalytic role in detoxification (22), (23). This reduction is due to the reduced levels of GSH. There is also a decrease in the levels of non-enzymatic anti-oxidants such as Vit-C, which states that there is an increased defense mechanism against oxidative damage in diabetes mellitus. The decrease in the levels of these non-enzymatic antioxidant parameters may be due to an increased turnover for preventing oxidative damage in these patients, thus suggesting an increased defense against oxidative damage (24).

It could be concluded that type-2 diabetic patients are more prone to thyroid abnormalities, which requires regular follow-up. Oxidative stress may play a major role in the pathogenesis and the development of diabetes mellitus and a decreased antioxidant status shows a necessity for the therapeutic administration of antioxidants as supplementary therapy to the diabetic cases. Extensive studies are required in future to reduce the morbidity of diabetes mellitus and its complications.

References

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Wild S, Roglic G, Green A, Sicree R, King H. Global prevalence of diabetes. Estimates for the year 2000 and projections for2030.Diabetes Care, 2004; 27:1047-1053.
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Perros P, Mc crimmon RS, Shaw G, Frier BM. Frequency of thyroid dysfunction in diabetic patients: value of annual screening. Diabetes Med, 1995:12(7):622-627.
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Sheetz MJ, King GL. Molecular understanding of hyperglycemia‘s adverse effects for diabetic complications. JAMA, 2002; 288:2579- 2588.
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Beck MM, Levander OA. Dietary oxidative stress and potentiation of viral infection. Annu Rev Nutr,1998; 18:93-116.
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Frei B. Reactive oxygen species and antioxidant vitamins: mechanisms of action. Am J Med, 1994; 97: S5-S13.
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Donald DH. Oxidative stress and vascular disease, Arterioscler Thromb Vasc Biol 2005; 26:689-695.
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Liu SX, Hou FF, Guo ZJ et al: Advanced oxidation protein products accelerate atherosclerosis through promoting oxidative stress and inflammation. Arterioscler Thromb Vasc Biol, 2006; 26:1156-1162.
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Krishna Mohan S and Venkata Ramana G. Status of lipid peroxidation, glutathione, ascorbic acid, and vitamin E and antioxidant enzymes in patients with pregnancy induced – hypertension (PIH). Indian J Physiol Pharmacol, 2007; 51 (3): 284 –288
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Frazer CG, Browing MCK. Measuring serum thyroglobulin. Lancet 1985; 816-819.
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Holl RW, Bohm B, Loos U et al. Thyroid autoimmunity in children and adolescents with type-1 DM. Effects of age, gender and HLA type. Horm Res,1999; 52(3).113-118.
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Yagi K. Lipid peroxides and human diseases. Chem Phys Lipids, 1978; 45: 337-351.
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Sinnhuber RO, Yu TC, Yu TC. Characterization of red pigment formed in thiobarbituric acid determination of oxidative rancidity. Food Res, 1958; 23: 626-630.
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Beutler E, Duron O, Kelly BM. Improved method for determination of blood glutathione. J Lab Clin Med, 1963; 61: 882-888.
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Tietz NW (Ed. ).Textbook of Clinical Chemistry. W.B. Saunders Company, Philadelphia, London, Toronto.2004; pp.960-962.
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Kasper DL, Braunwald E, Hauser S, Longo D, Jameson JL, Fauci AS(Eds.).Diabetes mellitus. In: Harrison’s Principles of Internal Medicine.16th Edn. 2004. McGraw Hill Professional, USA. pp. 2152- 2180.
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Suzuki Y: Nanno M: Gemma R et al. Plasma free fatty acids inhibitor of extra thyroidal conversion of T4 to T3 & thyroid binding inhibitor in patients with various non-thyroidal illnesses. Endocrinol Jpn, 1992; 39:445-53.
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Suzuki J, Nanno M, Gemma R, Tanaka I, Taminato T, Yoshimi T. The mechanism of thyroid abnormalities in patients with diabetes mellitus. Nippon Niabunpi Gakki Zashi 1994; 7(4):465-70.
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Celani HF, Bonati HE, Stucci N. Prevalence of abnormal thyrotropin concentrations measured by a sensitive assay in patients with type 2 diabetes mellitus. Diabetes Res, 1994; 27 (1) 15-25.
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Suzuki H, Hiraiwa M, Suzika Y. Hasigam Y, Shimoda S. Thyroid function in non-thyroidal illness. Specific changes in serum levels of thyroid hormones in patients with non-thyroidal illness. Nippon Niabunpi Gakki Zashi, 1984; 60 (6) 738-55.
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Murray RK, Granner DK, Rodwell VW (Eds.).Harper’s Illustrated Biochemistry. 27thEdn.2006.McGraw Hill Lange International Edition. pp.128-129.
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Deneke SM, Farberg TZ. Regulation of cellular glutathione lung cells Mol.Physiol,1994; 1163-1173.
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Listowsky I, Abramovitz M, Homma H et al. Intracellular binding and transport of hormones and xenobiotics by glutathione-s-transferase. Drug Metab Res, 1988; 19:305-318.
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Ketley JN, Habig WH, Jacoby WB. Binding of non substrate ligands to glutathione-s-transferases. J Biol Chem, 1976; 250:8670-8673.
24.
K M Surapaneni , Venkata Ramana G. Status of lipid peroxidation, glutathione, ascorbic acid, vitamin E and antioxidant enzymes in patients with osteoarthritis. Indian J Med Sciences, 2007; 61 (1): 9 – 14

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