Prevalence and predictors of thyroid dysfunction amongst patients with Type 2 diabetes mellitus in Pakistan.

Introduction: Diabetes and thyroid disorders are the two most common disorders amongst endocrine diseases. Uncontrolled diabetes mellitus (DM) may disturb thyroid metabolism by disturbing the levels of thyroid hormones in the plasma. This study was undertaken to determine the prevalence and thyroid dysfunction in type 2 diabetic population presenting in a public sector tertiary care teaching hospital. Materials and Methods: This descriptive cross-sectional study was conducted in Civil Hospital Karachi (CHK) in the department of medicine from October 01, 2018, to March 31, 2019. The study population consisted of 317 patients diagnosed with DM type 2 based on American Diabetes Association (ADA) criteria. Patients with fasting blood sugar ≥ 126 mg/dL, or HbA1c >6.5 (%), and 2 h postprandial blood glucose levels >200 mg/dL were included. After a minimum of 8 h of fasting, plasma samples of patients were collected and sent for fasting blood glucose, HbA1c, FT3, FT4, and thyroid-stimulating hormone (TSH). Descriptive statistics were calculated. Post-stratification Chi-squared test was applied, and a P value of ≤ 0.05 was considered significant. Results: Among all enrolled DM type 2 patients, 207 (65.3%) were male with a mean age of 46.54 ± 8.72 years. Mean fasting blood sugar (FBS), random blood sugar (RBS), and HbA1c were 212.76 ± 26.91 (mg/dL), 328.89 ± 52.89 (mg/dL), and 9.43 ± 2.47 (%), respectively. The mean duration of DM was 7.81 ± 3.15 years. Mean FT3, FT4, and TSH were 113.13 ± 44.40 (ng/dL), 7.63 ± 3.11 (mg/dL) and 2.64 ± 2.57 (mIU/mL), respectively. In the present study, 55 (17.4%) patients had subclinical hypothyroidism, 27 (8.5%) had hypothyroidism, 19 (6.0%) had hyperthyroidism, and 16 (5.0%) had subclinical hyperthyroidism. Significant association of thyroid dysfunction was established with age group, female gender, and family history of thyroid dysfunction (P =< 0.001). Conclusion: The prevalence of thyroid dysfunction is higher among patients with type 2 diabetes mellitus (T2DM), in which hypothyroidism was the most common dysfunction with more prevalence among female patients.

Knowledge and practice of ethics among postgraduates in a public sector tertiary care hospital.

OBJECTIVE: To explore the present state of competency in clinical ethics among postgraduate trainees in a tertiary care hospital. METHODS: The interview-based cross-sectional study was conducted at the Civil Hospital, Karachi, from September 2018 to March 2019, and comprised postgraduate trainees of either gender in any year of the training programme across all specialties. Data was collected using self-reported questionnaire seeking opinion about present working conditions regarding clinical ethical issues on the hospital ground and problems they face from day to day. Data was analysed using SPSS 23. RESULTS: Of the 153 subjects, 96(62.7%) were females, 73(47.7%) were from Medicine and allied disciplines, and 80(52.3%) were from Surgery and allied disciplines. The primary source of their clinical ethics' understanding was derived from their workplace [116(75.82%)]. While only 104 (68%) of the subjects knew about the Hippocratic Oath's contents, less than 10% knew about Nuremberg Code and Helsinki declaration. They mainly relied on their seniors at work for guidance on ethical issues [108 (70.59%)]. Overall, the subjects lacked basic knowledge of medical ethics and failed to practise ethical conduct during their training. CONCLUSIONS: The knowledge of medical ethics was found to be unsatisfactory among doctors, and timely intervention was needed to improve the situation.

COVID-19-associated Coagulopathy and Thromboembolism: Determination of Their Patterns and Risk Factors as Predictors of Mortality Among Severe COVID-19 Patients.

BACKGROUND: Coronavirus Disease 2019 (COVID-19) is associated with Coagulopathy (CAC) and Venous Thromboembolism (VTE). These are well-reported complications of COVID-19 infection. Earlier publications have shown that CAC and thromboembolism are predictors of mortality among COVID-19 patients with severe disease. MATERIALS AND METHODS: A prospective study was conducted in the Intensive Care Unit (ICU) where all confirmed COVID-19 patients were enrolled and followed until death or ICU discharge. CAC, VTE, along with all comorbidities, were recorded. Predictors of mortality were determined by univariate and multivariate regression. RESULTS: Among 261 patients with COVID-19, 48.3% survived and 51.7% died. CAC was present in 53.2% and 76.3% of the survivors and non-survivors, respectively (p<0.001); 89 patients (31.4%) had VTE (p=0.36) and 11 patients (4.2%) had arterial thrombosis (p=0.76) among survivors and nonsurvivors. Age between 71-80 years (p=0.009), male gender (p=0.045), CAC (p<0.001), comorbidities like chronic kidney disease (CKD, p=0.013), chronic obstructive pulmonary disease (COPD, p=0.001) and asthma (p=0.046), were significant predictors of mortality. CONCLUSION: A severe complication of COVID-19 is CAC, such as sepsis-induced coagulopathy, overt disseminated-coagulopathy and VTE. Old age, various comorbidities (e.g., COPD, CKD, or asthma), CAC, VTE (pulmonary embolism) and coagulation parameters with critical severity score (D-dimers, platelets, prothrombin time) and the SOFA (Sequential Organ Failure Assessment) score were significant predictors of mortality among COVID-19 patients.

The Neuro-Vascular Consequence of Diabetes: Foot Amputation and Evaluation of its Risk Factors and Health-Related Economic Impact.

BACKGROUND: The rising prevalence of type 2 diabetes mellitus (T2DM) with the huge burden of diabetic foot amputation is a challenge to the health economy of Pakistan and other countries. Identification of various risk factors for amputation, along with its financial burden, is needed to address this problem. OBJECTIVES: This study aimed to determine the financial burden and risk factors associated with T2DMrelated foot amputation. METHODS: Retrospective hospital-based study from January 2017 to December 2018. Patients with T2DM with and without amputation were enrolled. The direct medical costs of amputation along with various risk factors, were determined. Risk factors were evaluated by logistic regression analysis. RESULTS: A total of 1460 patients with T2DM were included; 484 (33%) patients had an amputation. The mean total cost of below knee, fingers and toe amputation was 886.63±23.91, 263.35 ±19.58 and 166.68 ± 8.47 US$, respectively. This difference among groups was significant (p<0.0001). Male gender (odds ratio, OR: 1.29, 1.01-1.63, p=0.037), peripheral artery disease (OR: 1.93, 1.52-2.46, p=0.000), peripheral neuropathy (OR: 1.31, 1.40-1.63, p=0.000), prior diabetic foot ulcer (OR: 2.02, 1.56- 2.56, p=0.000) and raised glycated haemoglobin (HbA1c) (OR: 3.50, 2.75-4.4, p=0.000) were risk factors for amputation. CONCLUSION: The health-related financial impact of amputations is high. Peripheral artery disease, peripheral neuropathy, prior diabetic foot ulcer and raised HbA1c were risk factors for amputation.

Haemorrhagic versus non haemorrhagic ascites in cirrhosis: Their relationship and impact on prognosis of liver cirrhosis.

OBJECTIVES: To evaluate the impact of haemorrhagic ascites on prognosis of patients with advance cirrhosis, this study was further aimed to assess the relationship between haemorrhagic ascites and advance cirrhosis and its effect on prognosis. METHODS: Eight hundred and thirty-eight patients having liver cirrhosis with ascites were analyzed retrospectively (over three years) while segregated into two groups haemorrhagic and non haemorrhagic ascites. Patient outcome variables were identified among both groups and independent predictors for survival were analyzed. Kaplan-Meier survival estimates determined survival rate comparison between groups. RESULTS: Haemorrhagic ascites was detected in (26.6%) patients. Spontaneous haemorrhagic ascites(79%) was the main cause of haemorrhagic ascites followed by hepatocellular carcinoma (14%) and iatrogenic (7.6%). Spontaneous bacterial peritonitis and acute kidney injury were statistically significant (p= 0.0001, 0.0001) among groups. Overall mortality at year three was higher (83%) in haemorrhagic ascites group. Survival among both groups (haemorrhagic versus non haemorrhagic) at one month, one year and three year was found to be significant (p= 0.000, 0.000 and 0.000). CONCLUSION: Haemorrhagic ascites impact overall survival with more mortality in comparison to non haemorrhagic ascites. Haemorrhagic ascites was an independent predictor of survival. Haemorrhagic ascites is possibly considered another predictor of survival among advance cirrhosis.

GeneXpert in stool: Diagnostic yield in Intestinal Tuberculosis.

BACKGROUND: Diagnosing intestinal (Luminal) tuberculosis is challenging due to limited yield of diagnostic modalities like CT scan, colonoscopy with blind ileal biopsies. GeneXpert MTB/RIF (Xpert) assays for diagnosing tuberculosis have been performed in the body secretions with excellent results. Its yield in stool is tested in this study. OBJECTIVE: The study aims to evaluate the yield of GeneXpert assay in stool of suspected cases of intestinal tuberculosis. METHODS: Hundred patients with suspected intestinal tuberculosis underwent routine biochemical tests, radiological investigations, colonoscopy with caecal and blind ileal biopsies for histopathology. Fresh stool samples were collected, processed for DNA extraction, tested using 2:1 ratio of GeneXpert reagent to sample to give positive or negative results for Mycobacterium tuberculosis and Rifampicin resistance. RESULTS: Out of hundred participants, 52% were female. Mean age was 28.21 ± 12.13. CT scan and colonoscopy findings suggestive of TB were present in 47% and 43% participants respectively. GeneXpert in stool was positive in 20% cases. Considering mucosal biopsy with histopathology of intestinal specimens as diagnostic of abdominal Tuberculosis, sensitivity and specificity of GeneXpert was 39.1% and 85.7% respectively. CONCLUSION: Stool GeneXpert assay offers an alternative approach to detect intestinal tuberculosis rapidly with good diagnostic accuracy. Although it cannot replace the AFB culture and histopathology but contribute for early diagnosis and management.

Non-invasive assessment of large esophageal varices with liver cirrhosis ; a study conducted in Pakistan.

The assessment of non-invasive parameters for the prediction of large esophageal varices among patients with liver cirrhosisis is of utmost importance. In this study, non-invasive parameters for prediction of large esophageal varices were retrospectively evaluated. The presence of esophageal varices grade III and IV was classified as large esophageal varices positive while no varices or grade I and II were classified as large esophageal varices negative. There were 473 (90.09%) patients with ascites [mild 38 (8.03%), moderate 257 (54.33%) and severe 178 (37.63%)]. Frequency of esophageal varices was found to be higher (n=415, 79.04%). Whereas, large esophageal varices were found in 251 (47.81%) patients. The sensitivity, specificity, positive predicted value, negative predicted value and test accuracy of thrombocytopenia in predicting large esophageal varices were found to be 88.05%, 59.85%, 66.77%, 84.54% and 73.33% respectively. A significant association for large esophageal varices was observed for low platelet counts (AOR : 0.98, 95% CI : 0.97-0.99), high bilirubin level (AOR : 1.22, 95% CI : 1.07-1.39), ascites (AOR : 1.98, CI : 1.02-3.85) and Child score A (AOR : 0.26, 95% CI : 0.09-0.75) and Child Score B (AOR : 0.42, 95% CI : 0.28-0.61). In conclusion, low platelet count, high bilirubin level and ascites are found to be non-invasive predictive factor for large esophageal varices. J. Med. Invest. 66 : 248-251, August, 2019.

Disseminated strongyloidiasis in an immunocompetent male: A Case Report.

Strongyloidiasis is a human parasitic disease caused by infection of Strongyloidesstercoralis. It can manifest from asymptomatic eosinophilia in an immunocompetent host and disseminate the disease in the immunocompromised ones. The inconsistency of eosinophilia and low sensitivity of a standard microscopic stool examination makes it difficult to diagnose the disease. We report a case of chronic strongyloidiasis who, despite being immunocompetent, developed dissemination. The patient was a 30-years-old male who presented with diarrhoea, vomiting, high-grade fever and dyspnoea. On examination, he was pale, oedematous and had ascites with systolic murmurs in tricuspid area. After a fullworkup for differentials, biopsy confirmed the diagnosis of strongyloidiasis. Echocardiogram revealed vegetations on mitral and tricuspid valves and regurgitation through the valves, which confirmed dissemination to endocardium. A course of Ivermectin 9 mg daily for two weeks eradicated the infection in time. In conclusion, awareness for physicians and the use of various diagnostic methods like serology, endoscopy and biopsy should be considered for high risk patients.

The ability of the new ALBI scoring in predicting mortality, complications and prognostic comparison among cirrhotics.

INTRODUCTION: Albumin-bilirubin (ALBI) is a newly devised scoring system for prognostication of liver cirrhosis. The ALBI has recently been validated and found superior to Child-Turcotte-Pugh score (CTP) and Model for End stage Liver Disease (MELD) in assessing severity of liver disease. AIM: To determine the ALBI score's mortality prediction among cirrhotics, associated complications and to compare its prognostic proficiency to that of MELD and CTP. MATERIAL AND METHODS: The diagnostic accuracy of CTP, MELD and ALBI scores for mortality in hospitalized cirrhotic patients was determined by receiver operating characteristic curve (ROC) analysis. The areas under the ROC curve were calculated, with confidence intervals (CI) of 95%. The best cut-off values were ascertained with the greatest specificity and sensitivity. RESULTS: The study showed overall in-hospital mortality of 25.5%. Median CTP score was 10.2 (IQR = 3) and area under curve (AUC) was 0.842 (95% CI: 0.817-0.868, p < 0.001) with sensitivity of 75.0% and specificity of 79.2%. Median MELD score was 20.9 (IQR = 7.2) and AUC was 0.836 (95% CI: 0.810-0.863, p < 0.001) with sensitivity of 76.6% and specificity of 76.7%. Median ALBI score was -1.1 (IQR = 1.0), and AUC of ALBI was 0.852 (95% CI: 0.826-0.879, p < 0.001) with sensitivity and specificity of 78.1%. CONCLUSIONS: The objective prognostication and easy utilization of ALBI make it a useful alternative to MELD and CTP and therefore favour its applicability in clinical practice. Further validations in large prospective cohorts are needed for prognostic value of ALBI in cirrhosis and its complications.

Systemic Lupus Erythematosus Presenting as Longitudinally Extensive Transverse Myelitis and Nephritis: A Case Report.

Systemic lupus erythematosus (SLE) is an autoimmune disorder that can potentially affect any organ. It usually presents between the ages of 15 and 45 with 9:1 ratio of female to male patients. Its clinical manifestations vary among people of different ethnicities. Longitudinally extensive transverse myelitis (LETM) is a rare life-threatening complication of SLE. We, herein, report a case of 26-year-old male diagnosed with LETM along with lupus nephritis. The patient presented with high-grade fever associated with chills and burning micturition followed by progressive bilateral lower limb weakness and urinary retention. His physical examination showed decreased bilateral lower limb power, absent reflexes, and mute plantars. His abdominal reflexes were also found to be absent and sensory level was identified at T10. T2 weighted magnetic resonance imaging (MRI) of the dorsal spine showed hyper-intense signals between T5-L1 suggestive of extensive longitudinal myelitis. Renal biopsy confirmed the presence of lupus nephritis stage III + V. Anti-nuclear antibodies (ANA) were reactive and anti-dsDNA was positive, indicative of SLE as the underlying cause of his clinical manifestations. The treatment strategy proved to be beneficial in our patient. However, there is still a vast gap between understanding the mechanisms of self-reactive diseases such as SLE and the appropriate therapeutic approach. As Pakistan's first documented case of Lupus Myelitis, we hope to delve deeper into this matter.

Neuromyelitis Optica (NMO) with Abdominal Tuberculosis (TB).

Neuromyelitis Optica (NMO), previously regarded as a form of multiple sclerosis, is defined by Gault and Devic, as a retrobulbar neuritis or papillitis accompanied by acute myelitis and occasionally other neurological symptom or signs not restricted to the spinal cord or optic nerves. With the diagnosis of specific antibodies, probable role of humoral immunity supports its pathogenesis. Only a few cases of NMO have been reported in association with pulmonary tuberculosis (TB). Here we report a case of young girl with acute onset paraplegia diagnosed to have NMO, who later on during hospital stay developed ascites which cultured positive for Mycobacterium tuberculosis. This association of abdominal TB with NMO is under-reported in literature.

Amyloidosis with Multiple Myeloma Presenting with Acromegalic Features.

Amyloidosis and multiple myeloma are included in the same spectrum of clonal plasma cell disorders. Amyloidosis can present with localized deposits or manifest as systemic disease involving multiple organs. Here we are reporting a case of an elderly female, having amyloidosis leading to facial disfigurement and neuropathy for many years and then presenting with concomitant multiple myeloma as an incidental diagnosis with no typical symptoms related to it at all.

Fever of unknown origin at a teritiary care teaching hospital in Pakistan.

The aim of this study was to determine the causes of fever of unknown origin (FUO) at a tertiary care teaching hospital in Pakistan. We conducted this cross sectional descriptive study at the Department of Medicine, Civil Hospital Karachi, from January 2006 to December 2011. We reviewed the medical records of all patients aged > 12 years with a primary diagnosis of FUO. We excluded those who did not meet inclusion criteria. Two hundred five patients were analyzed, 111 (54%) were male. The mean age of patients was 38 +/-14 years. The mean duration of fever prior to hospitalization was 37 +/- 16 days and the mean time taken to reach a final diagnosis was 19 +/- 14 days. A diagnosis was established in 171 patients. Infections, especially tuberculosis, were the most common cause of FUO, followed by connective tissue diseases and malignancies. Causes of FUO and their frequencies in the population should be known because FUO is most often caused by an unusual presentation of a common disease, but may also be caused by a rare condition. Common diseases should be suspected first when investigating FUO. Factors causing delay in diagnosis should be identified and overcome to improve outcomes.

Clinical profile and management outcome of diabetic foot ulcers in a tertiary care hospital.

OBJECTIVE: To determine major risk factors and management outcome of diabetic foot ulcers in order to prevent amputation. STUDY DESIGN: Cross-sectional descriptive study. PLACE AND DURATION OF STUDY: Study was conducted at the Department of Medicine, Civil Hospital Karachi, from January 2005 to December 2006. PATIENTS AND METHODS: One-hundred and sixteen consecutive diabetic patients, with foot ulcers of Wagner's grade 1 to 4 were assessed at baseline for demographic information, detailed history, neuropathy, peripheral pulses and frequency of diabetic complication. Glycemic control was determined on the basis of HbA1c levels. Appropriate medical and surgical treatments were carried out and patients were followed-up until healing or for 6 months as end point of study. Outcome was recorded as healed, incomplete healing and amputated. RESULTS: A majority of subjects had type 2 diabetes (95.7%) with male predominance (66%). The mean age was 54.29 +/- 7.71 years. Most of the patients were overweight, hyperglycemic and had diabetes > 10 years duration. Neuropathic ulcers were found in 91 (78.4%) patients, while rest of the 25 (22.6 %) had neuroischemic ulcers. Wound cultures revealed polymicrobial organisms. Foot ulcers of 89 (77.7%) patients healed without amputation and 17 (14.7%) patients had minor or major amputations. Long-duration of diabetes, poor glycemic control and type of foot ulcers had effect on prognosis (p<0.05). CONCLUSION: Effective glycemic control, optimal wound care, aggressive medical management and timely surgical intervention may decrease disabling morbidity with better outcome of diabetic foot ulcer.

Serum retinol binding protein as an indicator of vitamin A status in cirrhotic patients with night blindness.

BACKGROUND/AIM: Vitamin A deficiency is known to be associated with night blindness. Plasma retinol binding protein (RBP) estimation highly correlates with plasma retinol concentration to predict vitamin A status. Serum RBP estimation is reasonably simple, inexpensive, and highly applicable in less technologically developed settings. We studied the correlation of plasma vitamin A levels (by RBP estimation) and ocular manifestation in patients with liver cirrhosis. MATERIALS AND METHODS: This prospective, cohort study included 137 patients with liver cirrhosis. Ocular manifestations in these patients were recorded along with detailed history and clinical examination. Blood samples after overnight fasting were measured for RBP levels. The characteristics of cirrhotic patients with and without eye findings were compared. RESULTS: Out of 137 patients, 55% were males. The causes of cirrhosis were hepatitis C virus in 61%, hepatitis B virus in 32%, alcoholics in 3%, and primary biliary cirrhosis in 3%. Ocular manifestations were found in 47% patients. RBP levels were found to be low in 44%, normal in 40%, and relatively high in 16% patients. Low levels of RBP compared to normal were associated with opthalmological findings of hypovitaminosis A (P < 0.001). CONCLUSION: The measurement of plasma RBP as an alternative to serum retinol estimation to detect relative hypovitaminosis A is simple, easy and reliable. Vitamin A level is strongly related to the severity of liver disease. Opthalmological manifestations in patients with liver cirrhosis may be preventable by early detection of hypovitaminosis A with serum RBP level, but larger studies are required before recommendation of vitamin A supplementation.

Acne treated successfully with azithromycin.

AIM: To study the efficacy, safety, and compliance of 500 mg azithromycin thrice weekly for 12 weeks in acne vulgaris. METHODS: An open-label, noncomparative study was carried out for 12 weeks at the outpatient clinics of Aga Khan University Hospital, Abassi Shaheed Hospital, and Burhani Community Hospital in Karachi, Pakistan. Thirty-five adolescent and postadolescent patients with moderate to severe papulopustular acne vulgaris were enrolled. All patients completed the study. Azithromycin, 500 mg orally thrice weekly for 12 weeks, was used. After the baseline visit, patients were scheduled to return at four-weekly intervals for 12 weeks. Efficacy was gauged by the percentage clearance of papulopustular acne lesions. Safety assessments included the monitoring of adverse events, and compliance was checked at the four-weekly regular visits up to 12 weeks. RESULTS: Twenty-nine patients (82.9%) showed remarkable improvement in the first 4 weeks with 60% reduction of their inflammatory papulopustular lesions. Maximum clearance (80%) was observed at 12 weeks. Residual postinflammatory pigmentation and pitted and linear scarring represented the aftermath of the relapsing pattern of acne. Six patients (17.1%) showed slow clearance with eruptions of new lesions. Adverse events, such as heartburn and nausea, were reported by four patients (11.4%). All patients completed the 12-week study period. CONCLUSION: Azithromycin, 500 mg thrice weekly for 12 weeks, is a safe and effective treatment of acne vulgaris with excellent patient compliance.

Hypokalemic quadriparesis with normotensive primary hyperaldosteronism.

This case report describe a 45 years old female who presented with hypotonia, hyporeflexia, and motor weakness of all four limbs with bilateral flexor planter response due to severe hypokalemia. The patient was finally diagnosed as a case of normotensive primary aldosteronism. Her CT scan abdomen was done which excluded adrenal adenoma. Aldosterone antagonist led to excellent response and recovery.

Farmacologis e terapeutica: Acne tratada com sucesso com azitromicina / Acne treated successfully with azithromycin

AIM: To study the efficacy, safety, and compliance of 500 mg azithromycin thrice weekly for 12 weeks in acne vulgaris. METHODS: An open-label, noncomparative study was carried out for 12 weeks at the outpatient clinics of Aga Khan University Hospital, Abassi Shaheed Hospital, and Burhani Community Hospital in Karachi, Pakistan. Thirty-five adolescent and postadolescent patients with moderate to severe papulopustular acne vulgaris were enrolled. All patients completed the study. Azithromycin, 500 mg orally thrice weekly for 12 weeks, was used. After the baseline visit, patients were scheduled to return at four-weekly intervals for 12 weeks. Efficacy was gauged by the percentage clearance of papulopustular acne lesions. Safety assessments included the monitoring of adverse events, and compliance was checked at the four-weekly regular visits up to 12 weeks. RESULTS: Twenty-nine patients (82.9%) showed remarkable improvement in the first 4 weeks with 60% reduction of their inflammatory papulopustular lesions. Maximum clearance (80%) was observed at 12 weeks. Residual postinflammatory pigmentation and pitted and linear scarring represented the aftermath of the relapsing pattern of acne. Six patients (17.1%) showed slow clearance with eruptions of new lesions. Adverse events, such as heartburn and nausea, were reported by four patients (11.4%). All patients completed the 12-week study period. CONCLUSION: Azithromycin, 500 mg thrice weekly for 12 weeks, is a safe and effective treatment of acne vulgaris with excellent patient compliance.