Safety of high-risk diabetic patients during Ramadan at a tertiary care hospital in Pakistan, practicing updated IDF DAR guidelines.

Objective: To determine trend of following medical advice and safety of high-risk diabetic patients during Ramadan practicing updated IDF DAR guidelines. Methods: The cross-sectional study was conducted at Outpatient Department of Diabetes, Endocrinology and Metabolic Disorders Hayatabad Medical Complex Peshawar, Pakistan from April to June 2022, and comprised of high-risk diabetic patients (>6.0) based on updated IDF-DAR guidelines 2022 intending to fast. A questionnaire was designed to document patient risk factors score, type and duration of diabetes, HbA1c, comorbidities and complications developed during Ramadan. Data was analyzed using SPSS 20. Results: Among all 130 participants, 78(60%) followed medical advice and did not fast and 52(40%) patients fasted against medical advice during month of Ramadan. Out of 130 participants, 89.2% were having type-2 diabetes Mellitus, 55.4% were female and mean age of participants was 52+14.6.40%. In fasting group, 57.7% were in the age range of 16 to 50 years while in non-fasting group 69.2% participants were more than 50 years old (P-value 0.031). There were 80.8% female participants in fasting group versus 38.5% in non-fasting group (P-value 0.001). Hypoglycemia occurred in 58.3% patients in fasting group and 29.3% non-fasting group. (P-value 0.021). On the other hand, 27.8% patients in fasting group and 55.2% of non-fasting group had hyperglycemia (P-value 0.025). Conclusion: Despite advised against fasting in these high-risk patients as per IDF DAR guidelines, almost half of patients fasted considering fasting a religious obligation. Those who fasted had significant hypoglycemia despite adjustment of medications as in guidelines. There is need of more intensive education before fasting, especially in high-risk diabetic patients.

Covid-induced thyroiditis.

Thyroiditis is one of the manifestations of novel Covid-19 virus. Thyroid function test (TFTs) shows typical features of hyperthyroidism. Inflammatory markers and thyroid scan give clue to the diagnosis. This report is about a 39-year-old female who presented with signs and symptoms of thyrotoxicosis along with pain in the neck, odynophagia, and intermittent fever after recovering from Covid-19 a few weeks back. She had no significant history of past medical or endocrine disease. TFTs revealed high T3 and T4 and low TSH. Thyroid scan revealed decrease uptake and ESR was 115. She was started on NSAID, steroids, and beta blocker. Four weeks later, she reverted with the resolution of symptoms and normal TFTs.

Endocrine disorders in Beta-Thalassemia major patients at a Tertiary Care Hospital.

Objectives: To determine the frequency of endocrine disorders in Beta-Thalassemia Major (BTM) patients presenting for Endocrine Evaluation to the Department of Diabetes, Endocrinology and Metabolic Diseases, Hayatabad Medical Complex, Peshawar, Pakistan, a tertiary care hospital. Method: This descriptive study was conducted in the Department of Diabetes, Endocrinology and Metabolic Diseases, Hayatabad Medical Complex, Peshawar from October 2019 to August 2021. All patients with BTM presenting for endocrine evaluation were included in the study. Height and weight were assessed and plotted on the standard charts. For secondary sexual characteristics tanner staging was used. Blood samples for hormonal profile were taken according to standard protocol and sent for endocrine assessment. Results: A Total of 135 patients BTM were enrolled in the study comprising of 70 (51.9%) males and 65 (48.1%) females. Their mean age was 14.8±3.9 years, mean height 138.5±13.01 cm, mean weight 35.9±8.4 kg, mean BMI 18.6±2.8 kg/m2, mean age of transfusion started was 6.7±3.99 months, mean duration of transfusion 13.6±4.03 years and mean duration of chelation therapy received 6.1±4.5 years. Regarding endocrine complications, out of 135 patients assessed, one hundred (74.1%) had height less than 5th centile and fifteen (11.1%) had diabetes mellitus. For thyroid and parathyroid function, 58 and 13 were tested respectively, out of which 16 (27.6%) and 6 (46.2%) had thyroid dysfunction and hypoparathyroidism. Out of 91 patients assessed for pubertal delay, 61 (67.03%) had delayed puberty. Conclusions: High percentage of endocrine complications were found in patients with BTM. Severity and multiplicity of endocrine organs involvement was dependent on duration of the disease and lack of compliance with chelation therapy.

Efficacy and safety of combination of empagliflozin and metformin with combination of sitagliptin and metformin during Ramadan: an observational study.

BACKGROUND: Management of diabetes during fasting is a clinical challenge. Sodium glucose co-transporter -2 inhibitors (SGLT2i) are considered safe with a low risk of hypoglycemia. However, studies on SGLT2i are scarce. This study was designed to compare the efficacy, safety, and tolerability of empagliflozin with metformin during Ramadan in comparison with sitagliptin and metformin. METHODS: It was a prospective, observational study, conducted at 11 different sites all across Pakistan on an outpatient basis during Ramadan (May 2021-June 2021). including 132 patients, 88 who received metformin and sitagliptin, and 44 patients who received metformin and empagliflozin. RESULTS: Patients of the SGLT-2i group experienced similar symptomatic hypoglycemic episodes (15.9%) as the sitagliptin group. There was an improvement in blood sugar levels after the use of SGLT-2i (RBS 181 ± 64 before Ramadan vs 162 ± 53 after Ramadan). HbA1c also improved after the use of SGLT-2i before and after Ramadan (7.2 ± 0.8 vs 6.9 ± 0.9 for Metformin + Empagliflozin and 7.8 ± 1.5 vs 7.6 ± 1.6 for Metformin and sitagliptin). Weight and BMI improved after the use of SGLT-2i (BMI 36.5 ± 4.8 before Ramadan and 33.7 ± 2.4 after Ramadan). There were no reported cases of urinary tract infection in the empagliflozin group. CONCLUSION: SGLT-2 inhibitors combined with metformin for patients with diabetes during Ramadan fasting is as effective, safe and well tolerated as DPP4 combined with metformin.

Safety and efficacy of Empagliflozin in Pakistani Muslim patients with type 2 diabetes (SAFE-PAK); a randomized clinical trial.

BACKGROUND: Sodium-Glucose-Co-Transporter 2 (SGLT2) inhibitor (Empagliflozin) is an effective drug in controlling blood glucose through predominantly glycosuria. Glycosuria increases the risk of genitourinary infections in diabetes. This study was aimed to establish the safety and efficacy of Empagliflozin (Group-A) versus standard care (Group-B) in Pakistani Muslim individuals with type 2 diabetes. METHODS: A multicenter, randomized clinical trial was conducted in five cities across Pakistan from July 2019 to August 2020. Patients of both genders aged 18-75 years, body mass index (BMI) ≤ 45 kg/m2, glycosylated hemoglobin (HbA1c) 7-10% (53 mmol/mol to 86 mmol/mol) and treatment-naive to Empagliflozin were included. Treatment was given for 24 weeks, and allocation was done through randomization. RESULTS: Out of 745 screened patients, 333 met the eligibility criteria, and a total of 244 (73.3%) patients were enrolled. More hypoglycemic events were reported in the standard care group, whereas positive urine culture, fungal infection, dehydration, and hypotension occurrence were comparable between the two groups. The 6 months mean HbA1c reduction was significant in both groups; (Group-A: 0.91 ± 0.15; p < 0.001 vs. Group-B2: 0.79 ± 0.14; p < 0.001). Efficacy comparison at 6 months revealed a significant reduction in weight and systolic blood pressure (SBP) in Group A only (Group-A: 1.4 ± 0.4 kg; p < 0.002 vs. Group-B: 0.01 ± 0.5 kg; p < 1.00), (Group-A: 5.1 ± 1.7 mmHg; p < 0.012 vs. Group-B: 2.3 ± 1.7 mmHg; p < 0.526). CONCLUSIONS: Empagliflozin was a safe drug compared to standard care in Pakistani Muslim patients with diabetes. It was as effective as standard care in the clinical setting but achieved glycemic control by reducing weight and SBP in type 2 diabetes patients. TRIAL REGISTRATION: This study was registered in the NIH US National Library of Medicine clinical trials registry at Clinicaltrials.gov with the registration number: NCT04665284 on 11/12/2020.

Asymptomatic urinary tract infections and associated risk factors in Pakistani Muslim type 2 diabetic patients.

BACKGROUND: One of the leading long-term complications of type 2 diabetes mellitus (T2DM) includes renal dysfunction and urinary tract infections (UTI) which are considered to be prevalent in uncontrolled diabetes. Moreover, physiological factors like age, gender, duration of diabetes, other diabetic complications like neuropathy, autonomic neuropathy and glycosuria are also considered as predisposing factors for increased prevalence of UTI in diabetes which can be symptomatic or asymptomatic. METHODS: This was a cross-sectional, multi-centre study including diabetic patients from 12 clinical sites spread across major cities of Pakistan. The inclusion criteria were adult Pakistani population of age between 18 to 75 years both genders and suffering from T2DM irrespective of duration. A detailed clinical history of the past 3 months was recorded and, biochemical investigations of blood samples were conducted. Urine culture analysis performed identified the type of pathogen present and was done only for asymptomatic patients. RESULTS: A total of 745 type 2 diabetic patients were initially screened, out of 545 patients considered for final analysis 501 (91.92%) were negative and the rest 44 (8.08%) had positive urine culture. Female gender had a significantly higher proportion of positive urine culture (77.27%, p-value< 0.001). Body mass index and mean age had insignificant distribution among the two groups of positive and negative urine culture, with age 40-59 years having higher proportion (70.45%) in the positive group. Escherichia coli was detected in most of the positive samples (52.3%). All bacterial samples were found resistant to Ciprofloxacin. CONCLUSION: Diabetic Pakistani muslim female patients are identified to be at high risk of suffering from asymptomatic UTI and age more than 40 years is an important risk factor. Escherichia coli was the most common causative organism among people living in this geographical area.

Frequency of non-alcoholic fatty liver disease in patients with type-2 diabetes mellitus and its associated risk factors.

OBJECTIVE: Non-Alcoholic Fatty Liver Disease (NAFLD) is emerging as a major public health problem globally especially in patients with Type-2 Diabetes mellitus (T2DM). This study aimed to assess the frequency of NAFLD in patients with T2DM and to study its associated risk factors. METHODS: This descriptive study was conducted from April 2020 to October 2020 at the Hayatabad Medical Complex, Peshawar. Adult patients with T2DM were included in the study and underwent abdominal ultrasound for the identification of NAFLD. All the relevant clinical and biochemical characteristics were measured. RESULTS: Out of 384 participants, 236 patients (61.5%) had NAFLD on ultrasound. Patients with NAFLD had higher mean BMI, higher HbA1c, increased waist circumference, raised ALT, higher triglyceride, and low HDL. Logistic regression analysis revealed a statistically significant association with central obesity (OR = 5.448, 95% CI = 1.416-20.959, p = 0.014), higher BMI (OR = 4.435, 95% CI = 2.127-9.246, p < 0.0001), higher HbA1c [> 11%] (OR = 3.602, 95% CI = 1.438-9.019, p = 0.006), and elevated ALT (OR = 3.211, 95% CI = 1.509-6.835, p = 0.002). The highest odds for NAFLD were found for hypertriglyceridemia (OR = 11.624, 95% CI = 5.405-24.998, p < 0.0001) and low HDL (OR = 11.543, 95% CI = 2.590-51.439, p = 0.001), respectively. CONCLUSIONS: High frequency of NAFLD along with its associated clinical and laboratory risk factors were revealed. This underpins the significance of screening T2DM patients for NAFLD and assessment for and modification of its associated risk factors in routine clinical practice.

Correlation between serum leptin level and Body mass index (BMI) in patients with type 2 diabetes Mellitus.

OBJECTIVE: To correlate serum leptin levels in obese and non-obese type 2 diabetic patients and compare them with healthy individuals. METHODS: The case-control study was conducted at the Lady Reading Hospital, Peshawar, and the Rehman Medical College, Peshawar, Pakistan, from June to November 2017, and comprised type 2 diabetic patients and and an equal number of healthy controls. Fasting blood glucose, glycated haemoglobin, serum leptin, and body mass index were assessed in obese and non-obese subjects. Relation between body mass index and serum leptin level was explored. Data was analysed using SPSS 20. RESULTS: Of the 96 subjects, 48(50%) were in each of the two groups. Among the cases, there were 23(48%) men and 25(52%) women with an overall mean age of 51.27±11.7 years. The control group had 28(58%) men and 20(42%) women with an overall mean age of 49.3±12.1 years. Serum leptin levels were significantly higher in obese 9.42±1.87ng/ml and non-obese 7.21±3.78 ng/ml patients than the controls 5.38±2.20 ng/ml (p<0.05). Serum leptin concentration was significantly correlated with body mass index, fasting blood glucose and BMI, FBG and glycated haemoglobin (p<0.001 each). CONCLUSIONS: Increased levels of serum leptin could be used as a risk factor in the development of type 2 diabetes mellitus.

Association of homocysteine with body mass index, blood pressure, HbA1c and duration of diabetes in type 2 diabetics.

OBJECTIVE: To determine the Homocysteine levels in type 2 diabetics and correlate homocysteine with HbA1c levels, BMI, blood pressure and duration of diabetes. METHODS: This cross-sectional study was conducted in Endocrinology Unit of Hayatabad Medical Complex (HMC) Peshawar and Rehman Medical Institute (RMI) Peshawar over a period of six months from July 2015 to December 2015. Data was recorded and analyzed in SPSS v 20. P value of less than 0.05 was taken as significant. Bivariate Pearson's correlation test was used to see the relationship between homocysteine and BMI, systolic BP and duration of diabetes. RESULTS: One hundred twenty five patients were included in our study in which female were 68% and 32% were male with mean age of 51.45 ±8.37 years. Mean BMI expressed in kg/m2 was 28.71±4.76, mean systolic blood pressure was 130±20.98 mmHg, mean diastolic blood pressure was 83.36±11.28 mmHg and mean duration of diabetes was 7.018± 6.18 years. Significant correlation was found between systolic blood pressure (r: 0.239, p: 0.007) and duration of diabetes with homocysteine (r: 0.302, p: 0.001). The correlation of homocysteine with HbA1c and BMI was not significant. CONCLUSION: Systolic blood pressure and duration of diabetes showed a significant positive correlation with homocysteine. The correlation of homocysteine with HbA1c was not certain from researcher's point of view and further studies of larger sample size and longer duration must be conducted to ascertain the association between the two variables.

Frequency Of Undiagnosed Chronic Obstructive Pulmonary Disease In Patients With Coronary Artery Disease.

BACKGROUND: Chronic obstructive airway disease (COPD) is considered as risk factor for coronary artery disease (CAD) along with other risk factors. This study was conducted to determine the frequency of undiagnosed chronic obstructive pulmonary disease in patients with coronary artery disease. METHODS: This cross-sectional study was conducted in the Pulmonology and Cardiology wards/OPD's of Khyber Teaching Hospital Peshawar. Patients more than 35 years of age, diagnosed with CAD of either gender were included. Patients already diagnosed with COPD, recent myocardial infarction (within 7 days), left ventricular impairment, pneumothorax, bronchiectasis, comatose patient, asthmatic and those with chest trauma were excluded. All the patients underwent spirometry examination before and after administration of salbutamol (5 mg for 5 minutes) via nebulizer. FEV1/FVC less than 70% confirmed the presence of COPD. RESULTS: Out of 151 patients, 57 (37.7%) were found to have COPD. Among them, 39 (68.42%) were male and 18 (31.57%) were female. Among male patients with COPD, 82.05% (n=32) were smokers and 17.94% (n=7) were nonsmokers while in females with COPD no one was smoker. CONCLUSIONS: COPD is an under-diagnosed progressive disease in patients with high risk patients with coronary artery disease.

SHORT STATURE: WHA T IS THE CAUSE IN OUR POPULATION.

BACKGROUND: Globally children and adolescents with growth failure are referred to specialized units for evaluation and management. We designed this study to determine the cause of short stature in children and adolescents referred to our endocrine unit for evaluation and further management. METHODS: This descriptive cross sectional study was performed in the Department of Endocrine, Diabetes and Metabolic Diseases, Hayatabad Medical Complex, Peshawar. Children and adolescents between 2-20 years with height below 2 SDS or less then 3rd percentile for their age and gender were included while those with kyphoscoliosis, thalassemia major, diabetes mellitus type-1 were excluded. Detailed history was obtained followed by detailed physical examination and a pre-set penal of investigations. RESULTS: Seventy-three children with mean chronological age of 11.75.3 ± 4.06 years, 56.31% boys and 43.83% girls (p < 0.05) were included. Mean height was 117.28 ± 17.55 cm, -4.23 ± 2.06 SDS below for this population age group. Mean parental height was 156.87 ± 11.82 cm, mean bone age was 8.56 ± 4.03 years while mean bone age delay was 3.23 ± 1.94 years. Common causes found were variants of normal growth present in 38.35%. Constitutional Delay of Growth and Puberty (CDGP) were found in 13.7%, Familial Short Stature (FSS) in 11.0% while overlapping features of both in other 13.7%. Isolated Growth Hormone Deficiency (GHD) was found in 23.3%, primary hypothyroidism in 9.6% and pan- hypopituitarism in 2.7%. Common non endocrine causes found were Turner's syndrome, rickets, chronic anaemia, bronchial asthma and achondroplasia. CONCLUSION: Isolated GHD, CDGP and FSS, primary hypothyroidism and Turner's syndrome are the most common causes of short stature in our set up.

Association Of Serum Total Bilirubin Level With Diabetic Retinopathy In Type 2 Diabetes Mellitus.

BACKGROUND: Serum bilirubin has anti-inflammatory, antioxidant and immunological properties. It is considered a protective substance against atherosclerotic and microvascular complications of diabetes mellitus (DM). This study was designed to find the association between total serum bilirubin concentration and diabetic retinopathy (DR). METHODS: This case control study was conducted in the Department of Endocrinology, Diabetes and Metabolic Diseases, Hayatabad Medical Complex, Peshawar. Type-2 DM patients more than 18 years of age of either gender with duration of T2DM more than 6 months were included and sub categorized in two groups. Cases (DM with DR) and Controls (DM without DR) while patients with acute and chronic liver diseases, haemolytic anaemia, history of chronic alcohol consumption, use of hepatotoxic drugs (anti-tuberculous, anti-epileptic), women on oral contraceptive pills were excluded. All participants underwent ophthalmic examination at diabetic retinopathy screening clinic followed by pre designed set of investigations. RESULTS: A total of 152 patients, 76 cases and 76 controls were included. Serum bilirubin concentration was found inversely and independently (p 0.000) associated and inversely co related (r -0.345and p 0.000) with prevalence of DR. Cases were concentrated in the lower quartiles of serum bilirubin concentration and vice versa. Low haemoglobin (p 0.00) and longer duration of DM (0.003) were independently and directly associated with prevalence of DR. CONCLUSIONS: Serum bilirubin concentration is inversely and independently associated and inversely correlated with the prevalence of DR and may predict progression of DR over time.

Diabetic Foot Ulcers and Their Surgical Management: Our Experience at Hayatabad Medical Complex, Peshawar.

BACKGROUND: Surgeons face a therapeutic challenge while treating diabetic foot ulcers (DFUs), particularly in underdeveloped nations with limited healthcare resources and a high proportion of patients who arrive at medical institutions with advanced foot ulcers. OBJECTIVE: To assess the effectiveness of treatment in patients with DFUs and to demonstrate how early surgical intervention and appropriate bedside medical care can improve results. MATERIAL AND METHODS: This prospective study was carried out at Hayatabad Medical Complex, Peshawar, Pakistan, to assess how DFUs changed over a period between November 2021 and December 2022 at the wards and at the outpatient department of endocrinology and general surgery. A diabetic patient's foot is first screened for ulceration in the endocrinology department, and only those with active ulcers are referred to the surgical department. RESULTS: According to the Wagner classification, there were six (13.6%) cases in grade I, 11 (25%) in grade 2, 10 (22.7%) in grade 3, 13 (29.5%) in grade 4, and four (9%) in grade 5. Among comorbidities, a family history of diabetes mellitus was noted in 25 (56.8%) patients, followed by tobacco chewing and alcohol in 10 (22.7%) and hypertension in nine (20.4%) patients. CONCLUSION: Diabetes foot ulceration is the most common reason for non-traumatic lower limb amputation in people with diabetes mellitus and is a significant cause of morbidity and mortality.