Prevalence and Associations of Metabolic Syndrome in an Urban High Diabetes Risk Population in a Low/Middle-Income Country.

Background: We aimed to assess the burden of metabolic syndrome (MetS), and evaluate the phenotypic variation of MetS in a population at high risk for diabetes in urban Karachi, Pakistan. Methods: This study was embedded in a lifestyle intervention trial for the prevention of type 2 diabetes mellitus. The study population comprised participants who belonged to urban households in Karachi, Pakistan. Results: Among 15,590 individuals who were screened through diabetes risk score (DRS), 3945 individuals met the criteria for a high DRS (≥60). After excluding 1780 participants due to refusals and ineligibility, 2165 were enrolled, a total of 1188 subjects (54.9%) met the International Diabetes Federation criteria for MetS, and a total of 1199 subjects (55.4%) participants met the US National Cholesterol Education Program. Raised serum triglycerides (TGs) and low high-density lipoprotein (HDL) cholesterol were significantly associated with MetS. On multivariate logistic regression, higher body mass index levels (obese category: odds ratio [OR] = 2.14, 95% confidence interval [CI] 1.56-2.95), age >44 years (OR = 2.64, 95% CI 1.93-3.60), and family history of diabetes in both parents (OR = 1.71, 95% CI 1.15-2.54) were found to be independently associated with MetS, whereas higher education (OR = 0.78, 95% CI 0.57-1.06) and physical activity levels (OR = 0.74, 95% CI 0.57-0.96) had lower odds of MetS. Conclusion: One in two individuals with a high DRS in an urban low/middle-income country setting met the criteria for MetS. Patients with atherogenic dyslipidemia defined as low HDL and high TGs represent unique subphenotypes of MetS in this population.

Nonalcoholic Fatty Liver Diseases among Recently Diagnosed Patients with Diabetes Mellitus and Risk Factors.

AIM: Prevalence of obesity and type 2 diabetes mellitus (T2DM), both of which represent are related to nonalcoholic fatty liver disease (NAFLD), is an increasing trend among Asian people. The study aimed to assess the prevalence of NAFLD in T2DM with their risk factors in the Southern part of Pakistan. MATERIALS AND METHODS: A cross-sectional study was accomplished during 2008-2013 at The Aga Khan University Hospital, Karachi, Pakistan. Adult patients diagnosed with T2DM during last 6 months were enrolled in this study. NAFLD was identified using ultrasound of the liver. Clinical and biochemical relevant measurements were accomplished. RESULTS: Out of a total of 203 patients with T2DM, NAFLD was detected in 146 patients (71.9%). Multivariate analysis revealed that NAFLD was significantly associated with dyslipidemia (OR 2.38, 95% CI 1.06-5.34, p = 0.035), higher LDL (OR 1.02, 95%CI 1.01-1.03, p = 0.003), H bA1c (OR1.27, 95% CI 0.97-1.68, p = 0.045) and diastolic blood pressure (OR 1.05, 95% CI 1.01-1.10, p = 0.009). The highest odds of 10.8 for NAFLD (95% CI 4.9-24, p = 0.001) was found for the combination of hypertension, dyslipidemia, body mass index (BMI), waist circumference, lack of physical inactivity, triglycerides, lower HDL, LDL, HbA1c, and ALT (multiplicative analysis). CONCLUSION: High incidence of NAFLD with the association of different lifestyle-related factors has been analyzed. It unmasks the need for screening for NAFLD in newly diagnosed DM patients in Pakistan with the assessment of parameters of risk factors. HOW TO CITE THIS ARTICLE: Butt AS, Hamid S, et al. Nonalcoholic fatty Liver Diseases Among Recently Diagnosed Patients With Diabetes Mellitus and Risk Factors. Euroasian J Hepatogastroenterol 2019;9(1):9-13.

Patterns, control and complications of diabetes from a hospital based registry established in a low income country.

BACKGROUND: Diabetes registry enables practitioners to measure the characteristics and patterns of diabetes across their patient population. They also provide insight into practice patterns which can be very effective in improving care and preventing complications. The aim of this study was to assess the patterns, control levels and complications at the baseline of the patients attending clinic at the large tertiary care hospital in Karachi, Pakistan with the help of the registry. This can be used as a reference to monitor the control and also for a comparison between peer groups. METHODS: This was a cross sectional study with the data obtained from diabetes registry collected with the help of pre-designed questionnaire. HbA1c was used as a central diabetes measure and other related factors and complications were assessed with it. RESULTS: Only 16.6% of the participants had optimal HbA1c ≤ 7.0%. 52.9% of the patients were classified as having poor control defined by HbA1c of >8%. Three fourth of the study population were obese according to Asian specific BMI cutoffs and majority had type 2 diabetes with duration of diabetes ranging from less than one to about 35 years, mean(SD) duration being 7.6 years (7.1). Overall only 4% of the patients were on combine target of HbA1c, LDL and BP. Results of multivariable logistic regression showed that the odds of having optimal glycemic control increased by 3% with every one year increase in age. In addition, having longer duration of diabetes was associated with 56% lower odds of having good glycemic control. Moreover, having higher triglyceride levels was associated with 1% lower odds of having good glycemic control. CONCLUSION: This highlights the large burden of sub optimally controlled people with diabetes in Pakistani population, a low income country with huge diabetes prevalence and ineffective primary health care system creating enormous health and economic burden.

Central adiposity is significantly higher in female compared to male in Pakistani type 2 diabetes mellitus patients.

BACKGROUND: Type 2 diabetes mellitus (DM) rates are increasing rapidly in South Asians. Cardiovascular complications are more frequent and occur earlier in our patients than patients in many other ethnic groups. Reasons for this are not fully understood. AIMS: The aim of this study is to evaluate the body total and central fat percentage in type 2 Diabetes Mellitus patients and to check correlation with BMI, waist circumference and metabolic profile. SETTINGS AND DESIGN: A cross-sectional study conducted at endocrine clinic, Aga Khan University Hospital Karachi, Pakistan, from May to December 2012. MATERIALS AND METHODS: Patients of either gender with type 2 diabetes mellitus were randomly selected. A separate proforma for each patient was recorded for demographics, risk factors, bioelectrical impedance measurement for body fat and investigations. STATISTICAL ANALYSIS: Correlation between body fat and other covariate were compared by Pearson correlation coefficient test. A P < 0.05 was considered significant. SPSS19.0 was used to analyze the data. RESULTS: One hundred and seventy five patients (95 male and 80 female) with mean age of 54.1 ± 12 years were evaluated. Mean duration of diabetes was 8.1 years, mean HbA1c was 8.1% and 53.7% were on oral agents and rest were on insulin with or without oral agents. Hypertension was present in 65.7%, 13.7% had known coronary artery disease and 2.3% had cerebrovascular disease. Mean BMI in males was 29.1 ± 4.74 kg/m(2) and females 31.7 ± 5.3 kg/m(2). Mean waist circumference in males was 107.3 ± 16.6 cm and 103 ± 12 cm in females. Total body fat percentage (%BF) in males was 30.9 ± 7.1% and females 40 ± 8.2% with 89% of the total cohort having total body fat percentage above the normal, less than 25% central fat percentage was 13.3 ± 5.2% in males and 14.6 ± 5.5% in females with 79.4% of cohort having increased central fat (normal <9%). Total and central body fat correlated with BMI (r = 0.68, P < 0.001) and waist circumference (r = 0.66, P < 0.001) but not with HbA1c, triglyceride level or with fasting or random blood glucose levels. Women had significantly higher total body fat percentage compared to men (P < 0.001) although central fat percentage was similar in both sexes. CONCLUSIONS: High body fat percentage, waist circumference are seen especially in woman and central body fat percentage in both sexes among patients with type 2 diabetes mellitus in Pakistan. Body fat percentage should be measured and followed as this may be an important contributing factor to the high macrovascular complication rate in this part of world.

Case report: nocardia infection associated with ectopic cushings.

BACKGROUND: Cushing's syndrome results from exposure to excess glucocorticoids. Ectopic Cushings is endogenous ACTH dependant form of Cushing's associated with markedly raised ACTH and cortisol levels. This leads to an impaired immune response, setting the stage for occurrence of opportunistic infections. Nocardiosis is a gram positive bacterial infection caused by aerobic actinomycetes in genus Nocardia. We report a series of patients diagnosed with ectopic Cushings, having pneumonia with Nocardia spp. In one of these cases, the manifestations of Cushing's disappeared with treatment for Nocardia. CASE PRESENTATION: Two middle aged men of Asian descent presented to the Endocrine clinic: the first with history of exertional shortness of breath, and weight loss for 1 year, the other with facial swelling, disturbed sleep and lethargy for a month. The third case was a young Asian male who presented with progressive weakness & weight loss for 2 months. All three patients had uncontrolled hypertension, high blood sugars & were hypokalemic (K: 2.52, 2.9, 1.5 mmol/l); 24 hour urine cortisol was elevated at 2000, 27216 and 9088 (32-243 ug/24 hours); ACTH 68.5, 159, 255 [0-48 pg/ml), respectively. Their MRI pituitary was normal, inferior petrosal sinus sampling revealed no central peripheral gradient. CT chest of these subjects demonstrated cavitatory lung lesions; microscopic analysis of respiratory samples was suggestive of infection with Nocardia spp. Histopathology of bronchoscopic-guided biopsy revealed no malignancy. Antihypertensives, insulin, potassium replacement, ketoconazole & trimethoprim-sulphamethoxazole (TS) were initiated. The patients' symptomatology improved & cavitatory lesions resolved with treatment. The primary source for the ectopic cushings remained unknown. The first case required bilateral adrenalectomy. The second case followed a progressively downhill course leading to death. In the third case, we were able to completely taper off ketoconazole, potassium, insulin & antihypertensives, after starting TS. CONCLUSION: Opportunistic infections are known to be associated with Cushing's syndrome, and higher levels of glucocorticoid secretion are found in patients with ectopically produced ACTH. Pulmonary nocardiosis is important differential to consider. This series includes the first case reported in which signs and symptoms of cushings subsided after treatment of Nocardia.

The learners' perspective on internal medicine ward rounds: a cross-sectional study.

BACKGROUND: Ward rounds form an integral part of Internal Medicine teaching. This study aimed to determine the trainees' opinions regarding various aspects of their ward rounds, including how well they cover their learning needs, how they would like the rounds to be conducted, and differences of opinion between medical students and postgraduates. METHODS: A cross-sectional study was conducted on a total of 134 trainees in Internal Medicine, comprising medical students, interns, residents and fellows, who were asked to fill in a structured, self-designed questionnaire. Most of the responses required a rating on a scale of 1-5 (1 being highly unsatisfactory and 5 being highly satisfactory). RESULTS: Teaching of clinical skills and bedside teaching received the lowest overall mean score (Mean +/- SD 2.48 +/- 1.02 and 2.49 +/- 1.12 respectively). They were rated much lower by postgraduates as compared to students (p < 0.001). All respondents felt that management of patients was the aspect best covered by the current ward rounds (Mean +/- SD 3.71 +/- 0.72). For their desired ward rounds, management of patients received the highest score (Mean +/- SD 4.64 +/- 0.55), followed by bedside examinations (Mean +/- SD 4.60 +/- 0.61) and clinical skills teaching (Mean +/- SD 4.50 +/- 0.68). The postgraduates desired a lot more focus on communication skills, counselling and medical ethics as compared to students, whose primary focus was teaching of bedside examination and management. A majority of the respondents (87%) preferred bedside rounds over conference room rounds. Even though the duration of rounds was found to be adequate, a majority of the trainees (68%) felt there was a lack of individual attention during ward rounds. CONCLUSIONS: This study highlights important areas where ward rounds need improvement in order to maximize their benefit to the learners. There is a need to modify the current state of ward rounds in order to address the needs and expectations of trainees.

Clinical factors associated with mortality in dengue infection at a tertiary care center.

We conducted a cross-sectional study to investigate the clinical factors associated with mortality in patients with dengue viral infection at a tertiary care center over a 3 year period. Six hundred ninety-nine patients with a clinical diagnosis of dengue fever (DF), dengue hemorrhagic fever (DHF) and dengue shock syndrome (DSS) during the study period were included in the study. Data were collected with a predesigned form comprised of demographics, duration of fever, associated symptoms, diagnosis of DF, DHF and DSS, and laboratory parameters [complete blood count, coagulation tests, creatinine, serum glutamic pyruvic transaminase (SGPT)]; dengue IgM was checked in all patients by ELISA. Outcomes (survival/mortality) and complications were recorded. Mortality was the primary outcome measure. DF constituted 86.4% (604), DHF constituted 11.6% (81) and DSS constituted 2% (14) of patients. The mortality rate was 2.7% (19). The mean white blood cell count in those who died was 13.3, in those who survived was 5.3, the difference was significant (p = 0.02). The mean BUN in those who died was 33.2, those who survived was 13.8, (p = 0.007). The mean bicarbonate level in those who died was 17.1, those who survived was 18.5 (p < 0.001). Mean activated partial thromboplastin time in those who died was 56.8, those who survived was 36.8 (p = 0.01). The mean SGPT in those who died was 802, those who survived was 176 (p = 0.01). Those who died were significantly (p < 0.001) more likely to have severe hepatitis (63%) than those who survived (13.8%). On multivariate logistic regression analysis, having an SGPT >300 mg/dl, bleeding, an altered mental status and shock at presentation were all significantly associated with mortality in patients with dengue virus infection (p = 0.008, p < 0.001, p < 0.001, p < 0.001, respectively).

Does choice of therapy save costs and improve outcomes in hyperthyroid patients?

OBJECTIVE: To compare cost of treating hyperthyroidism with antithyroid medications (ATD) versus radioactive iodine (RAI). As secondary outcome we also analyzed data in terms of remission rates. METHODS: This was a retrospective comparative analysis of hyperthyroid patients treated with ATD or RAI from January 2000 to December 2005. Cost of ATD, TSH. FT4, doctors visits; thyroid technetium scan and RAI treatment were calculated for the duration of treatment and for one year of follow-up after remission. RESULTS: A total of 143 patients were included, with an average duration of follow-up of 32 months. Mean age was 41 +/- 15.5 years and M: F' ratio was 1: 2. More expenses were incurred in treating patients with ATD (Rs. 28,900 +/- 15 400 or US$ 481.67 +/- 256.67) than with RAI (Rs.18.800 +/- 15800 or US$313.33 +/- 263.33). The former cost Rs.10,100 (US$ 168.33) more, (p < 0.001; 95%). Remission rate in the RAI group were significantly higher than the ATD group (81.3% vs 49.5%, p = 0.006). CONCLUSION: Treatment of hyperthyroid patients with RAI is not only better in terms of remission of disease, but it is also a more cost effective modality, and should be considered as first line of treatment.

Vitamin B12 deficiency common in primary hypothyroidism.

OBJECTIVE: To assess the prevalence and clinical features of B12 deficiency in hypothyroid patients and to evaluate clinical response in symptoms to B12 replacement therapy. METHODS: One hundred and sixteen hypothyroid patients from our endocrine clinic were evaluated for signs and symptoms of vitamin B12 deficiency. Laboratory parameters including Haemoglobin (Hb), MCV, Vitamin B12 levels and presence of anti thyroid antibodies were analyzed. Patients with low B12 levels were treated with parenteral intramuscular vitamin B12 monthly, and monitored for improvement of symptoms. RESULTS: A total of 116 patients (95 females and 21 males) were evaluated. Forty six (39.6%) hypothyroid patients had low vitamin B12 levels. Males and females had the same prevalence of B12 deficiency. Generalized weakness, impaired memory, depression, numbness and decreased reflexes were more frequently noted in B12 deficient patients, but failed to achieve statistical significance when compared with B12 sufficient patients. The mean Hb in B12 deficient group was 11.9 +/- 1.6 mg/dl and 12.4 +/- 1.7 mg/dl in the B12 sufficient group, however the mean MCV did not differ in the two groups. Patients with B12 deficiency did not have a higher prevalence of anaemia. Thyroid antibodies were checked in half the patients and 67% had positive titers for anti thyroid antibodies. Prevalence of vitamin B12 deficiency did not differ in patients with positive antibodies (43.2%) compared to those with negative antibodies (38.9%) (p= 0.759). Twenty four hypothyroid patients with B12 deficiency received intramuscular vitamin B12 injections monthly and improvement in symptoms was noted in 58.3% of these subjects. Additionally, 21 subjects complained of symptoms consistent with B12 deficiency but who had normal range B12, levels and were prescribed monthly B12 injections and 8 (40%) had good subjective clinical response at 6 months. CONCLUSIONS: There is a high (approx 40%) prevalence of B12 deficiency in hypothyroid patients. Traditional symptoms are not a good guide to determining presence of B12 deficiency. Screening for vitamin B12 levels should be undertaken in all hypothyroid patients, irrespective of their thyroid antibody status. Replacement of B12 leads to improvement in symptoms, although a placebo effect cannot be excluded, as a number of patients without B12 deficiency also appeared to respond to B12, administration.